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pharmacology multi-part question and need a sample draft to help me learn.
Read the attached article and name five (5) teaching strategies for patients with myasthenia gravis in order to prevent exacerbations and/or to keep them safe
Requirements: 1 paragraph
44 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.comMyasthenia gravis (MG) is an autoim-mune disease that causes weakness and fatigue in the voluntary muscle groups due to the body’s immune system attack-ing the neuromuscular junction where nerve cells connect with muscles. The muscle groups most commonly impacted are in the eyes, mouth, face, and neck, but can extend to the limbs and respira-tory system. MG affects approximately 20 in 100,000 people each year in the United States. Although MG more commonly affects female patients younger than age 40, it can occur in male and female pa-tients at any age and of any race or eth-nicity. MG isn’t contagious or hereditary; however, it may be congenital.PathophysiologyMG is the result of an antibody-mediated autoimmune response, causing the body’s immune system to target and attack certain muscle receptors that re-ceive nerve impulses. In normal muscle contraction, when the impulse reaches the nerve ending at the neuromuscular junction, a chemical called acetylcho-line is released that binds to recep-tors, causing the muscle to contract. Because MG is an autoimmune disease, antibodies are produced by the immune system that block or destroy normal acetylcholine receptor sites (see What’s happening?). This prevents muscle con-traction from occurring; over time, the response to repeated stimulation even-tually causes the muscle weakness and fatigue that characterize MG.Research suggests that the thymus may play a role in the autoimmune pro-cess. Located behind the breastbone, the thymus gland aids early immune system development. It typically gets smaller with age; however, it remains enlarged in adults with MG and may contain certain abnormal cells that stimulate antibody development, triggering an autoimmune response.A research study was conducted to determine whether collected evidence demonstrated a benefit for MG patients to undergo thymectomy. A randomized trial followed individuals who had a thy-mectomy in combination with traditional treatment of prednisone versus those who received prednisone alone. Notably, the results revealed that individuals who had their thymus removed had less muscle weakness and improved clinical out-comes related to MG as compared with those who solely received prednisone treatment.Although the cause of MG is unknown, it’s known that MG isn’t a genetic or communicable disease. However, there are a small percentage of individuals with MG who have a family history of the disease. MG spontaneously devel-ops with age as a direct result of the Focus on: Myasthenia gravisThis rare neuromuscular condition is treatable, with most affected individuals living healthy, full lives.By Jean Brennan, MSN; Rebecca J. Sullivan, BSN; Deborah J. Bryant, BSN; Stephanie Glasel, BSN; Keshla Macek, BSN; and Evelyn Louise Olson, MSN44 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.com
www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 45MARK MILLER / SCIENCE SOURCEwww.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 45
46 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.combody’s antibody-mediated autoimmune response.Signs and symptomsThe signs and symptoms of MG are variable and progressive. Ocular muscle weakness is often the first sign, causing ptosis (eyelid drooping) and diplopia (double vision). Other common symp-toms include dysarthria (impaired or slurred speech), dysphagia (difficulty swallowing), weakness in the upper and lower limbs, and generalized muscle fatigue. Symptoms of MG may fluctuate with activity and start and stop suddenly.Respiratory muscles may be affected by a myasthenic crisis—an acute onset of severe respiratory muscle weakness, leading to respiratory distress that often requires intubation. Myasthenic crisis can be triggered by stress, respiratory infec-tion, or surgery. To avoid or reduce the risk of myasthenic crisis, it’s important for patients with MG to take medications as prescribed and avoid people with respira-tory infections.Regardless of the timing or severity of symptoms, the hallmark feature of MG is muscle fatigue that worsens with exer-tion and improves with rest. Factors that exacerbate MG symptoms are emotional upset, hypothyroidism, hyperthyroidism, pregnancy, menstrual cycle, and increased body temperature.Although MG affects only the muscles under voluntary control, implications of the disease are far reaching. Because ocular muscles are most commonly affected, impaired vision is expected. Other complications include impaired communication, altered nutrition, and risk of aspiration related to affected throat and neck muscles.In neonatal MG, about 15% of babies born to mothers with autoimmune MG develop a feeble cry, poor sucking, respi-ratory distress, or hypotonia (also known as floppy baby syndrome), which can be reversed by medication or blood exchange to remove antibodies.DiagnosticsThe highly variable presentation of MG makes it a challenging disease to diag-nose. A head-to-toe physical and thor-ough neurologic exam is an essential first What’s happening?A: Normal acetylcholine (ACh) receptor site. B: ACh receptor site in myasthenia gravis.Paul P, Day R, Williams B. Brunner & Suddarth’s Canadian Textbook of Medical-Surgical Nursing. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.AxonACh vesiclesACh receptorsABAxonAntibodiesMuscle endplateNerveMuscle endplate
www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 47step. Many patients with MG experience exacerbations and remissions; symptoms may be sudden and can present unilater-ally or asymmetrically.Because muscle weakness characteristi-cally worsens with activity and improves with rest, early testing for MG may involve a continuous or repetitive use of affected muscles to determine the extent of weakness. For example, a healthcare provider may have a patient look skyward without blinking for a few minutes while watching for drooping eyelids. Afterward, the patient may close his or her eyes and lay down to see if ocular muscle behavior improves.An ice pack test can be used to deter-mine whether the cause of ptosis is from MG or the result of another condition. This test can be performed at the bedside to aid in accurate diagnosis of MG. An ice pack is placed on the eyelid for 2 minutes, followed by measurement of the eyelid for improvement. The ice pack test is highly sensitive and considered a safe and effec-tive diagnostic test for MG when ptosis is a clinical presentation.If MG is suspected, blood tests and other routine exams are available to sub-stantiate findings consistent with the disease. Lab draws indicate the presence of antibodies in the blood. A Tensilon test, involving the injection of I.V. edrophoni-um chloride, often results in a temporary increase in muscle strength. Electromyog-raphy or nerve conduction studies show impaired neuromuscular transmission. Computed tomography can identify thy-mus gland abnormalities or confirm the presence of a thymoma (a tumor on the outside of the thymus).TreatmentMG can be a devastating diagnosis, but the prognosis is usually positive and there are various treatment options. Treat-ment may include the acetylcholinester-ase inhibitor pyridostigmine to increase acetylcholine release in the presynaptic neuromuscular junction. Unfortunately, this usually only has a mild effect on decreasing symptoms. Immunosuppres-sive therapies include medications such as prednisone and prednisolone to de-crease the body’s inflammatory response. Rituximab is a potent treatment aimed at B lymphocytes and T cell responses; how-ever, there’s concern that the use of ritux-imab may lead to additional autoimmune disorders. Lastly, monoclonal antibody drugs are used because they interfere with B and T cells, complement, or other immunoactive elements.If a thymoma is present with the diag-nosis of MG, a thymectomy is recom-mended. This is because the thymus has a major role in the production of acetylcho-line receptor antibodies, which bind to the acetylcholine receptors and interfere with muscle functioning. One study found that thymectomy with the use of prednisone allowed for the reduction of prednisone dosage by over 25%, decreasing unwanted adverse reactions of prednisone therapy.The goal of all therapies is improve-ment in the patient’s quality of life, including measurable improvements in difficulty swallowing solid foods and shortness of breath at rest. The patient’s psychosocial needs must be considered in the treatment plan, as well as the patient’s feelings about his or her ability to func-tion and the response to the treatment plan. Interventions should be individual-ized. The use of a health-related quality-of-life disease-specific measuring tool, such as the Myasthenia Gravis Quality-of-Life Questionnaire, allows for a clinically Signs and symptoms• Ptosis• Diplopia• Dysarthria• Dysphagia• Upper and lower limb weakness• Generalized muscle fatigue (worsening with exertion and improving with rest)sheetcheat
48 Nursing made Incredibly Easy! March/April 2018 www.NursingMadeIncrediblyEasy.combased assessment to identify areas that need to be addressed for the patient to feel he or she is achieving an optimal level of health.Nursing interventionsA comprehensive nursing assessment is essential for patients with MG. The first step is obtaining a detailed medi-cal history, along with a subjective de-scription of symptoms, followed by a neurologic evaluation. Next, testing all voluntary muscles for both muscle strength and fatigability helps assess the severity of specific muscle weak-ness and the extent of functional im-pairment. Ask the patient about the lo-cation and severity of reduced muscle strength. Another consideration is the timing of muscle weakness, including onset, duration, and frequency. Focus on ocular muscles; bulbar muscles used for chewing, swallowing, and speech; facial muscles; head and neck muscles; and limb muscles. Also assess the patient’s breathing activity for short-ness of breath or increased respiratory effort.Nursing interventions should be tai-lored to the patient’s symptoms and the degree of muscle impairment. When ocu-lar muscles are impaired, a patient may have visual difficulty that can contribute to falls. Maintaining a clean, clutter-free environment and offering a patch for the affected eye promotes safety. Aspiration precautions should be followed, includ-ing assessment of the gag reflex before meals and placing the patient in the high Fowler position when eating. Swallow-ing and chewing impairment should also be monitored. In myasthenic cri-sis, aggressive respiratory treatment, such as mechanical ventilation, may be necessary. Provide pulmonary hygiene as needed to minimize respiratory complications.Teach the patient strategies to manage fatigue and conserve energy, including planning and pacing activities, and avoid-ing overexertion to minimize exacerba-tions of MG. Patient education should also include continued support, quality of life, and coping.To long lifeMG is a chronic autoimmune disease affecting the neuromuscular system. Muscle weakness and fatigue typically impact the muscles of the eye, mouth, neck, and face, and can extend to the limbs and respiratory system. Symp-toms that worsen with activity and im-prove with rest are hallmark character-istics of this disease. Patients with MG experience periods of exacerbations and remissions, but symptoms can be well controlled with a unique combination of therapies. Myasthenic crisis is a medical emergency, often requiring mechani-cal ventilation and respiratory support. Comprehensive nursing assessment, key pointsNursing interventions• Take a detailed patient history.• Perform a physical and neurologic evaluation.• Test muscular strength and endurance. • Assess respiratory function and provide appropriate support.• Maintain a clean, clutter-free environment for safety.• Offer an eye patch for the affected eye.• Implement aspiration precautions.• Provide patient teaching.on the webon the webMayo Clinic: www.mayoclinic.org/diseases-conditions/myasthenia-gravis/symptoms-causes/syc-20352036Medline Plus: https://medlineplus.gov/myastheniagravis.htmlMyasthenia Gravis Foundation of America:www.myasthenia.org/WhatisMG.aspxNational Institute of Neurological Disorders and Stroke: www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Myasthenia-Gravis-Fact-SheetNational Organization for Rare Disorders: https://rarediseases.org/rare-diseases/myasthenia-gravis/
www.NursingMadeIncrediblyEasy.com March/April 2018 Nursing made Incredibly Easy! 49proper patient education, support from healthcare providers, and prompt inter-ventions ensure that patients with MG understand how to manage their dis-ease and live long, healthy lives. ■REFERENCESAmerican Association of Neuroscience Nurses. Care of the patient with myasthenia gravis. www.myasthenia.org/LinkClick.aspx?fileticket=I2Imja5gU4s%3D&tabid=101.Cioncoloni D, Casali S, Ginanneschi F, et al. Major motor-functional determinants associated with poor self-reported health-related quality of life in myasthenia gravis patients. Neurol Sci. 2016;37(5):717-723.Copstead-Kirkhorn L, Banasik JL. Pathophysiology. 5th ed. St. Louis, MO: Elsevier Saunders; 2012.Gupta M. Ice test in the diagnosis of myasthenic ptosis. Neurol India. 2016;64(6):1173-1174.Howard JF. Myasthenia gravis: a summary. www.myas-thenia.org/HealthProfessionals/ClinicalOverviewofMG.aspx.Koopman WJ, LeBlanc N, Fowler S, Nicolle MW, Hulley D. Hope, coping, and quality of life in adults with myas-thenia gravis. Can J Neurosci Nurs. 2016;38(1):56-64.National Institute of Neurological Disorders and Stroke. Myasthenia gravis fact sheet. www.ninds.nih.gov/ disorders/myasthenia_gravis/detail_myasthenia_gravis.htm#3153_5.National Organization for Rare Disorders. Myasthenia gravis. http://rarediseases.org/rare-diseases/ myasthenia-gravis.U.S. Department of Health and Human Services. Care of the patient with myasthenia gravis. www.guideline.gov/summaries/summary/46659.Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med. 2016;375(6):511-522.At Northern Arizona VA Medical Center in Prescott, Ariz., Jean Brennan is a Geriatrics and Extended Care Clinical Nurse Educator, Rebecca J. Sullivan and Deborah J. Bryant are RN Case Managers, Stephanie Glasel is an RN Nurse Coordinator/Navigator, Keshla Macek is a Charge Nurse, and Evelyn Louise Olson is a Clinical Educator.The authors have disclosed no financial relationships related to this article.DOI-10.1097/01.NME.0000529950.14582.95
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