PATHOPHYSIOLOGY

Predisposing Factor
Age
Incidence of Myasthenia Gravis occurs between ages 15-35 for women. (Porth p.1131) Our patient is 29 years old. Myasthenia Gravis is three times more common in women than men.
(Porth, p1131)

Gender

Hereditary

A person born into family with history of certain autoimmune disease is at risk of developing such autoimmune disease.
(www.emedicine.com)

Precipitating Factor
Poor environment Poor house/ office
Ventilation crowded environment Location

Constant exposure to dust or chemical substances can weaken the immune system of every individual that lead to infection.
(www.emedicine.com)

Stress
Occupation

Stress can weaken the immune system. According to psychoneuroimmunology, they found consistent stress-related increases in numbers of total white blood cell, as well as decreases in the numbers of helper T cells, suppressor T cells, and cytotoxic T cells, B cell, and natural killer T cells. (www.emedicine.com)

Precipitating Factor

Predisposing Factor

Decrease # of T-cell

Abnormal DNA mutation

Alteration of the Tcells function

Difference in the variable Region of antibodies

Production of abnormal T-Cells

Abnormal Antibodies Inhibit muscle specific Protein MuSK

Unable to recognize Selfantigen

Attacking the Acetylcholine Receptor Sites

Malformations of Neuromuscular Junction

Destruction of Acetylcholine Receptor Sites

Decreased Patency Of Neuromuscular Junction

Decrease # of functioning Acetylcholine Receptors site

Decrease Acetylcholine to Receptor site binding

Decrease Depolarization

Impaired muscle contraction

Myasthenia Gravis

Myasthenia Gravis

S/sx Expressionless face Nasal timbre Ptosis Diplopia Dysphagia Dysarthria Dysphonia Weakness of all Extremities

Diagnostic Test
Acetylcholine Receptor Antibody

A blood test for the abnormal antibodies can be performed to see if they are present. Acetylcholine Receptor Antibody testing - Approximately 85% of MG patients have this antibody and, when detected, is a guaranteed diagnosis.

Tensilon test

The edrophonium chloride (Tensilon) test is performed by injecting this chemical into a vein. Improvement of strength immediately after the injection provides strong support for the diagnosis of MG.

Anti-MuSK Antibody testing A blood test for the remaining 15% of seronegative (SN) MG patients, those who have tested negative for the acetylcholine antibody, 40-70% test positive for the anti-MuSK antibody. The remaining patients have an unidentified antibody causing their MG.

Nursing Diagnosis
Fatigue r/t generalized muscle weakness 2 MG.
Independent Action: Schedule/ organize activities Assist pt. with ADLs These can minimize energy expenditure and prevent injury with activities

Collaborative:

Pyridostismine bromide 65mg/ tab, 1 tab t.i.d.

Pyridostigmine is used to improve muscle strength in patients with a certain muscle disease (myasthenia gravis). It works by preventing the breakdown of a certain natural substance (acetylcholine) in your body. Acetylcholine is needed for normal muscle function.

Azathioprine 50mg tab O.D.

An immunosuppressive medication that decreases the actions of the bodys immune system. Drugs that suppress the immune system are used in patients with myasthenia gravis because MG is an autoimmune disorder that results from the production of abnormal antibodies.

 Prednisone 20mg, 1 tab q 12

Prednisone is a corticosteroid hormone (glucocorticoid). It decreases your immune system's response to various diseases to reduce symptoms such as swelling and allergic-type reactions. It is used to treat conditions such as arthritis, blood disorders, breathing problems, certain cancers, eye problems, immune system diseases, and skin diseases.
S/sx Inability to expectorate respiratory muscle weakness

Disruption of mechanical defense Invasion of microorganism in nasal

From MG

Colonization of microorganism Invasion of microorganism in the lungs

If treated: Medications Laboratories Surgeries Health Teachings

If treated

Activation of immune system

Release of Endotoxin and exotoxins

If complaint

If not compliant

Inflammation of the Lungs parenchyma

Lessen the S/sx

Further distraction of Acetylcholine Receptor sites

PNEUMONIA

S/Sx: Cough Crackles

Diagnostic Test
Jan. 5 - Increased WBC- 14-16x10g/l Neutrophils- 90 x10g/l Lymphocytes- 4x10g/l Jan. 9- ETA/ GSCS result The culture result reveals that the specific type of bacteria called Acinetobacter baumaanii is susceptible to certain types of antibiotics such as: Amikacin, Ampi/Sulbactam, Ceftaxidine, Ciprofloxacin, Gentamicin, Ticarcillin and Tobramycin; hence, effective in killing these types of microorganisms.

Nursing Diagnosis
Ineffective airway clearance r/t retained tracheobronchial secretions 2 MG, CAP Independent Action: Suction secretion ,prn It mechanically clears airway in pt. who is unable to do so because of ineffective cough. Assist pt. in performing Deep breathing exercises Deep breathing facilitates maximum expansion of the lung areas. Collaborative Sultamicilline 150mg, 1 tab. B.i.d. Acinetobacter baumaanii is susceptible to
Sultamicilline

From MG

Colonization of microorganism Invasion of microorganism in the lungs

If treated: Medications Laboratories Surgeries Health Teachings

If treated

Activation of immune system

Release of Endotoxin and exotoxins

If complaint

If not compliant

Inflammation of the Lungs parenchyma

Lessen the S/sx

Further distraction of Acetylcholine Receptor sites

PNEUMONIA

More less amount of receptor sites for acetylcholine binding

Myasthenic Crisis S/Sx: Respiratory distress Severe body weakness Absent of gag reflex

Diagnostic Test
12/27 ABG- partially compensated Respiratory alkalosis with hypoxia

Nursing Diagnosis
Risk for Aspiration r/t muscle weakness 2 MG Independent Action: Assess Gag reflex Pt. with weak gag reflex is at risk for aspiration Keep pt. upright for 30-60 min. after meals The upright position facilitates the gravitational flow of food or fluid through the alimentary tract and reduces the risk of aspiration. Keep suction equipment at bedside and suction necessary. This is necessary to maintain patent airway. Collaborative:
Monitor ABG and pulse oximeter pulling of secretions leads to pneumonia which will lead to more aggressive interventions.

More less amount of receptor sites for acetylcholine binding

Myasthenic Crisis S/Sx: Respiratory distress Severe body weakness Absent of gag reflex If treated If not treated

DEATH

From MG

Colonization of microorganism Invasion of microorganism in the lungs

If treated: Medications Laboratories Surgeries Health Teachings

If treated

Activation of immune system

Release of Endotoxin and exotoxins

If complaint

If not compliant

Inflammation of the Lungs parenchyma

Lessen the S/sx

Further distraction of Acetylcholine Receptor sites

PNEUMONIA

Criteria
a. Duration of illness

Poor

Fair Good

Justification
Our patient has been diagnosed with Myasthenia Gravis for more than a year now. She has been admitted for a few times due to the complications led by her illness. During the first few weeks upon the onset of symptoms, the patient continued working as a clerk. She only sought for medical intervention when she can no longer bear the symptoms she felt.

(1)

(2)

(3)

b. Onset of Illness

c. Precipitating Factors

With the precipitating factors, our patient has poor prognosis since her age bracket falls in middle adulthood (29 years old). Considering also that she is a female and such disease is common in their gender.

d. Willingness to take Medications

Our patient was able to comply with her medications as evidenced by taking in her medicine on time and having sufficient financial resources to sustain her medications.

e. Age

Myasthenia Gravis commonly affects young adult women, usually those under the age of 40. Since our patient is 29 years old, she has a poor prognosis when age is considered. Our patient lives in a stressful environment. Stress can trigger the remission of symptoms

f. Environment

g. Family Support

The patients family is supportive. They are always there when she needs them.

Score: 2+2+1+3+1+1+3= 13/7=1.85 (poor - fair)

Based on the data, our patient got an average score of 1.85 in 7 criteria which means poor to fair prognosis. In addition, both fair and good prognosis got 2 criteria while the precipitating factors, age, and environment got a score of 1 or poor prognosis. With this data, our patient is more susceptible for the recurrence of the disease. If this will not be corrected, this will lead to poor prognosis.

If the patient is compliant with the treatment, she will have a significant improvement in her muscle weakness and can expect to live a normal life. If some factors such as stress Will be encountered then there is possible recurrence.