Prepared by: Group 5 Rho Vince Malagueo Iana Villania Arabelle Bitara Jonah Joan Bullecer Jeffrey Lopez

Sarah Jane Baal Joelymer Madrid Joyce Burac Karen Esteban

 Myasthenia

gravis (from Greek "muscle", "weakness", and Latin: gravis "serious"; abbreviated MG) is an autoimmune neuromuscular disease leading to fluctuating muscle weakness and fatigability. It is an autoimmune disorder, in which weakness is caused by circulating antibodies that block acetylcholine receptors at the postsynaptic neuromuscular junction, inhibiting the excitatory effects of the neurotransmitter acetylcholine on nicotinic receptors throughout neuromuscular junctions.

Biological Data:
Name: Patient X Address: San Juan, Iriga City Birth Place: Iriga City Sex: Female Religion: Roman Catholic Marital Status: Married Occupation: House Wife Date of interview: Wednesday, July 17, 2013

Chief Complaints:
DOB Inability to move the extremities Apnea Fatigue

History of Present Illness

Partient X, 56 years old, female, was admitted in SMJHFI on May 27, 2013 with the following chief complaints; body weakness, severe difficulty of breathing,difficulty in swallowing and speaking.One week prior to admission, the patient had already experienced the exacerbations of the previously diagnosed myasthenia gravis, namely; body weakness and fatigue that worsened during the end of the day usually in the early evening. The signs and symptoms of the disease started to develop on the last quarter of January 2013. On February 2013, she was admitted at SMJHFI and then diagnosed with myasthenia gravis

Then after 2 weeks, she was referred to BMC on March 2013, and thymectomy thru sternotomy procedure was performed on April 2013. Two weeks after the operation she was discharged from BMC. Then last May 27, 2013 she was rushed again to SMJHFI with the chief complaint of DOB, inability to move the extremities, apnea and fatigue and was admitted in ICU and was intubated for 1 month. Her X-ray result shows thyroid cystic masses.Then Tracheostomy and Thyroidectomy were performed last July 1, 2013. She responded well to the medications given (mestinon, prostigmine, prednisone).

The patient had respiratory infections before. She was never been hospitalized due to any illness. She denied to have Hypertension and diabetes. She doesnt take any medications before.

FAMILY HISTORY
The patient doesnt have any relatives who had similar disorders.

Current Health Information

Allergies: No known Allergies Habits: Does not smoke and take alcohol, caffeine, drugs Exercise pattern: No active exercise Sleep pattern: Pt. usually sleeps at 8 to 9 pm then wakes up at 5 to 6 am. She does not suffer from any sleep disturbances.

CHRONIC AUTOIMMUNE NEUROMUSCULAR DISEASE + ------------------------------------------------=MYASTHENIA GRAVIS

 Central

Nervous System Brain Spinal Cord Peripheral Nervous System Cranial Nerves Spinal Nerves Autonomic Nervous System

 Dendrites-

for receiving electrochemical

messages Cell Body Axon- carries electrical impulses away from the cell body

 Neuron

to Neuron Neuron to target tissue e.g. Acetylcholine

PREDISPOSING FACTOR

Age Gender Familial Race

PATHOPHYSIOLOGY

PRECIPITATING FACTOR
Occupation Lifestyle Nutrition/Diet Environmental Exposure to Chemicals Infections

Thymic Hyperplasia/Tumor

Acetylcholinesterase

Diffusion of Ach from the Myoneural junction

Immunologic Disturbance Production of Autoantibodies against Ach receptor Sites

Enzymatic Breakdown of Ach

Destruction of Ach Receptors

resistance to Ach Fewer Ach Receptors Available

Availability of Ach

S/Sx: Ptosis Bulbar Symptoms Laryngeal Spasm Dysphonia Intercostal muscle weakness

Impaired Myoneural Impulse Transmission

Voluntary Muscle Weakness

Clinical manifestations that arise in cases of myasthenia gravis varies from each class, however, in patients with signs and symptoms of myasthenia gravis may occur, namely: Disorders of the eye such as the diplopia (double vision), ptosis (eyelid weakness). Disorders of the facial muscles such as difficulty chewing, swallowing and talking. Disorders of the palatal and pharyngeal muscle weakness, so that the patient is not able to swallow and it is the risk of aspiration. Weakness of neck muscles so the patient's head is hard upright.

 Weakness

of the respiratory muscles such as the diaphragm and intercostal muscles resulted in disruption of breathing. Myasthenia crisis, caused by deficiency of acetylcholine, a condition caused by changes or drug dependence, emotional and physical stress, infection or surgery. Cholinergic crisis, caused by the excess of acetylcholine as a result of an overdose of medication / toxic effects of the administration of acetylcholine.

Myasthenia crisis:
increased blood pressure tachycardia restless fear increased bronchial secretions, tears and sweat generalized muscle weakness loss of reflex cough difficulty breathing, swallowing and speech decrease in urine output

Cholinergic crisis:
decreased blood pressure bradycardia restless fear increased bronchial secretions, tears and sweat generalized muscle weakness difficulty breathing, swallowing and speech nausea, vomiting diarrhea abdominal cramps.

Examination: Thyroid Gland Examination date:6/28/13 THYROID GLAND The right lobe of the thyroid gland is markedly enlarged showing a multilobulated septated solid mass with cystic areas with an AP diameter of 3.5cm. No microcalcifications noted. The left lobe is not enlarged. It measures 1.8X1.2X3.1 cm. there is 1.6x1.1cm mixed solid and cystic mass in the upper pole of the left lobe. No microcalcifications noted.

The isthmus is thickened measuring 0.5 cm. There is no cervical lymphadenopathy bilaterally.
IMPRESSION: Enlarged thyroid gland with at least two mixed solid and cystic masses, as described.

Examination: Chest AP Exam Date:6/23/13

The domes of the diagphragms are evenly shaped and positioned in proper height. The sinus are not obliterated. The pleura shows no thickening. Both lung fields have the same transparency and no geographic or rounded densities. There is a harmonic bronchovascular branching right into the periphery of the lungs.

The upper mediastinal shadow is not enlarged The tracheal band is not narrowed. The hili is not enlarged. Cardiac silhoutte is not widened. The visualized parts of the skeleton are normal. The soft tissue of the chest wall is not conspiciuous. Stemotomy wires are in place.

Endotracheal tube is in place,the tip of which is seen at the level of T3-T4. IMPRESSION: Cardiomegaly

EXAMINATION

RESULT

NORMAL VALUE

Ph PCO2
PO2 HCO3-

7.43 44
84 28.6

7.20-7.60 30-50mmHg
70-700 Mmo1/1

Hct SO2
Hb

39 96
13.0

90/100%
12.0-17.0g/dl

REMARKS: HCO3-24-48mmol/L (Henry)

Test CBC WHITE BLOOD CELLS RED BLOOD CELLS HEMOGLOBIN HEMATOCRIT MCV MCH

Result

Reference

Unit

19.37 5.31 150.0 0.432 81.4 28.2

4.8-10.8 (M)4.7-6.1 (F) 4.2-5.4 (M) 140-180 (F)120-160 (M)0.420-0.520 (F)0.370-0.470 (M)80-94 (F)81-99 27.0-31.0

10^3/uL 10^6/uL 6/L

fL pg

MCHC
PLATELET

347.0
273

330-370
130-400

G/L
10^3/UL

TEST NEUTROPHIL LYMPHOCYTE MONOCYTE

RESULT 0.858 0.104 0.031

REFERENCE 0.4-0.7 0.19-0.48 0.034-0.090

UNIT

EOSINOPHILS
BASOPHILS Neutrophil (#)

0.005
0.002 16.61

0.0-0.070
0.0-0.015 1.9-8.0 10^3/uL

Lymphocytes (#)
Monocyte (#) Eosinophils (#) Basophils (#)

2.02

0.9-5.2
0.16-1.00

10^3/uL
10^3/UL 10^3/uL 10^3/uL

0.09 0.04

0.0-0.8 0.0-0.2

EXAMINATION Sodium

RESULT

NORMAL VALUE 136-146

UNITS mmol/L

Potassium

3.65

3.4-5.10

mmo/L

SURGICAL MANAGEMENT

tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is usually placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube.

 General

anesthesia is used, unless the situation is critical. In that case, local anesthesia is injected into the area to reduce the discomfort caused by the procedure. The neck is cleaned and draped. Surgical cuts are made to expose the tough cartilage rings that make up the outer wall of the trachea. The surgeon then creates an opening into the trachea and inserts a tracheostomy tube.

tracheostomy may be done if you have: A large object blocking the airway An inability to breathe on your own An inherited abnormality of the larynx or trachea Breathed in harmful material such as smoke, steam, or other toxic gases that swell and block the airway Cancer of the neck, which can affect breathing by pressing on the airway

 Paralysis

of the muscles that affect swallowing Severe neck or mouth injuries Surgery around the voicebox (larynx) that prevents normal breathing and swallowing

 The

risks for any anesthesia are: Problems breathing Reactions to medications, including heart attack and stroke
The

risks for any surgery are: Bleeding Infection Nerve injury, including paralysis

 Other

risks include: Damage to the thyroid gland Erosion of the trachea (rare) Puncture of the lung and lung collapse Scar tissue in the trachea that causes pain or trouble breathing

 If

the tracheostomy is temporary, the tube will eventually be removed. Healing will occur quickly, leaving a minimal scar. Sometimes, a surgical procedure may be needed to close the site (stoma). Occasionally a stricture, or tightening of the trachea may develop, which may affect breathing. If the tracheostomy tube is permanent, the hole remains open.

 Most

patients need 1 to 3 days to adapt to breathing through a tracheostomy tube. It will take some time to learn how to communicate with others. At first, it may be impossible for the patient to talk or make sounds. After training and practice, most patients can learn to talk with a tracheostomy tube. Patients or family members learn how to take care of the tracheostomy during the hospital stay. Home-care service may also be available.

 You

should be able to go back to your normal lifestyle. When you are outside, you can wear a loose covering (a scarf or other protection) over the tracheostomy stoma (hole). Use safety precautions when you are exposed to water, aerosols, powder, or food particles.

thyroidectomy is an operation that involves the surgical removal of all or part of the thyroid gland. Surgeons often perform a thyroidectomy when a patient has thyroid cancer or some other condition of the thyroid gland (such as hyperthyroidism) or goiter. Other indications for surgery include cosmetic (much enlarged thyroid), or symptomatic obstruction (causing difficulties in swallowing or breathing).

 Thyroidectomy

is a common surgical procedure that has several potential complications or sequela including: temporary or permanent change in voice, temporary or permanently low calcium, need for lifelong thyroid hormone replacement, bleeding, infection, and the remote possibility of airway obstruction due to bilateral vocal cord paralysis. Complications are uncommon when the procedure is performed by an experienced surgeon.

 Thyroid

cancer Toxic thyroid nodule (produces too much thyroid hormone) Multinodular goiter (enlarged thyroid gland with many nodules), especially if there is compression of nearby structures Graves' disease, especially if there is exophthalmos (bulging eyes) Thyroid nodule, if fine needle aspirate (FNA) results are unclear

 Hemithyroidectomy

- Entire isthmus is removed along with 1 lobe. Done in benign diseases of only 1 lobe. Subtotal thyroidectomy - Done in toxic thyroid, primary or secondary, and also for toxic multinodular goiter (MNG). Partial thyroidectomy - Removal of gland in front of trachea after mobilization. Done in nontoxic MNG. Its role is controversial.

 Near

total thyroidectomy - Both lobes are removed except for a small amount of thyroid tissue (on one or both sides) in the vicinity of the recurrent laryngeal nerve entry point and the superior parathyroid gland. Done in papillary thyroid carcinoma. Total thyroidectomy - Entire gland is removed. Done in case of follicular carcinoma of thyroid, medullary carcinoma of thyroid. Hartley Dunhill operation - Removal of 1 entire lateral lobe with isthmus and partial/subtotal removal of opposite lateral lobe. Done in nontoxic MNG.

steps of Thyroidectomy:[1] Horizontal anterior neck incision (if possible, within a skin crease) Create upper and lower flaps between the platysma and strap muscles Divide vertically between the strap muscles and anterior jugular veins Separate the strap muscles from the thyroid gland Divide the middle thyroid vein Mobilize the superior pole of the thyroid lobe. Divide the superior thyroid artery and vein close to the thyroid gland (avoid injury to the external branch of the superior laryngeal nerve and the superior parathyroid gland)
Main

 Identify

the recurrent laryngeal nerve whenever possible using the nerve monitoring device Identify the inferior parathyroid artery Divide the inferior thyroid artery and vein Separate the thyroid lobe and isthmus from the trachea Repeat this process for the other thyroid lobe. Remove the thyroid gland Reapproximate the strap muscles Reapproximate the platysma muscle Close the skin with a subcuticular stitch

 Hypothyroidism/Thyroid

insufficiency in up to 50% of

patients after ten years Laryngeal nerve injury in about 1% of patients, in particular the recurrent laryngeal nerve: Unilateral damage results in a hoarse voice. Bilateral damage presents as laryngeal obstruction after surgery and can be a surgical emergency: an emergency tracheostomy may be needed. Recurrent Laryngeal nerve injury may occur during the ligature of the inferior thyroid artery. Hypoparathyroidism temporary (transient) in many patients, but permanent in about 1-4% of patients

 Anesthetic

complications

Infection
Stitch

granuloma Chyle leak Haemorrhage/Hematoma (This may compress the airway, becoming life-threatening.) Surgical scar/keloid Removal or devascularization of the parathyroids. Thyroid storm in operations performed for hyperthyroidism

Surgical Thymectomy
Most neurologists advocate thymectomy for the majority of patients with generalized myasthenia without thymoma. Factors influencing the decision may include age, duration and severity of the disease, and response to medication. Although no adverse effects have been reported as a consequence of thymectomy in children, it is preferable to delay thymectomy until puberty if possible because of the established role of the thymus in development of the immune system. Also, although thymectomy has been advocated for elderly myasthenia gravis patients, there is uncertainty about the persistence of thymic tissue in such patients after the age of 60.

The goal of thymectomy as a treatment for myasthenia gravis is to induce remission, or at least improvement, permitting a reduction in immunosuppressive medication. The mechanism by which thymectomy produces benefits in myasthenia gravis is still uncertain. In general, acetylcholine receptor-antibody levels fall after thymectomy, although there are conflicting reports. On theoretical grounds, there are several possible mechanisms. First, removal of the thymus may eliminate a source of continued antigenic stimulation. If the thymic myoid cells are the source of autoantigen then their removal might allow the immune response to subside. Second, thymectomy may remove a reservoir of B cells that are secreting acetylcholine-receptor antibody. Third, thymectomy may is some way correct a disturbance of immune regulation in myasthenia gravis.

Cues

Nsg diagnosis Nsg goal Risk for aspiration related to muscle weakness and generalized fatigue To demonstrate techniques to prevent and/or correct aspiration

Expected outcome Client will experience no aspiration as evidenced by noiseless respirations, clear breath sounds, odorless secretions possibly after hours of intervention

Nsg intervention
Mealtimes should coincide with the peak effects of anticholinesteras e medication ex: Pyridostigmine bromide (Mestinon) Provides symptomatic relief by inhibiting the breakdown of acetylcholine and increasing the relative concentration of available acetylcholine at the neuromuscular junction. -Upper airway patency is facilitated by upright position -This type of consistency can be swallowed more easily. Aids in swallowing effort..

Patients HOB will be elevated to semi-fowlers position Patients food will have a puddinglike Consistency

Cues

Nursing diagnosis

Nursing goal

Expected outcome

Nursing intervention

Subjective: nahihirapan siyang humingaas verbalized by watcher Objective: dyspnea, RR=

In effective breathing pattern related to respiratory muscle weakness

Client will establish effective breathing pattern

After nursing interventions client will establish normal pattern of breathing as evidenced by absence of cyanosis and other signs and symptoms of hypoxia

INDEPENDENT: auscultate chest, note rate and depth of respirations -To evaluate presence/character of breath sounds elevate HOB or have client sit up on chair -to promote physiological and psychological ease of maximal inspirations Encourage slower/deeper respirations -to assist the clt in taking control of the situation Encourage adequate rest period -to limit fatigue Suction airway as needed -to clear secretions DEPENDENT: Administer medication as indicated - To promote deeper

Cues

Nsg diagnosis

Nsg goal

Expected outcome

Nsg intervention

Subjective: wala siyang gana kumain, as reported by the watcher

Objective: Weakness of muscles required for swallowing Poor muscle tone

Imbalanced nutrition: less than body requirements related to intubation and muscle paralysis

Client will demonstrate stable weight

Client will establish progressive gain toward goal with normalizatio n of laboratory values and absence of science of malnutrition

Weigh at regular interval

-To monitor effectiveness of dietary plan -To detrmine factors affecting appetite, food intake and absorption

Asses drug interactions, disease effects, allergies, intubation etc Discuss eating habits, including food preference, intolerance, aversions Assist in treating or managing underlying causative factors Administer pharmaceutical agent as indicated

-To appeal to patients taste

Loss of weight

Cues

Nsg diagnosis

Nsg goal

Expected Nsg intervention outcome

Subjective: nanghihina talaga siya, as verbalized by patient

objective: lack of energy, decreased performanc e

Fatigue may be related to disease states

Client will report improved sense of energy

Client will participat e in desired activities at level of ability with improved sense of energy readily within 42-72 hours

identify presence of physical conditions

Discuss lifestyle changes or limitations imposed by fatigue state Note daily energy pattern Advise the patient together with the watcher to have adequate rest period Assist with self care needs,: keep bed in low position and assist with ambulation as indicated

For asessment of contributing factors

To assist in evaluating impact on clients life

Helpful in determining pattern of activity To promote energy

To assist the pt cope w ith fatigue

Encourage the pt to do whatever possible, encourage use of assistive devices as needed

To conserve energy with other task

Cues

nsg diagnosis Self care deficit may be related to decreased strength

Nsg goal Client will perform self care activities within level of own ability

Expected outcome Client will verbalize knowledge of healthcare practices and will demonstrate techniques and lifestyle changes to meet self care needs readily after rendering of interventions

Nsg intervention
Encourage patient to perform selfcare to the maximum of ability as defined by the pt Assist accdg to degree of disability; allow as much autonomy as possible Anticipate hygenic needs, provide assistive device/ aids as indicated Encourage stretching exercises and use of cold compacts as indicated Promotes independence and sense of control may decrease feeling of helplessness Patients quality of life is enhanced

Objective: Feeding self care deficit, -inability to ingest food safely,hand le utensils toileting selfcare deficit,-get to toilet for commode,c arry out proper toilet hygiene

reduces fatigue, anhancing participation in self-care Helps decrease spasticity

Cues subjective : statement s reflecting misconcep tion

Nsg diagnosis

Nsg goal Client will verbalize understanding of condition, disease process Patient will demonstrate knowledge of medication management, importance of rest, coping strategies, and prevention/ma nagement of complications

Expected outcome
The patient will verbalize an understanding of the drug regimen, the action and purpose of the drugs, side effects and contraindications . The patient will develop a plan to avoid overexertion in daily life.

Nsg intervention
Teach patient about the actions of meds, and importance of regimen. The patient will verbalize the consequences delaying med intake, including S&S of myasthenic and cholinergic crisis. Teach strategies for patient to conserve their energy. The patient will develop coping strategies to avoid overexertion. If eyes cannot close properly, instruct patient to patch/tape eyes closed for short intervals to avoid corneal damage. Medication education is very important for the patient who has myasthenia gravis. Many side effects are possible, and the drugs have numerous contraindications. Developing new habits based around the limitations of myasthenia gravis will help the patient to maintain an active Lifestyle Patient teaching on interventions to help prevent corneal damage will lower the risk for this complication of myasthenia gravis.

Deficient knowledge R/T drug therapy, potential for crisis (myasthenic or Objective: cholinergic), Inaccurate and self-care followmanagement through of instruction s Inappropri ate behaviors

The patient will demonstrat e the correct method for patching/t aping the eyes.

Risk for constipation related to insuficient physical activity

Client will demonstra te behaviours to prevent developing problem

After 24 to 42 hours of intervention : client will maintain usual pattern of bowel functioning Client will verbalize understandin g of risk factors and appropriate intervention s related to individual situation

Instruct in balanced fiber and bulk in diet Promote adequate fluid intake, Encourage activity and exercisew /n limits of individual activity Administer

To improve consistency of stool and to facilitate passage through colon To stimulate bowel activity To stimulate contraction s of intestines

MEDICATIONS
Medications Mestinon 60 mg Azathioprine 50 mg Prednisone 20 mg Lactulose 30 cc C-lium fiber 1sachet Lanzoprazole 30 mg Frequency 2tabs 3 x day 1 tab 2 x day 1 tab OD OD OD OD Time 5 am-11am-5pm11pm am-pm am hs pm 30 mis before breakfast

SPECIAL INSTRUCTIONS:
Take mestinon on time to prevent myasthenic crisis or cholinergic crisis. Observe for the signs of cholinergic crisis.

aerobic exercises. Active exercises are contraindicated to patients suffering from myasthenia gravis to prevent the exacerbations of signs and symptoms.

TREATMENT:
The objective of treatment involves suppression of autoantibody production, increasing the availability of acetylcholine in the myoneural junction, preventing crises, and managing the signs and symptoms. These are achieved by giving immunosuppressant, antiacetylcholinesterase, and palliative medications.

HEALTH TEACHING
Because of the nature of her disease and the effects of the medications given, the patient was advised of the following: 1. Take Mestinon on time to avoid myasthenic and cholinergic crisis. 2. Avoid mingling with people having communicable diseases because of suppressed immune system. Infections may cause myasthenic crisis. 3. Watch out for the s/sx of crises. 4. Regularly perform tracheostomy suctioning using aseptic technique to avoid aspiration and respiratory infections. 5. Encouraged the patient to have enough rest and sleep and avoid stress. Stress may contribute to the development of myasthenic crsis. 6. Give soft diet to avoid aspiration and constipation

OUT-PATIENT
The cient must comply with the following check-up: Dr. Cabauatan After 1week (Tue, Wed, thu) 10 am Dr. Pornillos On July 26, 2013 (Clinic)

DIET
The recommended diet of the patient is soft diet to avoid aspiration and constipation. The pt. was advised also to increase oral fluid intake to liquefy secretions. Recommended diet: 1. Reduce protein intake to 10 percent of total calories; replace animal protein as much as possible with plant protein.Eliminate milk and milk products (substitute other calcium sources).Eat more fruits and vegetables (make sure that they are organically grown).Eliminate polyunsaturated vegetable oils, margarine, vegetable shortening, all partially hydrogenated oils, and all foods (such as deep-fried foods) that might contain trans-fatty acids.

Use extra-virgin olive oil as your main fat.Increase your intake of omega-3 fatty acids. In addition, patients with myasthenia gravis are often advised to eat plenty of foods high in potassium, such as oranges, tomatoes, apricots and their juices, bananas and broccoli which can help control the fatigue that often characterizes the disease.

SEX
N/A