HESI Case Study: Myasthenia Gravis
While walking down the hallway to begin client rounds, the charge nurse glances into the client's room and observes the primary nurse in the room. The charge nurse notices that the primary nurse asks the client her name and then immediately administers a medication.
-------
The nurse discusses medications with the client.
--------
The client's chest tubes are removed. Two days later she is sitting on the side of the bed and states that she is hungry. The HCP advances her diet from full liquids to a regular diet.
------
The nurse continues to discuss the medication prescribed for the client.
-------
The nurse is encouraging the client to cough and deep-breathe. The client tells the nurse it hurts a great deal when she coughs and takes deep breaths.
-----
6. Which statement(s) indicates to the nurse that the client understands the medication teaching? (Select all that apply. One, some, or all options may be correct.)
"I must carry an identification card while on my medication regimen." The client should carry identification describing the disease and the medication regimen at all times. Any emergency personnel or other HCP should be aware of the client's disease process. "I need to try to take the medication on time." Since the medication peaks in 2 hours and the duration of effect is 3 to 6 hours, doses need to be timed to prevent return of muscle weakness symptoms.
8. Which statement by the client indicates she understands the client teaching provided by the nurse?
"I will avoid anyone that has a respiratory infection." Infections can result in an exacerbation of MG and can cause extreme weakness. In addition, the client with MG should increase fluid intake to help mobilize and expectorate sputum to aid in the prevention of respiratory complications.
25. Which statement indicates the client understands the instructions provided by the nurse?
"I will call my healthcare provider if I have a temperature of 100.0° F(37.7° C) or higher." Any elevation in temperature that is greater than 100.0° F(37.7° C) indicates an infection, which may be respiratory, systemic, or incisional and should be reported to the HCP.
Which statement indicates to the nurse that the medication teaching has been effective?
"If I have any weakness or choking episodes, I will call my healthcare provider." Approximately 50% of clients with MG go into total remission after a thymectomy. However, if symptoms reoccur, the client may have to be placed on medications again.
16. How should the nurse respond?
"There is a gland that is usually inactive after puberty that sometimes continues to produce antibodies. Removing it sometimes cures myasthenia gravis." In about 75% of clients with MG, the thymus gland (which is usually inactive after puberty) continues to produce antibodies that trigger an autoimmune response in MG. A thymectomy, the removal of the thymus gland, cures myasthenia gravis in about 50% of the clients.
13. What is the best response by the nurse?
"This must be very scary; I will sit with you and we can talk for a while." Acknowledgement of the mother-in-law's feelings and therapeutic use of self-provide the opportunity for the mother-in-law to verbalize her fears and concerns. The nurse may later choose to encourage further communication with the HCP, or offer information about support groups.
By the next day, the client has improved and is able to feed herself, perform activities of daily living, and ambulate without assistance. Her diarrhea has subsided. After 48 hours she is discharged from the hospital and has an appointment to see her HCP in 1 week.
------
The client undergoes plasmapheresis at the bedside.
------
During the office appointment, the HCP discusses a thymectomy, which is a surgical procedure that may cure myasthenia gravis. After the HCP leaves the office, the client's husband says to the nurse, "I am not sure what the healthcare provider was saying. How will this surgery cure my wife's disease?"
----
It is determined that the client is experiencing a cholinergic crisis, possibly due to an overdose of anticholinesterase medication.
----
The HCP admits the client to the medical unit for observation and writes admitting prescriptions.
----
The HCP leaves the room and the nurse continues to discuss the diagnosis and treatment of myasthenia gravis with the client and her husband.
----
The nurse evaluates the effectiveness of the discharge teaching.
----
She is diagnosed with myasthenia gravis. Her husband tells the nurse he does not understand how myasthenia will affect his wife.
-----
15. Which action should the nurse take when they arrive?
Allow the client and her husband to see the HCP. The client should be allowed to see the HCP to monitor her medical condition.
1. Which response to the test indicates that she has myasthenia gravis (MG)?
A noticeably marked improvement in her muscle strength. Clients with MG show a significant improvement in muscle strength that lasts approximately 5 minutes when edrophonium chloride is injected. This test confirms the diagnosis
Section 6
A week later, the client and her husband arrives 35 minutes late for the appointment with the HCP.
12. Which action should the nurse implement first?
Administer intravenous atropine. Atropine is the antidote for a cholinergic crisis and should be administered as soon as it is determined that the client is in a cholinergic crisis rather than a myasthenia crisis.
17. Which intervention should the nurse implement prior to the plasmapheresis?
Assess the complete blood cell and platelet count. These lab values should be assessed because clients undergoing plasmapheresis are at high risk for anemia and coagulation problems secondary to hemolysis of cells.
21. As the client is completing her meal request form she asks the nurse to assist her in choosing the best foods to eat. What food would the nurse recommend for this client?
Broccoli rice casserole, roll, and water. This selection would be easy to swallow. Recommended nutrition is soft food that can be easily chewed and swallowed.
24. What action should the nurse implement?
Continue reviewing the discharge instructions with the client and her husband. Including the husband in the conversation can assist the client and the husband in
7. Which intervention should the nurse direct toward the client's husband?
Demonstrate how to perform abdominal thrusts correctly. The client is at risk for choking and knowing specific measures to help her during choking episodes is a priority. Remember, airway is priority.
20. Which intervention should the nurse implement?
Demonstrate how to splint the incision when coughing. The thoracotomy and chest incision will cause pain when the client is coughing. The nurse should demonstrate how to splint the incision to help the pain. Pulmonary hygiene must be a priority to prevent pulmonary complications of atelectasis and pneumonia.
Section 1
Diagnosis The client's husband notices that her left eyelid is drooping, and she tells him she is experiencing double vision. After another choking episode, he brings his wife back to the healthcare provider (HCP), who now thinks she may have myasthenia gravis. The HCP administers a edrophonium chloride test to help confirm the diagnosis of myasthenia gravis (MG).
4. How should the nurse respond about the expected outcome of pyridostigmine therapy? (Select all that apply. One, some, or all options may be correct.)
Increases ability to independently perform activities of daily living (ADLs). This medication promotes muscle contraction, improving muscle strength and allowing the client to perform ADLs without assistance. Prevents the breakdown of acetylcholine, a natural substance, in the body. Acetylcholine is needed for normal muscle function.
11. In planning care for the client the nurses should identify which nursing diagnosis as a priority?
Ineffective airway clearance. The body's inability to contract muscles effectively results in a poor cough mechanism, decreased rib expansion, diminished diaphragmatic movement, and decreased expiratory effort. Therefore, ineffective airway clearance is the priority client problem.
Section 7
It is decided that the surgery is the best option. The client is admitted to the hospital for the thymectomy. Prior to the surgery, plasmapheresis is performed to remove antiacetylcholine receptor antibodies so the client will have improved muscle strength to be in the best physical condition prior to the surgery.
19. Which intervention should the nurse implement?
Monitor for fluctuation or tidaling in the water-seal compartment. Fluctuation or tidaling indicates air is being removed from the pleural space.
Section 4
One month after the office visit, the client is admitted to the emergency department with a sudden exacerbation of motor weakness, diaphoresis, blurred vision, and diarrhea.
18. Which part of the assessment indicates to the nurse that the client is experiencing a complication from this procedure? (Select all that apply. One, some, or all options may be correct.)
Positive Chvostek's and Trousseau's signs. These positive signs indicate hypocalcemia which is a complication of plasmapheresis that occurs when the anticoagulant citrate dextrose binds with calcium. Elevation of temperature occurs. Complications from plasmapharesis may include fever, rash and wheezing.
22. Which action should the nurse implement?
Praise the UAP for making this statement while the client is eating. Using small bites of food and chewing thoroughly may help prevent aspiration; therefore, the nurse should praise the UAP for reinforcing the correct dysphagia precautions.
23. Which action should the charge nurse take?
Review the need for two forms of identification with the nurse at the medication cart. The Joint Commission's National Patient Safety Goals requires that two forms of identification be used when medication or blood products are administered. These may include the client's name, along with the hospital identification number on the arm band, or the client's date of birth. The charge nurse should take action as soon as the primary nurse leaves the client's room to prevent a recurrence of the action with another client.
Section 9
The client is taken to surgery the next morning, where a thoracotomy with a sternal split procedure is performed to remove the thymus gland. Upon her return to the unit following surgery, she has an anterior midsternal chest tube attached to a closed-chest drainage system.
Section 10
The client progresses without complications and is transferred to the surgical unit. The nurse overhears the female unlicensed assistive personnel (UAP) telling the client "You should chew your food thoroughly before swallowing."
9. Which referral to a member of the interdisciplinary team should the nurse make for the client?
Speech therapist. A speech therapist addresses swallowing problems. Clients with MG are dysphagic and are at risk for aspiration. The speech therapist can help match food consistency to the client's ability to swallow, which helps enhance client safety.
5. Which instruction about taking pyridostigmine should the nurse include in the plan of care?
Take the medication 30 minutes prior to meals. This medication will increase muscle strength to help enhance swallowing and chewing during meals, and it will increase strength prior to activities such as brushing hair, brushing teeth, or putting on make-up.
Section 2
The HCP prescribes the anticholinesterase pyridostigmine for her. She asks the nurse how the medication therapy will help her.
10. Which further data indicates to the nurse the client is experiencing a cholinergic crisis?
The Tensilon test does not show improvement in muscle strength. The edrophonium chloride test not only diagnoses MG, but it also helps determine which type of crisis the client is experiencing. In a myasthenia crisis, the test is positive (the client's muscle strength improves), and in a cholinergic crisis, the test is negative (there is no improvement in muscle strength).
2. How should the nurse respond?
The body is not able to transmit nerve impulses, which results in muscle weakness. In MG, antibodies destroy or block neuromuscular junction receptor sites, resulting in a decreased number of acetylcholine receptors. This results in a decrease in the muscle's ability to transmit nerve impulses and contract.
Section 11
The client continues to improve and is being discharged from the hospital after 5 days. The nurse is providing discharge instructions to the client when her husband enters the room.
Meet the Client
The client has a 3-month history with complaints of fatigue, exhaustion, and multiple episodes of choking because she did not have the strength to chew the food. The healthcare provider (HCP) was unable to diagnose the problem and told the client to rest and eat soft foods that did not require chewing.
Section 5
The client is admitted to the medical unit in stable condition. Her mother-in-law is sitting in the waiting room crying. The nurse offers support. The mother-in-law shares with the nurse that client's husband doesn't know what is going to happen to him and the children if the client doesn't get better. She is scared that her daughter-in-law is going to die.
Section 8
The nurse notifies the surgeon of the clients low calcium level. The client receives calcium via intravenous push, and the calcium level is now within normal limits. Her condition stabilizes, and she is scheduled for surgery the next morning.
Section 3
The nurse prepares a plan of care for the client and her family.
3. Which statement by the client is correct?
When I am fatigued I will rest. The goal for the client is to maintain a quality of life appropriate for the disease course.