ALTAR, Catherine Sienna B.
BS Nursing III – D
January 12, 2021
CASE SCENARIO
D.S. is a 74-year-old retired social worker who has been on your floor for several days
receiving q.i.d. plasmapheresis for myasthenia gravis (MG). She has a type 2 DM for 3 years and
low back pain secondary to spinal stenosis. She received 2 steroid injections into her spine for
pain 2 to 3 weeks before her admission, which was followed by progressive, symmetric,
weakness in her lower extremities proximal > distal; R foot numbness; poor eye-hand
coordination; and significant hand weakness. On admission, D.S. was unable to bear any weight
and take fluids through a straw. There have been periods of exacerbation and remission since
admission.
Shows the features of a patient with myasthenia gravis (left), and the facial features of a normal patient (right)
1. You are visiting with D.S.’s grandson who tells you he is just starting medical school and
he would like to know more about MG so that he can discuss it with his grandmother.
What do you tell him?
Myasthenia gravis (MG) is a chronic autoimmune disorder in which antibodies destroy
the communication between nerves and muscle, resulting in weakness of the skeletal
muscles. Myasthenia gravis affects the voluntary muscles of the body, especially those
that control the eyes, mouth, throat and limbs.
MG is often called the “snowflake disease” because it differs so much from person to
person. The degree of muscle weakness and the muscles that are affected vary greatly
from patient to patient and from time to time.
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2. He asks you to explain how plasmapheresis works. How would you explain this
treatment?
Therapeutic plasma exchange (TPE), also known as plasmapheresis, removes and
replaces a patient's blood plasma. TPE is used in the treatment of various autoimmune
diseases, in which the body recognizes a part of itself as foreign and generates proteins,
called autoantibodies.
Blood is withdrawn from the patient’s body to the apheresis machine through one of the
catheter tubes. After the blood enters the machine, the blood cells will be segregated from
the plasma.
The machine works in two ways:
o In the first process, the blood cells will be segregated from the plasma by rotating
the blood at very high speed (centrifugation).
o In the second process, the blood cells get segregated from the plasma by special
membrane. The membrane has tiny pores which filters the plasma by leaving
behind the blood cells.
The blood cells will then reconstitute with the plasma substitute or donor plasma. The
new reconstituted blood is then transfused back into the person’s body through other
catheter tube.
A single plasmapheresis treatment will last for about 1-3 hrs. The length of procedure
depends on the patient’s body size and the amount of plasma that is required to get
exchanged. The patient should take appropriate rest for a short period after the treatment.
The patient may require 2-3 treatments for each week.
3. He asks what drugs are used to treat MG. You explain, although neostigmine
(prostigmin) and pyridostigmine (Mestinon) are often used in combination, drug regimens
and doses are highly individualized. Identify the appropriate drug classification and
explain the action of these two drugs to D.S.’s grandson.
DRUG/MEDICATION DRUG CLASSIFICATION MECHANISM OF ACTION
Neostigmin (prostigmin) Neostigmine is in the cholinergic Neostigmine inhibits the hydrolysis of
family of medications. It works by acetylcholine by competing with
blocking the action of acetylcholine for attachment to
acetylcholinesterase and therefore acetylcholinesterase at sites of cholinergic
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increases the levels of acetylcholine. transmission. It enhances cholinergic action
Neostigmine was patented in 1931. by facilitating the transmission of impulses
across neuromuscular junctions.
Pyridostigminbe Mestinon (pyridostigmine) is a Pyridostigmine inhibits acetylcholinesterase
(Mestinin) cholinesterase inhibitor used to treat in the synaptic cleft by competing with
the symptoms of myasthenia gravis. acetylcholine for attachment to
Mestinon is also used in military acetylcholinesterase, thus slowing down the
personnel who have been exposed to hydrolysis of acetylcholine, and thereby
nerve gas. Mestinon is available in increases efficiency of cholinergic
generic form. transmission in the neuromuscular junction
and prolonges the effects of acetylcholine.
4. D.S. told her grandson that after taking her morning medications, she often experienced
nausea, heartburn, slight SOB, sweating, and she felt her heart beating rapidly. What can
you tell him about this?
Mestinon (pyridostigmine) is a cholinesterase inhibitor used to treat the symptoms of myasthenia
gravis. Mestinon is also used in military personnel who have been exposed to nerve gas.
Mestinon is available in generic form. Common side effects of Mestinon include:
nausea, increased pale skin,
vomiting, saliva/mucus, watery eyes,
upset stomach, decreased pupil warmth or tingly
diarrhea, size, feeling, or
abdominal cramps, increased urination, rash or itching.
increased sweating
or cold sweat,
Tell your doctor if you have unlikely but serious side effects of Mestinon including:
new or increased muscle slow heartbeat,
cramps/weakness/twitching, dizziness, or
shortness of breath, headache.
new or increased difficulty
swallowing
5. Describe a myasthenic crisis.
Myasthenic crisis is a life-threatening condition that is defined as worsening
of myasthenic weakness requiring intubation or noninvasive ventilation
Myasthenic crisis is a complication of myasthenia gravis characterized by worsening of
muscle weakness, resulting in respiratory failure that requires intubation and mechanical
ventilation. Advances in critical care have improved the mortality rate associated
with myasthenic crisis.
6. List six nursing problem statements that would be appropriate for D.S.
1. Impaired gas to ineffective and muscle
exchange, related breathing pattern weakness
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2. Risk for aspiration, 8. High risk for 15. Diarrhea
related to difficulty ineffective 16. High risk for injury
swallowing breathing pattern 17. Risk for infection
3. Fatigue, related to 9. Impaired 18. Fear
increased energy swallowing 19. Hopelessness
needs from 10. Risk for fluid 20. Caregiver role
muscular volume deficit strain
involvement 11. Risk for
4. Impaired physical imbalanced
mobility, nutrition less than
5. Fatigue body requirements
6. High risk for 12. High risk for disuse
aspiration syndrome
7. High risk for 13. Urinary
ineffective airway incontinence
clearance 14. Bowel incontinence
7. List five factors that could predispose D.S. to an exacerbation of her illness.
Gender: Women are known to be more susceptible to autoimmune diseases because of
different basic immune response in men and women. Women produce
more antibodies against infections and traumas.
Stress and other psychological factors: there are strong evidences showing the adverse
effect of stress on immune system and the beginning of autoimmune diseases.
Fatigue
Illness
Some medications — such as beta blockers, quinidine gluconate, quinidine sulfate,
quinine, phenytoin, certain anesthetics and some antibiotics
Pregnancy
Menstrual periods
8. D.S. asks you what the doctors meant when they were talking about some kind of a
challenge test. You realize they must have been discussing the possibility of performing an
edrophonium (Tensilon) challenge. What is a Tensilon challenge, and what information will
it yield?
Tensilon test is a diagnostic test used to evaluate myasthenia gravis, which is a
neuromuscular condition characterized by muscle weakness. The test involves an
injection of Tensilon (edrophonium), after which your muscle strength is evaluated to
determine whether your weakness is caused by myasthenia gravis or not.
The Tensilon test uses the drug Tensilon (edrophonium) to help your doctor diagnose
myasthenia gravis. Tensilon prevents the breakdown of the chemical acetylcholine, a
neurotransmitter that nerve cells release to stimulate your muscles.
9. What are aminoglycosides, and why are they contraindicated in patients with MG?
Aminoglycosides are used in the treatment of severe infections of the abdomen and
urinary tract, as well as bacteremia and endocarditis. They are also used for prophylaxis,
especially against endocarditis. Resistance is rare but increasing in frequency.
The aminoglycoside class of antibiotics consists of many different agents. In the United
States, gentamicin, tobramycin, amikacin, plazomicin, streptomycin, neomycin, and
paromomycin are approved by the US Food and Drug Administration (FDA) and are
available for clinical use.
Aminoglycosides affect neuromuscular transmission by both inhibiting acetylcholine
release pre-synaptically and blocking the acetylcholine receptor post-synaptically. This
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class of antibiotics has been associated with aggravating pre-existing MG and
postoperative respiratory distress.
10. D.S.’s grandson wants to know when she’ll be able to go home. How do you respond?
If the patient’s conditions improved over the next few days such as improvement on
muscle strength, increased general muscle function and prevent swallowing and breathing
problems, the patient can be discharged.
11. What supportive measures can you suggest to D.S.’s grandson that he can undertake or
arrange on behalf of his grandmother?
There is no cure for myasthenia gravis, but the symptoms can generally be controlled.
Myasthenia gravis is a lifelong medical condition. Early detection is key to managing this
condition.
The goal of treatment is to increase general muscle function and prevent swallowing and
breathing problems. Most people with myasthenia gravis can improve their muscle
strength and lead normal or near normal lives. In more severe cases, help may be needed
with breathing and eating.
OTHER PRECAUTIONS INCLUDE:
o Wash your hands often; keep them away from your face. Most germs are spread
by hand-to-mouth contact.
o Get a flu shot every year. Ask your healthcare provider about pneumonia
vaccines.
o Stay out of crowds, especially in the winter; that’s when more people have colds
and the flu.
o Don't drink alcohol. Alcohol can increase weakness.
o Make an appointment with a dietitian. During extended times of weakness, you
may need to change your diet to prevent choking. A dietitian can help you plan
for these times. Here are some tips that should help:
o Eat soft foods, such as mashed potatoes or applesauce, to make swallowing easier.
o Eat warm (not hot) foods.
o Eat slowly. Cut your food into small pieces and chew it thoroughly before
swallowing.
REFERENCES:
(1) https://www.aafp.org/afp/1998/1115/p1811.html
(2) https://nyulangone.org/conditions/myasthenia-gravis-in-adults/support
(3) https://www.hopkinsmedicine.org/health/conditions-and-diseases/myasthenia-
gravis#:~:text=Myasthenia%20gravis%20(MG)%20is%20a,%2C%20mouth%2C
%20throat%20and%20limbs
(4) https://nyulangone.org/conditions/myasthenia-gravis-in-adults/support
(5) https://utswmed.org/conditions-treatments/therapeutic-plasma-
exchange/#:~:text=Therapeutic%20plasma%20exchange%20(TPE)%2C,and
%20generates%20proteins%2C%20called%20autoantibodies.
(6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726100/#
(7) https://www.saintlukeskc.org/health-library/discharge-instructions-myasthenia-gravis
(8) https://www.sakraworldhospital.com/plasmapheresis/9-sx/63
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(9) https://www.rxlist.com/mestinon-side-effects-drug-center.htm
