- Fatigue related to muscle weakness as evidenced by decreased gait velocity and difficulty in maintaining usual physical activity
- Ineffective Airway Clearance related to weak oropharyngeal muscle contractions and decreased ability to cough and swallow as evidenced by absent or ineffective cough and adventitious breath sounds
- Risk for Aspiration related to weak oropharyngeal muscle contractions and depressed gag reflex as evidenced by signs and symptoms.
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Verbalize unable to perform any activities Objective Data: -Limited range of motion -Poor balance -Decreased muscle strength -Restlessness -Poor concentration -Headache -Irritability | Fatigue related to muscle weakness as evidenced by decreased gait velocity and difficulty in maintaining usual physical activity | The patient will demonstrate increased activity levels and participate in desired activities The patient will participate in supportive therapy to improve fatigue and muscle strength | 1. Encourage the patient to perform activities as tolerated. Allowing the patient to perform activities of daily living with adequate rest periods in between will promote a sense of control and independence. 2. Assist the patient in identifying MG triggers. A patient can prevent an MG flare by understanding their triggers. Common triggers include illness/infections, inadequate sleep, some medications, extreme temperatures, menstruation, alcohol, and stress. 3. Refer the patient to appropriate therapies. Physical therapy and occupational therapy can assist with motor strength exercises and recommend strategies and equipment to assist with ADLs. 4. Prepare for IVIG therapy. Intravenous immunoglobulin (IVIG) is a transfused blood product that is believed to destroy damaged antibodies through healthy donor antibodies. A nurse can administer the transfusion in a medical office or the patient’s home. This treatment can be given for an MG crisis, to prevent an impending crisis, or as a treatment to stabilize the patient prior to surgery. 5. Prepare for surgery. For some patients, the thymus gland itself or a tumor in the thymus gland (known as a thymoma) may contribute to MG. In an attempt to reduce symptoms, and in some cases cure patients, a thymectomy is performed. | The patient demonstrated increased activity levels and participate in desired activities The patient participated in supportive therapy to improve fatigue and muscle strength |
| Subjective Data: Verbalizes unable to breathe properly Objective Data: -Adventitious breath sounds -Abnormal respiratory rate, rhythm, and depth -Declining oxygen saturation -Ineffective or absent cough reflex -Copious mucus production -Hypoxemia -Restlessness -Orthopnea -Cyanosis | Ineffective Airway Clearance related to weak oropharyngeal muscle contractions and decreased ability to cough and swallow as evidenced by absent or ineffective cough and adventitious breath sounds | The patient will demonstrate effective coughing, clear breath sounds, and clear airways without respiratory distress symptoms The patient will verbalize one strategy to maintain airway strength and support | 1. Monitor the patient’s ability to swallow or cough. Since the primary symptom of MG is muscle weakness, it is important to monitor the patient’s ability to swallow or cough. This can help determine the progression of the disease and the need for additional interventions to protect the patient’s airway. 2. Suction secretions as needed. Suctioning secretions help patients with MG who are unable to cough or swallow. 3. Elevate the head of the bed. Elevating the head of the bed improves lung expansion and makes breathing easier. 4. Educate on myasthenia gravis crisis. An MG crisis occurs when the respiratory muscles weaken and result in respiratory failure. This can be life-threatening and requires emergency assistance. Educate the client to seek assistance if they notice dyspnea, accessory muscle use, and a weak cough. 5. Refer for pulmonary function tests. PFTs can assist in diagnosing MG as well as monitoring the progression of the disease. Not all patients will experience respiratory muscle involvement, but routine assessment can help prevent a crisis or other complications. | Patient maintained a patent airway as evidenced by clear breath sounds, oxygen saturation within normal limits, and the ability to cough to clear secretions. Patient avoided specific behaviors or factors that worsen secretions and airway clearance. Patient/caregiver demonstrated techniques to effectively clear secretions. Patient/caregiver verbalized signs and symptoms of ineffective airway clearance. |
| Subjective Data: The patient complains of coughing and difficulty breathing. The patient reports a recent episode of choking while eating. Objective Data: -Increased respiratory rate (RR) and decreased oxygen saturation levels. -Fever and elevated white blood cell count. -Chest auscultation reveals crackles and decreased breath sounds. | Risk for Aspiration related to weak oropharyngeal muscle contractions and depressed gag reflex as evidenced by signs and symptoms. | The patient will maintain a patent airway and demonstrate clear breath sounds The patient will demonstrate strategies to safely swallow | Patients at an increased risk for aspirating should have functioning suctioning equipment at the bedside for immediate use. 2. Performing suctioning as necessary. Patients with a large amount of secretions or who cannot clear the secretion themselves may require frequent suctioning. 3. Keep the head of the bed elevated after feeding. Whether self-feeding, assisting with feeding, administering medications or tube feedings, the head of the bed should remain elevated for 30 minutes to one hour after oral intake. 4. Implement other feeding techniques. Patients who require assistance with feeding should be fed small bites slowly. Some patients may require coaching to remind them to chew and swallow. Allow rest before feeding times, as this may decrease the patient’s difficulty with swallowing. Do not distract or allow the patient to talk while chewing or swallowing. 5. Consult with speech therapy. If swallowing is impaired, the patient requires further screening. A speech-language pathologist (SLP) can test swallowing with different foods and liquids. They can also teach the patient techniques to reduce swallowing such as the “chin-tuck” maneuver. 6. Follow diet modifications. Use thickening agents as ordered and ensure proper diet modifications such as pureed or mechanical soft foods if these are specified. Thicker foods and liquids are less likely to be aspirated so diet recommendations should be instituted for people at high risk of aspiration. 7. Position properly. Patients with drooling or uncontrolled secretions should be placed side-lying to allow secretions to drain and not pool in their mouths. Patients on continuous tube feeds should always have the head of the bed elevated at least 30 degrees. 8. Educate about conditions that can cause aspiration. Esophageal strictures (narrowing of the esophagus) can trap food. Gastroesophageal reflux disease (GERD) is a condition that causes gastric acid to back up into the esophagus which can cause damage and lead to strictures. Delayed gastric emptying doesn’t empty food as quickly as it should which can cause reflux, vomiting, and other problems. 9. Request medication formulation changes. Patients who cannot swallow pills may need medications to be administered in liquid, IV, or powder form. Some pills cannot be crushed and may not come in other forms. In these situations, the nurse should consult a pharmacist. 10. Monitor tube-feeding patients closely. Check residuals as ordered, often every 4 hours. Always alert the provider if residuals are increasing, bowel sounds are hypoactive or absent, if there is any vomiting or frequent diarrhea, and if abdominal distention is observed. 11. Provide mouth care. Mouth care prior to meals increases the desire to eat, while oral care following meals removes any residual food that could cause aspiration | Patient will not experience aspiration, as observed by clear lung sounds, unlabored breathing, absence of coughing, and oxygen saturation within normal limits. Patient and/or caregiver will demonstrate appropriate techniques to prevent aspiration. Patient and/or caregiver will verbalize potential risk factors for aspiration |