Myasthenia gravis can affect any muscle, but the most commonly affected are the muscles that control eye movements, eyelids, chewing, swallowing, coughing and facial expressions. Shoulders, hips, neck, muscles that control body movement and muscle that helps breathing can also attacked.
Myasthenia Gravis Patients are usually not the same from one person to another person. Based on the data, the disease is still relatively rare because the lack of knowledge about the symptoms of the disease.
The symptoms that arise are the some of the weaker muscles. The muscles most frequently attacked are the muscles that control eye movements, eyelids, speech, swallowing, chewing, and more severe respiratory muscles are attacked.
In 90% of patients with Myasthenia Gravis initial symptoms appear is the ocular muscles that cause the decrease eyelids and double vision. Clearly visible physically. Obviously the symptoms will appear and spread further attack other muscles. Until a more severe attack the respiratory muscles are usually visible from weakening cough. In fact there is shortness of breath and can be fatal.
Nursing Diagnosis for Myastenia Gravis
Activity intolerance related to muscle weakness
Characterized by:
Subjective Data:
- Patients say tired after doing the activity.
- Patients report muscle weakness.
Objective Data:
- Patient seems tired and listless.
- Patient was not able to take action to meet their daily needs.
- Increased pulse.
- Increased blood pressure.
- Breathing increases.
- Decreased muscle strength.
Outcomes:
- Full muscle strength.
- Atrophy does not occur.
- Good muscle tone.
- Patients can perform the activity gradually.
- Muscle weakness does not occur.
Intervention:
1. Assess the strength of muscles, ptosis, diplopia, eye movement, ability to chew, swallow, cough reflex, talk.
R /: The rate of muscle weakness may be different in other parts of the body.
2. Assess muscle strength before and after drug administration.
R /: Knowing the effects of drug administration.
3. Perform scheduled breaks, keep quiet surroundings.
R /: Period after the break, increased muscle strength.
4. Encourage participation in treatment.
R /: Train activity gradually.
Nursing Diagnosis for Myastenia Gravis
Impaired verbal communication related to muscle weakness.
Characterized by:
Subjective Data:
- Patients say difficulty speaking
- Patients appear to difficulties in verbal expression.
- Changes in behavior are not willing to communicate.
- The use of sign language / body.
Patients expressing themselves verbally or non-verbally.
Intervention:
1. Assess the patient's ability to speak with the examination of cranial nerves V, VII, IX, X, XII.
R /: knowing the patient's ability to speak.
2. Ask a closed question, yes or no or body movements.
R /: Facilitate patient easily answered.
3. Talk with slow motion.
R /: Can see the speaker's lip movements.
4. Use images, paper or other means.
R /: Using media allows patients to express desire.
5. Inform staff or family, about the limitations of the patient in communication.
R /: Communication patterns that one would add to the frustration of patients.
