Myasthenia Gravis Case Presentation

8/13/2019 Myasthenia Gravis Case Presentation

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Myasthenia Gravis

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In Partial FulfillmentOf the Requirements inDavao Medical Center

Critical Care Nursing Program

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A Case tud! Presented to thetaff of Davao Medical Center

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ESTRADA, Jay Mart A.LAYNO, Jaclyn C.

MARTINEZ, Gla ys E.ORTIZANO, M!nr!e S.

RAMOS, Maria "ristina #.STA. ANA, Yra G$yneth %ir&inia #.

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March "##$

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TA'LE O( CONTENTS

#a&es

I& Introduction '

II& O()ectives *

A& +eneral O()ectives,& -ecific O()ectives

III& Nursing .istor!

A& Demogra-hic data /,& .istor! of Present Illness 0

C& .istor! of Past Illness 0D& Famil! ,ac1ground 23& ocio4Cultural ,ac1ground of the Patient 2F& +enogram 5

I6& Anatom! and Ph!siolog! $4"%

6& Patho-h!siolog! ""4"/

6I& Nursing Assessment "04"$

6II& Nursing Diagnosis and 7heories '#4'"

6III& 8a( tudies and Diagnostic 39ams ''4*"

I:& Doctor;s Orders *'4*0

:& Nursing Care Plans *24/"

:I& Drug tud! /'405

:II& Discharge Plan 0$42$

:III& Prognosis 5#

:I6& References 5%

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INTROD)CTION

A& ,ac1ground of the Case

M!asthenia Crisis is an e9acer(ation of M!asthenia +ravis& It is characteri res-irator! muscles and (ul(ar=ea1ness com(ine to cause res-irator! com-romise& An inadequate cough and anim-aired gag refle9 caused (! (ul(ar =ea1ness result in -oor air=a! clearance&Res-irator! su--ort and air=a! -rotection are 1e! interventions for caring for the -atientin crisis&

M!asthenia Crisis is the life threatening com-lication of M!asthenia +ravis4 anautoimmune disorder affecting the m!oneural )unction? characteri


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,& O()ectives of the Case tud!

General Objectives E

7hat =e =ould (e a(le to gather sufficient information regarding our -atient;scondition for (etter understanding on the disease studied and to come u- =ith a =ell4directed and =ell organi

3sta(lish ra--ort =ith the client and her famil! to o(tain -ertinent information Formulate an introduction that gives a (rief vie= of the -atient;s disease and

condition> et o()ectives that =ould guide the grou- in underta1ing the stud!> Ma- out the clients maternal and -aternal lineage including her illnesses through

a genogram and relate them to the client;s condition> Identif! the heath histor!? including the -resent and -ast health histor! of the

-atient> 7horoughl! assess the client in a ce-halocaudal manner> Discuss the affected s!stem (! -resenting the anatom! and -h!siolog! (rought

a(out (! the -atient;s disease> 7race the -atho-h!siolog! of the -atient;s illness thorough a diagram -resentationand integrate =ith the s!m-tomatolog! and etiolog!>

Present the la(orator! studies and diagnostic e9ams undergone (! the -atient> Present the different nursing care -lan that serves as our guide in evaluating the

effectives of our care to the -atient and the -atient;s -rogress throughout thestud!>

Itemi Ans=er an! questions raised u- (! the -anelists> Meet our o()ectives -resented a(ove&

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N)RSING *ISTORY

A& Demogra-hic Data

NameE Flordeluna +ocela

AddressE Puro1 '4A 8a Fili-ina? 7agum Cit!

Date of ,irthE une 2? %$2$

Place of ,irthE Ce(u Cit!

AgeE "$ !rs& Old

tatusE ingle

+enderE Female

Nationalit!E Fili-ino

ReligionE Roman Catholic

FatherE uan

MotherE Necita

3ducational AttainmentE College +raduate Com-uter cience? niversit! of

Mindanao? 7agum Cit!B

Occu-ationE Cler1

Admitting DiagnosisE M!asthenic Crisis

Admitting Ph!sicianE Dr& Dhar!l P& +uillermo

Admitting Cler1E Magno 3standarte

Chief Com-laintE d!s-nea

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0


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,& .istor! of Present Illness

7hree da!s -rior to her admission? our -atient had -roductive cough? colds and -tosis& hedid not ta1e an! medications for cough (ut =as advised (! her sister to increase fluid inta1e

-er da!? =hich she did& he )ust =ore sunglasses to hide her -tosis =hen going out from her

house to her -lace of =or1& +enerall!? ever! time her condition =ould =orsen she =ould )ustrest G continue to =or1 after her s!m-toms lessen or relieved& Nine hours -rior to her -resentadmission? our -atient had sudden onset of d!s-nea and difficult! in s=allo=ing? Hnaglisod 1oug ginha=a ug tulon (isan la=a! as ver(ali


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On Fe(ruar! "##5? she =as admitted at Davao Medical Center due to difficult! ins=allo=ing and -tosis& he =as admitted in M3D main IMC %& After ' da!s? she =asdischarged&

D& Famil! ,ac1groundFlor;s -arents are natives of Ce(u& .o=ever? the! decided to migrate in 7agum Cit!& 7he!

had %" children G Flor (eing the %# th& 7he famil! had t=ins? Ms& and Ms& P? =ho are the!oungest among the si(lings&

,oth -arents =ere h!-ertensive G died due to its com-lication? ho=ever? unrecalled (! theinformant to =hat s-ecific cause of death& .!-ertension is the main illness in some of themem(ers of their famil!& Mr& 3? F? +? .? G had such illness& In addition to this? Mr& . also haddrug4induced mental illness according to the informant& On to- of (eing an occasional alcoholicdrin1er? Mr& . G are chain smo1ers& Mr& F is a solel! alcoholic drin1er =hile Mr& is a solel!

chain smo1er& Ms& P suffers from insomnia& Among the si(lings? onl! Flor had (een e9-eriencingm!asthenia gravis G t=o of their si(lings? =hose names our -atient cannot recall? died at ver!earl! age&

All the ten children =ere a(le to finish their college education& 7heir -arents made sure ofthat and their eldest? Mr& 3? hel-ed his -arents get them through college& .e? Flor? and Ms& R=or1s in a com-an! =ho e9-orts (ananas in 7i(ungco&

3& ocio4Cultural ,ac1ground of the Patient

Our -atient? Flor? studied at the niversit! of Mindanao finishing Com-uter cience& he

=or1s as a cler1 in an e9-ort (usiness in 7i(ungco& he has (een =or1ing there for t=o !ears&.aving to =or1 for %" hours a da!? she gets stressed at times =hich shortens her =or1ing hours

(ecause she has to ta1e some rest& After the s!m-toms of -rogressive =ea1ness G fatiga(ilit!=ere evident? she =or1ed onl! for a(out 5 hours& @hen she doesn;t feel =ell? she sometimes goesto a Hhilot to give her relief& Our -atient lives =ith her sister (ut she is not quite close to hersi(lings and is not ver! o-en to them&

Flor has a (o!friend for more than a !ear no= and he has (een there to su--ort her des-iteher condition& he easil! gets along =ith other -eo-le and hasn;t have had an! trou(le =ith them&

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(. GENOGRAM

nrecalled num(er of si(lings Drin1er Insomnia

Neonatal death M!asthenia +ravis No additional information

.!-ertension mo1er Pneumonia

nrecalled cause of death Mental illness nrecalledgender

Mr& :

Mr& 3? /%

Mr& F? *$

Mr& +? *2

Mr& .? */

Mr& ? *'

Mr& ? '2 Mr& 8? '%

Ms&:

Mr& A

Ms&,

Mr& C Ms&D

Ms&P?"2

Ms.R, +

Ms& ?"2

Mr& Ms& Mr& Ms&

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ANATOMY - #*YSIOLOGY

Ne r!/ sc lar 0 ncti!n3lectron microgra-h sho=ing a cross section through

the neuromuscular )unction& 7 is the a9on terminal? Mis the muscle fi(er& 7he arro= sho=s )unctional folds=ith (asal lamina& Posts!na-tic densities are visi(leon the ti-s (et=een the folds& cale is #&' m& ourceE

NIM.

A neuromuscular )unction NM B is the s!na-se or )unction of the a9on terminal of a motoneuron =ith the motor end -late? the highl!4e9cita(leregion of muscle fi(er -lasma mem(rane res-onsi(le for initiation of action -otentials across the

muscleQs surface? ultimatel! causing the muscle to contract& In verte(rates? the signal -assesthrough the neuromuscular )unction via the neurotransmitter acet!lcholine&Anat!/y

+lo(al vie= of a neuromuscular )unctionE%& A9on"& Motor end4-late'& Muscle fi(er *& M!ofi(ril

'& !na-tic vesicle*& Nicotinic acet!lcholine rece-tor /& Mitochondrion

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Motor neuron efferentB a9ons originating in the s-inal cord enter muscle fi(ers? =herethe! s-lit into man! unm!elinated (ranches& 7hese terminal fi(ers run along them!oc!tes to end at the neuromuscular )unction? =hich occu-ies a de-ression in thesarcolemma& 3ach motor neuron can innervate from one to over "/?### %S muscle fi(ers?

(ut muscle fi(er receives in-uts from onl! one motor neuron&

In the terminal (outon of the motor nerve? structures 1no=n as -res!na-tic active

Mechanis/ !1 acti!n-on the arrival of an action -otential at the a9on terminal? voltage4de-endent

calcium channels o-en and Ca"T ions flo= from the e9tracellular fluid into the motor

neuronQs c!tosol& 7his influ9 of Ca"T triggers a (iochemical cascade that causesneurotransmitter4containing vesicles to fuse to the motor neuronQs cell mem(rane andrelease acet!lcholine into the s!na-tic cleft? a -rocess 1no=n as e9oc!tosis&

Acet!lcholine diffuses across the s!na-tic cleft and (inds to the nicotinicacet!lcholine rece-tors that dot the motor end -late&

7he rece-tors are ligand4gated ion channels? and =hen (ound (! acet!lcholine?the! o-en? allo=ing sodium and -otassium ions to flo= in and out of the muscleQs c!tosol?res-ectivel!&

,ecause of the differences in electrochemical gradients across the -lasmamem(rane? more sodium moves in than -otassium out? -roducing a local de-olari

Devel!2/ent !1 the ne r!/ sc lar 0 ncti!n7he formation of the neuromuscular )unction during em(r!onic develo-ment is =ellunderstood&

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During develo-ment? the gro=ing end of motor neuron a9ons secrete a -rotein 1no=n asagrin&

7his -rotein (inds to several rece-tors on the surface of s1eletal muscle&7he rece-tor =hich seems to (e required for formation of the neuromuscular

)unction is called the Mu -rotein Muscle s-ecific 1inaseB&

Mu is a rece-tor t!rosine 1inase 4 meaning that it induces cellular signaling (!causing the release of -hos-hate molecules to -articular t!rosines on itself? and on -roteins =hich (ind the c!to-lasmic domain of the rece-tor&

-on activation (! its ligand agrin? Mu signals via t=o -roteins called UDo142U and Ura-s!nU? to induce UclusteringU of acet!lcholine rece-tors AChRB&

In addition to the AChR and Mu ? other -roteins are then gathered? to form theend-late to the neuromuscular )unction& 7he nerve terminates onto the end-late? formingthe NM &

The I// ne Syste/An immune s!stem is a collection of (iological -rocesses =ithin an organism that

-rotects against disease (! identif!ing and 1illing -athogens and tumour cells& It detects a=ide variet! of agents? from viruses to -arasitic =orms? and needs to distinguish themfrom the organismQs o=n health! cells and tissues in order to function -ro-erl!& Detectionis com-licated as -athogens can evolve ra-idl!? -roducing ada-tations that avoid theimmune s!stem and allo= the -athogens to successfull! infect their hosts&

7o survive this challenge? multi-le mechanisms evolved that recogni

so-histicated defense mechanisms& 7he immune s!stems of verte(rates consist of man!t!-es of -roteins? cells? organs? and tissues? =hich interact in an ela(orate and d!namicnet=or1& As -art of this more com-le9 immune res-onse? the human immune s!stemada-ts over time to recognise s-ecific -athogens more efficientl!& 7his ada-tation -rocessis referred to as Uada-tive immunit!U or Uacquired immunit!U and creates immunologicalmemor!& Immunological memor! created from a -rimar! res-onse to a s-ecific -athogen?

-rovides an enhanced res-onse to secondar! encounters =ith that same? s-ecific -athogen& 7his -rocess of acquired immunit! is the (asis of vaccination&

Disorders in the immune s!stem can result in disease& Immunodeficienc! diseasesoccur =hen the immune s!stem is less active than normal? resulting in recurring and life4threatening infections& Immunodeficienc! can either (e the result of a genetic disease?

such as severe com(ined immunodeficienc!? or (e -roduced (! -harmaceuticals or aninfection? such as the acquired immune deficienc! s!ndrome AID B that is caused (! theretrovirus .I6& In contrast? autoimmune diseases result from a h!-eractive immunes!stem attac1ing normal tissues as if the! =ere foreign organisms& Common autoimmunediseases include rheumatoid arthritis? dia(etes mellitus t!-e % and lu-us er!thematosus&Immunolog! covers the stud! of all as-ects of the immune s!stem =hich has significantrelevance to human health and diseases& Further investigation in this field is e9-ected to

-la! a serious role in -romotion of health and treatment of diseases&

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Layere e1ense7he immune s!stem -rotects organisms from infection =ith la!ered defenses of

increasing s-ecificit!& Most sim-l!? -h!sical (arriers -revent -athogens such as (acteriaand viruses from entering the organism& If a -athogen (reaches these (arriers? the innate

immune s!stem -rovides an immediate? (ut non4s-ecific res-onse& Innate immunes!stems are found in all -lants and animals& "S .o=ever? if -athogens successfull! evadethe innate res-onse? verte(rates -ossess a third la!er of -rotection? the ada-tive immunes!stem? =hich is activated (! the innate res-onse& .ere? the immune s!stem ada-ts itsres-onse during an infection to im-rove its recognition of the -athogen& 7his im-rovedres-onse is then retained after the -athogen has (een eliminated? in the form of animmunological memor!? and allo=s the ada-tive immune s!stem to mount faster andstronger attac1s each time this -athogen is encountered&

C!/2!nents !1 the i// ne syste/Innate i// ne syste/ A a2tive i// ne syste/

Res-onse is non4s-ecific Pathogen and antigen s-ecific res-onse39-osure leads to immediate ma9imalres-onse

8ag time (et=een e9-osure and ma9imalres-onse

Cell4mediated and humoral com-onents Cell4mediated and humoral com-onents No immunological memor! 39-osure leads to immunological memor!Found in nearl! all forms of life Found onl! in )a=ed verte(rates

,oth innate and ada-tive immunit! de-end on the a(ilit! of the immune s!stem todistinguish (et=een self and non4self molecules& In immunolog!? self molecules are thosecom-onents of an organismQs (od! that can (e distinguished from foreign su(stances (!the immune s!stem& Conversel!? non4self molecules are those recogni


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acidic? =hile semen contains defensins and


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com-onent of the innate immune res-onse& Man! s-ecies have com-lement s!stems?including non4mammals li1e -lants? fish? and some inverte(rates&

In humans? this res-onse is activated (! com-lement (inding to anti(odies thathave attached to these micro(es or the (inding of com-lement -roteins to car(oh!drateson the surfaces of micro(es& 7his recognition signal triggers a ra-id 1illing res-onse& 7he

s-eed of the res-onse is a result of signal am-lification that occurs follo=ing sequential -roteol!tic activation of com-lement molecules? =hich are also -roteases& Aftercom-lement -roteins initiall! (ind to the micro(e? the! activate their -rotease activit!?=hich in turn activates other com-lement -roteases? and so on& 7his -roduces a catal!ticcascade that am-lifies the initial signal (! controlled -ositive feed(ac1& 7he cascaderesults in the -roduction of -e-tides that attract immune cells? increase vascular

-ermea(ilit!? and o-soni -hagol!sosome& Phagoc!tosis evolved as a means of acquiring nutrients? (ut this role =ase9tended in -hagoc!tes to include engulfment of -athogens as a defense mechanism&Phagoc!tosis -ro(a(l! re-resents the oldest form of host defense? as -hagoc!tes have

(een identified in (oth verte(rate and inverte(rate animals& Neutro-hils and macro-hages are -hagoc!tes that travel throughout the (od! in

-ursuit of invading -athogens& Neutro-hils are normall! found in the (loodstream and arethe most a(undant t!-e of -hagoc!te? normall! re-resenting /# to 0# of the totalcirculating leu1oc!tes& During the acute -hase of inflammation? -articularl! as a result of

(acterial infection? neutro-hils migrate to=ard the site of inflammation in a -rocesscalled chemota9is? and are usuall! the first cells to arrive at the scene of infection&Macro-hages are versatile cells that reside =ithin tissues and -roduce a =ide arra! ofchemicals including en

Dendritic cells DCB are -hagoc!tes in tissues that are in contact =ith the e9ternalenvironment> therefore? the! are located mainl! in the s1in? nose? lungs? stomach? and

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intestines& 7he! are named for their resem(lance to neuronal dendrites? as (oth haveman! s-ine4li1e -ro)ections? (ut dendritic cells are in no =a! connected to the nervouss!stem& Dendritic cells serve as a lin1 (et=een the (odil! tissues and the innate andada-tive immune s!stems? as the! -resent antigen to 7 cells? one of the 1e! cell t!-es ofthe ada-tive immune s!stem&

Mast cells reside in connective tissues and mucous mem(ranes? and regulate theinflammator! res-onse& 7he! are most often associated =ith allerg! and ana-h!la9is&,aso-hils and eosino-hils are related to neutro-hils& 7he! secrete chemical mediatorsthat are involved in defending against -arasites and -la! a role in allergic reactions? suchas asthma& Natural 1iller N cellsB cells are leu1oc!tes that attac1 and destro! tumorcells? or cells that have (een infected (! viruses&

A a2tive7he ada-tive immune s!stem evolved in earl! verte(rates and allo=s for a

stronger immune res-onse as =ell as immunological memor!? =here each -athogen isUremem(eredU (! a signature antigen& 7he ada-tive immune res-onse is antigen4s-ecific

and requires the recognition of s-ecific Hnon4self antigens during a -rocess calledantigen -resentation& Antigen s-ecificit! allo=s for the generation of res-onses that aretailored to s-ecific -athogens or -athogen4infected cells& 7he a(ilit! to mount thesetailored res-onses is maintained in the (od! (! Umemor! cellsU& hould a -athogen infectthe (od! more than once? these s-ecific memor! cells are used to quic1l! eliminate it& Ly/2h!cytes

7he cells of the ada-tive immune s!stem are s-ecial t!-es of leu1oc!tes? calledl!m-hoc!tes& , cells and 7 cells are the ma)or t!-es of l!m-hoc!tes and are derived fromhemato-oietic stem cells in the (one marro=& , cells are involved in the humoralimmune res-onse? =hereas 7 cells are involved in cell4mediated immune res-onse&

,oth , cells and 7 cells carr! rece-tor molecules that recogni


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7CRB (inds to this s-ecific antigen in a com-le9 =ith the M.C Class I rece-tor ofanother cell& Recognition of this M.CEantigen com-le9 is aided (! a co4rece-tor on the 7cell? called CD5& 7he 7 cell then travels throughout the (od! in search of cells =here theM.C I rece-tors (ear this antigen& @hen an activated 7 cell contacts such cells? itreleases c!toto9ins? such as -erforin? =hich form -ores in the target cellQs -lasma

mem(rane? allo=ing ions? =ater and to9ins to enter& 7he entr! of another to9in calledgranul!sin a -roteaseB induces the target cell to undergo a-o-tosis& 7 cell 1illing of hostcells is -articularl! im-ortant in -reventing the re-lication of viruses& 7 cell activation istightl! controlled and generall! requires a ver! strong M.CLantigen activation signal? oradditional activation signals -rovided (! Uhel-erU 7 cells&

*el2er T cells.el-er 7 cells regulate (oth the innate and ada-tive immune res-onses and hel-

determine =hich t!-es of immune res-onses the (od! =ill ma1e to a -articular -athogen&7hese cells have no c!toto9ic activit! and do not 1ill infected cells or clear -athogensdirectl!& 7he! instead control the immune res-onse (! directing other cells to -erform

these tas1s&.el-er 7 cells e9-ress 7 cell rece-tors 7CRB that recogni


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' ly/2h!cytes an anti3! iesA , cell identifies -athogens =hen anti(odies on its surface (ind to a s-ecific

foreign antigen& /%S 7his antigenLanti(od! com-le9 is ta1en u- (! the , cell and -rocessed (! -roteol!sis into -e-tides& 7he , cell then dis-la!s these antigenic -e-tides

on its surface M.C class II molecules& 7his com(ination of M.C and antigen attracts amatching hel-er 7 cell? =hich releases l!m-ho1ines and activates the , cell& As theactivated , cell then (egins to divide? its offs-ring -lasma cellsB secrete millions ofco-ies of the anti(od! that recogni


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Active /e/!ry an i// ni6ati!n8ong4term active memor! is acquired follo=ing infection (! activation of , and

7 cells& Active immunit! can also (e generated artificiall!? through vaccination& 7he -rinci-le (ehind vaccination also called immuni selenium>vitamins A? C? 3? and ,0> and folic acid vitamin ,$B also reduces immune res-onses&Additionall!? the loss of the th!mus at an earl! age through genetic mutation or surgicalremoval results in severe immunodeficienc! and a high susce-ti(ilit! to infection&

Immunodeficiencies can also (e inherited or QacquiredQ& Chronic granulomatousdisease? =here -hagoc!tes have a reduced a(ilit! to destro! -athogens? is an e9am-le ofan inherited? or congenital? immunodeficienc!& AID and some t!-es of cancer causeacquired immunodeficienc!&

A t!i// nityOveractive immune res-onses com-rise the other end of immune d!sfunction?

-articularl! the autoimmune disorders& .ere? the immune s!stem fails to -ro-erl!distinguish (et=een self and non4self? and attac1s -art of the (od!& nder normal

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circumstances? man! 7 cells and anti(odies react =ith Hself -e-tides& One of thefunctions of s-eciali


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agent& RNA silencing mechanisms are -articularl! im-ortant in this s!stemic res-onse asthe! can (loc1 virus re-lication&

#hysi!l!&ical re& lati!n.ormones can act as immunomodulators? altering the sensitivit! of the immune

s!stem& For e9am-le? female se9 hormones are 1no=n immunostimulators of (othada-tive and innate immune res-onses& ome autoimmune diseases such as lu-user!thematosus stri1e =omen -referentiall!? and their onset often coincides =ith -u(ert!&,! contrast? male se9 hormones such as testosterone seem to (e immunosu--ressive&Other hormones a--ear to regulate the immune s!stem as =ell? most nota(l! -rolactin?gro=th hormone and vitamin D& It is con)ectured that a -rogressive decline in hormonelevels =ith age is -artiall! res-onsi(le for =ea1ened immune res-onses in agingindividuals& Conversel!? some hormones are regulated (! the immune s!stem? nota(l!th!roid hormone activit!&

7he immune s!stem is enhanced (! slee- and rest? and is im-aired (! stress&Diet ma! affect the immune s!stem> for e9am-le? fresh fruits? vegeta(les? and

foods rich in certain fatt! acids ma! foster a health! immune s!stem& 8i1e=ise? fetalundernourishment can cause a lifelong im-airment of the immune s!stem& In traditionalmedicine? some her(s are (elieved to stimulate the immune s!stem? such as echinacea?licorice? ginseng? astragalus? sage? garlic? elder(err!? shiita1e and ling


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-articularl! useful in designing thera-eutic anti(odies? assessing li1el! virulence ofmutations in viral coat -articles? and validation of -ro-osed -e-tide4(ased drugtreatments& 3arl! techniques relied mainl! on the o(servation that h!dro-hilic aminoacids are overre-resented in e-ito-e regions than h!dro-ho(ic amino acids> ho=ever?more recent develo-ments rel! on machine learning techniques using data(ases of

e9isting 1no=n e-ito-es? usuall! on =ell4studied virus -roteins? as a training set& A -u(licl! accessi(le data(ase has (een esta(lished for the cataloguing of e-ito-es from -athogens 1no=n to (e recogni (arrier \ for e9am-le? (! using a t!-e II secretion s!stem& Alternativel!? using a t!-e III

secretion s!stem? the! ma! insert a hollo= tu(e into the host cell? -roviding a direct routefor -roteins to move from the -athogen to the host& 7hese -roteins are often used to shutdo=n host defenses&

An evasion strateg! used (! several -athogens to avoid the innate immune s!stemis to hide =ithin the cells of their host also called intracellular -athogenesisB& .ere? a

-athogen s-ends most of its life4c!cle inside host cells? =here it is shielded from directcontact =ith immune cells? anti(odies and com-lement& ome e9am-les of intracellular

-athogens include viruses? the food -oisoning (acterium almonella and the eu1ar!otic -arasites that cause malaria Plasmodium falci-arumB and leishmaniasis 8eishmanias--&B& Other (acteria? such as M!co(acterium tu(erculosis? live inside a -rotectiveca-sule that -revents l!sis (! com-lement& Man! -athogens secrete com-ounds thatdiminish or misdirect the hostQs immune res-onse& ome (acteria form (iofilms to -rotectthemselves from the cells and -roteins of the immune s!stem& uch (iofilms are -resentin man! successful infections? e&g&? the chronic Pseudomonas aeruginosa and,ur1holderia cenoce-acia infections characteristic of c!stic fi(rosis& Other (acteriagenerate surface -roteins that (ind to anti(odies? rendering them ineffective> e9am-lesinclude tre-tococcus -rotein +B? ta-h!lococcus aureus -rotein AB? andPe-tostre-tococcus magnus -rotein 8B&

7he mechanisms used to evade the ada-tive immune s!stem are morecom-licated& 7he sim-lest a--roach is to ra-idl! change non4essential e-ito-es aminoacids andLor sugarsB on the surface of the -athogen? =hile 1ee-ing essential e-ito-esconcealed& 7his is called antigenic variation& An e9am-le is .I6? =hich mutates ra-idl!?so the -roteins on its viral envelo-e that are essential for entr! into its host target cell areconstantl! changing& 7hese frequent changes in antigens ma! e9-lain the failures ofvaccines directed at this virus& 7he -arasite 7r!-anosoma (rucei uses a similar strateg!?constantl! s=itching one t!-e of surface -rotein for another? allo=ing it to sta! one ste-ahead of the anti(od! res-onse& Mas1ing antigens =ith host molecules is anothercommon strateg! for avoiding detection (! the immune s!stem&

""


23/85

#AT*O#*YSIOLOGY

A. ETIOLOGY

#re is2!sin& 1act!r

Factor Rationale

Age 7 Incidence of M!asthenia +ravis occurs (et=eenages %/4'/ for =omen& Our -atient? =ho is "$!ears old? falls into this age (rac1et&

.ereditar!

8 +enetics is a factor on one;s health& ince the

-atient has histor! of auto immune diseases inthe famil!? it is also li1el! for her to develo- -arallel diseases&

e9 L M!asthenia +ravis is more common in =omenthan men&

#reci2itatin& (act!r

Factor Rationale

Poor environment

LConstant e9-osure to dust or chemical su(stancescan =ea1en the immune s!stem of ever!individual& 7herefore? the -atient (ecomesvulnera(le to infections&

tress

Ltress can =ea1en the immune s!stem&According to -s!choneuroimmunolog!? the!found consistent stress4related increases innum(ers of total =hite (lood cell? as =ell asdecreases in the num(ers of hel-er 7 cells?su--ressor 7 cells? and c!toto9ic 7 cells? , cell?and natural 1iller 7 cells&

"'


24/85

'. SIGNS AND SYM#TOMS

Symptoms39treme muscle=ea1ness

L 7he state or qualit! of (eing =ea1> lac1 of strength?firmness? vigor? or the li1e> fee(leness&

Ptosis L A droo-ing of the u--er e!elid&Di-lo-ia L A -athological condition of vision in =hich a singlenvo()ect a--ears dou(le&

D!s-hagia L It refers to im-aired s=allo=ing& Normal -rocess ofs=allo=ing or deglutition can (e disru-ted due to a=ea1 muscle&

D!sarthria LD!sarthria is a s-eech disorder that is due to a=ea1ness or incoordination of the s-eech muscles&-eech is slo=? =ea1? im-recise or uncoordinated&

Cough L A sudden? nois!? and violent e9-ulsion of air from thechest? caused (! irritation in the air -assages? or (! therefle9 action of nervous or gastric disorder? etc&

Crac1les L 7o ma1e a succession of slight shar- sna--ing noises&Increase @,C L Due to the -resence of microorganism in (od!&Res-irator! distress L Out=ardl! evident? -h!sicall! la(ored ventilation or

res-irator! efforts> clinicall! evident ina(ilit! toadequatel! ventilate andLor o9!genate& 7his iscurrentl! the -referred term to use in referring toveterinar! -atients =ho -resent =ith severe res-irator!difficult! &

"*


25/85

#AT*O#*YSIOLOGY

#re is2!sin& (act!rs9 #reci2itatin& (act!rs9[Poor environment [ Age

]]]]]]]]]]] [ tress [ +ender [ .ereditar!

A(normal DNA Inhi(it muscle

mutations s-ecific -roteins

Decrease ^ of Differences in the varia(le74cells regions of anti(odies Malformations of

Neuromuscular

unction Alterations of the Production of a(normal74cells functions ,4cells

Decreased -atenc!of Neuromuscular

A(normal anti(odies unction

na(le to recogni


26/85

:::::::::::::::::::: MYAST*ENIA GRA%IS :::::::::::::::::::::::::::::::::

S/S: S/S:

> Ptosis >Inability to expectorate> Diplopia

> Dysphagia > Dysarthria Disru-tion of mechanical

[ Weakness of all Extremities defense

Invasion of microorganismin nasal

If treatedE If not treated[ Medications Coloni Respiratory istress > !o"gh

> Se#ere bo y $eakness > !rackles > %bsent of gag reflex > Increase W&!

"0


27/85

N)RSING ASSESSMENT

Date of %ssessment: anuar! *? "##$

I&'eneral S"r#ey

he =as received l!ing on (ed? intu(ated (ut res-onsive and =ith +C #f %%&@ith endotracheal tu(e at level "# attached to mechanical ventilator =ith the follo=ingset4u-E FiO" 0# > 76 /##> RR %0> IE3 %E' and on AC Mode& he;s =earing a cleanhos-ital go=n and loo1s according to age& @ith mesomor-hic (od! (uilt? =ith height of/;' and =eighs //4/5 1gs& ,od! =ea1ness noted and moves =ith assistance& he;s -lacedon moderate high (ac1 rest and =ith ongoing intravenous fluid of Plain 8actated Ringerregulated at %"#ccLhour infusing =ell at right metacar-al vein&

II&Skin

1in com-le9ion is fair and dr! =ith good s1in turgor and =arm to touch&C!anosis is not noted on nail (eds? li-s and (uccal mucosa& @ith good ca-illar! refilltime of less than ' seconds -er minute and =ith =ell4trimmed toe and finger nails& 3demais not noted on (oth u--er and lo=er e9tremities&

III& (ea

.ead is normoce-halic in configuration and -ro-ortional to the (od! si


28/85

readil! res-onded to normal voice tones& he can also hear the tic1ing sounds of the cloc1" to ' cms a=a! from the unoccluded ear =ith one ear occluded alternatel!&

6I& )ose

39ternal nose is s!mmetrical and straight& Discharges and s=elling not noted&7enderness and lesions not noted on e9ternal nose u-on -al-ation& @ith nasogastric tu(eat right nares =ith distal end closed? -atent and intact& Nasal mucosa is -in1 and =ith nolesions noted& Nasal se-tum is intact and in midline& Ma9illar! and frontal sinuses are nottender u-on -al-ation&

6II& *o"th

8i-s are uniforml! -in1 in color and are soft and moist& 7ongue is located in themidline and can move freel!& No ulceration noted in the soft and hard -alate& @ithendotracheal tu(e at level "# attached to mechanical ventilator& alivation noted& ,uccal

mucosa is -in1 in color and a--ears to (e smooth =ith no lesions noted& +ums are -in1ish in color =ith no sign of (leeding&

6III& )eck

7rachea is located in the midline of the nec1& 8!m-h nodes are not -al-a(le&7h!roid gland is not visi(le u-on ins-ection& ugular 6eins =ere not visi(le u-onins-ection =hile -laced in a semi4fo=ler;s -osition =ith head su--orted on a small

-illo=&

I:& !hest an l"ngs

!mmetrical lung e9-ansion is noted u-on res-iration& @hee


29/85

:II& %b omen

7he general contour of the a(domen =as flat um(ilicus is free from dischargesand inflammation u-on ins-ection& tretch mar1s not noted& @ith normal (o=el sounds

ranging from 04%% (o=el sounds in all quadrants u-on auscultation u-on auscultation&7enderness or (ladder distortion not noted =hen -al-ated on all four quadrants&

:III& 'enito-"rinary

Pu(ic hair =ere evenl! distri(uted and =ith s!mmetrical la(ia& No unusualdischarges? nodules and edema noted& @ith Fole! catheter attached to uro(ag draining toam(er4colored urine&

:I6& &ack an extremities

Deformit! or lesions not noted on shoulder and arms& Muscle atro-h! is notnoted& @ea1ness noted and =ith a grading muscle strength of 'L/ on (oth u--er andlo=er e9tremities =hich is /# normal strength and normal movement against gravit!&@ith -ositive dee- tendon refle9 noted and for=ard arm a(duction time of 5 seconds&

"$


30/85

(R"&'") &%R*% "SS%SS %

Cranial Nerve Name Assessment

I Olfactor! A(le to identif! different mild aromas such as

coffee and orange =ith e!es closed&II O-tic Can see o()ects in the -eri-her! =hen loo1ingstraight ahead&

III Oculomotor A(le to follo= the -en =ith a distance of '# cms&a=a! using onl! the e!es =ith head in a fi9ed

-osition =hile e!es are slo=l! moving in anorderl! manner through the si9 cardinal field ga equal in si


31/85

N)RSING DIAGNOSIS AND T*EORIES

DE(INITION ACCORDING TO NANDA9

Ine11ective air$ay clearance

A state in =hich an individual is una(le to clear secretions or o(structions from theres-irator! tract to maintain air=a! -atenc!&

(ati& e

A state in =hich an individual is e9-eriencing an over=helming sustained sense ofe9haustion and decreased ca-acit! for -h!sical and mental =or1 at usual level&

Ris; 1!r As2irati!n

A state in =hich a -erson is at ris1 for entr! of gastrointestinal secretion? oro-har!ngealsecretions or solids or fluids into tracheo(ronchial -assages&

C!rrelati!n t! N rsin&8N!n:n rsin& The!ries

A(raham Maslo= %$2#B? -erha-s the most reno=ned needs theorist? ran1s human needson five levels& 7he five levels in ascending order are as follo=s&

o Physiologic )ee s & Needs such as air? food? =ater? shelter? rest? slee-? activit!?and tem-erature maintenance are crucial for survival&

o Safety an sec"rity & 7he need for safet! has (oth -h!sical and -h!siologicas-ects& 7he -erson needs to feel safe? (oth in the -h!sical environment and inrelationshi-s&

o +o#e an belongingness & 7he third level of needs includes giving and receivingaffection? attaining a -lace in a grou-? and maintaining the feeling of (elonging&

o Self-esteem nee s & 7he individual needs (oth self4esteem i&e& feeling ofinde-endence? com-etence? and self4res-ectB and esteem from others i&e&recognition? res-ect? and a--reciationB&

o Self 4act"ali,ation @hen the need for self4esteem is satisfied? the individualstrives for self4actuali


32/85

(eings& One cannot function as an individual if these needs are not met& Nursing carefocuses on the -h!siologic needs of an individual&Eri;s!n failure to achieve a tas1 influences the -erson;s a(ilit! toachieve the ne9t tas1& 7hese develo-mental tas1s can (e vie=ed as a series of crisis? andsuccessful resolution of these crises is su--ortive to the -erson;s ego& Failure to resolvethe crises is damaging to the ego& 3ri1son;s eight stages reflect (oth -ositive and negativeas-ects of the critical life -eriods& 3ach -hase has its develo-mental tas1? and theindividual must find a (alance (et=een&

@hen using 3ri1son;s develo-mental frame=or1? nurses should (e a=are ofindicators of -ositive and negative resolution of each stage& Nurses can enhance a client;sdevelo-ment (! (eing a=are of the -erson;s develo-mental stage and (! hel-ing the

-erson develo- co-ing s1ills relative to stressors e9-erienced in that level&

Our client (elongs to the stage of adulthood "/40/B !ears old =ith a tas1 ofgenerativit! versus stagnation& Our client remains to (e -roductive (! doing sim-le tas1sat home in =hich she can e9tend hel- to her famil! des-ite her condition& Other -ositiveindicators includes concern for others and creativit!&

( AYE G LENN A 'DELLA*


33/85

7he a(ove nursing -ro(lems can (e correlated to our client;s condition and nursingdiagnoses&

%IRGINIA *ENDERSON


34/85

LA'ORATORY ST)DIES AND DIAGNOSTIC E>AMS

Complete Blood Count/ Platelet Count

DateE Decem(er "2? "##5

La3!rat!ryTest

Rati!nale Res lt Re1erence%al e

ClinicalSi&ni1icance

Ly/2h!cytes

M!n!cytes

E!sin!2hil

'as!2hil

#latelet C! nt

8!m-hoc!te is at!-e of =hite (lood cell -resent inthe (lood&It hel-s -rotect the (od! againstdiseases and fight infections&

Monoc!tes leave the (lood and (ecome macro-hages and dendriticcells &

7o indicate allergic reactions? -resence of -roto


35/85

DateE Decem(er "2? "##5

La3!rat!ryTest

Rati!nale Res lt Re1erence%al e


Gl c!se R'S

Creatinine

S! i /

#!tassi /

Measures the (lood sugarat an! -oint in time? notnecessaril! a certainamount of time after ameal? snac1 or (everage&

Creatinine has (een foundto (e a fairl! relia(leindicator of 1idne!function&

As the 1idne!s (ecomeim-aired?the creatinine level in the

(lood =ill rise due to -oorclearance (! the 1idne!s&

odium is necessar! for (lood and (od! fluids?transmission of nerveim-ulses? heart activit!?

and certain meta(olicfunctions&Potassium -la!s anessential role in theres-onse of nerves tostimulation and in thecontraction of muscles&Cellular en

-otassium to =or1 -ro-erl!&

'&0# mmolL8

2%&"# mmolL8

%*0#mmolL8

*&'# mmolL8

'&$40&%#

/'4%%/

%'/4%//

'&/4/&/

8o=.!-ogl!cemia

Normal

Normal

Normal

'/


36/85

ENDOTRAC*EAL AS#IRATION ?ETA GS8CS@

DateE anuar! '? "##$

(in in&9GRAM STAIN ?DIRECT@9]6er! fe= gram TB cocci]Others seenE Pus cells

S sce2ti3ility Test Res lt

Date9 anuar! $? "##$S2eci/en E 3ndotracheal 7u(e As-irateC lt re Res lt9 Moderate gro=th of Acineto(acter (aumaanii

Anti(iotic dis1s Inter-retationResistant Intermediate usce-ti(leAmi1acin ]Am-iL ul(actam ]Ceftria9one ]Cefota9ime ]Cefta9idine ]Ci-roflo9acin ]+entamicin ]7icarcillin ]7o(ram!cin ]

7he culture result reveals that the s-ecific t!-e of (acteria called Acineto(acter (aumaanii is susce-ti(le to certain t!-es of anti(iotics such asE Ami1acin?Am-iL ul(actam? Cefta9idine? Ci-roflo9acin? +entamicin? 7icarcillin and 7o(ram!cin>hence? effective in 1illing these t!-es of microorganisms&

On the other hand? Ceftria9one and Cefota9ime are anti(iotics that the (acteria might (esusce-ti(le or might (e resistant&

COM#LETE 'LOOD CO)NT8#LATELET CO)NT.3MA7O8O+

DateE anuar! /? "##$

E a/inati!n Rati!nale Res lt Re1erence %al e


.emoglo(in.g(B

7his is a measure of the totalamount of hemoglo(in in the

%#$ gLl MaleE%'/4%2/

lightl! lo=

'0


37/85

-eri-heral (lood& FemaleE%%/4%//

Ma! indicateanemia or fluidretention&

Pac1ed Cell

6olume.ctB

It is considered an integral -art of a -ersonQs com-lete (lood count results&

#&'/ gLl MaleE

#&*#4#&/"FemaleE#&'04#&*5

lightl! lo=

Ma! indicateanemia or fluidretention&

Red ,loodCells

7his is a count of the num(er ofthe circulating R,Cs in % mm' ofthe -eri-heral venous (lood&

'&5' gLl *&"40&% 8o=

Anemia

8eu1oc!tes 8eu1oc!tes function as a first lineof defense against foreign -rotein

entering the (od!&

7he test is used to determineinfection or inflamation&

%*4%09%#gLl

Neutro-hilsegmenters

Indicates if there is (acterialinvasion (ecause the! are the firstto arrive at the infection site&

$# 9%#gLl #&//4#&2/ .igh

Ma! indicateinfection orinflammation&

8!m-hoc!tes Indicates if there is activated cellmediated res-onse and humoralmediated res-onse& It hel-s -rotect

the (od! againstdiseases and fight infections&

*9%#gLl #&"#4#&'/ .igh

Increase in thenum(er ofl!m-hoc!tes ma!indicate that thegeneral defenses!stems of the (od!

have (een -enetrated (!dangerous invadingmicroorganisms&

'2
http://en.wikipedia.org/wiki/Complete_blood_counthttp://en.wikipedia.org/wiki/Complete_blood_count


38/85

Monoc!tes Partici-ate in -rotecting the (od!from infections&

09%#gLl #"4# .igh

Ma! indicateinfection such as

tu(erculosis?he-atitis? and -ancreatitis&

PlateletCount

It -la!s a great role in (loodcoagulation& If the value dro-smuch (elo= "#?###L l? there is adanger of uncontrolled (leeding

"/2gLl %/#4*##9%#gLl

Normal

DateE anuar! 5? "##$

E a/inati!n Rati!nale Res lt Re1erence%al e


Che/istry

Calcium

odium

7o aid diagnosis ofendocrine disordersand acid4(ase (alance

Calcium is needed formuscle contraction?

(lood vesselcontraction ande9-ansion? thesecretion of hormonesand en

7o evaluate fluid4(ase (alance? and related

"&* mmolL8

%*0 mmolL8

"&"4"&0

%'04%//

Normal

Normal

'5
http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/Clotting.html#plateletshttp://users.rcn.com/jkimball.ma.ultranet/BiologyPages/C/Clotting.html#platelets


39/85

-otassium

neuromuscular? renaland adrenal function

7o evaluate clinicalsigns of h!-er1alemiaand h!-o1alemia&

*&%# mmolL8 '&/4/&/ Normal

ARTERIAL 'LOOD GAS S)MMARY RES)LT

Date (iO + 2*2&'/42&*/mm.g

#CO +'/4*/mm.g

2O + 5#4%##mm.g

*CO B""4"2 mmolLl

'E?ec1@4"B4T"B mmolLl

CtCO +"'4'#


%"L"2L#5 2&0#0 %5&* 0$&/ %2&$ 4'&0 %5&/ Res-irator!al1alosis -artialcom-ensation=ith h!-o9emia

#%L#%L#$ 2&*"$ '*&' 0%&5 ""&" 4"&% "'&' Res-irator!al1alosisuncom-ensated=ith moderateh!-o9emia

#%L#'L#$ 0# 2&**" *"&5 %*0&% "5&/ *&* "$&5 Meta(olical1alosisuncom-ensated=ith more thatadequate

o9!genation

#%L#*L#$ *# 2&*'" *#&0 %/'&% "0&/ "&" "2&2 Normal arterial (lood gas =ithmore thatadequateo9!genation

'$


40/85

#%L#/L#$ 5# 2&*$% '2 %"%&' "2&0 *&' "5&2 Meta(olical1alosisuncom-ensated=ith more that

adequateo9!genation

#%L#$L#$ *# 2&'$% *'&' %*/&" "/&2 #&2 "2 Normal arterial (lood gas =ithmore thatadequateo9!genation

An arterial 3l!! &as ?A'G@ test is !ne t!9

Chec1 for severe (reathing -ro(lems and lung diseases? such as asthma? c!sticfi(rosis ? or chronic o(structive -ulmonar! disease &

ee ho= =ell treatment for lung diseases is =or1ing& Find out if !ou need e9tra o9!gen or hel- =ith (reathing mechanical ventilationB& Find out if !ou are receiving the right amount of o9!gen =hen !ou are using

o9!gen in the hos-ital& Measure the acid4(ase level in the (lood of -eo-le =ho have heart failure? 1idne!

failure? uncontrolled dia(etes ? slee- disorders? severe infections? or after a drugoverdose&

Arterial (lood gas A,+B values alone do not -rovide enough information to diagnose a -ro(lem& 7he! cannot tell =hether lo= levels are caused (! lung and heart -ro(lems&Arterial (lood gas values are most hel-ful =hen the! are revie=ed =ith othere9aminations and tests&An A,+ test is often done for a -erson =ho is in the hos-ital (ecause of severe in)ur! orillness& 7he test can measure ho= =ell the -ersonQs lungs and 1idne!s are =or1ing andho= =ell the (od! is using energ!&An A,+ test ma! (e most useful =hen a -ersonQs (reathing rate is increased or decreasedor =hen the -erson has ver! high (lood sugar glucoseB levels? a severe infection? or heartfailure&

C!/2lete3l!! c! nt8#lateletc! nt

N rsin& c!nsi erati!ns +re test

39-lain the im-ortance of the -rocedure to the -atient and ofsignificant others&

7ell the -atient that a (lood sam-le =ill (e ta1en and =ho =ill -erform the veni-uncture&

*#
http://health.yahoo.com/respiratory-diagnosis/asthma/healthwise--sta123346.htmlhttp://health.yahoo.com/respiratory-diagnosis/cystic-fibrosis/healthwise--stc123784.htmlhttp://health.yahoo.com/respiratory-diagnosis/cystic-fibrosis/healthwise--stc123784.htmlhttp://health.yahoo.com/respiratory-diagnosis/chronic-obstructive-pulmonary-disease/healthwise--stc123675.htmlhttp://health.yahoo.com/respiratory-diagnosis/diabetes/healthwise--std120744.htmlhttp://health.yahoo.com/respiratory-diagnosis/diabetes/healthwise--std120744.htmlhttp://health.yahoo.com/respiratory-diagnosis/asthma/healthwise--sta123346.htmlhttp://health.yahoo.com/respiratory-diagnosis/cystic-fibrosis/healthwise--stc123784.htmlhttp://health.yahoo.com/respiratory-diagnosis/cystic-fibrosis/healthwise--stc123784.htmlhttp://health.yahoo.com/respiratory-diagnosis/chronic-obstructive-pulmonary-disease/healthwise--stc123675.htmlhttp://health.yahoo.com/respiratory-diagnosis/diabetes/healthwise--std120744.html


41/85

39-lain to the -atient that he ma! fell slight discomfort from theneedle -uncture and the tourniquet&

3nsure that the (lood sam-le is into ta1en from the intravenousline& .emodilution =ith intravenous fluid cause false decrease inthe values of some tests&

'ntra test Direct the -atient to (reathe normall! and to avoid unnecessar!

movements& O(serve standard -recautions on ho= to collect s-ecimens and

record it in the -atient;s chart& For adults? dra= venous (lood to '4 / ml tu(e& 8a(el the s-ecimen com-letel! and trans-ort -ro-erl! to the

la(orator!& +ost test

Record the time of the (lood sam-le is dra=n (ecause the countervar! de-ending on the time of the da!&

3nsure that the su(dermal (leeding has sto--ed (efore removingthe -ressure& If the hematoma develo-e a--l! =arm&

+recautions:o Com-letel! feel the collection tu(e&o Invert gentl! the tu(e several times to mi9 the sam-le =ith the

anticoagulant&

Gl c!se:R'S

,lood is t!-icall! dra=n from a vein? usuall! from the inside ofthe el(o= or the (ac1 of the hand&

7he site is cleaned =ith germ41illing medicine antise-ticB& 7he health care -rovider =ra-s an elastic (and around the u--er

arm to a--l! -ressure to the area and ma1e the vein s=ell =ith (lood&

7he health care -rovider gentl! inserts a needle into the vein& 7he (lood collects into an airtight vial or tu(e attached to the needle&7he elastic (and is removed from !our arm&

Once the (lood has (een collected? the needle is removed? and the -uncture site is covered to sto- an! (leeding&

In infants or !oung children? a shar- tool called a lancet ma! (eused to -uncture the s1in and ma1e it (leed&

7he (lood collects into a small glass tu(e? or onto a slide or teststri-& A (andage ma! (e -laced over the area if there is an!

(leeding&Arterial +re test

*%


42/85


43/85

to e9-ose small sterile chimne! on ca-& Remove catheter from late9 tu(e& Push late9 tu(e over small chimne! to seal s-ecimen tra-& 7o retain microorganisms in the s-utum tra-& ent to la(orator!&

A ia&n!sis can 3e c!n1ir/e in several $ays, incl in& the 1!ll!$in&9 %cetylcholine Receptor %ntibo y

A (lood test for the a(normal anti(odies can (e -erformed to see if the! are -resent&Acet!lcholine Rece-tor Anti(od! testing 4 A--ro9imatel! 5/ of M+ -atients havethis anti(od! and? =hen detected? is a guaranteed diagnosis&

%nti-*"S. %ntibo y testing

A (lood test for the remaining %/ of seronegative NB M+ -atients? those =hohave tested negative for the acet!lcholine anti(od!? *#42# test -ositive for the anti4Mu anti(od!& 7he remaining -atients have an unidentified anti(od! causing theirM+&

ensilon0 test

7he edro-honium chloride 7ensilon B test is -erformed (! in)ecting this chemicalinto a vein& Im-rovement of strength immediatel! after the in)ection -rovides strongsu--ort for the diagnosis of M+&

Electromyography

3M+B studies can -rovide su--ort for the diagnosis of M+ =hen characteristic -atterns are -resent& Re-etitive Nerve timulation to chec1 for a -ost4s!na-tic defect?ingle Fi(er 3M+? or a muscle (io-s! to loo1 for anti(odies ma! also (e used&

Single 1iber E*'

tudies can -rovide su--ort for the diagnosis of M+ =hen characteristic -atternsare -resent&

*'


44/85

DOCTOR on AC Mode

**


45/85

Insert N+7 French %0> distal end closed O7F at "### 1cal in 0 divided feedings +ive ranitidine /# mg I677 no= then q5 DiagnosisE A,+ no= On M.,R 7ransfer to IC % +%#>8*B For com-liance of P!ridostigmine

%"L'%L#5 at $E## AM

till fro 37A + C TB secretions> decrease P!ridostigmine I ta( q%" hift h!drocortisone to -rednisone "# mg % ta(let q%" I6F of d/ 8R at %"# ccLhour 7ransfer to IC % level *? score of %# uction secretions regularl!

%L%L#$ For A,+ no= Follo=4u- 37A + C For re-eat C,Cb PC Decrease FIO" to $# =ith decrements at %# until 0# A,+ after % hour at FIO" of 0# Refer to MROD if O" saturation is b$# or =ith signs of res-irator! distress ROME Cefota9ime % gram I677 q5

o Acet!lc!steine 0## mg sachet? % sachet dilute to "##cc =ater 7IDL N+7o al(utamol % ne( q0o P!ridostigmine % ta(let q%"L ngto Prednisone "#mgL ne( % ta(let q%"LN+7

uction secretions -er orem and 37 Do s-ot chec1 of O" saturation On M.,R

%L"L#$ Continue mechanical ventilator su--ort

%L'L#$ till fro 37A + C For A,+ stat al(utamol ne(uli


46/85

%L'L#$ at 5E"# AM For re-eat C,C? PC toda! A


47/85

Chest ta--ing -ost ne(uli


48/85

A,+ after % hour and refer 3ncourage to e9-ectorate .oo1 to face mas1 at 0 8PM

%L%"L#$ 7ransfer to Med Main 8"B For re-eat C,C? PCb A,+ -rior to trans4out 7o consume " more doses of Chloram-henicol then discontinue

*5


49/85

Date8Ti/e C es Nee

N rsin&Dia&n!sis

$ith rati!naleO30ective

!1 CareN rsin& Interventi!ns $ith rati!nale

Eval ati!n

anuar!/?

"##$

at

5E##AM

S 30ective9: On Mechanicalventilator =ith a+C of %%

O30ective9 Productivecough noted

,od!=ea1nessnoted

Presence of (i(asalcrac1les noted

TB @hee


50/85


51/85

Increase Pa CO" and decreasing PaO" are signs ofres-irator! failure

/%


52/85

Date8Ti/e

C es Nee N rsin&Dia&n!sis $ith

rati!nale

O30ective!1 Care

N rsin& Interventi!ns $ith rati!nale Eval ati!n

an& /?"##$

5E##am

S 30ective9 On mechanical

ventilator @ith +C of

%%L%/

O30ective9 TB (od!

=ea1ness decreased

muscle tone decreased

activit! -erformance

=ith -eriods ofinterru-tedslee-

tired loo1ing motor functionE

'L/ 'L/

'L/ 'L/

AC7I6I7

4

3:3R CI

3

PA773R

N

Fatigue related tomuscle =ea1nesssecondar! tom!asthenia gravis

7he hallmar1 ofm!asthenia gravisis fatiga(ilit!&Muscles (ecome

-rogressivel!=ea1er during

-eriods of activit!and im-rove after

-eriods of rest&===&emedicine&comB

ourceE+ulanic1 andM!ers? NursingCare Plans? -& /2

STO At the end ofour 5 hrs& shift?

-atient =ill (ea(le to

-artici-ateactivel! innormal activities

LTO After t=o=ee1s? -atient=ill demonstrateim-rovedactivit!tolerance asevidenced (!E Maintaining

a (alance (et=een=or1? rest?e9ercise?andrecreation>

PerformingAD8s=ithoute9cessivefatigue

Assess characteristics of fatigue& 7his descri(es the amount of fatigue e9-erienced& It alsoallo=s the nurse to com-are changes in the -atient;s fatiguelevel over time& It is im-ortant to determine if the -atient;s levelof fatigue is constant or if it varies overtime&

Assess for -ossi(le causes of fatigue& Identif!ing the related factors =ith fatigue can aid in

determining -ossi(le causes and esta(lishing a colla(orative -lan of care&

Assess -atient;s a(ilit! to -erform activities of dail! livingAD8sB&

Fatigue can limit the -erson;s a(ilit! to -artici-ate in self4careand -erform his or her role res-onsi(ilities in the famil! andsociet!& 3valuate the -atient;s slee- -atters for qualit!? quantit!?

time ta1en to fall aslee-? and feeling u-on a=a1ening& Changes in the -erson;s slee- -attern ma! (e a contri(utingfactor in the develo-ment of fatigue&

Assess the -atient;s level of e9ercise and -h!sical activit!& ,oth increased -h!sical e9ertion and limited levels of

e9ercise can contri(ute to fatigue&

Assist the -atient to develo- a schedule for dail! activit!and rest&

A -lan that (alances -eriods of activit! =ith -eriods of restcan hel- the -atient com-lete desired activities =ithout addingto levels of fatigue&

Monitor the -atient;s energ! e9-enditure =ith activit!& Changes in o9!gen saturation? res-irator! rate? and heart rate=ill reflect the -atient;s tolerance for activit!& Assist the -atient =ith activities of dail! living AD8sB& 7his can minimi


53/85

Instruct -atient to increase inta1e of car(oh!drates? -rotein?vitamins? and minerals&

7hese -rovide energ! resources&

Provide =ith adequate rest -eriods& Promoting effective rest can contri(ute to energ! restoration&

Minimi A

P!ridostigmine is used to im-rove muscle strength in -atients=ith a certain muscle disease m!asthenia gravisB& It =or1s

(! -reventing the (rea1do=n of a certain natural su(stanceacet!lcholineB in !our (od!& Acet!lcholine is needed fornormal muscle function&

/'


54/85

Date8Ti/e

C es Nee N rsin&Dia&n!sis $ith

rati!nale

O30ective!1 Care

N rsin& Interventi!ns $ith rati!nale Eval ati!n

an%%?

"##$$E##am

S 30ective9Hdili -a 1a!o 1oma1atulon

O30ective9 Productive

cough noted TB muscle

=ea1nessnoted

@ea1 gagrefle9 noted

Fatiguenoted

Im-aireds=allo=ingnoted

+urgl!voicequalit!noted

7hic1?=hitishtenacioussecretions

Post % hourofe9tu(ation

On NPO

N

7R I7IO

NA84

M37A,O8IC

PA773R

N

Ris1 forAs-iration relatedto res-irator!muscle =ea1nesssecondar! toM!asthenia+ravis

,ecauseM!asthenia+ravis ma!involve themuscles ofres-iration? theclient ma!e9-erienced!s-nea andineffective coughand s=allo=ingmechanisms?=hich ma! leadto as-iration&

ourceE,lac1 and.a=1s? Medical4urgical Nursing?

-& "%5*

STOAt the end ofour 5 hrs& shift?our -atient =ill

(e a(le todemonstratetechniques to

-revent andLorcorrectas-iration asevidence (! nosign ofas-iration suchas coughingand effective

(reathing -attern

LTO@ithin "=ee1s? the

-atient =ille9-erience noas-iration asevidenced (!noiselessres-iration andodorlesssecretions&

Assess oral secretions for color? amount andconsistenc!

Patient =ith thic1 tenacious secretions areincreased ris1 for as-iration

Plan for a -eriod of "#4'4 minutes of rest (efore meals

Patients =ith M!asthenia +ravis tire ver!easil!&

Coordinate =ith -atient;s meal =ith -ea1 drugaction

Anticholinesterase medications such as Neostigmine ProstigminB given *#40# minutes (efore meals =ill -rovide -ea1 action over themealtime&

ee- -atient u-right for '#40# minutes aftermeals&

7he u-right -osition facilitates the gravitationalflo= of food or fluid through the alimentar! tractand reduces the ris1 of as-iration&

ee- suction equi-ment at (edside and suctionas necessar!

7his is necessar! to maintain -atent air=a!&

Instruct on signs and s!m-toms of as-iration 7his aids in a--ro-riatel! assessing high4ris1situations and determining =hen to call for furtherevaluation&

G!al /et.

7OPatientdemonstrated

techniques to -reventas-irationsuch as l!ingu-right =hilefeeding

87OPatient =asnot a(le toe9-eriencean!as-iration asevidenced (!noiselessres-irationand odorlesssecretions&

/*


55/85

39-lain to the -atient the need for -ro-er -ositioning

7his decreases ris1 of as-iration&

Colla(orativeE

Monitor Arterial ,lood +ases A,+sB G Pulseo9imeter&Pooling of secretions leads to -neumonia =hich=ill lead to more aggressive interventions

Administer medications such asE P!ridostigmine (romide 0/ mgLta( I ta(let 7ID> P!ridostigmine is used to im-rove muscle strength

in -atients =ith a certain muscle diseasem!asthenia gravisB& It =or1s (! -reventing the

(rea1do=n of a certain natural su(stanceacet!lcholineB in !our (od!& Acet!lcholine isneeded for normal muscle function&

al(utamol % ne( q0 Rela9ation of air=a! smooth muscle =ith

su(sequent (ronchodilation for easier mo(ili


56/85

DR)G ST)DY

+eneric name Ranitidine .Cl

,rand name antac

Classification Antiulcer drug

Dosage andFrequenc!

/# mg I677 q5

Indications Duodenal and gastric ulcer

3rosive eso-hagitis.eart(urn+3RDMaintenance thera-! for duodenal or gastric ulcer

Action Com-etitivel! inhi(its action of histamine on the ." at the rece-tor sites of -arietal cells? decreasing gastric acid secretion&

Adverse

Reactions L ide

3ffects

CN E headache? malaise

33N7E (lurred vision.3PA7ICE )aundiceO7.3RE (urning and itching at in)ection site

Drug Interactions AntacidsE Ma! interfere =ith ranitidine a(sor-tion&Dia


57/85

Instruct -atient on -ro-er use of O7C -re-aration? as indicated&Remind -atient ta1ing -rescri-tion drug once dail! to ta1e it at

(edtime for (est results&Instruct -atient to ta1e =ithout regard to meals (ecause a(sor-tion is

not affected (! food&

rge -atient to avoid cigarette smo1ing&

+eneric name Acet!lc!steine

,rand name Mucom!st

Classification Mucol!tic Agent

Dosage and Frequenc! 0## mg % ta(let at .

Indications Mucol!tic> management of conditions associated =ith thic1 viscidmucous secretions

Action Degrades mucus? allo=ing easier mo(ili


58/85

and ma! resolve =ith continued administration&

Assess -atient for nausea? vomiting? and urticaria& Notif! -h!sician if these occur

Acet!lc!steine infusion should (e interru-ted until s!m-tomsresolve and carefull! restarted& If ana-h!lactoid reaction recurs?discontinue acet!lc!steine and use alternative form of treatment&

+eneric name al(utamol

,rand name Proventil

Classification ,ronchodilator

Dosage andFrequenc! % Ne( q *

Indicationsal(utamol is used in cases of (ronchos-asm in -atients =ith reversi(leair=a! o(structionE mild and moderate attac1s of d!s-nea in -atients

suffering from (ronchial asthma> mild and moderate (ronchoo(struction in -atients =ith chronic (ronchitis and lung em-h!sema&

Action As =ith other V"4adrenergic rece-tor agonists? sal(utamol (inds to V"4adrenergic rece-tors =ith a higher affinit! than V%4rece-tors& In the air=a!?activation of V"4rece-tors results in rela9ation of (ronchial smooth muscle&resulting in a =idening of the air=a! (ronchodilationB& Inhaled sal(utamolsulfate has a ra-id onset of action? -roviding relief =ithin /4%/ minutes ofadministration&

AdverseReactions L ide

3ffects

.eadache> tremor> tach!cardia> h!-ertension> an9iet!& Rarel! nausea?vomiting? and s1in rash can (e o(served&

Drug InteractionsIn cases of concurrent administration =ith MAO4inhi(itors orantide-ressants? a -otentiation of the cardiovascular effects is o(served&7he V4(loc1ers antagoni


59/85

NursingRes-onsi(ilities

o ,efore using sal(utamol for inhalation ma1e sure !our doctor or -harmacist 1no=sE

If !ou are -regnant? tr!ing for a (a(! or (reast4feeding& If !ou suffer from h!-erth!roidism an over active th!roid glandB& If !ou suffer from heart -ro(lems& If !ou suffer high (lood -ressure& If !ou suffer from dia(etes&

o Do not sto- ta1ing sal(utamol =ithout s-ea1ing to !our doctor first&o If !our usual dose of sal(utamol does not -rovide at least three

hours relief from asthma s!m-toms s-ea1 =ith !our doctor&o Do not smo1e& mo1ing causes severe irritation and damage to the

lungs& It =ill ma1e !our condition =orse and =ill reduce the (eneficial effects of !our medication&

o If !ou have dia(etesE Chec1 !our (lood glucose levels regularl! asthis -re-aration can affect the levels of sugar in !our (lood&

o al(utamol aerosol inhalers no= contain CFC free -ro-ellants?=hich ma! feel and taste different to inhalers that contain CFCs& If!ou e9-erience an! -ro(lems =ith this t!-e of inhaler !ou shoulds-ea1 =ith !our doctor&

+eneric name Cefota9ime

,rand name Claforan

Classification Anti(iotic

Dosage andFrequenc!

% gram I677 q5

Indications Cefota9ime is used for infections of the res-irator! tract ? s1in ? (ones ? )oints ? urogenital s!stem ? meningitis ? and se-ticemia & It generall! has goodcoverage against most +ram4negative (acteria ? =ith the nota(le e9ce-tionof Pse" omonas & It is also effective against most +ram4-ositive cocci e9ce-t for Enterococc"s &%S It is active against -enicillin 4resistant strains ofStreptococc"s pne"moniae & It has modest activit! against the anaero(ic

&acteroi es fragilis &Inhi(its (acterial cell =all s!nthesis (! (inding to one or more of the

/$
http://en.wikipedia.org/wiki/Respiratory_tracthttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Urogenital_systemhttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Gram-negative_bacteriahttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Gram-positive_coccihttp://en.wikipedia.org/wiki/Enterococcushttp://en.wikipedia.org/wiki/Enterococcushttp://en.wikipedia.org/wiki/Cefotaxime#cite_note-Merck-0http://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Bacteroides_fragilishttp://en.wikipedia.org/wiki/Respiratory_tracthttp://en.wikipedia.org/wiki/Skinhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Jointhttp://en.wikipedia.org/wiki/Urogenital_systemhttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Septicemiahttp://en.wikipedia.org/wiki/Gram-negative_bacteriahttp://en.wikipedia.org/wiki/Pseudomonashttp://en.wikipedia.org/wiki/Gram-positive_coccihttp://en.wikipedia.org/wiki/Enterococcushttp://en.wikipedia.org/wiki/Cefotaxime#cite_note-Merck-0http://en.wikipedia.org/wiki/Penicillinhttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Bacteroides_fragilis


60/85

Action -enicillin4(inding -roteins P,PsB =hich in turn inhi(its the finaltrans-e-tidation ste- of -e-tidogl!can s!nthesis in (acterial cell =alls? thusinhi(iting cell =all (ios!nthesis& ,acteria eventuall! l!se due to ongoingactivit! of cell =all autol!tic en

AdverseReactions L ide3ffects

The /!st 1re ent a verse reacti!ns ?&reater than = @ are9 8ocal *&' B 4 In)ection site inflammation =ith I6 administration& Pain ?induration ? and tenderness after IM in)ection&.!-ersensitivit! "&* B 4 Rash ? -ruritus ? fever ? eosino-hilia and lessfrequentl! urticaria and ana-h!la9is &+astrointestinal %&* B 4 Colitis ? diarrhea ? nausea ? and vomiting&!m-toms of -seudomem(ranous colitis can a--ear during or after

anti(iotic treatment& Nausea and vomiting have (een re-orted rarel!&

Drug InteractionsIncreased ne-hroto9icit! has (een re-orted follo=ing concomitantadministration of ce-halos-orins and aminogl!coside anti(iotics&

Ce-halos-orins? including cefota9ime sodium? are 1no=n to occasionall!induce a -ositive direct Coom(s test&

Contraindications It is contraindicated in -atients =ho have sho=n h!-ersensitivit! tocefota9ime sodium or the ce-halos-orin grou- of anti(iotics&


O(tain cuture and sensitivit! -rior to thera-!&O(serve for signs and s!m-toms of ana-h!la9is during first dose&se cautiousl! in -atients h!-ersensitive to -enicillin (ecause of

-ossi(ilit! of cross4sensitivit! =ith other (eta4lactam anti(iotics&Also use cautiousl! in -atients =ith histor! of colitis and renal

insufficienc!&7his medication is administered (! in)ection or infusion& Advise -atient or caregiver to immediatel! inform health care -rovider ifin)ection4site -ain or redness? s1in rash? hives? itching? or shortnessof (reath occur during treatment&Maintain adequate h!dration "4' 8Lda! of fluidsB unless instructedto restrict fluid inta1e&Advise -atient or caregiver to re-ort signs of su-erinfection tohealth care -roviderE (lac1 furr! tongue? =hite -atches in mouth?foul4smelling stools? vaginal itching or discharge&@arn -atient that diarrhea containing (lood or -us ma! (e a sign of

a serious disorder and? if noted after discharge? to see1 medical careif noted and not to treat at home&Patients should (e told that although it is common to feel (etterearl! in the course of thera-!? the medication should (e ta1ene9actl! as directed& 1i--ing doses or not com-leting the fullcourse of thera-! ma! %B decrease the effectiveness of theimmediate treatment and "B increase the li1elihood that (acteria=ill develo- resistance and =ill not (e treata(le (! Cefota9ime or

0#
http://www.rxlist.com/script/main/art.asp?articlekey=3979http://www.rxlist.com/script/main/art.asp?articlekey=4723http://www.rxlist.com/script/main/art.asp?articlekey=15911http://www.rxlist.com/script/main/art.asp?articlekey=15911http://www.rxlist.com/script/main/art.asp?articlekey=5209http://www.rxlist.com/script/main/art.asp?articlekey=5095http://www.rxlist.com/script/main/art.asp?articlekey=3425http://www.rxlist.com/script/main/art.asp?articlekey=3425http://www.rxlist.com/script/main/art.asp?articlekey=3425http://www.rxlist.com/script/main/art.asp?articlekey=33429http://www.rxlist.com/script/main/art.asp?articlekey=33429http://www.rxlist.com/script/main/art.asp?articlekey=5919http://www.rxlist.com/script/main/art.asp?articlekey=5919http://www.rxlist.com/script/main/art.asp?articlekey=10935http://www.rxlist.com/script/main/art.asp?articlekey=10935http://www.rxlist.com/script/main/art.asp?articlekey=3555http://www.rxlist.com/script/main/art.asp?articlekey=2780http://www.rxlist.com/script/main/art.asp?articlekey=2985http://www.rxlist.com/script/main/art.asp?articlekey=2985http://www.rxlist.com/script/main/art.asp?articlekey=4510http://www.rxlist.com/script/main/art.asp?articlekey=5099http://www.rxlist.com/script/main/art.asp?articlekey=8121http://www.rxlist.com/script/main/art.asp?articlekey=8121http://www.rxlist.com/script/main/art.asp?articlekey=3979http://www.rxlist.com/script/main/art.asp?articlekey=4723http://www.rxlist.com/script/main/art.asp?articlekey=15911http://www.rxlist.com/script/main/art.asp?articlekey=5209http://www.rxlist.com/script/main/art.asp?articlekey=5095http://www.rxlist.com/script/main/art.asp?articlekey=3425http://www.rxlist.com/script/main/art.asp?articlekey=33429http://www.rxlist.com/script/main/art.asp?articlekey=5919http://www.rxlist.com/script/main/art.asp?articlekey=10935http://www.rxlist.com/script/main/art.asp?articlekey=3555http://www.rxlist.com/script/main/art.asp?articlekey=2780http://www.rxlist.com/script/main/art.asp?articlekey=2985http://www.rxlist.com/script/main/art.asp?articlekey=4510http://www.rxlist.com/script/main/art.asp?articlekey=5099http://www.rxlist.com/script/main/art.asp?articlekey=8121


61/85


62/85

C6E (rad!cardia? h!-otension&+IE a(dominal cram-s? diarrhea? e9cessive salivation? nausea? vomiting&DermE s=eating? rashes&

Drug Interactions Cholinergic effects ma! (e antagoni


63/85

+eneric name Prednisone

,rand name Deltasone

Classification Adrenocorticosteroids

Dosage andFrequenc!

"# mg % ta( q %"

Indications evere inflammation? immunosu--ression

Action Decreases inflammation? mainl! (! sta(ili su--resses immune res-onse> stimulates (one marro=> and

influences -rotein? fat? and car(oh!drate meta(olism&


CN E eu-horia? insomnia? -s!chotic (ehavior? -seudotumor cere(ri?vertigo? headache? -aresthesia? sei


64/85

doctorQs name? name of drug? and dose ta1en& @arn -atient on long4term thera-! a(out cushingoid s!m-toms

moonface? (uffalo hum-B and to notif! doctor of sudden =eightgain or s=elling&

Advise -atient receiving long4term thera-! to consider e9ercise or

-h!sical thera-!& Also tell -atient to as1 doctor a(out vitamin D orcalcium su--lement&

7ell -atient to re-ort slo= healing& Advise -atient receiving long4term thera-! to have -eriodic

o-hthalmic e9aminations& Instruct -atient to avoid e9-osure to infections and to contact

doctor if e9-osure occurs&

+eneric name A


65/85

Digo9inE ma! cause elevated digo9in levels& Monitor dogo9in levelsclosel!&7heo-h!llineE ma! increase -lasma theo-h!lline levels =ith othermacrolides> effect of a


66/85

Der/9 rashes? urticaria&*e/at9 AP8A 7IC AN3MIA? (one marro= de-ression? neutro-enia?throm(oc!to-enia&Ne r!9 -eri-heral neuritis&Misc9 AN+IO3D3MA? +RA NDROM3 IN N3@,ORN ? fever&

Drug Interactions Ma! increase effects of the follo=ing drugsE oral h!-ogl!cemic agents?=arfarin ? and -hen!toin

Pheno(ar(ital or rifam-in ma! decrease chloram-henicol (lood levels

Ma! dela! res-onse to vitamin , or folic acid thera-!

Contraindications .!-ersensitivit!

Previous to9ic reaction to chloram-henicol

Patients =ith severe he-atic or renal disease? increased ris1 of reactionsdue to ina(ilit! to meta(oli (ruising> fever> sore throat> nausea> vomiting>diarrhea> num(ness? tingling? or (urning -ain or =ea1ness in hands orfeet occurs&

j Instruct -atient to re-ort signs of su-erinfection stomatitis? -erianalitching? vaginal discharge? feverB

j 3m-hasi


67/85

Indications

Action !nthesisu--resses the normal immune res-onse& Increases car(oh!drate? fat? and

-rotein meta(olism&AdverseReactions L ide3ffects

CN E Insomnia? nervousness+IE Increased a--etite? indigestion

Drug Interactions Increase ris1 of h!-o1alemia =ith diuretics? am-hotericin ,? ticarcillin&Ma! increase digo9in to9icit! due to h!-o1alemia&

Contraindications .!-ersensitivit!> P D> tu(erculosis? fungal infections or an! sus-ectedinfections? h!-ertension? dia(etes mellitus&

Nursing

Res-onsi(ilities

Instruct to administer oral drugs =ith food or mil1 earl! in the

morning to reduce +I u-set&Do not increase doses and do not sto- a(ru-tl! =ithout consulting

!our doctor

Re-ort an! visual distur(ance or severe +I distress? sudden=eight gain? s=elling? sore throat? fever? or signs of infection&

Instruct -atient not to ta1e =ith as-irin or an! medication =ithoutconsulting -rovider&

Discuss a diet lo= in sodium? high in 6itamin D? -rotein and -otassium&

Avoid e9-osure to cantagiona nad notif! doctor for an! signs ofinfection&

+eneric name Ceftria9one

,rand name Roce-hin

Classification Ce-halos-orin

Dosage andFrequenc!

% gram I677 q%"

02


68/85

Indications 7reatment for lo=er res-irator! tract infections&

Action Inhi(its (acterial cell =all s!nthesis& Most effective against ra-idl!gro=ing organisms&


Nausea? vomiting? diarrhea&Ana-h!la9is ma! occur&

Ne-hroto9icit!7hrom(oc!to-enia

Drug Interactions Increase ris1 of (leeding =hen given =ith anticoagulants? or throm(ol!ticagents& Pro(enecid ma! increase serum levels of ce-halos-orins&

Contraindications.!-ersensitivit! to ce-halos-orins or -enicillin& Caution =ith renalLhe-aticim-airment? (leeding disorders or +I disease&

Contraindicated in -atients =ith 1no=n allerg! to the ce-halos-orin classof anti(iotics&


Assess histor! of -revious allergic reactions

Instruct -atient to administer on an em-t! stomach for (etterresults&

Monitor @,C counts? cultures? and P7&

Assess , N and creatinine levels =ith renal im-airment&

Monitor 6 ? I and O

If dia(etic? monitor glucose levels&Re-ort unresolved? eas! (leeding or (ruising

+eneric name ultamicillin

,rand name am-icillin4sul(actam , )nasyn

Classification AMINOP3NICI88IN

Dosage andFrequenc!

%/# mg % ta(let ,ID

05


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Indications Other salmonella infections+onococcal infectionsu--urative and uns-ecified otitis mediaAcute sinusitisAcute fi(rinous (ronchitis

Acute mem(ranous (ronchitisAcute -seudomem(ranous (ronchitisAcute -urulent (ronchitisAcute crou-ous (ronchitisAcute tracheo(ronchitis

Action Antimicro(ial effect


Ana-h!lactic shoc1 Angioneurotic oedemaDiarrhoea39foliative dermatitisInterstitial ne-hritis8euco-enia

NauseaPain in )oints 4 arthralgiaP!re9iaRash7hrom(oc!to-enia

Drug Interactions 8i1el! interaction of PRO,3N3CID increasing the AN7IMICRO,IA8effect of 87AMICI88IN& suall! no ris1&

Contraindications Penicillin allerg!Adverse reaction to -enicillinsAdverse reaction to am-icillinPersonal histor! of -enicillin allerg!


o Inform -rescri(er of all -rescri-tions? O7C medications? or her(al -roducts !ou are ta1ing? and an! allergies !ou have&

o Do not ta1e an! ne= medication during thera-! unless a--roved (! -rescri(er&

o 7his medication is administered (! infusionLin)ection& Re-ortimmediatel! -ain? redness? s=elling? or (urning at

in)ectionLinfusion site or feelings of acute an9iet!? chest tightness?or difficult! s=allo=ing&

o Maintain adequate h!dration "4' 8Lda! of fluidsB unless instructedto restrict fluid inta1e&

o If !ou have dia(etes? drug ma! cause false test results =ithClinitest urine glucose monitoring> use of another t!-e of glucosemonitoring is -refera(le&

o Ma! cause diarrhea if -ersistent? consult -rescri(er for a--roved

0$


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medicationB& Re-ort rash or -ersistent? o--ortunistic infection

+eneric name A


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dar1 urine? -ruritus? and !ello= s1in and sclera> and for increasedal1aline -hos-hatise? (iliru(in? A 7? and A87 levels&@arn -atient to re-ort even mild infections colds? fever? sorethroat? malaiseB (ecause drug is a -otent immunosu--ressant&Instruct -atient to avoid conce-tion during thera-! and for *

months after thera-! sto-s&@arn -atient that some hair thinning is -ossi(le&Advise -atient to re-ort unusual (leeding or (ruising&7ell -atient that drug ma! (e ta1en =ith food to decrease nausea&Advise -atient to use soft (ristled tooth(rush and -erform oral carecautiousl! to decrease ris1 of (leeding&

2%


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DISC*ARGE #LAN

M e icati!ns#re nis!ne + /& = ta3let =+Ti/in&9 Fa/ - F2/#atient teachin&

7ell -atient not to discontinue drug a(ru-tl! or =ithout doctorQs consent& Instruct -atient to ta1e drug =ith food or mil1& 7each -atient signs and s!m-toms of earl! adrenal insufficienc!E fatigue? muscular

=ea1ness? )oint -ain? fever? anore9ia? nausea? d!s-nea? di


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Pyridostigmine 60 mg/ tablet 1 tablet q12

Timing: 6am, 6pm

Patient teaching

Instruct -atient to ta1e medication as directed& Do not s1i- or dou(le u- on missed doses&Patients =ith a histor! of d!s-hagia should have a nonelectric or (atter!4o-erated (ac14u- alarm cloc1 to remind them of e9act dose time& Patients =ith d!s-hagia ma! not (ea(le to s=allo= medication if the dose is not ta1en e9actl! on time& 7a1ing dose late ma!result in m!asthenic crisis& 7a1ing dose earl! ma! result in cholinergic crisis& Patients=ith m!asthenia gravis must continue this regimen as a life4long thera-!

Advise -atient to carr! identification descri(ing disease and medication regimen at alltimes

Instruct -atient to s-ace activities to avoid fatigueE ercise

3ncourage -t to -erform dee- (reathing G coughing e9ercises at least '4/9 a da!&

o Dee2 'reathin& e ercises

o Its goal is to 1ee- e9-and lungs G -romote lung h!giene&

o ProcedureE

%& it on the edge of the (ed or lie su-ine =ith 1nees fle9 to rela9 thea(dominal muscles&

"& Place hands on the a(domen to feel =hether the chest rises to indicate thatthe lungs are e9-anded&

'& Inhale through nose until the a(domen (alloons out=ard G hold in thecount of five&

*& Instruct the client to e9hale through -urse li-s =hile contracting thea(dominal muscles&

o C! &hin& E ercises

o 7o mo(ili


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%& 8ean for=ard slightl! from a sitting -osition on (ed or chair&

"& Inhale through the nose&

'& 39hale through the mouth&

*& Re-eat ste-s " G ' three times

/& Inhale dee-? then contract the a(dominal muscles G cough once or t=ice&

A/3 lati!n !r al;in&

o It is (est to =al1 at least '# minutes cumulativel! -er da! to -romote circulation&

3ncourage to -erform ROM e9ercises Fle9ion? rotation? a(duction? adduction ofe9tremities to -romote circulation&

It is (est to e9ercise at the same time of the da!? if -ossi(le&

)ote: St!2 any activity i1 severe sh!rt !1 3reath, 2ain, / scle $ea;ness !r i66inessevel!2s.

Y!&a a series of gentle stretching movements& .as (een -racticed in India for centuries&It can reduce stress G fatigue? im-rove (alance G s-asticit!? G hel- (o=el G (laddermanagement& Practitioners of !oga often sa! that it increases their energ! G vitalit!&

Tai chi 7ai chi is a Chinese martial art& It is not? ho=ever? a martial art in the st!le of

,ruce 8ee or ac1ie Chan& Dee- (reathing? rela9ation? G slo=? gentle movements are the -rimar! elements& Often referred to as a method of Hmoving meditation ? tai chi is aconditioning regimen that is even gentler than most forms of !oga& 7ai chi is usuall!

-erformed as an ordered set of slo=? elegant motions that -romote (alance throughthoughtful consideration of movements G heightening of (od! a=areness& 7rue to its,uddhist roots? tai chi see1s to relieve stress? im-rove focus G muscle tone? G develo-

(alance of mind G (od!& Recent clinical studies have confirmed that tai chi -roducesmeasura(le (enefits in im-roving (alance? lo=ering (lood -ressure? G im-rovingcardiovascular health&

Maintain a rela9ed lifest!le? -ractice rela9ation e9ercises and learn to meditate&

T hera2y8 T reat/entater thera2y3ncourage -t to drin1 "4' liters of =ater -er da!& 7o -romote h!dration G elimination ofto9ins in the (od!&

2*


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M sic thera2y8isten to mello= or Ins-irational songsLmusic& It -roduces rela9ation G desired changes inemotions? (ehaviors? G -h!siolog!&T! ch thera2y7he use of touch can transmit energ! to -erson =ho is ill G in)ured to -otentate the healing

-rocess& It gives comfort to -atient&Diverti!nal activity

se guided imager!E see or feel a (rilliant =hite or golden healing light enter the to- of!our head? flo= through !our muscles and organs? strengthening and invigoratingthem&Do these e9ercises dail! for a(out an hour& Avoid stress? emotional u-sets? hot

(aths? hot sho=ers and hot food? have -lent! of rest& ,efore -erforming a difficult tas1?close !our e!es and vividl! imagine -erforming that tas1 =ith ease& 7hen o-en !our e!esand do it& As much as -ossi(le (e outside in natural surroundings& .ave frequent shorte9-ose of !our un-rotected s1in to mild sunlight&

It can relieve (! diverting the mind from the stressful im-ulse G focuses it on -leasant things

Me itati!n thera2y7his thera-! can quiet the mind G focus it n the -resent G to release fears? =orries? an9iet! Gdou(ts concerning the -ast G the future&

S r&ical thera2yA th!mectom! is a surgical removal of the th!mus gland& 7he th!mus has (een demonstrated to

-la! a role in the develo-ment of M+& It is removed in an effort to im-rove the =ea1ness caused (! M+? G to remove a th!moma if -resentlas/a2heresisPlasma-heresis? or -lasma e9change? ma! (e useful in the treatment of M+ also& 7his -rocedureremoves the a(normal anti(odies from the -lasma of the (lood& 7he im-rovement in musclestrength ma! (e stri1ing? (ut is usuall! short4lived? since -roduction of the a(normal anti(odiescontinues& @hen -lasma-heresis is used? it ma! require re-eated e9changes& Plasma e9changema! (e es-eciall! useful during severe M+ =ea1ness or -rior to surger!&

N!n2har/ac!l!&ical treat/ent !1 !c lar MG ?i1 ever evel!2s@ @earing e!elid ta-e a s-ecial t!-e of ta-e used to hold the e!elids o-en =ithout in)uring

the e!elidsB& 7his can (e used for -tosis G ma! (e -refera(le to drug thera-! that altersthe immune s!stem using agents such as glucocorticoids -rednisone or similar agentsB?

a


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sing e!elid crutches clever devises attached to glasses to hold the e!elids o-enB for -tosis G e!eglass -risms for di-lo-ia& 7hese are rarel!4used? older methods of treatm

Documents

Myasthenia Gravis Case Presentation