Myasthenia Gravis

_____________________ In Partial Fulfillment Of the Requirements in Davao Medical Center Critical Care Nursing Program __________________ A Case tud! Presented to the taff of Davao Medical Center ___________________ ESTRADA, Jay Mart A. LAYNO, Jaclyn C. MARTINEZ, Gla ys E. ORTIZANO, M!nr!e S. RAMOS, Maria "ristina #. STA. ANA, Yra G$yneth %ir&inia #. ___________________ March "##$ ___________________

TA'LE O( CONTENTS
#a&es I& II& Introduction O()ectives A& +eneral O()ectives ,& -ecific O()ectives III& Nursing .istor! A& Demogra-hic data ,& .istor! of Present Illness C& .istor! of Past Illness D& Famil! ,ac1ground 3& ocio4Cultural ,ac1ground of the Patient F& +enogram I6& 6& 6I& 6II& 6III& I:& :& :I& :II& :III& Anatom! and Ph!siolog! Patho-h!siolog! Nursing Assessment Nursing Diagnosis and 7heories 8a( tudies and Diagnostic 39ams Doctor;s Orders Nursing Care Plans Drug tud! Discharge Plan Prognosis / 0 0 2 2 5 $4"% ""4"/ "04"$ '#4'" ''4*" *'4*0 *24/" /'405 0$42$ 5# 5% ' *

:I6& References

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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<ed (! severe generali<ed muscle =ea1ness and res-irator! and (ul(ar =ea1ness that ma! result in res-irator! failure& Crisis ma! result from disease e9acer(ation or a s-ecific -reci-itating event& 7he most common -reci-itator is infection> others include medication change? surger!? -regnanc!? and high environmental tem-erature& Neuromuscular res-irator! failure is the critical com-lication of crisis> res-irator! muscles and (ul(ar =ea1ness com(ine to cause res-irator! com-romise& An inadequate cough and an im-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 -atient in crisis& M!asthenia Crisis is the life threatening com-lication of M!asthenia +ravis4 an autoimmune disorder affecting the m!oneural )unction? characteri<ed (! var!ing degrees of =ea1ness of the voluntar! muscles& @omen tend to develo- the disease at an earlier age A"#4*# !ears oldB com-ared to men A0#42# !ears oldB? and =omen are affected more frequentl!& M!asthenia +ravis ma! (e associated =ith other autoimmune disorders& Patients =ith famil! mem(ers =ho suffer from the disorder such as rheumatoid arthritis? scleroderma and lu-us er!thematosus ma! have increase ris1 for M!asthenia +ravis& 7he incidence is % case -er "/#?### -ersons& M!asthenia Crisis ma! com-licate in %/4"#C of -atients =ith M!asthenia +ravis& 7he crisis occurred =ithin " !ears of disease onset in ma)orit! of the cases& Infections =ere the most common -rimar! -reci-itants of crisis occurring in 0/C of -atients& 7here are %'?0## -eo-le in D A =ho are re-orted to have M!asthenia +ravis according to the statistics featured at the internet (! ===&=rongdiagnosis&com and *?'%" re-orted cases in the Phili--ines& 7hese statistics ho=ever is not accurate since statistics are increasing each !ear and there are still unre-orted cases =orld=ide& 7he initial manifestation involves the ocular muscles =hich includes di-lo-ia and -tosis& Ma)orit! of the -atients e9-erience muscle =ea1ness of the face and throat& It is a motor disorder =ith no effect on sensation and coordination& Our su()ect for this case is Ms& Flordeluna +ocela? "$ !ears old? single and a resident of 7agum Cit!& he has (een diagnosed to have M!asthenia +ravis last "##2 and has sought medical interventions since then& he =as admitted last Decem(er "2? "##5 at Davao Medical Center due to d!s-nea& D-on her recent admission to Davao Medical Center? she =as diagnosed to have M!asthenic Crisis& Our grou- aims to meet our s-ecified o()ectives and direct ourselves to have an in4de-th stud! regarding M!asthenia Crisis and to tac1le issues regarding the disease&

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,& O()ectives of the Case tud!

General ObjectivesE 7hat =e =ould (e a(le to gather sufficient information regarding our -atient;s condition for (etter understanding on the disease studied and to come u- =ith a =ell4 directed and =ell organi<ed case stud!& Specific Objectives: 7he a(ove o()ective =ould (e o(tained if =e are guided =ith the follo=ing s-ecific o()ectivesE Find a -atient for this case stud!> 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 -resentation and 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 the stud!> Itemi<e the drugs -rescri(ed to the client4 it;s action? indications? contraindications? side effects and its corres-onding considerations in administration Render health teaching for the discharge of the -atient&

During our case presentation, our group would be able to: Discuss thoroughl! and com-rehensivel! the su()ect of our case stud!> Ans=er an! questions raised u- (! the -anelists> Meet our o()ectives -resented a(ove&

N)RSING *ISTORY
A& Demogra-hic Data
NameE Flordeluna +ocela AddressE Puro1 '4A 8a Fili-ina? 7agum Cit! Date of ,irthE Fune 2? %$2$ Place of ,irthE Ce(u Cit! AgeE "$ !rs& Old tatusE ingle +enderE Female Nationalit!E Fili-ino ReligionE Roman Catholic FatherE Fuan MotherE Necita 3ducational AttainmentE College +raduate ACom-uter cience? Dniversit! 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

,& .istor! of Present Illness

7hree da!s -rior to her admission? our -atient had -roductive cough? colds and -tosis& he did 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 )ust rest G continue to =or1 after her s!m-toms lessen or relieved& Nine hours -rior to her -resent admission? our -atient had sudden onset of d!s-nea and difficult! in s=allo=ing? Hnaglisod 1o ug ginha=a ug tulon (isan la=a!I as ver(ali<ed& he )ust sat in an orthoneic sitting -osition to relieve her d!s-nea G =as afraid to eat or drin1 due to difficult! of s=allo=ing& he tried slee-ing as earl! as $E## -m (ut she =asn;t a(le to slee-? so she as1 her sister to massage her (ac1 G e9trimities? =hile a--l!ing 3fficacent oilJ? until she =ere a(le to sle-t at around %E## am& At around *E## am she =o1e u- due to her =orsening condition& @hen she could not ta1e it an!more? she informed her sister and the! sought consult =hich had (een the reason for her admission& At /E## am she =as (rought in? am(ulator!? =ith her sister at the 3mergenc! room of Davao Medical Center G =as ordered (! Dr& +uillermo to (e admitted to ICD % under =hite service? on DA7 =ith trict as-iration -recaution& O" inhalation K ' 8PM =ere given -er nasal cannula? venocl!sis started =ith D/ 8R % liter K %"# ccLhr& ,lood s-ecimen =as ta1en for la(orator! =or14u- G =as medicated =ith P!ridostigmine 0/ mgLta( G .!drocortisone %## mg I677& he =as relieved =ith her d!s-nea -artiall!& At $E'/ am her d!s-nea still -ersist so the AP ordered to increase O" inhalation K 0 8PM& .er condition =as relieved then&

C& .istor! of Past Illness

Our -atient is com-lete =ith immuni<ations =hen she =as a child as claimed& he e9-erienced common illnesses such as cough? flu? and colds& During her childhood da!s? she had also e9-erienced chic1en -o9 and measles& he had not (een in an! accident? though& he had not (een hos-itali<ed in her !ounger !ears& On A-ril "##2? -atient e9-erienced difficult! in s=allo=ing? s-ea1ing? ina(ilit! to e9-ectorate? and eas! fatiga(ilit!& he had sought consult at Con-inco Clinic at 7agum Cit! at =as told to (e under stress and =as -rescri(ed =ith unrecalled medications G vitamins& he continued to =or1 (ut instead of her usual %" hours? she onl! =or1ed for 5 hours a da! (ecause she gets tired easil!& A month later? she e9-erienced (od! =ea1ness? -tosis? and -hotosensitivit! (ut =as not admitted& he =as onl! advised to have rest if (od! =ea1ness occurs G =ear sunglasses for -tosis G -hotosensitivit!& On Novem(er "##2? she =as admitted at Davao Regional .os-ital at 7agum Cit! (ecause of difficult! of (reathing& Associated =ith it are other s!m-toms such as -aral!sis and slurring of s-eech& he =as intu(ated for t=o da!s and also had a nasogastric tu(e inserted in her nose& During that admission =as she diagnosed =ith M!asthenia +ravis& he =as -rescri(ed =ith P!ridostigmine 0/ mgLta( 7ID and -rednisone "# mg % ta(let q%" =hich she com-lied =ell&

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

D& Famil! ,ac1ground

Flor;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 (! the informant to =hat s-ecific cause of death& .!-ertension is the main illness in some of the mem(ers of their famil!& Mr& 3? F? +? .? G F had such illness& In addition to this? Mr& . also had drug4induced mental illness according to the informant& On to- of (eing an occasional alcoholic drin1er? Mr& . G F are chain smo1ers& Mr& F is a solel! alcoholic drin1er =hile Mr& M is a solel! chain smo1er& Ms& P suffers from insomnia& Among the si(lings? onl! Flor had (een e9-eriencing m!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 of that 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 Dniversit! 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 goes to a HhilotI to give her relief& Our -atient lives =ith her sister (ut she is not quite close to her si(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-ite her condition& he easil! gets along =ith other -eo-le and hasn;t have had an! trou(le =ith them&

(. GENOGRAM
Mr& N Ms& N Mr& O Ms& O

Mr& A

Mr& :

Ms& ,

Mr& C

Ms& D

Ms& :

Mr& 3? /%

Mr& +? *2

Mr& F? *'

Mr& M? '2 Mr& 8? '%

Ms&P?"2

Mr& F? *$

Mr& .? */ Drin1er M!asthenia +ravis mo1er Mental illness Insomnia

Ms. R, +,

Ms& ? "2

Dnrecalled num(er of si(lings Neonatal death .!-ertension Dnrecalled cause of death

No additional information Pneumonia Dnrecalledgender $

ANATOMY - #*YSIOLOGY
Ne.r!/.sc.lar 0.ncti!n
3lectron microgra-h sho=ing a cross section through the neuromuscular )unction& 7 is the a9on terminal? M is the muscle fi(er& 7he arro= sho=s )unctional folds =ith (asal lamina& Posts!na-tic densities are visi(le on the ti-s (et=een the folds& cale is #&' Pm& ourceE NIM.

A neuromuscular )unction ANMFB is the s!na-se or )unction of the a9on terminal of a motoneuron =ith the motor end -late? the highl!4e9cita(le region 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 -asses through the neuromuscular )unction via the neurotransmitter acet!lcholine& Anat!/y

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

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

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Motor neuron AefferentB a9ons originating in the s-inal cord enter muscle fi(ers? =here the! s-lit into man! unm!elinated (ranches& 7hese terminal fi(ers run along the m!oc!tes to end at the neuromuscular )unction? =hich occu-ies a de-ression in the sarcolemma& 3ach motor neuron can innervate from one to over "/?### R%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 <ones accumulate s!na-tic vesicles filled =ith the neurotransmitter acet!lcholine& On the muscle side of the )unction? the muscle fi(er is folded into grooves called -re)unctional folds that mirror the -res!na-tic active <ones? the s-aces (et=een the folds contain the en<!me acet!lcholinesterase& 7he muscle surface is covered (! the s!na-tic (asal lamina& Post)unctional folds are characteristic of s1eletal muscle? -articularl! in fast muscle fi(ers& Mechanis/ !1 acti!n D-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 causes neurotransmitter4containing vesicles to fuse to the motor neuronQs cell mem(rane and release 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 nicotinic acet!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 -lasma mem(rane? more sodium moves in than -otassium out? -roducing a local de-olari<ation of the motor end -late 1no=n as an end4-late -otential A3PPB& 7his de-olari<ation s-reads across the surface of the muscle fi(er into transverse tu(ules? eliciting the release of calcium from the sarco-lasmic reticulum? thus initiating muscle contraction& 7he action of acet!lcholine is terminated =hen the en<!me acet!lcholinesterase degrades the neurotransmitter and the unh!drol!sed neurotransmitter diffuses a=a!& Acet!lcholine is a neurotransmitter s!nthesi<ed in the human (od! from dietar! choline and acet!l coen<!me A& One of the first neurotransmitters discovered? the su(stance =as originall! referred to as UvagusstoffU (ecause it =as found to (e released (! the stimulation of the vagus nerve& 8ater? it =as esta(lished that acet!lcholine is? in fact? im-ortant in the stimulation of all muscle tissue and that its action ma! (e either e9citator! or inhi(itor!? de-ending on a num(er of factors& @ithin the (od!? the s!na-tic action of acet!lcholine usuall! quic1l! comes to a halt? the neurotransmitter naturall! (rea1ing do=n soon after its release& .o=ever? some nerve gases are designed to th=art this (rea1do=n? causing -rolonged stimulation of the rece-tor cells and resulting in severe muscle s-asms Devel!2/ent !1 the ne.r!/.sc.lar 0.ncti!n 7he formation of the neuromuscular )unction during em(r!onic develo-ment is =ell understood&

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During develo-ment? the gro=ing end of motor neuron a9ons secrete a -rotein 1no=n as agrin& 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 M -rotein AMuscle s-ecific 1inaseB& Mu M 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& D-on activation (! its ligand agrin? Mu M signals via t=o -roteins called UDo14 2U and Ura-s!nU? to induce UclusteringU of acet!lcholine rece-tors AAChRB& In addition to the AChR and Mu M? other -roteins are then gathered? to form the end-late to the neuromuscular )unction& 7he nerve terminates onto the end-late? forming the NMF&

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 them from the organismQs o=n health! cells and tissues in order to function -ro-erl!& Detection is com-licated as -athogens can evolve ra-idl!? -roducing ada-tations that avoid the immune s!stem and allo= the -athogens to successfull! infect their hosts& 7o survive this challenge? multi-le mechanisms evolved that recogni<e and neutrali<e -athogens& 3ven sim-le unicellular organisms such as (acteria -ossess en<!me s!stems that -rotect against viral infections& Other (asic immune mechanisms evolved in ancient eu1ar!otes and remain in their modern descendants? such as -lants? fish? re-tiles? and insects& 7hese mechanisms include antimicro(ial -e-tides called defensins? -hagoc!tosis? and the com-lement s!stem& 6erte(rates such as humans have even more 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!namic net=or1& As -art of this more com-le9 immune res-onse? the human immune s!stem ada-ts over time to recognise s-ecific -athogens more efficientl!& 7his ada-tation -rocess is referred to as Uada-tive immunit!U or Uacquired immunit!U and creates immunological memor!& 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! diseases occur =hen the immune s!stem is less active than normal? resulting in recurring and life4 threatening infections& Immunodeficienc! can either (e the result of a genetic disease? such as severe com(ined immunodeficienc!? or (e -roduced (! -harmaceuticals or an infection? such as the acquired immune deficienc! s!ndrome AAID B that is caused (! the retrovirus .I6& In contrast? autoimmune diseases result from a h!-eractive immune s!stem attac1ing normal tissues as if the! =ere foreign organisms& Common autoimmune diseases 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 significant relevance 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

e1ense 7he 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 (acteria and 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 immune s!stems are found in all -lants and animals&R"S .o=ever? if -athogens successfull! evade the innate res-onse? verte(rates -ossess a third la!er of -rotection? the ada-tive immune s!stem? =hich is activated (! the innate res-onse& .ere? the immune s!stem ada-ts its res-onse during an infection to im-rove its recognition of the -athogen& 7his im-roved res-onse is then retained after the -athogen has (een eliminated? in the form of an immunological memor!? and allo=s the ada-tive immune s!stem to mount faster and stronger attac1s each time this -athogen is encountered& C!/2!nents !1 the i//.ne syste/ Innate i//.ne syste/ Res-onse is non4s-ecific 39-osure leads to immediate ma9imal res-onse Cell4mediated and humoral com-onents No immunological memor! Found in nearl! all forms of life A a2tive i//.ne syste/ Pathogen and antigen s-ecific res-onse 8ag time (et=een e9-osure and ma9imal res-onse Cell4mediated and humoral com-onents 39-osure leads to immunological memor! Found onl! in )a=ed verte(rates

,oth innate and ada-tive immunit! de-end on the a(ilit! of the immune s!stem to distinguish (et=een self and non4self molecules& In immunolog!? self molecules are those com-onents of an organismQs (od! that can (e distinguished from foreign su(stances (! the immune s!stem& Conversel!? non4self molecules are those recogni<ed as foreign molecules& One class of non4self molecules are called antigens Ashort for anti(od! generatorsB and are defined as su(stances that (ind to s-ecific immune rece-tors and elicit an immune res-onse& S.r1ace 3arriers everal (arriers -rotect organisms from infection? including mechanical? chemical and (iological (arriers& 7he =a9! cuticle of man! leaves? the e9os1eleton of insects? the shells and mem(ranes of e9ternall! de-osited eggs? and s1in are e9am-les of the mechanical (arriers that are the first line of defense against infection& .o=ever? as organisms cannot (e com-letel! sealed against their environments? other s!stems act to -rotect (od! o-enings such as the lungs? intestines? and the genitourinar! tract& In the lungs? coughing and snee<ing mechanicall! e)ect -athogens and other irritants from the res-irator! tract& 7he flushing action of tears and urine also mechanicall! e9-els -athogens? =hile mucus secreted (! the res-irator! and gastrointestinal tract serves to tra- and entangle microorganisms& Chemical (arriers also -rotect against infection& 7he s1in and res-irator! tract secrete antimicro(ial -e-tides such as the V4defensins& 3n<!mes such as l!so<!me and -hos-holi-ase A" in saliva? tears? and (reast mil1 are also anti(acterials& 6aginal secretions serve as a chemical (arrier follo=ing menarche? =hen the! (ecome slightl!

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acidic? =hile semen contains defensins and <inc to 1ill -athogens& In the stomach? gastric acid and -roteases serve as -o=erful chemical defenses against ingested -athogens& @ithin the genitourinar! and gastrointestinal tracts? commensal flora serve as (iological (arriers (! com-eting =ith -athogenic (acteria for food and s-ace and? in some cases? (! changing the conditions in their environment? such as -. or availa(le iron& 7his reduces the -ro(a(ilit! that -athogens =ill (e a(le to reach sufficient num(ers to cause illness& .o=ever? since most anti(iotics non4s-ecificall! target (acteria and do not affect fungi? oral anti(iotics can lead to an Hovergro=thI of fungi and cause conditions such as a vaginal candidiasis Aa !east infectionB&R 7here is good evidence that re4introduction of -ro(iotic flora? such as -ure cultures of the lacto(acilli normall! found in un-asteuri<ed !oghurt? hel-s restore a health! (alance of micro(ial -o-ulations in intestinal infections in children and encouraging -reliminar! data in studies on (acterial gastroenteritis? inflammator! (o=el diseases? urinar! tract infection and -ost4surgical infections& Innate Microorganisms or to9ins that successfull! enter an organism =ill encounter the cells and mechanisms of the innate immune s!stem& 7he innate res-onse is usuall! triggered =hen micro(es are identified (! -attern recognition rece-tors? =hich recogni<e com-onents that are conserved among (road grou-s of microorganisms?R or =hen damaged? in)ured or stressed cells send out alarm signals? man! of =hich A(ut not allB are recogni<ed (! the same rece-tors as those that recogni<e -athogens&R Innate immune defenses are non4s-ecific? meaning these s!stems res-ond to -athogens in a generic =a!& 7his s!stem does not confer long4lasting immunit! against a -athogen& 7he innate immune s!stem is the dominant s!stem of host defense in most organisms& *./!ral an che/ical 3arriers In1la//ati!n Inflammation is one of the first res-onses of the immune s!stem to infection& 7he s!m-toms of inflammation are redness and s=elling? =hich are caused (! increased (lood flo= into a tissue& Inflammation is -roduced (! eicosanoids and c!to1ines? =hich are released (! in)ured or infected cells& 3icosanoids include -rostaglandins that -roduce fever and the dilation of (lood vessels associated =ith inflammation? and leu1otrienes that attract certain =hite (lood cells Aleu1oc!tesB& Common c!to1ines include interleu1ins that are res-onsi(le for communication (et=een =hite (lood cells> chemo1ines that -romote chemota9is> and interferons that have anti4viral effects? such as shutting do=n -rotein s!nthesis in the host cell& +ro=th factors and c!toto9ic factors ma! also (e released& 7hese c!to1ines and other chemicals recruit immune cells to the site of infection and -romote healing of an! damaged tissue follo=ing the removal of -athogens& C!/2le/ent syste/ 7he com-lement s!stem is a (iochemical cascade that attac1s the surfaces of foreign cells& It contains over "# different -roteins and is named for its a(ilit! to Hcom-lementI the 1illing of -athogens (! anti(odies& Com-lement is the ma)or humoral

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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 that have attached to these micro(es or the (inding of com-lement -roteins to car(oh!drates on 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& After com-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!tic cascade that am-lifies the initial signal (! controlled -ositive feed(ac1& 7he cascade results in the -roduction of -e-tides that attract immune cells? increase vascular -ermea(ilit!? and o-soni<e AcoatB the surface of a -athogen? mar1ing it for destruction& 7his de-osition of com-lement can also 1ill cells directl! (! disru-ting their -lasma mem(rane& Cell.lar 3arriers 8eu1oc!tes A=hite (lood cellsB act li1e inde-endent? single4celled organisms and are the second arm of the innate immune s!stem& 7he innate leu1oc!tes include the -hagoc!tes Amacro-hages? neutro-hils? and dendritic cellsB? mast cells? eosino-hils? (aso-hils? and natural 1iller cells& 7hese cells identif! and eliminate -athogens? either (! attac1ing larger -athogens through contact or (! engulfing and then 1illing microorganisms& Innate cells are also im-ortant mediators in the activation of the ada-tive immune s!stem& Phagoc!tosis is an im-ortant feature of cellular innate immunit! -erformed (! cells called Q-hagoc!tesQ that engulf? or eat? -athogens or -articles& Phagoc!tes generall! -atrol the (od! searching for -athogens? (ut can (e called to s-ecific locations (! c!to1ines& Once a -athogen has (een engulfed (! a -hagoc!te? it (ecomes tra--ed in an intracellular vesicle called a -hagosome? =hich su(sequentl! fuses =ith another vesicle called a l!sosome to form a -hagol!sosome& 7he -athogen is 1illed (! the activit! of digestive en<!mes or follo=ing a res-irator! (urst that releases free radicals into the -hagol!sosome& Phagoc!tosis evolved as a means of acquiring nutrients? (ut this role =as e9tended 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 are the most a(undant t!-e of -hagoc!te? normall! re-resenting /#C to 0#C of the total circulating 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 -rocess called 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! of chemicals including en<!mes? com-lement -roteins? and regulator! factors such as interleu1in %& Macro-hages also act as scavengers? ridding the (od! of =orn4out cells and other de(ris? and as antigen4-resenting cells that activate the ada-tive immune s!stem Dendritic cells ADCB are -hagoc!tes in tissues that are in contact =ith the e9ternal environment> 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 have man! s-ine4li1e -ro)ections? (ut dendritic cells are in no =a! connected to the nervous s!stem& Dendritic cells serve as a lin1 (et=een the (odil! tissues and the innate and ada-tive immune s!stems? as the! -resent antigen to 7 cells? one of the 1e! cell t!-es of the ada-tive immune s!stem& Mast cells reside in connective tissues and mucous mem(ranes? and regulate the inflammator! 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 mediators that are involved in defending against -arasites and -la! a role in allergic reactions? such as asthma& Natural 1iller ANM cellsB cells are leu1oc!tes that attac1 and destro! tumor cells? or cells that have (een infected (! viruses& A a2tive 7he 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 is Uremem(eredU (! a signature antigen& 7he ada-tive immune res-onse is antigen4s-ecific and requires the recognition of s-ecific Hnon4selfI antigens during a -rocess called antigen -resentation& Antigen s-ecificit! allo=s for the generation of res-onses that are tailored to s-ecific -athogens or -athogen4infected cells& 7he a(ilit! to mount these tailored res-onses is maintained in the (od! (! Umemor! cellsU& hould a -athogen infect the (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? called l!m-hoc!tes& , cells and 7 cells are the ma)or t!-es of l!m-hoc!tes and are derived from hemato-oietic stem cells in the (one marro=& , cells are involved in the humoral immune res-onse? =hereas 7 cells are involved in cell4mediated immune res-onse& ,oth , cells and 7 cells carr! rece-tor molecules that recogni<e s-ecific targets& 7 cells recogni<e a Hnon4selfI target? such as a -athogen? onl! after antigens Asmall fragments of the -athogenB have (een -rocessed and -resented in com(ination =ith a HselfI rece-tor called a ma)or histocom-ati(ilit! com-le9 AM.CB molecule& 7here are t=o ma)or su(t!-es of 7 cellsE the 1iller 7 cell and the hel-er 7 cell& Miller 7 cells onl! recogni<e antigens cou-led to Class I M.C molecules? =hile hel-er 7 cells onl! recogni<e antigens cou-led to Class II M.C molecules& 7hese t=o mechanisms of antigen -resentation reflect the different roles of the t=o t!-es of 7 cell& A third? minor su(t!-e are the WX 7 cells that recogni<e intact antigens that are not (ound to M.C rece-tors& In contrast? the , cell antigen4s-ecific rece-tor is an anti(od! molecule on the , cell surface? and recogni<es =hole -athogens =ithout an! need for antigen -rocessing& 3ach lineage of , cell e9-resses a different anti(od!? so the com-lete set of , cell antigen rece-tors re-resent all the anti(odies that the (od! can manufacture& "iller T cells Miller 7 cell are a su(4grou- of 7 cells that 1ill cells infected =ith viruses Aand other -athogensB? or are other=ise damaged or d!sfunctional& As =ith , cells? each t!-e of 7 cell recognises a different antigen& Miller 7 cells are activated =hen their 7 cell rece-tor

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A7CRB (inds to this s-ecific antigen in a com-le9 =ith the M.C Class I rece-tor of another cell& Recognition of this M.CEantigen com-le9 is aided (! a co4rece-tor on the 7 cell? called CD5& 7he 7 cell then travels throughout the (od! in search of cells =here the M.C I rece-tors (ear this antigen& @hen an activated 7 cell contacts such cells? it releases 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 called granul!sin Aa -roteaseB induces the target cell to undergo a-o-tosis& 7 cell 1illing of host cells is -articularl! im-ortant in -reventing the re-lication of viruses& 7 cell activation is tightl! controlled and generall! requires a ver! strong M.CLantigen activation signal? or additional 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 heldetermine =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 -athogens directl!& 7he! instead control the immune res-onse (! directing other cells to -erform these tas1s& .el-er 7 cells e9-ress 7 cell rece-tors A7CRB that recogni<e antigen (ound to Class II M.C molecules& 7he M.CEantigen com-le9 is also recogni<ed (! the hel-er cellQs CD* co4rece-tor? =hich recruits molecules inside the 7 cell Ae&g& 8c1B that are res-onsi(le for 7 cellQs activation& .el-er 7 cells have a =ea1er association =ith the M.CEantigen com-le9 than o(served for 1iller 7 cells? meaning man! rece-tors Aaround "##'##B on the hel-er 7 cell must (e (ound (! an M.CEantigen in order to activate the hel-er cell? =hile 1iller 7 cells can (e activated (! engagement of a single M.CEantigen molecule& .el-er 7 cell activation also requires longer duration of engagement =ith an antigen4-resenting cell& 7he activation of a resting hel-er 7 cell causes it to release c!to1ines that influence the activit! of man! cell t!-es& C!to1ine signals -roduced (! hel-er 7 cells enhance the micro(icidal function of macro-hages and the activit! of 1iller 7 cells& In addition? hel-er 7 cell activation causes an u-regulation of molecules e9-ressed on the 7 cellQs surface? such as CD*# ligand Aalso called CD%/*B? =hich -rovide e9tra stimulator! signals t!-icall! required to activate anti(od!4-roducing , cells& 45 T cells WX 7 cells -ossess an alternative 7 cell rece-tor A7CRB as o--osed to CD*T and CD5T AYVB 7 cells and share the characteristics of hel-er 7 cells? c!toto9ic 7 cells and NM cells& 7he conditions that -roduce res-onses from WX 7 cells are not full! understood& 8i1e other QunconventionalQ 7 cell su(sets (earing invariant 7CRs? such as CD%d4 restricted Natural Miller 7 cells? WX 7 cells straddle the (order (et=een innate and ada-tive immunit!& On one hand? WX 7 cells are a com-onent of ada-tive immunit! as the! rearrange 7CR genes to -roduce rece-tor diversit! and can also develo- a memor! -henot!-e& On the other hand? the various su(sets are also -art of the innate immune s!stem? as restricted 7CR or NM rece-tors ma! (e used as -attern recognition rece-tors& For e9am-le? large num(ers of human 6W$L6X" 7 cells res-ond =ithin hours to common molecules -roduced (! micro(es? and highl! restricted 6X%T 7 cells in e-ithelia =ill res-ond to stressed e-ithelial cells&Z

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' ly/2h!cytes an anti3! ies A , cell identifies -athogens =hen anti(odies on its surface (ind to a s-ecific foreign antigen&R/%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 a matching hel-er 7 cell? =hich releases l!m-ho1ines and activates the , cell& As the activated , cell then (egins to divide? its offs-ring A-lasma cellsB secrete millions of co-ies of the anti(od! that recogni<es this antigen& 7hese anti(odies circulate in (lood -lasma and l!m-h? (ind to -athogens e9-ressing the antigen and mar1 them for destruction (! com-lement activation or for u-ta1e and destruction (! -hagoc!tes& Anti(odies can also neutrali<e challenges directl!? (! (inding to (acterial to9ins or (! interfering =ith the rece-tors that viruses and (acteria use to infect cells& Alternative a a2tive i//.ne syste/ Although the classical molecules of the ada-tive immune s!stem Ae&g& anti(odies and 7 cell rece-torsB e9ist onl! in )a=ed verte(rates? a distinct l!m-hoc!te4derived molecule has (een discovered in -rimitive )a=less verte(rates? such as the lam-re! and hagfish& 7hese animals -ossess a large arra! of molecules called varia(le l!m-hoc!te rece-tors A68RsB that? li1e the antigen rece-tors of )a=ed verte(rates? are -roduced from onl! a small num(er Aone or t=oB of genes& 7hese molecules are (elieved to (ind -athogenic antigens in a similar =a! to anti(odies? and =ith the same degree of s-ecificit!& I//.n!l!&ical /e/!ry @hen , cells and 7 cells are activated and (egin to re-licate? some of their offs-ring =ill (ecome long4lived memor! cells& 7hroughout the lifetime of an animal? these memor! cells =ill remem(er each s-ecific -athogen encountered and can mount a strong res-onse if the -athogen is detected again& 7his is Uada-tiveU (ecause it occurs during the lifetime of an individual as an ada-tation to infection =ith that -athogen and -re-ares the immune s!stem for future challenges& Immunological memor! can either (e in the form of -assive short4term memor! or active long4term memor!& #assive /e/!ry Ne=(orn infants have no -rior e9-osure to micro(es and are -articularl! vulnera(le to infection& everal la!ers of -assive -rotection are -rovided (! the mother& During -regnanc!? a -articular t!-e of anti(od!? called Ig+? is trans-orted from mother to (a(! directl! across the -lacenta? so human (a(ies have high levels of anti(odies even at (irth? =ith the same range of antigen s-ecificities as their mother& ,reast mil1 also contains anti(odies that are transferred to the gut of the infant and -rotect against (acterial infections until the ne=(orn can s!nthesi<e its o=n anti(odies& 7his is -assive immunit! (ecause the fetus does not actuall! ma1e an! memor! cells or anti(odies44it onl! (orro=s them& 7his -assive immunit! is usuall! short4term? lasting from a fe= da!s u- to several months& In medicine? -rotective -assive immunit! can also (e transferred artificiall! from one individual to another via anti(od!4rich serum&

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Active /e/!ry an i//.ni6ati!n 8ong4term 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 Aalso called immuni<ationB is to introduce an antigen from a -athogen in order to stimulate the immune s!stem and develo- s-ecific immunit! against that -articular -athogen =ithout causing disease associated =ith that organism& 7his deli(erate induction of an immune res-onse is successful (ecause it e9-loits the natural s-ecificit! of the immune s!stem? as =ell as its induci(ilit!& @ith infectious disease remaining one of the leading causes of death in the human -o-ulation? vaccination re-resents the most effective mani-ulation of the immune s!stem man1ind has develo-ed& Most viral vaccines are (ased on live attenuated viruses? =hile man! (acterial vaccines are (ased on acellular com-onents of micro4organisms? including harmless to9in com-onents& ince man! antigens derived from acellular vaccines do not strongl! induce the ada-tive res-onse? most (acterial vaccines are -rovided =ith additional ad)uvants that activate the antigen4-resenting cells of the innate immune s!stem and ma9imi<e immunogenicit!& Dis!r ers !1 h./an i//.nity 7he immune s!stem is a remar1a(l! effective structure that incor-orates s-ecificit!? induci(ilit! and ada-tation& Failures of host defense do occur? ho=ever? and fall into three (road categoriesE immunodeficiencies? autoimmunit!? and h!-ersensitivities& I//.n! e1iciencies Immunodeficiencies occur =hen one or more of the com-onents of the immune s!stem are inactive& 7he a(ilit! of the immune s!stem to res-ond to -athogens is diminished in (oth the !oung and the elderl!? =ith immune res-onses (eginning to decline at around /# !ears of age due to immunosenescence& In develo-ed countries? o(esit!? alcoholism? and drug use are common causes of -oor immune function& .o=ever? malnutrition is the most common cause of immunodeficienc! in develo-ing countries& Diets lac1ing sufficient -rotein are associated =ith im-aired cell4mediated immunit!? com-lement activit!? -hagoc!te function? IgA anti(od! concentrations? and c!to1ine -roduction& Deficienc! of single nutrients such as iron> co--er> <inc> selenium> vitamins A? C? 3? and ,0> and folic acid Avitamin ,$B also reduces immune res-onses& Additionall!? the loss of the th!mus at an earl! age through genetic mutation or surgical removal results in severe immunodeficienc! and a high susce-ti(ilit! to infection& Immunodeficiencies can also (e inherited or QacquiredQ& Chronic granulomatous disease? =here -hagoc!tes have a reduced a(ilit! to destro! -athogens? is an e9am-le of an inherited? or congenital? immunodeficienc!& AID and some t!-es of cancer cause acquired immunodeficienc!& A.t!i//.nity Overactive 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!& Dnder normal

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circumstances? man! 7 cells and anti(odies react =ith HselfI -e-tides& One of the functions of s-eciali<ed cells Alocated in the th!mus and (one marro=B is to -resent !oung l!m-hoc!tes =ith self antigens -roduced throughout the (od! and to eliminate those cells that recogni<e self4antigens? -reventing autoimmunit!& *y2ersensitivity .!-ersensitivit! is an immune res-onse that damages the (od!Qs o=n tissues& 7he! are divided into four classes A7!-e I I6B (ased on the mechanisms involved and the time course of the h!-ersensitive reaction& 7!-e I h!-ersensitivit! is an immediate or ana-h!lactic reaction? often associated =ith allerg!& !m-toms can range from mild discomfort to death& 7!-e I h!-ersensitivit! is mediated (! Ig3 released from mast cells and (aso-hils&R 7!-e II h!-ersensitivit! occurs =hen anti(odies (ind to antigens on the -atientQs o=n cells? mar1ing them for destruction& 7his is also called anti(od!4de-endent Aor c!toto9icB h!-ersensitivit!? and is mediated (! Ig+ and IgM anti(odies& Immune com-le9es Aaggregations of antigens? com-lement -roteins? and Ig+ and IgM anti(odiesB de-osited in various tissues trigger 7!-e III h!-ersensitivit! reactions& 7!-e I6 h!-ersensitivit! Aalso 1no=n as cell4mediated or dela!ed t!-e h!-ersensitivit!B usuall! ta1es (et=een t=o and three da!s to develo-& 7!-e I6 reactions are involved in man! autoimmune and infectious diseases? (ut ma! also involve contact dermatitis A-oison iv!B& 7hese reactions are mediated (! 7 cells? monoc!tes? and macro-hages& Other /echanis/s It is li1el! that a multicom-onent? ada-tive immune s!stem arose =ith the first verte(rates? as inverte(rates do not generate l!m-hoc!tes or an anti(od!4(ased humoral res-onse& Man! s-ecies? ho=ever? utili<e mechanisms that a--ear to (e -recursors of these as-ects of verte(rate immunit!& Immune s!stems a--ear even in the most structurall!4sim-le forms of life? =ith (acteria using a unique defense mechanism? called the restriction modification s!stem to -rotect themselves from viral -athogens? called (acterio-hages& Pro1ar!otes also -ossess acquired immunit!? through a s!stem that uses CRI PR sequences to retain fragments of the genomes of -hage that the! have come into contact =ith in the -ast? =hich allo=s them to (loc1 virus re-lication through a form of RNA interference& Pattern recognition rece-tors are -roteins used (! nearl! all organisms to identif! molecules associated =ith -athogens& Antimicro(ial -e-tides called defensins are an evolutionaril! conserved com-onent of the innate immune res-onse found in all animals and -lants? and re-resent the main form of inverte(rate s!stemic immunit!& 7he com-lement s!stem and -hagoc!tic cells are also used (! most forms of inverte(rate life& Ri(onucleases and the RNA interference -ath=a! are conserved across all eu1ar!otes? and are thought to -la! a role in the immune res-onse to viruses& Dnli1e animals? -lants lac1 -hagoc!tic cells? and most -lant immune res-onses involve s!stemic chemical signals that are sent through a -lant& @hen a -art of a -lant (ecomes infected? the -lant -roduces a locali<ed h!-ersensitive res-onse? =here(! cells at the site of infection undergo ra-id a-o-tosis to -revent the s-read of the disease to other -arts of the -lant& !stemic acquired resistance A ARB is a t!-e of defensive res-onse used (! -lants that renders the entire -lant resistant to a -articular infectious

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agent& RNA silencing mechanisms are -articularl! im-ortant in this s!stemic res-onse as the! 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 (oth ada-tive and innate immune res-onses& ome autoimmune diseases such as lu-us er!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 hormone levels =ith age is -artiall! res-onsi(le for =ea1ened immune res-onses in aging individuals& 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? fetal undernourishment can cause a lifelong im-airment of the immune s!stem& In traditional medicine? some her(s are (elieved to stimulate the immune s!stem? such as echinacea? licorice? ginseng? astragalus? sage? garlic? elder(err!? shiita1e and ling<hi mushrooms? and h!sso-? as =ell as hone!& tudies have suggested that such her(s can indeed stimulate the immune s!stem? although their mode of action is com-le9 and difficult to characteri<e& Mani2.lati!n in /e icine 7he immune res-onse can (e mani-ulated to su--ress un=anted res-onses resulting from autoimmunit!? allerg!? and trans-lant re)ection? and to stimulate -rotective res-onses against -athogens that largel! elude the immune s!stem Asee immuni<ationB& Immunosu--ressive drugs are used to control autoimmune disorders or inflammation =hen e9cessive tissue damage occurs? and to -revent trans-lant re)ection after an organ trans-lant& Anti4inflammator! drugs are often used to control the effects of inflammation& 7he glucocorticoids are the most -o=erful of these drugs> ho=ever? these drugs can have man! undesira(le side effects Ae&g&? central o(esit!? h!-ergl!cemia? osteo-orosisB and their use must (e tightl! controlled& 7herefore? lo=er doses of anti4inflammator! drugs are often used in con)unction =ith c!toto9ic or immunosu--ressive drugs such as methotre9ate or a<athio-rine& C!toto9ic drugs inhi(it the immune res-onse (! 1illing dividing cells such as activated 7 cells& .o=ever? the 1illing is indiscriminate and other constantl! dividing cells and their organs are affected? =hich causes to9ic side effects& R$5S Immunosu--ressive drugs such as c!clos-orin -revent 7 cells from res-onding to signals correctl! (! inhi(iting signal transduction -ath=a!s& 8arger drugs A[/## DaB can -rovo1e a neutrali<ing immune res-onse? -articularl! if the drugs are administered re-eatedl!? or in larger doses& 7his limits the effectiveness of drugs (ased on larger -e-tides and -roteins A=hich are t!-icall! larger than 0### DaB& In some cases? the drug itself is not immunogenic? (ut ma! (e co4administered =ith an immunogenic com-ound? as is sometimes the case for 7a9ol& Com-utational methods have (een develo-ed to -redict the immunogenicit! of -e-tides and -roteins? =hich are

"%

-articularl! useful in designing thera-eutic anti(odies? assessing li1el! virulence of mutations in viral coat -articles? and validation of -ro-osed -e-tide4(ased drug treatments& 3arl! techniques relied mainl! on the o(servation that h!dro-hilic amino acids 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<a(le (! , cells& 7he emerging field of (ioinformatics4 (ased studies of immunogenicit! is referred to as immunoinformatics& Mani2.lati!n 3y 2ath!&ens 7he success of an! -athogen is de-endent on its a(ilit! to elude host immune res-onses& 7herefore? -athogens have develo-ed several methods that allo= them to successfull! infect a host? =hile evading detection or destruction (! the immune s!stem& R%#/S ,acteria often overcome -h!sical (arriers (! secreting en<!mes that digest the (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 route for -roteins to move from the -athogen to the host& 7hese -roteins are often used to shut do=n host defenses& An evasion strateg! used (! several -athogens to avoid the innate immune s!stem is to hide =ithin the cells of their host Aalso called intracellular -athogenesisB& .ere? a -athogen s-ends most of its life4c!cle inside host cells? =here it is shielded from direct contact =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 APlasmodium falci-arumB and leishmaniasis A8eishmania s--&B& Other (acteria? such as M!co(acterium tu(erculosis? live inside a -rotective ca-sule that -revents l!sis (! com-lement& Man! -athogens secrete com-ounds that diminish or misdirect the hostQs immune res-onse& ome (acteria form (iofilms to -rotect themselves from the cells and -roteins of the immune s!stem& uch (iofilms are -resent in man! successful infections? e&g&? the chronic Pseudomonas aeruginosa and ,ur1holderia cenoce-acia infections characteristic of c!stic fi(rosis& Other (acteria generate surface -roteins that (ind to anti(odies? rendering them ineffective> e9am-les include tre-tococcus A-rotein +B? ta-h!lococcus aureus A-rotein AB? and Pe-tostre-tococcus magnus A-rotein 8B& 7he mechanisms used to evade the ada-tive immune s!stem are more com-licated& 7he sim-lest a--roach is to ra-idl! change non4essential e-ito-es Aamino acids andLor sugarsB on the surface of the -athogen? =hile 1ee-ing essential e-ito-es concealed& 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 are constantl! changing& 7hese frequent changes in antigens ma! e9-lain the failures of vaccines 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 steahead of the anti(od! res-onse& Mas1ing antigens =ith host molecules is another common strateg! for avoiding detection (! the immune s!stem&

""

#AT*O#*YSIOLOGY
A. ETIOLOGY #re is2!sin& 1act!r
Factor Age 7 Rationale Incidence of M!asthenia +ravis occurs (et=een ages %/4'/ for =omen& Our -atient? =ho is "$ !ears old? falls into this age (rac1et& 8 +enetics is a factor on one;s health& ince the -atient has histor! of auto immune diseases in the famil!? it is also li1el! for her to develo-arallel diseases& M!asthenia +ravis is more common in =omen than men&

.ereditar!

e9

#reci2itatin& (act!r
Factor Poor environment L Rationale Constant e9-osure to dust or chemical su(stances can =ea1en the immune s!stem of ever! individual& 7herefore? the -atient (ecomes vulnera(le to infections& tress can =ea1en the immune s!stem& According to -s!choneuroimmunolog!? the! found consistent stress4related increases in num(ers of total =hite (lood cell? as =ell as decreases in the num(ers of hel-er 7 cells? su--ressor 7 cells? and c!toto9ic 7 cells? , cell? and natural 1iller 7 cells& "'

tress

'.

SIGNS AND SYM#TOMS

Symptoms 39treme muscle =ea1ness Ptosis Di-lo-ia D!s-hagia

L L L L

D!sarthria Cough Crac1les Increase @,C Res-irator! distress

L L L L L

7he state or qualit! of (eing =ea1> lac1 of strength? firmness? vigor? or the li1e> fee(leness& A droo-ing of the u--er e!elid& A -athological condition of vision in =hich a single nvo()ect a--ears dou(le& It refers to im-aired s=allo=ing& Normal -rocess of s=allo=ing or deglutition can (e disru-ted due to a =ea1 muscle& D!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& A sudden? nois!? and violent e9-ulsion of air from the chest? caused (! irritation in the air -assages? or (! the refle9 action of nervous or gastric disorder? etc& 7o ma1e a succession of slight shar- sna--ing noises& Due to the -resence of microorganism in (od!& Out=ardl! evident? -h!sicall! la(ored ventilation or res-irator! efforts> clinicall! evident ina(ilit! to adequatel! ventilate andLor o9!genate& 7his is currentl! the -referred term to use in referring to veterinar! -atients =ho -resent =ith severe res-irator! difficult!&

"*

#AT*O#*YSIOLOGY
#re is2!sin& (act!rs9 [Poor environment ]]]]]]]]]]] [ tress #reci2itatin& (act!rs9 [ Age [ +ender [ .ereditar!

A(normal DNA mutations Decrease ^ of 74cells Alterations of the 74cells functions Differences in the varia(le regions of anti(odies Production of a(normal ,4cells A(normal anti(odies Dna(le to recogni<e elf4antigens Attac1ing the Acet!choline Rece-tor ites Destruction of Acet!choline Rece-tor ites Decrease ^ of functioning Acet!lcholine Rece-tor sites Decrease Acet!choline to rece-tor site (inding Decrease De-olari<ation Im-aired muscle contraction

Inhi(it muscle s-ecific -roteins

Malformations of Neuromuscular Function Decreased -atenc! of Neuromuscular Function

"/

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

S/S: > Ptosis > Diplopia > Dysphagia > Dysarthria [ Weakness of all Extremities

S/S: >Inability to expectorate Disru-tion of mechanical defense Invasion of microorganism in nasal

If treatedE [ Medications [ 8a(oratories [ urgeries [ .ealth teachings

If not treated Coloni<ation of microorganims Invasion of microorganism in the lungs Activation of immune !stem

If com-liant 8essen the L

If not com-liant Further destruction of acet!lcholine Rece-tor sites More less amount of rece-tor sites for Acet!lcholine (inding

Release of 3ndoto9in and e9oto9ins Inflammation of the lungs -arench!ma #NE)MONIA

---------------------S/S: > Respiratory istress > Se#ere bo y $eakness > %bsent of gag reflex

!"S#$%&'" (R'S'S S/S: > !o"gh > !rackles > Increase W&!

"0

N)RSING ASSESSMENT
Date of %ssessment: Fanuar! *? "##$ 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=ing set4u-E FiO"_ 0#C> 76_ /##> RR_ %0> IE3_ %E' and on AC Mode& he;s =earing a clean hos-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 -laced on moderate high (ac1 rest and =ith ongoing intravenous fluid of Plain 8actated Ringer regulated 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! refill time of less than ' seconds -er minute and =ith =ell4trimmed toe and finger nails& 3dema is 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<e& .ead circumference is /5 cms& he has fine and evenl! distri(uted ling (lac1 hair& 8ice? dandruff and lacerations not noted& Nodules? masses and de-ressions are not -al-ated& Face a--ears to (e round in sha-e& Forehead is smooth and not furro=ed =ith =rin1les& Noted to have snarl face =hen smiling& I6& Eyes 3!e(ro=s a--eared normal =ith no -resence of tear or laceration& Ptosis noted on (oth e!es (ut more -rominent on left e!elid& ,lin1ing refle9 is -resent =ith a--ro9imatel! %04"# involuntar! (ilateral (lin1ing -er minute& No edema and s=elling noted& 3!e(ro=s are s!mmetrical aligned and =ith equal movement& 3!elashes are equall! distri(uted and curved slightl! out=ard& clera a--ears =hite and -al-e(ral con)unctiva is smooth and -in1& Pa-illar! si<e is 'mm and (ris1l! reactive to light and accommodation& 3!e movement is s!mmetrical& 6& Ears 39ternal -inna is s!mmetrical in sha-e and same color as in the facial s1in& No masses? s=elling or lesions noted u-on ins-ection and -al-ation& Auricle is mo(ile? firm and non tender& Pinna recoils after it is folded& Mastoid -rocess is non tender u-on -al-ation& Minimal amount of cerumen on (oth ears are noted& .earing acuit! is normal since she "2

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(e at right nares =ith distal end closed? -atent and intact& Nasal mucosa is -in1 and =ith no lesions noted& Nasal se-tum is intact and in midline& Ma9illar! and frontal sinuses are not tender u-on -al-ation& 6II& *o"th 8i-s are uniforml! -in1 in color and are soft and moist& 7ongue is located in the midline and can move freel!& No ulceration noted in the soft and hard -alate& @ith endotracheal 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& Fugular 6eins =ere not visi(le u-on ins-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<es noted on (oth lung fields u-on auscultation& Productive cough noted and a(le to suction =hitish secretions -er endotracheal tu(e& Patient =as as1ed to sa! Hninet!4nineI and Hone? t=o? threeI re-eatedl! and increased fremitus noted u-on -al-ation on (oth lo=er lung fields& Dia-hragmatic e9cursion is *cms u-on -ercussion& :& (eart No -ulsation or -recordial (ulge noted u-on ins-ection& 7he location of a-ical (eat is at the left midclavicular line /th intercostal s-ace u-on auscultation& No murmurs and an! unusualities noted& :I& &reast an %xillae lightl! unequal si<e of (reast =ith s1in uniforml! the same color =ith (od! s1in& 8esions? nodules and masses are not noted u-on -al-ation& 7he areola =as light (ro=n in color and =ith no discharges noted&

"5

:II& %b omen 7he general contour of the a(domen =as flat um(ilicus is free from discharges and 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 unusual discharges? nodules and edema noted& @ith Fole! catheter attached to uro(ag draining to am(er4colored urine& :I6& &ack an extremities Deformit! or lesions not noted on shoulder and arms& Muscle atro-h! is not noted& @ea1ness noted and =ith a grading muscle strength of 'L/ on (oth u--er and lo=er e9tremities =hich is /#C normal strength and normal movement against gravit!& @ith -ositive dee- tendon refle9 noted and for=ard arm a(duction time of 5 seconds&

"$

(R"&'") &%R*% "SS%SS %&# Cranial Nerve I II III Name Olfactor! Assessment

I6

6I 6II 6III I: : :I

:II

A(le to identif! different mild aromas such as coffee and orange =ith e!es closed& O-tic Can see o()ects in the -eri-her! =hen loo1ing straight ahead& 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 an orderl! manner through the si9 cardinal field ga<e? from the center of the e!e ? the si9 ocular movements and (ac1 to center& N!stagmus not noted& Pu-ils are (lac1 in color> equal in si<e =ith a diameter of "4' millimeters? equall! round and reactive to light stimulation& 7rochlear 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 an orderl! manner through the si9 cardinal field ga<e? from the center of the e!e ? the si9 ocular movements and (ac1 to center& 7rigeminal ,lin1 refle9 =as elicited =hen lateral sclera =as lightl! touched (! a sterile cotton s=a( =hile the client loo1s u-=ard& A(le to identif! sensation =hen a =is- of cotton =as used to touch the -atient;s forehead =ith e!es closed& A(le to identif! dee- sensation =hen used =ith (lunt and shar- ends of a safet! -in& A(ducens 3!e(all moves laterall! and =ith normal e9tra ocular e!e movement& Facial narling =as noted =hen as1ed to smile& A(le to raise the e!e(ro=s and closed e!es tightl!& Auditor! A(le to hear =ithout difficult! =ords s-o1en during the conversation& +losso-har!ngeal A(le to move tongue from side to side and u- and do=n& 6agus till =ith endotracheal tu(e attached to mechanical ventilator Accessor! A(le to shrug shoulders against resistance from e9aminer;s hands and turn head to side against light resistance from e9aminer;s hand in (oth shoulders& .!-oglossal A(le to -rotrude tongue and move it from side to side& '#

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 the res-irator! tract to maintain air=a! -atenc!& (ati&.e A state in =hich an individual is e9-eriencing an over=helming sustained sense of e9haustion 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!ngeal secretions or solids or fluids into tracheo(ronchial -assages& C!rrelati!n t! N.rsin&8N!n:n.rsin& The!ries A(raham Maslo= A%$2#B? -erha-s the most reno=ned needs theorist? ran1s human needs on 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!siologic as-ects& 7he -erson needs to feel safe? (oth in the -h!sical environment and in relationshi-s& o +o#e an belongingness& 7he third level of needs includes giving and receiving affection? attaining a -lace in a grou-? and maintaining the feeling of (elonging& o Self-esteem nee s& 7he individual needs (oth self4esteem Ai&e& feeling of inde-endence? com-etence? and self4res-ectB and esteem from others Ai&e& recognition? res-ect? and a--reciationB& o Self4act"ali,ation- @hen the need for self4esteem is satisfied? the individual strives for self4actuali<ation? the innate need to develo- one;s ma9imum -otential and reali<e one;s a(ilities and qualities& 7he nursing diagnosis defined a(ove (elongs to the first level of needs =hich is the -h!siologic needs& Ph!siological needs are the survival needs& One must fulfill these needs in order to survive and function =ell& It is the most (asic needs of all human

'%

(eings& One cannot function as an individual if these needs are not met& Nursing care focuses on the -h!siologic needs of an individual& Eri;s!n<s Ei&ht Sta&es !1 Devel!2/ent 3ri1son envisions life as a sequence of levels of achievement& 3ach stage signals tas1 that must (e achieved& 7he resolution of the tas1 can (e com-lete? -artial or unsuccessful& 3ri1son (elieves that the greater the tas1 of each achievement? the healthier the -ersonalit! of the -erson> failure to achieve a tas1 influences the -erson;s a(ilit! to achieve the ne9t tas1& 7hese develo-mental tas1s can (e vie=ed as a series of crisis? and successful resolution of these crises is su--ortive to the -erson;s ego& Failure to resolve the crises is damaging to the ego& 3ri1son;s eight stages reflect (oth -ositive and negative as-ects of the critical life -eriods& 3ach -hase has its develo-mental tas1? and the individual must find a (alance (et=een& @hen using 3ri1son;s develo-mental frame=or1? nurses should (e a=are of indicators of -ositive and negative resolution of each stage& Nurses can enhance a client;s develo-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 A "/40/B !ears old =ith a tas1 of generativit! versus stagnation& Our client remains to (e -roductive (! doing sim-le tas1s at home in =hich she can e9tend hel- to her famil! des-ite her condition& Other -ositive indicators includes concern for others and creativit!& (AYE GLENN A'DELLA*<S += N)RSING #RO'LEMS A(dellah s-o1e of the -atient4centered a--roaches? she =rote of nurses identif!ing and solving s-ecific -ro(lems& 7his identification and classification of -ro(lems =as called the t!-olog! of "% nursing -ro(lems& A(dellahQs t!-olog! =as divided into three areasE A%B the -h!sical? sociological? and emotional needs of the -atient> A"B the t!-es of inter-ersonal relationshi-s (et=een the nurse and the -atient> and A'B the common elements of -atient care& 7he follo=ing are among the "% nursing -ro(lems conce-tuali<ed (! A(dellahE %& 7o -romote good h!giene and -h!sical comfort "& 7o -romote o-timal activit!? e9ercise? rest? and slee'& 7o -romote safet! through -revention of accidents? in)ur!? or other trauma and through the -revention of the s-read of infection *& 7o facilitate the maintenance of a su--l! of o9!gen to all (od! cells /& 7o facilitate the maintenance of nutrition of all (od! cells 0& 7o facilitate the maintenance of fluid and electrol!te (alance 2& 7o recogni<e the -h!siologic res-onses of the (od! to disease conditions 5& 7o facilitate the maintenance of regulator! mechanisms and functions $& 7o facilitate the maintenance of sensor! function %#& 7o use communit! resources as an aid in resolving -ro(lems arising from illness %%& 7o understand the role of social -ro(lems as influencing factors in the cause of illness

'"

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

%IRGINIA *ENDERSON<S += N)RSING #RO'LEMS .enderson descri(ed nursing in relation to the client and the client;s environment& he sa= the nurse as concerned =ith (oth health! and ill individuals? ac1no=ledged that nurses interact =ith clients even =hen recover! ma! not (e feasi(le& he conce-tuali<ed the nurse;s role as assisting sic1 or health! individuals to gain inde-endence in meeting %* fundamentals needs =hich are as follo=s that can (e related to our clients conditionE %& (reathing normall! "& eating and drin1ing adequatel! '& moving and maintaining desira(le -osition *& slee-ing and resting /& avoiding dangers in the environment and avoiding in)uring others

''

LA'ORATORY ST)DIES AND DIAGNOSTIC E>AMS

Complete Blood Count/ Platelet Count DateE Decem(er "2? "##5 La3!rat!ry Test Ly/2h!cytes Rati!nale 8!m-hoc!te is a t!-e of =hite (lood cell -resent in the (lood& It hel-s -rotect the (od! against diseases and fight infections& Res.lt %$C Re1erence Clinical %al.e Si&ni1icance "#4'/ lightl! lo= Decrease Ma! indicate immunodefic ienc! diseases& $C "4%# Normal

M!n!cytes

Monoc!tes leave the (lood and (ecome macro-hages and dendritic cells& 7o indicate allergic reactions? -resence of -roto<oa and helminthes&

E!sin!2hil

#C

%&#45&#

8o= 7he num(er of eosino-hils in the (lood is normall! quite lo= A# */#LPlB&

'as!2hil

7he num(er of (aso-hils also increases during infection& ,aso-hils accumulate at the site of infection or other inflammation

#C

#4%&#

Normal

#latelet C!.nt

8o= (lood -latelet count ma! lead to increased (ruising? -etechiae? (leeding from nose? gums and rectum&

'%% 9%#`'Lu8

%/#4*##

Normal

'*

DateE Decem(er "2? "##5 La3!rat!ry Test Rati!nale Res.lt '&0# mmolL8 Re1erence %al.e '&$40&%# Clinical Si&ni1icance 8o= .!-ogl!cemia

Gl.c!se R'S Measures the (lood sugar at an! -oint in time? not necessaril! a certain amount of time after a meal? snac1 or (everage& Creatinine Creatinine has (een found to (e a fairl! relia(le indicator of 1idne! function& As the 1idne!s (ecome im-aired? the creatinine level in the (lood =ill rise due to -oor clearance (! the 1idne!s& S! i./ odium is necessar! for (lood and (od! fluids? transmission of nerve im-ulses? heart activit!? and certain meta(olic functions& Potassium -la!s an essential role in the res-onse of nerves to stimulation and in the contraction of muscles& Cellular en<!mes need -otassium to =or1 -ro-erl!&

2%&"# mmolL8

/'4%%/

Normal

%*0&##mmolL8

%'/4%//

Normal

#!tassi./

*&'# mmolL8

'&/4/&/

Normal

'/

ENDOTRAC*EAL AS#IRATION ?ETA GS8CS@ DateE Fanuar! '? "##$ (in in&9 GRAM STAIN ?DIRECT@9 ]6er! fe= gram ATB cocci ]Others seenE Pus cells S.sce2ti3ility Test Res.lt Date9 Fanuar! $? "##$ S2eci/enE 3ndotracheal 7u(e As-irate C.lt.re Res.lt9 Moderate gro=th of Acineto(acter (aumaanii Anti(iotic dis1s Ami1acin Am-iL ul(actam Ceftria9one Cefota9ime Cefta9idine Ci-roflo9acin +entamicin 7icarcillin 7o(ram!cin Resistant Inter-retation Intermediate ] ] ] ] ] ] ] usce-ti(le ] ]

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 (e susce-ti(le or might (e resistant& COM#LETE 'LOOD CO)NT8#LATELET CO)NT .3MA7O8O+O DateE Fanuar! /? "##$ EAa/inati!n .emoglo(in A.g(B Rati!nale 7his is a measure of the total amount of hemoglo(in in the Res.lt %#$ gLl Re1erenc e %al.e MaleE %'/4%2/ Clinical Si&ni1icance lightl! lo=

'0

-eri-heral (lood&

FemaleE %%/4%// #&'/ gLl MaleE #&*#4#&/" FemaleE #&'04#&*5 *&"40&%

Ma! indicate anemia or fluid retention& lightl! lo= Ma! indicate anemia or fluid retention& 8o= Anemia

Pac1ed Cell 6olume A.ctB

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

Red ,lood Cells 8eu1oc!tes

7his is a count of the num(er of the circulating R,Cs in % mm' of the -eri-heral venous (lood& 8eu1oc!tes function as a first line of defense against foreign -rotein entering the (od!& 7he test is used to determine infection or inflamation&

'&5' gLl

%*4 %09%#gLl

Neutro-hils egmenters

Indicates if there is (acterial invasion (ecause the! are the first to arrive at the infection site&

$# 9%#gLl

#&//4#&2/

.igh Ma! indicate infection or inflammation&

8!m-hoc!tes

Indicates if there is activated cell mediated res-onse and humoral mediated res-onse& It hel-s -rotect the (od! against diseases and fight infections&

*9%#gLl

#&"#4#&'/

.igh Increase in the num(er of l!m-hoc!tes ma! indicate that the general defense s!stems of the (od! have (een -enetrated (! dangerous invading microorganisms&

'2

Monoc!tes

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

09%#gLl

#&#"4#&#0

.igh Ma! indicate infection such as tu(erculosis? he-atitis? and -ancreatitis&

Platelet Count

It -la!s a great role in (lood coagulation& If the value dro-s much (elo= "#?###LPl? there is a danger of uncontrolled (leeding

"/2gLl

%/#4 *##9%#gLl

Normal

DateE Fanuar! 5? "##$ EAa/inati!n Che/istry Calcium 7o aid diagnosis of endocrine disorders and acid4(ase (alance Calcium is needed for muscle contraction? (lood vessel contraction and e9-ansion? the secretion of hormones and en<!mes? and sending messages through the nervous s!stem& odium 7o evaluate fluid4(ase %*0 mmolL8 (alance? and related %'04%// Normal "&* mmolL8 "&"4"&0 Normal Rati!nale Res.lt Re1erence %al.e Clinical Si&ni1icance

'5

neuromuscular? renal and adrenal function

-otassium

7o evaluate clinical signs of h!-er1alemia and h!-o1alemia&

*&%# mmolL8

'&/4/&/

Normal

ARTERIAL 'LOOD GAS S)MMARY RES)LT Date (iO+ 2* 2&'/4 2&*/ mm.g 2&0#0 #CO+ '/4*/ mm.g 2O+ 5#4%## mm.g *COB ""4"2 mmolLl 'E ?ec1@ A4"B4 AT"B mmolLl 4'&0 Ct CO+ "'4 '# %5&/ Clinical Si&ni1icance

%"L"2L#5

%5&*

0$&/

%2&$

Res-irator! al1alosis -artial com-ensation =ith h!-o9emia Res-irator! al1alosis uncom-ensated =ith moderate h!-o9emia Meta(olic al1alosis uncom-ensated =ith more that adequate o9!genation Normal arterial (lood gas =ith more that adequate o9!genation

#%L#%L#$

2&*"$

'*&'

0%&5

""&"

4"&%

"'&'

#%L#'L#$

0#C

2&**"

*"&5

%*0&%

"5&/

*&*

"$&5

#%L#*L#$

*#C

2&*'"

*#&0

%/'&%

"0&/

"&"

"2&2

'$

#%L#/L#$

5#C

2&*$%

'2

%"%&'

"2&0

*&'

"5&2

Meta(olic al1alosis uncom-ensated =ith more that adequate o9!genation Normal arterial (lood gas =ith more that adequate o9!genation

#%L#$L#$

*#C

2&'$%

*'&'

%*/&"

"/&2

#&2

"2

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

Chec1 for severe (reathing -ro(lems and lung diseases? such as asthma? c!stic fi(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 Amechanical 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 drug overdose&

Arterial (lood gas AA,+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 other e9aminations and tests& An A,+ test is often done for a -erson =ho is in the hos-ital (ecause of severe in)ur! or illness& 7he test can measure ho= =ell the -ersonQs lungs and 1idne!s are =or1ing and ho= =ell the (od! is using energ!& An A,+ test ma! (e most useful =hen a -ersonQs (reathing rate is increased or decreased or =hen the -erson has ver! high (lood sugar AglucoseB levels? a severe infection? or heart failure& C!/2lete 3l!! c!.nt8 #latelet c!.nt N.rsin& c!nsi erati!ns +re test 39-lain the im-ortance of the -rocedure to the -atient and of significant others& 7ell the -atient that a (lood sam-le =ill (e ta1en and =ho =ill -erform the veni-uncture&

*#

39-lain to the -atient that he ma! fell slight discomfort from the needle -uncture and the tourniquet& 3nsure that the (lood sam-le is into ta1en from the intravenous line& .emodilution =ith intravenous fluid cause false decrease in the 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 counter var! de-ending on the time of the da!& 3nsure that the su(dermal (leeding has sto--ed (efore removing the -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

Arterial

,lood is t!-icall! dra=n from a vein? usuall! from the inside of the el(o= or the (ac1 of the hand& 7he site is cleaned =ith germ41illing medicine Aantise-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! (e used to -uncture the s1in and ma1e it (leed& 7he (lood collects into a small glass tu(e? or onto a slide or test stri-& A (andage ma! (e -laced over the area if there is an! (leeding& +re test

*%

3l!! &as 39-lain the im-ortance of the -rocedure to the -atient& 7ell the -atient that the -rocedure requires (lood sam-le& 39-lain =ho =ill -erform the arterial -uncture? =hen and =hich site& Inform the -atient that he need not restrict food and fluids& Instruct the -atient to (reathe normall! during the test? and =arm him that he ma! e9-erience a (rief thro((ing or cram-ing -ain at the -uncture site& 'ntra test Perform an arterial -uncture or dra= (lood from the arterial line& Dse a he-arini<e (lood gas s!ringe to dra= the (lood sam-le& 3liminate air from the sam-le? -lace it on ice immediatel! and trans-ort it for anal!sis& +ost test A--l! -ressure to the -uncture site for ' to / minutes if necessar! or until the (leeding has sto-? ta-e a cotton (all over it& If receiving anti coagulant a--l! -ressure longer than / minutes if necessar!& Monitor vital signs and o(serve signs of circulator! im-airment& @atch for (leeding from the -uncture site& +re test 39-lain -rocedure to the -atient& Assem(le suction equi-ment and ensure -ro-er suctioning& 7urn suction -ressure HonI -ressure not to e9ceed %"# mm mercur!& O-en s-ecimen tra- -ac1age? maintaining sterilit! of the tra-& Attach suction connecting to rigid connector and maintain sterilit! of the late9 tu(e& O-en suction catheter -ac1age? maintain sterilit! of the catheter& Pour sterile =ater into sterile cu-& 'ntra test Don sterile gloves& Attach catheter to sterlile tu(e of the s-ecimen tra-& Proceed =ith suctioning -rocedure& Collect s-ecimen inside tra-& Rinse catheter =ith sterile =ater&If necessar! to clear s-ecimen into the tra-& +ost test Remove suction AconnectingB tu(ing along =ith rigid connector *"

En !tracheal As2irate

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/C of M+ -atients have this anti(od! and? =hen detected? is a guaranteed diagnosis& %nti-*"S. %ntibo y testing

A (lood test for the remaining %/C of seronegative A NB M+ -atients? those =ho have tested negative for the acet!lcholine anti(od!? *#42#C test -ositive for the anti4 Mu M anti(od!& 7he remaining -atients have an unidentified anti(od! causing their M+& /ensilon0 test

7he edro-honium chloride A7ensilonaB test is -erformed (! in)ecting this chemical into a vein& Im-rovement of strength immediatel! after the in)ection -rovides strong su--ort for the diagnosis of M+& Electromyography

A3M+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 -atterns are -resent&

*'

DOCTOR<S ORDERS
%"L"2L#5 at /E## PM Admit -atient to ICD % under =hite service DA7 =ith AP 6 q* For com-lete (lood count? -latelet count? chest 94ra!? creatinine? sodium? -otassium @ith ongoing I6F of D/ 8R % liter at %"# ccL; MedicationsE P!ridostigmine 0/ mgLta( I ta(let 7ID> .!drocortisone %## mg I677 q5 @atch out for unusualities such res-irator! failure and d!s-nea O9!gen inhalation of ' liters -er minute %"L"2L#5 at $E'/ PM Continue o9!gen inhalation at 0 liters -er minute %"L"5L#5 Admit to med main =ard at level II Continue medications tart ceftria9one % gram I677 q%" I and O q shift %"L"$L#5 ATB drooling ATB Ptosis %"L'#L#5 ultamicillin %/# mg % ta(let ,ID Acet!lec!steine 0## mg % ta(let at . %"L'#L#5 Patient =as referred due to d!s-nea In res-irator! distress Intu(ate -atient no= =ith endotracheal tu(e and secured at level "# .oo1 to continue (ag valve ventilation =ith mechanical ventilator is not availa(le .oo1 to mechanical ventilator =ith the follo=ing set4u-E FIO"4 %##C> 764 /##>RR4%0> IE34%E'> on AC Mode **

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 ICD% A +%#>8*B For com-liance of P!ridostigmine

%"L'%L#5 at $E## AM %L%L#$ till fro 37A + C ATB secretions> decrease P!ridostigmine I ta( q%" hift h!drocortisone to -rednisone "# mg % ta(let q%" I6F of d/ 8R at %"# ccLhour 7ransfer to ICD % level *? score of %# uction secretions regularl! For A,+ no= Follo=4u- 37A + C For re-eat C,Cb PC Decrease FIO" to $#C =ith decrements at %#C until 0#C A,+ after % hour at FIO" of 0#C Refer to MROD if O" saturation is b$#C 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+7 o al(utamol % ne( q0 o P!ridostigmine % ta(let q%"L ngt o 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<ation q %/Lmin 9 " doses no= then q* uction secretions regularl!

*/

%L'L#$ at 5E"# AM For re-eat C,C? PC toda! A<ithrom!cin /## mg % ta(let OD 9 ' da!s %L'L#$ at 'PM 7ele-hone order of Dr& Decolongon to decrease FIO" to *#C& Refer if O" saturation is b $#C %L*L#$ at %"E%# AM 7ele-hone order of Dr& Padua to increase FIO" to 0#C %L*L#$ For re-eat A,+ toda! Re-eat C,C? PC Follo=4u- 37A + C uction secretions Retrieve chest 94ra! at (edside %L*L#$ at %%E/# PM .oo1 to line ne(uli<ation at FIO" '#C for '# minutes and as follo=sE 'o min? % hour? % and c hours? " hours Re-eat A,+ after " hours at line ne(uli<ation till fro C,C? PC If -atient cant com-l! =ith ceftria9one? ma! use chloram-henicol % gram I677 q0 %L/L#$ at *E/0 PM Increase FIO" to *#C Re-eat A,+ after % hour %L0L#$ at 2E#/ AM Follo= u- initial result of 37A + C till fro re-eat A,+ Continue FIO" at *#C %L0L#$ 7ele-hone order from Dr& duerequencia to maintain ventilator set4u%L2L#$ at 2E%/ AM till for sodium? -otassium toda! Revie= of medicationE o Chloram-henicol % gram I677 q0 o P!ridostigmine 0# mgL ta(let % ta(let q%"LN+7 o Prednisone "# mgLta(let % ta(let q%"LN+7 o al(utamol ne( q*

*0

Chest ta--ing -ost ne(uli<ation

%L2L#$ at 5E## AM .oo1 to line ne(uli<ation as -reviousl! ordered Refer to o" saturation b$#C %L2L#$ Arounds =ith Dr& 8aoB A<athio-rine /# mg c ta(let OD If still =ith secretions? ma! hold P!ridostigmine tem-oraril!& Resume if =ith no more secretions noted %L2L#$ at *E/# PM .old P!ridostigmine If to resume P!ridostigmine % ta(let 7ID Continue line ne(uli<ation %L5L#$ at 2E'# AM Com-liance of A<athio-rine Resume P!ridostigmine % ta(let 7ID Fro serum sodium? -otassium? and calcium .oo1 to line ne(uli<ation

%L5L#$ Arounds =ith Dr& 8imB For humidification %L$L#$ at 5E%/ AM .old P!ridostigmine tem-oraril! For A,+ toda! Continue line ne(uli<ation %L%#L#$ Continue Chloram-henicol for " more da!s Please re-eat A,+ no= and refer result For e9tu(ation once =ith unremar1a(le A,+ result

%L%%L#$ For e9tu(ation toda! Ne(uli<e =ith sal(utamol q%/ 9 ' doses no= then q* M.,R Maintain on NPO? continue O7F Please do s-ot chec1 of O" saturation and refer if b $#C

*2

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

%L%"L#$ 7ransfer to Med Main A8"B For re-eat C,C? PCb A,+ -rior to trans4out 7o consume " more doses of Chloram-henicol then discontinue

*5

Date8 Ti/e Fanuar! /? "##$ at 5E## AM

C.es S.30ective9 : On Mechanical ventilator =ith a +C of %% O30ective9 Productive cough noted ,od! =ea1ness noted Presence of (i(asal crac1les noted ATB @hee<ing in Anterior 8o=er Field Co-ious tracheo(ronchi al secretions Fatigue noted Decreased 3nerg! Noted Increased tactile fremitus at lo=er lung fields Dia-hragmatic e9cursion _

Nee A C 7 I 6 I 7 O 4 3 : 3 R C I 3 P A 7 7 3 R N

O30ective !1 Care Ineffective 7O Air=a! @ithin m! shift? Clearance our -atient =ill related to (e a(le toE retained Dis-la! tracheo(ronchial -atent air=a! ecretions Maintain an secondar! to M!asthenia O" saturation +ravis of $"C and a M!asthenia a(ove
Crisis occurs =hen muscle =ea1ness (ecomes severe enough to com-romise ventilation to the e9tent that ventilation su--ort and air=a! -rotection are needed& ourceE Porth? Patho-h!siolog! ? -& %%'"

N.rsin& Dia&n!sis $ith rati!nale

N.rsin& Interventi!ns $ith rati!nale

Inde-endent Assess air=a! for -atenc!& a Maintaining the air=a! is al=a!s the first -riorit!& Auscultate lung fields? noting areas of decreasedLa(sent airflo= and adventitious (reath sounds such as crac1les and =hee<es& a Decreased airflo= occurs in areas consolidated =ith fluid& Crac1les? rhonchi and =hee<es are heard on ins-iration andLor e9-iration in res-onse to fluid accumulation? thic1 secretions and air=a! o(struction& Assess rate? de-th of res-irations and chest movement& a 7ach!-nea? shallo= res-irations and as!mmetric chest movement are frequentl! -resent (ecause of discomfort of moving chest =all andLor fluid in lung& Assess changes in the vital signs and tem-erature a 7ach!cardia and h!-ertension ma!(e related to increased =or1 of (reathing& Fever ma! develo- in res-onse to retained secretions& 3levate head of the (ed and change -osition frequentl!& a 7his lo=ers the dia-hragm -romoting chest e9-ansion? aeration of lung segments? mo(ili<ation and e9-ectoration of secretions& Assist -atient in -erforming dee- (reathing e9ercises& a Dee- (reathing facilitates ma9imum e9-ansion of the lungs air=a!s& Maintain -lanned rest -eriods&

Eval.ati!n
G!al /et. STO At the end of our shift& our -atientE Maintained air=a! -atenc! as evidenced (! a(sence of c!anosis? res-irator! distress and tach!-nea& Maintained an O" saturation of $5 C 4 %##C Partici-ated in dee- (reathing e9ercises LTO Our -t =as e9tu(ated on Fanuar! %%? #$& On O" inhalation K 0 8-m -er face mas1? @ith O" sat of $/4$$C& RR %54"' c-m A4B use of accessor! muscles in

87O @ithin " =ee1s? our -t =ill (e %&e9tu(ated =ith no signs of res-irator! distress such asE eO" sat of f $#C eRR of %"4"# c-m eA4B use of accessor! muscles in (reathing

*$

*cms

a Promote energ! conservation techniques& uction secretions as indicated a It stimulates cough or mechanicall! clears air=a! in -atient =ho is una(le to do so (ecause of ineffective cough or decreased level of consciousness& Colla(orative Assist =ithLmonitor effects of ne(uli<er treatments and other res-irator! -h!siothera-! a 7his facilitates liquefication and removal of secretions& Administer medicationsA e&g&?anti(iotics? mucol!tic agents? (ronchodilators? e9-ectorantsB as indicated? noting effectiveness and side effects a It aids in the reduction of (ronchos-asm as =ell as mo(ili<ation of secretions Acet!lc!steine 0## mg sachet? % sachet dilute to "##cc =ater 7IDL N+7 a Degrades mucus? allo=ing easier mo(ili<ation and e9-ectoration al(utamol % ne( q0 a Rela9ation of air=a! smooth muscle =ith su(sequent (ronch odilation for easier mo(ili<ation G e9-ectoration of mucus& A<ithrom!cin /## mg % ta(let OD 9 ' da!s a ,inds to the /# su(unit of (acterial ri(osomes? (loc1ing -rotein s!nthesis> (acteriostatic or (actericidal? de-ending on concentration& P!ridostigmine (romide 0/ mgLta( I ta(let 7ID> a P!ridostigmine is used to im-rove muscle strength in -atients =ith a certain muscle disease Am!asthenia gravisB& It =or1s (! -reventing the (rea1do=n of a certain natural su(stance Aacet!lcholineB in !our (od!& Acet!lcholine is needed for normal muscle function& Monitor Arterial ,lood +ases AA,+sB

(reathing 39tu(ation? =ell tolerated&

ReferenceE +ulanic1 and M!ers? Nursing Care Plans -- %"4%*

/#

a Increase Pa CO" and decreasing PaO" are signs of res-irator! failure

/%

Date8 Ti/e Fan& /? "##$ 5E## am

C.es

Nee

N.rsin& Dia&n!sis $ith rati!nale

Fatigue related to muscle =ea1ness secondar! to m!asthenia gravis a 7he hallmar1 of m!asthenia gravis is fatiga(ilit!& Muscles (ecome -rogressivel! =ea1er during -eriods of activit! and im-rove after -eriods of rest& A===&emedicine& comB

O30ective !1 Care STO At the end of our 5 hrs& shift? -atient =ill (e a(le to -artici-ate activel! in normal activities LTO

N.rsin& Interventi!ns $ith rati!nale

Eval.ati!n

S.30ective9 On mechanical ventilator @ith +C of %%L%/ O30ective9 ATB (od! =ea1ness decreased muscle tone decreased activit! -erformance =ith -eriods of interru-ted slee tired loo1ing motor functionE 'L/ 'L/ 'L/ 'L/

A C 7 I 6 I 7 O 4 3 : 3 R C I 3 P A 7 7 3 R N

Assess characteristics of fatigue& a 7his descri(es the amount of fatigue e9-erienced& It also allo=s the nurse to com-are changes in the -atient;s fatigue level over time& It is im-ortant to determine if the -atient;s level of fatigue is constant or if it varies overtime& Assess for -ossi(le causes of fatigue& a 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! living AAD8sB& a Fatigue can limit the -erson;s a(ilit! to -artici-ate in self4care and -erform his or her role res-onsi(ilities in the famil! and societ!& 3valuate the -atient;s slee- -atters for qualit!? quantit!? time ta1en to fall aslee-? and feeling u-on a=a1ening& a Changes in the -erson;s slee- -attern ma! (e a contri(uting factor in the develo-ment of fatigue& Assess the -atient;s level of e9ercise and -h!sical activit!& a ,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 A -lan that (alances -eriods of activit! =ith -eriods of rest can hel- the -atient com-lete desired activities =ithout adding to levels of fatigue& Monitor the -atient;s energ! e9-enditure =ith activit!& a 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 AAD8sB& a 7his can minimi<e energ! e9-enditure and -revent in)ur! =ith activities&

G!al /et. 7O Patient =as a(le to -artici-ate activel! in normal activities =ith assistance such as range of motion e9ercises 87O Patient =as a(le to demonstrate im-roved activit! tolerance (! maintaining a (alance (et=een =or1? rest? e9ercise? and recreation and (! -erforming AD8s =ithout e9cessive fatigue and inde-endentl!&

After t=o =ee1s? -atient =ill demonstrate im-roved activit! tolerance as ourceE evidenced (!E +ulanic1 and M!ers? Nursing Maintaining a (alance Care Plans? -& /2 (et=een =or1? rest? e9ercise? and recreation> Performing AD8s =ithout e9cessive fatigue

/"

Instruct -atient to increase inta1e of car(oh!drates? -rotein? vitamins? and minerals& a 7hese -rovide energ! resources& Provide =ith adequate rest -eriods& a Promoting effective rest can contri(ute to energ! restoration& Minimi<e environmental stimuli? es-eciall! during -lanned times for rest and slee-& a ,right lighting? noise? visitors? frequent distractions? and clutter in the -atient;s -h!sical environment can inhi(it rela9ation? interru-t slee-Lrest? and contri(ute to fatigue& Colla(orativeE Administer medications such as> A<athio-rine /# mg c ta(let OD a An immunosu--ressive medication that decreses the actions of the (od!;s immune s!stem& Drugs that su--ress the immune s!stem are used in -atients =ith m!asthenia gravis (ecause M+ is an autoimmune disorder that results from the -roduction of a(normal anticodies& Prednisone "# mg % ta(let q%" a Prednisone is a corticosteroid hormone AglucocorticoidB& It decreases !our immune s!stemQs res-onse to various diseases to reduce s!m-toms such as s=elling and allergic4t!-e reactions& It is used to treat conditions such as arthritis? (lood disorders? (reathing -ro(lems? certain cancers? e!e -ro(lems? immune s!stem diseases? and s1in diseases& P!ridostigmine (romide 0/ mgLta( I ta(let 7ID> a P!ridostigmine is used to im-rove muscle strength in -atients =ith a certain muscle disease Am!asthenia gravisB& It =or1s (! -reventing the (rea1do=n of a certain natural su(stance Aacet!lcholineB in !our (od!& Acet!lcholine is needed for normal muscle function&

/'

Date8 Ti/e Fan %%? "##$ $E## am

C.es

Nee

N.rsin& Dia&n!sis $ith rati!nale

Ris1 for As-iration related to res-irator! muscle =ea1ness secondar! to M!asthenia +ravis a ,ecause M!asthenia +ravis ma! involve the muscles of res-iration? the client ma! e9-erience d!s-nea and ineffective cough and s=allo=ing mechanisms? =hich ma! lead to as-iration&

O30ective !1 Care
STO At the end of our 5 hrs& shift? our -atient =ill (e a(le to demonstrate techniques to -revent andLor correct as-iration as evidence (! no sign of as-iration such as coughing and effective (reathing -attern

N.rsin& Interventi!ns $ith rati!nale

Eval.ati!n

S.30ective9 Hdili -a 1a!o 1o ma1atulonI O30ective9 Productive cough noted ATB muscle =ea1ness noted @ea1 gag refle9 noted Fatigue noted Im-aired s=allo=ing noted +urgl! voice qualit! noted 7hic1? =hitish tenacious secretions Post % hour of e9tu(ation On NPO

N D 7 R I 7 I O N A 8 4 M 3 7 A , O 8 I C P A 7 7 3 R N

Assess oral secretions for color? amount and G!al /et. consistenc! a Patient =ith thic1 tenacious secretions are 7O Patient increased ris1 for as-iration demonstrated Plan for a -eriod of "#4'4 minutes of rest techniques to -revent (efore meals a Patients =ith M!asthenia +ravis tire ver! as-iration such as l!ing easil!& u-right =hile Coordinate =ith -atient;s meal =ith -ea1 drug feeding action a Anticholinesterase medications such as Neostigmine AProstigminB given *#40# minutes (efore meals =ill -rovide -ea1 action over the mealtime& 87O Patient =as not a(le to e9-erience an! as-iration as Mee- -atient u-right for '#40# minutes after evidenced (! meals& noiseless a 7he u-right -osition facilitates the gravitational res-iration flo= of food or fluid through the alimentar! tract and odorless and reduces the ris1 of as-iration& secretions&

LTO @ithin " =ee1s? the -atient =ill e9-erience no ourceE as-iration as ,lac1 and evidenced (! .a=1s? Medical4 noiseless urgical Nursing? res-iration and Mee- suction equi-ment at (edside and suction as necessar! -& "%5* odorless secretions& a 7his is necessar! to maintain -atent air=a!&

Instruct on signs and s!m-toms of as-iration a 7his aids in a--ro-riatel! assessing high4ris1 situations and determining =hen to call for further evaluation& /*

39-lain to the -atient the need for -ro-er -ositioning a 7his decreases ris1 of as-iration& Colla(orativeE
Monitor Arterial ,lood +ases AA,+sB G Pulse o9imeter& a Pooling of secretions leads to -neumonia =hich =ill lead to more aggressive interventions P!ridostigmine (romide 0/ mgLta( I ta(let 7ID> a P!ridostigmine is used to im-rove muscle strength in -atients =ith a certain muscle disease Am!asthenia gravisB& It =or1s (! -reventing the (rea1do=n of a certain natural su(stance Aacet!lcholineB in !our (od!& Acet!lcholine is needed for normal muscle function& al(utamol % ne( q0 a Rela9ation of air=a! smooth muscle =ith su(sequent (ronchodilation for easier mo(ili<ation G e9-ectoration of mucus& ReferenceE +ulanic1 and M!ers? Nursing Care Plans -"54'%

Administer medications such asE

//

DR)G ST)DY
+eneric name ,rand name Classification Dosage Frequenc! Indications Ranitidine .Cl Nantac Antiulcer drug and /# mg I677 q5 g g g g g Duodenal and gastric ulcer 3rosive eso-hagitis .eart(urn +3RD Maintenance 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& g g g g CN E headache? malaise 33N7E (lurred vision .3PA7ICE )aundice O7.3RE (urning and itching at in)ection site

Adverse Reactions L 3ffects Drug Interactions ide

g AntacidsE Ma! interfere =ith ranitidine a(sor-tion& g Dia<e-amE Decreased a(sor-tion of dia<e-am& Monitor -atient closel!& g @arfarinE Ma! interfere =ith =arfarin clearance& Monitor -atient closel!& Contraindicated in -atients =ith h!-ersensitivit! to drug and =ith acute -or-h!ria& g Dse cautiousl! in -atients =ith he-atic d!sfunction& g Assess -atient for a(dominal -ain& Note for -resence of (lood in stool? gastric as-irate&

Contraindications

Nursing Res-onsi(ilities

/0

g Instruct -atient on -ro-er use of O7C -re-aration? as indicated& g Remind -atient ta1ing -rescri-tion drug once dail! to ta1e it at (edtime for (est results& g Instruct -atient to ta1e =ithout regard to meals (ecause a(sor-tion is not affected (! food& g Drge -atient to avoid cigarette smo1ing&

+eneric name ,rand name Classification Dosage and Frequenc! Indications Action Adverse Reactions L ide 3ffects

Acet!lc!steine Mucom!st Mucol!tic Agent 0## mg % ta(let at . Mucol!tic> management of conditions associated =ith thic1 viscid mucous secretions Degrades mucus? allo=ing easier mo(ili<ation and e9-ectoration CNS9dro=siness& C%9vasodilation& EENT9rhinorrhea& Res29 bronchospasm? (ronchialLtracheal irritation? chest tightness? increased secretions& GI9 na"sea? #omiting? stomatitis& Der/9 pr"rit"s? rash? "rticaria? clamminess& Misc9 allergic reactions A-rimaril! =ith I6B? including ana-h!la9is? AN+IO3D3MA? chills? fever& Drug sta(ilit! and safet! of acet!lc!steine =hen mi9ed =ith other drugs in a ne(uli<er have not (een esta(lished& Acet!lc!steine is contraindicated in those -atients =ho are sensitive to it& Assess res-irator! function Alung sounds? d!s-neaB and color? amount? and consistenc! of secretions (efore and immediatel! follo=ing treatment to determine effectiveness of thera-!& Assess for ana-h!lactoid reaction& 3r!thema and flushing are common? usuall! occurring '#0# min after initiating infusion?

Drug Interactions Contraindications Nursing Res-onsi(ilities

/2

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-toms resolve and carefull! restarted& If ana-h!lactoid reaction recurs? discontinue acet!lc!steine and use alternative form of treatment&

+eneric name ,rand name Classification Dosage Frequenc! Indications and

al(utamol Proventil ,ronchodilator % Ne( q * al(utamol is used in cases of (ronchos-asm in -atients =ith reversi(le air=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& As =ith other V"4adrenergic rece-tor agonists? sal(utamol (inds to V"4 adrenergic 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! A(ronchodilationB& Inhaled sal(utamol sulfate has a ra-id onset of action? -roviding relief =ithin /4%/ minutes of administration& .eadache> tremor> tach!cardia> h!-ertension> an9iet!& Rarel! nausea? ide vomiting? and s1in rash can (e o(served& In cases of concurrent administration =ith MAO4inhi(itors or antide-ressants? a -otentiation of the cardiovascular effects is o(served& 7he V4(loc1ers antagoni<e the action of al(utamol& In cases of simultaneous administration =ith digitalis gl!cosides? theo-h!lline? oral antidia(etic agents? insulin? s!m-athomimetics? al(utamol can increase the to9icit! of these agents& .!-ersensitivit! to some of the drug ingredients

Action

Adverse Reactions L 3ffects

Drug Interactions

Contraindications

/5

Nursing Res-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 Aan 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! as this -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 should s-ea1 =ith !our doctor&

+eneric name ,rand name Classification Dosage Frequenc! Indications

Cefota9ime Claforan Anti(iotic and % gram I677 q5 Cefota9ime is used for infections of the res-irator! tract? s1in? (ones? )oints? urogenital s!stem? meningitis? and se-ticemia& It generall! has good coverage against most +ram4negative (acteria? =ith the nota(le e9ce-tion of Pse" omonas& It is also effective against most +ram4-ositive cocci e9ce-t for Enterococc"s&R%S It is active against -enicillin4resistant strains of Streptococc"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

/$

Action

-enicillin4(inding -roteins AP,PsB =hich in turn inhi(its the final trans-e-tidation ste- of -e-tidogl!can s!nthesis in (acterial cell =alls? thus inhi(iting cell =all (ios!nthesis& ,acteria eventuall! l!se due to ongoing activit! of cell =all autol!tic en<!mes Aautol!sins and murein h!drolasesB =hile cell =all assem(l! is arrested& Adverse The /!st 1reC.ent a verse reacti!ns ?&reater than =D@ are9 Reactions L ide 8ocal A*&'CB 4 In)ection site inflammation =ith I6 administration& Pain? 3ffects induration? and tenderness after IM in)ection& .!-ersensitivit! A"&*CB 4 Rash? -ruritus? fever? eosino-hilia and less frequentl! urticaria and ana-h!la9is& +astrointestinal A%&*CB 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!& Increased ne-hroto9icit! has (een re-orted follo=ing concomitant Drug Interactions administration 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(sh test& Contraindications Nursing Res-onsi(ilities It is contraindicated in -atients =ho have sho=n h!-ersensitivit! to cefota9ime 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& Dse 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 if in)ection4site -ain or redness? s1in rash? hives? itching? or shortness of (reath occur during treatment& Maintain adequate h!dration A"4' 8Lda! of fluidsB unless instructed to restrict fluid inta1e& Advise -atient or caregiver to re-ort signs of su-erinfection to health 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 care if noted and not to treat at home& Patients should (e told that although it is common to feel (etter earl! in the course of thera-!? the medication should (e ta1en e9actl! as directed& 1i--ing doses or not com-leting the full course of thera-! ma! A%B decrease the effectiveness of the immediate treatment and A"B increase the li1elihood that (acteria =ill develo- resistance and =ill not (e treata(le (! Cefota9ime or 0#

other anti(acterial drugs in the future& Renal function should (e carefull! monitored? es-eciall! if higher dosages of the aminogl!cosides are to (e administered or if thera-! is -rolonged? (ecause of the -otential ne-hroto9icit! and ototo9icit! of aminogl!coside anti(iotics&

+eneric name ,rand name Classification

P!ridostigmine Mestinon

Antim!asthenics? cholinergics

Dosage Frequenc! Indications

and

0/ mg % ta( 7ID i Dsed to increase muscle strength in the s!m-tomatic treatment of m!asthenia gravis i Reversal of nonde-olari<ing neuromuscular (loc1ing agents

Action

i Inhi(its the (rea1do=n of acet!lcholine and -rolongs its effects AanticholinesteraseB& 2 Increase intestinal and s1eletal muscle tone j ,roncj ,rad!cardia j Increased salivation j 8acrimation j =eating hial and ureteral constriction i Im-roved muscular function in -atients =ith m!asthenia gravis i Reversal of -aral!sis from nonde-olari<ing neuromuscular (loc1ing agents i Prevention of oman nerve gas to9icit!

Adverse Reactions L 3ffects

ide

CN E 3INDR3 ? di<<iness? =ea1ness& 33N7E lacrimation? miosis& Res-E (ronchos-asm? e9cessive secretions& 0%

C6E (rad!cardia? h!-otension& +IE a(dominal cram-s? diarrhea? e9cessive salivation? nausea? vomiting& DermE s=eating? rashes& Drug Interactions i Cholinergic effects ma! (e antagoni<ed (! other drugs -ossessing anticholinergic -ro-erties? including antihistamines? antide-ressants? atro-ine? halo-eridol? -henothia<ines? -rocainamide? quinidine? or diso-!ramide i Prolongs the action of de-olari<ing muscle4rela9ing agents and cholinesterase inhi(itors Asuccin!lcholine? decamethoniumB i to9icit! =ith other cholinesterase inhi(itors? including demecarium? echothio-hate? and isofluro-hate i Antim!asthenic effects ma! (e (! concurrent guanadrel Contraindications i .!-ersensitivit! to -!ridostigmine or (romides i Mechanical o(struction of the +I or +D tract i Mno=n alcohol intolerance As!ru- onl!B Nursing Res-onsi(ilities i Assess -ulse? res-irator! rate? and (lood -ressure (efore administration& Re-ort significant changes in heart rate Myasthenia Gravis i Assess neuromuscular status? including vital ca-acit!? -tosis? di-lo-ia? che=ing? s=allo=ing? hand gras-? and gait (efore administering and at -ea1 effect& i Advised to 1ee- a dail! record of their condition and the effects of this medication& i Advise -atient that she ma! have difficult! =ith dar1 ada-tation? increased s=eating and gastric u-set& iRe-ort unresolved nausea and vomiting? a(dominal cram-ing? difficult! urinatingand res-irator! difficult!

0"

+eneric name ,rand name Classification Dosage Frequenc! Indications Action and

Prednisone Deltasone Adrenocorticosteroids "# mg % ta( q %" evere inflammation? immunosu--ression

Decreases inflammation? mainl! (! sta(ili<ing leu1oc!te l!sosomal mem(ranes> 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? Adverse vertigo? headache? -aresthesia? sei<ures& Reactions L ide C6E heart failure? h!-ertension? edema? arrh!thmias? throm(o-hle(itis? 3ffects throm(oem(olism& 33N7E cataracts? glaucoma& +IE -e-tic ulceration? +I irritation? increased a--etite? -ancreatitis? nausea? vomiting& +DE menstrual irregularities& As-irin? indomethacin? other N AIDsE increased ris1 of +I distress and Drug Interactions (leeding& +ive together cautiousl!& ,ar(iturates? -hen!toin? rifam-inE decreased corticosteroid effect& Increase corticosteroid dosage? as ordered& Oral anticoagulantsE altered dosage requirements& Monitor P7 and INR closel!& Potassium4de-leting drugs such as thia<ide diureticsE enhanced -otassium4 =asting effects of -rednisone& Monitor serum -otassium levels& alic!latesE decreased serum salic!late levels& Monitor -atient for lac1 of salic!late effectiveness& Contraindications Nursing Res-onsi(ilities Contraindicated in -atients =ith h!-ersensitivit! to drug and in those =ith s!stemic fungal infections& 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<<iness? and fainting& Instruct -atient to carr! a card identif!ing his need for su--lemental s!stemic glucocorticoids during stress& 7his card should contain 0'

 +eneric name ,rand name Classification Dosage Frequenc! Indications and

doctorQs name? name of drug? and dose ta1en& @arn -atient on long4term thera-! a(out cushingoid s!m-toms Amoonface? (uffalo hum-B and to notif! doctor of sudden =eight gain 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 or calcium 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&

A<ithrom!cin Nithroma9 Anti4Infective Agents /## mg % ta(let OD for ' da!s Acute (acterial e9acer(ations of COPD caused (! .aemo-hilus influen<ae? Mora9ella A,ranhamellaB catarrhalis? or tre-tococcus -neumoniae> uncom-licated s1in and s1in4structure infections caused (! ta-h!lococcus aureus? tre-tococcus -!ogenes? or & agalactiae> second4 line thera-! of -har!ngitis or tonsillitis caused (! & -!ogenes44 ,inds to the /# su(unit of (acterial ri(osomes? (loc1ing -rotein s!nthesis> (acteriostatic or (actericidal? de-ending on concentration& CN E di<<iness? vertigo? headache? fatigue? somnolence& ide C6E -al-itations? chest -ain& +IE nausea? vomiting? diarrhea? a(dominal -ain? d!s-e-sia? flatulence? melena? cholestatic )aundice? -seudomem(ranous colitis& +DE candidiasis? vaginitis? ne-hritis& 1inE rash? -hotosensitivit!& OtherE angioedema& Aluminum4 and magnesium4containing antacidsE lo=ered -ea1 -lasma levels of a<ithrom!cin& e-arate administration times (! at least " hours& Car(ama<e-ine? c!clos-orine? -hen!toinE ma! increase levels of these drugs& Monitor levels closel!&

Action Adverse Reactions L 3ffects

Drug Interactions

0*

Digo9inE ma! cause elevated digo9in levels& Monitor dogo9in levels closel!& 7heo-h!llineE ma! increase -lasma theo-h!lline levels =ith other macrolides> effect of a<ithrom!cin is un1no=n& Monitor theo-h!lline levels carefull!& 7ria<olamE ma! decrease clearance of tria<olam& Monitor -atient for increased CN de-ression& Contraindications Nursing Res-onsi(ilities Contraindicated in -atients =ith h!-ersensitivit! to er!throm!cin or other macrolides& 7ell -atient to ta1e drug as -rescri(ed? even after he feels (etter& 7his drug ma! (e ta1en =ith or =ithout food& 7a1ing drug =ith food ma! reduce +I distress& 7a1e % hour (efore or " hours after meals Monitor for su-erinfection& Drug ma! cause overgro=th of nonsusce-ti(le (acteria or fungi& Do not ta1e =ith Aluminum or Magnesium content antacids&

+eneric name ,rand name Classification Dosage Frequenc! Indications

Chloram-henicol Chlorom!cetin

Anti4infectives and % gram I677 q0 7reatment of serious infections due to organisms resistant to other less to9ic anti(iotics or =hen its -enetra(ilit!into the site of infection is clinicall! su-erior to other anti(iotics to =hich the organism is sensitive& Inhi(its -rotein s!nthesis in susce-ti(le (acteria at the level of the /# ri(osome& CNS9 confusion? delirium? de-ression? headache& ide EENT9 (lurred vision? o-tic neuritis& GI9 (itter taste AI6 onl!B? diarrhea? enterocolitis? glossitis? nausea? stomatitis? vomiting&

Action Adverse Reactions L 3ffects

0/

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? +RAO ONDROM3 IN N3@,ORN ? fever& Drug Interactions Ma! increase effects of the follo=ing drugsE oral h!-ogl!cemic agents? =arfarin? and -hen!toin i Pheno(ar(ital or rifam-in ma! decrease chloram-henicol (lood levels i 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?Aincreased ris1 of reactions due to ina(ilit! to meta(oli<e and e9crete chloram-henicolB& Nursing Res-onsi(ilities Assess -atient for infection Avital signs? =ound a--earance? s-utum? urine? stool? and @,CB at (eginning of and throughout thera-!& j Assess -atients dail! for signs of (one marro= de-ression A-etechiae? sore throat? fatigue? unusual (leeding? (ruisingB& Advise -atient to contact health care -rofessional immediatel! if signs of unusual (leeding> (ruising> fever> sore throat> nausea> vomiting> diarrhea> num(ness? tingling? or (urning -ain or =ea1ness in hands or feet occurs& j Instruct -atient to re-ort signs of su-erinfection Astomatitis? -erianal itching? vaginal discharge? feverB j 3m-hasi<e the im-ortance of follo=4u- e9ams

+eneric name ,rand name Classification Dosage Frequenc! and

.!drocortisone Cort4dome? Cortef ? .!drocortone

Corticosteroid %## mg I677 q5 Anti4inflammator!? immunosu--ressant 00

Indications Action Adverse Reactions L 3ffects !nthesi<ed (! the adrenal corte9& 39hi(its anti4nflamator! -ro-erties> su--resses the normal immune res-onse& Increases car(oh!drate? fat? and -rotein meta(olism& CN E Insomnia? nervousness ide +IE Increased a--etite? indigestion Increase ris1 of h!-o1alemia =ith diuretics? am-hotericin ,? ticarcillin& Ma! increase digo9in to9icit! due to h!-o1alemia& .!-ersensitivit!> PDD> tu(erculosis? fungal infections or an! sus-ected infections? h!-ertension? dia(etes mellitus& g Instruct to administer oral drugs =ith food or mil1 earl! in the morning to reduce +I u-set& g Do not increase doses and do not sto- a(ru-tl! =ithout consulting !our doctor g Re-ort an! visual distur(ance or severe +I distress? sudden =eight gain? s=elling? sore throat? fever? or signs of infection& g Instruct -atient not to ta1e =ith as-irin or an! medication =ithout consulting -rovider& g Discuss a diet lo= in sodium? high in 6itamin D? -rotein and -otassium& g Avoid e9-osure to cantagiona nad notif! doctor for an! signs of infection&

Drug Interactions Contraindications Nursing Res-onsi(ilities

+eneric name ,rand name

Ceftria9one Roce-hin

Classification Dosage Frequenc!

Ce-halos-orin and % gram I677 q%"

02

Indications

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

Action Adverse Reactions L 3ffects

Inhi(its (acterial cell =all s!nthesis& Most effective against ra-idl! gro=ing organisms& Nausea? vomiting? diarrhea& ide Ana-h!la9is ma! occur& Ne-hroto9icit! 7hrom(oc!to-enia Increase ris1 of (leeding =hen given =ith anticoagulants? or throm(ol!tic agents& Pro(enecid ma! increase serum levels of ce-halos-orins& .!-ersensitivit! to ce-halos-orins or -enicillin& Caution =ith renalLhe-atic im-airment? (leeding disorders or +I disease& Contraindicated in -atients =ith 1no=n allerg! to the ce-halos-orin class of anti(iotics&

Drug Interactions Contraindications

Nursing Res-onsi(ilities

g Assess histor! of -revious allergic reactions g Instruct -atient to administer on an em-t! stomach for (etter results& g Monitor @,C counts? cultures? and P7& g Assess ,DN and creatinine levels =ith renal im-airment& g Monitor 6 ? I and O g If dia(etic? monitor glucose levels& g Re-ort unresolved? eas! (leeding or (ruising

+eneric name ,rand name

ultamicillin

am-icillin4sul(actam, )nasyn

Classification Dosage Frequenc! and

AMINOP3NICI88IN %/# mg % ta(let ,ID

05

Indications

Other salmonella infections +onococcal infections u--urative and uns-ecified otitis media Acute sinusitis Acute fi(rinous (ronchitis Acute mem(ranous (ronchitis Acute -seudomem(ranous (ronchitis Acute -urulent (ronchitis Acute crou-ous (ronchitis Acute tracheo(ronchitis Antimicro(ial effect Ana-h!lactic shoc1 ide Angioneurotic oedema Diarrhoea 39foliative dermatitis Interstitial ne-hritis 8euco-enia Nausea Pain in )oints 4 arthralgia P!re9ia Rash 7hrom(oc!to-enia 8i1el! interaction of PRO,3N3CID increasing the AN7IMICRO,IA8 effect of D87AMICI88IN& Dsuall! no ris1& Penicillin allerg! Adverse reaction to -enicillins Adverse reaction to am-icillin Personal 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-ort immediatel! -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 A"4' 8Lda! of fluidsB unless instructed to restrict fluid inta1e& o If !ou have dia(etes? drug ma! cause false test results =ith Clinitesta urine glucose monitoring> use of another t!-e of glucose monitoring is -refera(le& o Ma! cause diarrhea Aif -ersistent? consult -rescri(er for a--roved 0$

Action Adverse Reactions L 3ffects

Drug Interactions Contraindications

Nursing Res-onsi(ilities

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

+eneric name ,rand name Classification Dosage Frequenc! Indications Action Adverse Reactions L 3ffects and

A<athio-rine A<asan? Imuran? 7hio-rine

Immunosu--resant /# mg c ta(let OD

Dsed to su--ress the immune s!stem in m!asthenia gravis Dn1no=n? (ut thought to cause varia(le alterations in anti(od! -roduction CN E fever ide +IE nausea? vomiting? anore9ia? -ancreatitis? steatorrhea? diarrhea? a(dominal -ain& .ematologicE 8eu1o-enia? -!elosu--resion? macroc!tic anemia? -anc!to-enia? throm(oc!to-enia? immunosu--ression .e-aticE he-atoto9icit!? )aundice Musculos1eletalE arthralgia? m!algia 1inE rash? alo-ecia OtherE infections? increased ris1 of neo-lasia Drug4drugE o AC3 inhi(itorsE com(ination ma! cause sever leu1o-enia& Monitor -atient o Allo-urinolE im-airs inactivation of a<athio-rine& o C!clos-orineE ma! increase -lasma c!clos-orine levels& Monitor c!clos-orine levels& o Co4trimo9a<ole and other drugs that interfere =ith m!elo-oiesisE e9aggerates leu1o-enia? es-eciall! in renal trans-lant -atients& Monitor -atient closel!& o @arfarinE a<athio-rine ma! decrease action of =arfarin& It is contraindicated in -atients h!-ersensitive to drug and its com-onents& Dse cautiousl! in -atients =ith he-atic and renal d!sfunction& +ive drug after meals to minimi<e +I adverse effects& 7o -revent (leeding? avoid all I&M& in)ections =hen -latelet count is (elo= %##?###Lmm'& @atch for earl! signs of he-atoto9icit!? such as cla!4colored stools? 2#

Drug Interactions

Contraindications Nursing Res-onsi(ilities

dar1 urine? -ruritus? and !ello= s1in and sclera> and for increased al1aline -hos-hatise? (iliru(in? A 7? and A87 levels& @arn -atient to re-ort even mild infections Acolds? fever? sore throat? 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 care cautiousl! to decrease ris1 of (leeding&

2%

DISC*ARGE #LAN

Me

icati!ns #re nis!ne +E /& = ta3let C=+

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<<iness? and fainting& Instruct -atient to carr! a card identif!ing his need for su--lemental s!stemic glucocorticoids during stress& 7his card should contain doctorQs name? name of drug? and dose ta1en& @arn -atient on long4term thera-! a(out cushingoid s!m-toms Amoonface? (uffalo hum-B and to notif! doctor of sudden =eight gain 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 or calcium 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&

A6athi!2rine GE /& H ta3let OD

Ti/in&9 Fa/ a1ter eatin& 3rea;1ast #atient teachin& 7a1e this medication (! mouth once dail! as directed (! !our doctor& A<athio-rine should (e ta1en =ith food to reduce stomach u-set& Dosage is (ased on !our medical condition? =eight? and res-onse to thera-!& Do not increase !our dose or ta1e this medication more often =ithout !our doctorQs a--roval& Oour condition =ill not im-rove an! faster and the ris1 of serious side effects ma! (e increased& Do not sto- ta1ing this medication =ithout !our doctorQs a--roval& Dse this medication regularl! in order to get the most (enefit from it& Remem(er to use it at the same timeAsB each da!&

2"

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 (ac14 u- alarm cloc1 to remind them of e9act dose time& Patients =ith d!s-hagia ma! not (e a(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 all times Instruct -atient to s-ace activities to avoid fatigue

EAercise
3ncourage -t to -erform dee- (reathing G coughing e9ercises at least '4/9 a da!& o Dee2 'reathin& eAercises 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 the a(dominal muscles&

"& Place hands on the a(domen to feel =hether the chest rises to indicate that the lungs are e9-anded& '& Inhale through nose until the a(domen (alloons out=ard G hold in the count of five& *& Instruct the client to e9hale through -urse li-s =hile contracting the a(dominal muscles& o C!.&hin& EAercises o 7o mo(ili<e the secretion so the! can (e removed to -revent reoccurrence of -neumonia or =ith other lung com-lications& o ProcedureE

2'

%& 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 Ial;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 of e9tremities 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 i66iness evel!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 (ladder management& 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 Fac1ie Chan& Dee- (reathing? rela9ation? G slo=? gentle movements are the -rimar! elements& Often referred to as a method of Hmoving meditationI? tai chi is a conditioning 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 through thoughtful 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 -roduces measura(le (enefits in im-roving (alance? lo=ering (lood -ressure? G im-roving cardiovascular health&

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

Thera2y8 Treat/ent
Iater thera2y 3ncourage -t to drin1 "4' liters of =ater -er da!& a 7o -romote h!dration G elimination of to9ins in the (od!& 2*

M.sic thera2y 8isten to mello= or Ins-irational songsLmusic& a It -roduces rela9ation G desired changes in emotions? (ehaviors? G -h!siolog!& T!.ch thera2y 7he use of touch can transmit energ! to -erson =ho is ill G in)ured to -otentate the healing -rocess& a It gives comfort to -atient& Diverti!nal activity Dse 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 invigorating them&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!es and do it& As much as -ossi(le (e outside in natural surroundings& .ave frequent short e9-ose of !our un-rotected s1in to mild sunlight& a It can relieve (! diverting the mind from the stressful im-ulse G focuses it on -leasant things Me itati!n thera2y 7his thera-! can quiet the mind G focus it n the -resent G to release fears? =orries? an9iet! G dou(ts concerning the -ast G the future& S.r&ical thera2y A 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 -resent& #las/a2heresis Plasma-heresis? or -lasma e9change? ma! (e useful in the treatment of M+ also& 7his -rocedure removes the a(normal anti(odies from the -lasma of the (lood& 7he im-rovement in muscle strength ma! (e stri1ing? (ut is usuall! short4lived? since -roduction of the a(normal anti(odies continues& @hen -lasma-heresis is used? it ma! require re-eated e9changes& Plasma e9change ma! (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 Aa 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 alters the immune s!stem using agents such as glucocorticoids A-rednisone or similar agentsB? a<athio-rine AImuranJB? or c!clos-orine& A--l!ing a -atch to one e!e& 7his -ermits -atients =ith dou(le vision to see one image& If the same e!e is consistentl! -atched? vision in that e!e =ill decrease& 7herefore? it is im-ortant to alternate the -atch from one e!e to the other to avoid -ermanent vision loss&

2/

Dsing e!elid crutches Aclever 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 treatment for ocular M+&

*y&iene8 *ealth Teachin&s

*!$ t! 2revent h!/e in0.ry 7hings to do if !ou are in)ured Call for hel- at once& Mee- a tele-hone and emergenc! num(ers on a lo= ta(le& It =ill (e easier to reach if !ou fall and have difficult! getting u-& Consult =ith !our doctor even if !ou don;t thin1 !ou are (adl! hurt& General If !ou have an unstead! gait? using a =al1er or a cane after training (! a -h!sical thera-ist can lessen the ris1 of falling& Don;t hold onto furniture or =alls for su--ort& @ear lo=4heeled? comforta(le? su--ortive foot=ear =ith non4s1id soles at all times& ,e alert for o()ects that might cause !ou to tri-& Mee- =al1=a!s clear& Re-air an! holes or rough s-ots in !our flooring? =al1=a!s or ste-s& Mo- u- floor s-ills immediatel!& Avoid rushing to cross the street or to ans=er the tele-hone or door(ell& Dse non4s1id =a9ing floors& Ma1e certain that rugs lie flat& ecure them =ith car-et ta-e or tac1s& Don;t use throe rugs& Install sturd! railings of staircases& Mee- stairs fee of clutter& 7a1e time to regain !our (alance =hen rising from a chair or (ed& 7o maintain (alance =hen -ic1ing o()ects u- the floor? stoo- do=n? (ending !our 1nees rather than leaning for=ard? it in chairs that have armrests sturd! enough to assist !ou =hen getting u- or sitting do=n& Place light s=itches so that !ou can turn on lights (efore =al1ing into a dar1ened room& Install (right lighting throughout the house&

20

Install smo1e alarms on ever! level of !our home G (e certain that the! =or1& Install outdoor lights at all entrances to !our home& Ma1e a list of emergenc! -hone num(ers G addresses G 1ee- them in a -ractical -lace& In case of fire? have an emergenc! e9it -lan& Mee- a fire e9tinguisher hand!& Mee- a flashlight in a convenient location in case of -o=er outages& Consider using a -ersonal medical alarm hel- (utton s!stem such as 8ifelineJ& @ear a medical identification (racelet or -endant& If !ou live alone? have a famil! mem(er or friend chec1 on !ou dail!&

'e r!!/ Sa1ety Place !our (ed =ithin eas! reach of lights G tele-hone& Remove =heels or casters from !our (ed G chairs& Dse a night light to light the =a! (et=een !our (ed G the toilet&

'athr!!/ Sa1ety 8imit the time !ou s-end in the sho=er or (ath to avoid =ea1ness& .ave someone assist !ou =ith (athing if =ea1ness is a -ro(lem& Put non4s1id stri-s or a ru((er mat in the tu( or sho=er& Install gra( (ars on the =all or side of the tu( or sho=er& Dse a sho=er chair or (ath seat =ith ru((er gri-s of !ou re unstead!& Mee- the floor dr! to avoid sli--ing& Dse a hand4held sho=erhead to ma1e it easier for hel- in (athing G rinsing off& Install a raised toilet seat G gra( (ars on the =all if !ou have difficult! rising from a sitting -osition& 7o avoid (urns? set the hot =ater tem-erature at %"# or lo=er&

"itchen sa1ety lide a heav! container of food along the counter Aor use a cartB instead of lifting them =hen arms are =ea1&

22

Put food in smaller containers? =hich is easier to lift G handle& Place items that !ou use frequentl! =ithin eas! reach so there is no need to clim(& 7o -revent fire? 1ee- loose fitting clothes? to=els G curtains a=a! from the stove (urners&

O#D
Follo=4u- care is indicated G is essential to -romoting o-timal ada-tation to the disease -rocess& Provide information a(out communit! resources that can assist the client G significant others =ith home management G ad)ustment to changes in the lifest!le? (od! functioning? G roles& Reinforce the im-ortance of 1ee-ing a--ointments =ith the health care -rovider& Consult -h!sician if signs G s!m-toms of fatigue -ersist or =orsen& 3ncourage the -t to visit hos-ital of there are signs G s!m-toms occurred after ta1ing the medications&

Diet
+ood nutrition is im-ortant for ever!one& 7his is es-eciall! true =hen !ou have a chronic disorder li1e m!asthenia gravis AM+B =ith =hich some? (ut not all? -atients =ill e9-erience difficult! =ith che=ing and s=allo=ing& 7o maintain normal (od! function? !ou need a (alance diet =ith adequate nutrients& N.triti!nal #r!3le/s in MG 7here are some areas of nutritional concern for -eo-le =ith M+& First? (e a=are that nutritional deficiencies frequentl! result from ma1ing -oor food choices& Fatigue G difficult! =ith che=ing G s=allo=ing ma! interfere =ith nutrition G create safet! issues& Diet modifications ma! (e advisa(le if !ou are ta1ing a certain medicines for M+ Ch!!se a sensi3le Diet Choose a healthful diet =ith a variet! of food grou-s containing the nutrients that !ou need& Oour age? gender? si<e G activit! level determine the num(er of calories that !ou require dail!& A nutritious dail! diet includes food from five food grou-s =ith 04%% grain grou- servings? '4/ vegeta(le grou- servings? "4* fruit grou- servings? "4' mil1Ldair! grou- servings and "4' meat grou- servings& 8imit fats? oils? s=eets G salt& Choose sensi(le -ortion si<es& Avoid em-t! calorie foods& Ener&y C!nservati!n - Mealti/e 7r! to -lan !our meals =hen !our strength is o-tional& 3at slo=l! and rest (et=een (ites if necessar!& @hen fatigue is a -ro(lem later in the da!? tr! eating !our main meal earlier& Instead

25

of three larger meals? tr! eating five or si9 smaller meals& If !ou are ta1ing anticholinergic drugs li1e Mestin!n, eat !our meal a(out an hour after ta1ing !our medicine& Che$in& - S$all!$in& Di11ic.lties M+ s!m-toms are highl! varia(le& Not all -eo-le =ith M+ =ill have difficult! che=ing and s=allo=ing& .o=ever? =ea1ness of the tongue? )a=? mouth G throat muscles ma! ma1e it difficult for some to che= or s=allo= food& At times of =ea1ness? !ou ma! get easil! fatigue during meals and have difficult! eating the 1ind or amount of food that !ou need to eat adequate nutrients G calories& 7his could result in malnutrition G une9-ected =eight loss& Oou ma! at times e9-erience a sensation of food stic1ing in !our throat or eso-hagus& 8iquids ma! come (ac1 u- !our nose due to =ea1ness of the muscles that se-arate !our throat G nose& 7hroat =ea1ness ma! allo= -artiall! che=ed solid food to get lodged in !our air=a! G cause !ou to cough or cho1ed =hile eating& If the air=a! (ecomes (loc1ed (! a -iece o food G coughing door does not dislodge it? death could result& For this reason? it is advisa(le that famil! mem(ers ta1e a first aid course that includes instructions on =hen G ho= to -erform the .eimlich maneuver& In e9treme times of =ea1ness? !ou might have trou(le s=allo=ing !our medication or even !our o=n saliva& olid food? 8iquids or saliva could enter the air=a! G then go into the lungs? causing Has-irationI -neumonia& If !ou are having difficult! =ith che=ing G s=allo=ing? inform !our M+ -h!sician so that treatment modifications can (e considered to (etter manage M+ =ea1ness& If !ou are cho1ing frequentl! or having trou(le s=allo=ing !our medication or saliva? call !ou doctor immediatel!& Easier Che$in& - S$all!$in& Modif!ing the consistenc! of food can ma1e it feasi(le for !ou to get -ro-er nutrition =hen !ou are having difficult! =ith eating G drin1ing& Pre-are foods in a =a! that ma1es them soft? tender and eas! to che= and s=allo=& Cho-? mash or -uree foods& Moisten dr! foods =ith liquid& @hile eating? ta1e si-s of liquid to soften foods in !our mouth G -revent solids from stic1ing in !our throat& 7he thin consistenc! of fluids ma1es them more li1el! to get as-irated into the lungs (ecause the! travel quic1l! do=n the throat& Commercial thic1eners can (e added to thin liquids to give them a more managea(le consistenc! G reduce this ris1& ,od! -osition G !our mealtime environment are im-ortant& @hen eating? sit u-right in a chair G tilt !our head for=ard& Avoid distractions =hile !ou eat& Don;t tal1 G eat at the same time& If !ou continue to have -ro(lems =ith eating over an e9tended time -eriod? evaluations (! a nutritionist G a s-eech language -athologist ma! (e hel-ful& S2ecial Diet M! i1icati!ns Occasionall!? anticholinergic medicines li1e Mestinon ma! cause cram-ing G diarrhea& If this is a -ro(lem? chec1 =ith !our doctor to see if the dose of the medicine needs to (e reduced or if heLshe =ants to add an! medicine to hel- control the diarrhea& Do not ta1e an! over4the4counter anti4diarrheal drugs =ithout first consulting =ith !our doctor& If diarrhea -ersists? avoid foods that aggravate this condition& Aggravating foods include those =ith a high fat content? greas! foods? s-ic! foods G dair! -roducts& One e9ce-tion is !ogurt =ith active cultures? =hich is actuall! (eneficial& Avoid other=ise health! foods =ith insolu(le fi(er li1e ra= vegeta(les? (ran? dried or un-eeled fruit? =hole grains G -o-corn& Coffee? teas? G chocolate containing stimulant caffeine =ill s-eed u- the action of !our intestines? ma1ing diarrhea =orse? too& Diarrhea can cause fluid G mineral loss& Choose foods that are mild G easil! digesti(le (ut are rich in minerals li1e -otassium G sodium Aunless !ou are on a sodium4restricted dietB& 7r! eating

2$

smaller amounts of food G liquid throughout the da! instead of three large meals& Include foods li1e =hite rice? a--lesauce? ver! ri-e (ananas? (a1ed or (roiled chic1en or fish& 8ight sou-s =ith (arle! or =hite rice G mild vegeta(les are nutritious G hel-ful? too& @hen ta1en over an e9tended -eriod of time? steroid medicines such as -rednisone can cause (one thinning& If !ou have steroids? it is im-ortant to have adequate amounts of calcium G vitamin D in !our dail! diet& Recommendations usuall! include %/## mg& of calciumG *## to 0##I&D& of vitamin D dail! in food su--lements& Mil1 -roducts? coo1ed dar1 green leaf! vegeta(les? dried (eans? canned sardines or salmon G calcium4fortified )uices G cereals are rich in calcium& teroid use can also cause fluid retention? so it is im-ortant to reduce sodium G increase -otassium in !ou diet& Avoid salt& Coo1 =ith salt su(stitutes or use other s-ices& 3s-eciall! avoid smo1ed G cured meats? canned sou-s G vegeta(les? -ic1led -roducts G salted snac1s o an! food item that lists salt or sodium as one of its main ingredients& %ita/ins - Minerals rec!//en e 1!r Myasthenia Gravis % $i e #ariety of #itamins an minerals are in#ol#e in m"scle acti#ity3 partly in energy pro "ction an partly in the synthesis of proteins an ne"rotransmitters- /he main &-#itamins are essential for energy pro "ction in the m"scles an some impro#ement in myasthenia gra#is has been reporte $ith &-complex s"pplementation so that3 for instance3 less of the en,ymeblocking r"g $as re4"ire Se#eral #itamins ha#e been sho$n to ha#e a specific relationship $ith myasthenia gra#is *itamin ,-? =or1ing together =ith /an&anese? is the 1e! vitamin for the s!nthesis of acet!lcholine in the nerve endings& A lac1 of this vitamin? therefore? can cause a reduced signal from nerves to muscles and? =ith this? muscle =ea1ness and other neurological com-lications& 6itamin ,% also hel-s acet!lcholine to (ind to rece-tors& It also has a significant role in nerve e9citation and enhances the effects of acet!lcholine& Furthermore? =ith lo= vitamin ,% levels lactic acid accumulates in the muscles and causes fatigue? deficienc! can also lead to nerve degeneration& *itamin ,. is im-ortant for tissue res-iration? for the storage of gl!cogen in muscles and liver as =ell as for the meta(olism of gl!cine? an amino acid lin1ed =ith m!asthenia gravis& A deficienc! lo=ers the resistance to stress& 6itamin ,0 is essential for the s!nthesis of neurotransmitters and rece-tors& +antot/enic acid su--lies the acet!l -art in the s!nthesis of acet!lcholine& It o--oses the effects of su(stances that are 1no=n to (loc1 rece-tors& Pantothenic acid is the anti4stress vitamin? most im-ortant for health! adrenal glands? =hich are es-eciall! =ea1 =ith m!asthenia gravis *itamin ( is another anti4stress vitamin& It is essential for collagen s!nthesis& Collagen is the connective tissue (et=een muscle cells? cementing them together& 6itamin C is involved =ith the use of gl!cogen in muscles? =ith muscle contractions and e9ercise tolerance& It affects muscle meta(olism and the functioning of muscle mem(ranes& 7ogether =ith folic acid it is involved =ith the s!nthesis of neurotransmitters and steroid hormones& It has a mild anticholinesterase activit! and this enhances the action of the reduced amount of acet!lcholine that finds a rece-tor& A stud! on "### smo1ers revealed that their vitamin C (lood levels =ere *#C lo=er than those of non4smo1ers& M!asthenia gravis -atients re-orted increased muscle =ea1ness after smo1ing& *itamin ,-. and folic acid are required for the s!nthesis of choline (efore forming acet!lcholine& 6itamin A is needed for the immune s!stem? to -roduce steroid hormones and to -rotect the th!mus and adrenal glands from the effects of stress& 6itamin A deficient rats

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develo-ed =ea1ness of the head and leg muscles& 7he im-ortance of the stress4-rotective vitamins can (e seen in the o(servation that m!asthenia gravis frequentl! develo-s during or after a -eriod of intense stress& *itamin % is im-ortant to -rotect cell mem(ranes from damage through o9idation and -ero9idation? =hile a deficienc! causes changes in muscle -rotein =ith s=elling and fragmentation of individual muscle fi(res? leading to muscle =ea1ness? d!stro-h! and -aral!sis& It is directl! involved =ith the energ! meta(olism of muscles? deficienc! causes increased amounts of muscle -rotein to (rea1 do=n and (e e9-elled =ith the urine as it ha--ens in m!asthenia gravis *itamin % deficient chic1s have (een sho=n to develo- serious a(normalities of the central nervous s!stem& In other animals large amounts of Qold4ageQ -igment Ali-ofuscinB accumulates in the nerve cells& 7he develo-ment and function of all endocrine glands de-ends on it& 7he -ituitar! gland has an e9ce-tionall! high content of vitamin 3? %/ times higher than in other -arts of the (od!? =hile in the adrenal glands it is almost 0 times higher&

S2irit.al8 #sych!s!cial
3ncourage constant communication =ith the Almight! Father through -ra!ers& Offer self through listening to client;s concerns? this decreases client;s an9iet!& 3ncourage famil! to -ra! together G attend church services in their o=n religious -ractice& Maintain a good relationshi- =ith neigh(ors? relatives G famil! mem(ers G maintain an o-en communication& Do meditation G set a time for -ersonal -ra!er& 3ntertain trials G failures as ste- to=ard success 1no=ing that Hall things =or1 together for good to them =ho love the 8ordkI H7hose =ho =ait u-on the 8ord shall rene= their strength G mount u- on =ings li1e eagles? the! shall run G not (e =ear!? G the! shall stum(le (ut not fall&I Isaiah *#E'%& H7rust in the 8ord =ith all !our heart G lean not on !our o=n understanding? in all !our =a!s ac1no=ledge .im G .e =ill direct !our -ath& Prover(s 'E/40

(!r the Si&ni1icant Others $ith Myasthenia Gravis .o= can I -rovide emotional su--ort for a relative =ho has M+l Most m!asthenics (elieve that the su--ort of their famil! and friends is e9tremel! im-ortant to their tas1 of co-ing =ith this disease& Oour =illingness to (e a -art of !our relative;s su--ort s!stem is quite valua(le to=ard hisLher =ell (eing& Recogni<e that !our relative has e9-erienced a loss? i&e&? a loss of muscle strength? -erha-s also a loss of functioning at home? at =or1 or at -la!? and a loss of a -erce-tion

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of themselves as having a H=ell (od!I& 7herefore? allo= them time for grieving their losses& 7he stages of denial? anger? (argaining? de-ression and acce-tance are normal for -eo-le coming to terms =ith an! t!-e of ma)or loss& 8et them 1no= that !our are there to listen =hen the! =ant to tal1& Offer !our -resence and !our time& Don;t feel that !ou must solve all of their -ro(lems or give advice& ometimes a good listener =ho genuinel! cares is all that is needed& 3m-athi<e rather than -it!& 3m-ath! conve!s !our understanding of the other -erson;s feelings? =hereas -it! conve!s onl! !our distress at !our -erce-tion of their suffering& Pit! is not =elcomed (! most m!asthenics (ecause the! find it demorali<ing& Oour distress a(out their illness also com-els them to hel- !ou feel (etter (! offering !our assurances that the! =ill (e all right& 8earn as much as !ou can a(out M+& Request literature from !our local M+ Cha-ter& Attend M+ Meetings or su--ort grou-s =ith them if such -rograms are -rovided in !our area& @ith !our relative;s -ermission? !ou ma! =ant to accom-an! them to their doctor;s a--ointment so that !ou ma! hear? learn and as1 questions& M!asthenics ma! need hel- =ith certain tas1s? (ut find it difficult to as1 for hel-& 7he! are reluctant to (other -eo-le =ho the! 1no= are (us! =ith their o=n res-onsi(ilities& Offer to -erform s-ecific tas1s -eriodicall!? such as hel-ing =ith child care? hair st!ling? sho--ing for groceries? clothing? or their Christmas gifts? =ra--ing their -resents? driving them to a doctor;s a--ointment or ta1ing them out of the house for a social e9cursion& ,e -re-ared for the un-redicta(le u-s and do=ns of M+& 7he m!asthenic ma! have to cancel an eagerl! a=aited social outing due to une9-ected =ea1ness& Do not feel hurt or sus-ect that !ou are Hsingled outI for these cancellations& Man! m!asthenics hesitate to ma1e advance -lans? -referring instead? to do things =hen the! feel strong enough& No= for a fe= Hdon;ts&I Don;t give sim-listic advice li1e? HMa!(e !ou should )ust ta1e vitaminske9ercise morek eat (etterkget more rest?I etc& Chances are the! alread! have o-inions a(out these things? and !our statements reveal that !ou don;t understand the disease& Don;t minimi<e or dismiss their com-laints =ith Hif !ou =ouldn;t d=ell on it? it =ouldn;t seem so (ad&I No one can (e e9-ected to (e stoic and (rave at all times& M!asthenics frequentl! hear the comment? H(ut !ou loo1 so =ellmI @hile !ou ma! give this com-liment intending to (oost their moral? m!asthenics often thin1 that !ou are dou(ting that the! are indeed ill& Although the m!asthenic ma! loo1 li1e the -icture of health? (e a=are that the s!m-toms of muscle =ea1ness and ra-id fatigue are not al=a!s visi(le to !our e!es&

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Don;t disa--ear from the scene (ecause !ou don;t 1no= =hat to sa! or fear sa!ing something that =ould ma1e it =orse& Most m!asthenics =elcome !our questions a(out M+ and a--reciate the o--ortunit! to tal1 to someone =ho cares to listen& Don;t =ithdra= from a loved one (ecause !ou sus-ect an Hemotional -o=der 1egI =ill e9-lode if !ou (ring u- a -ro(lem the! are having& Rather? if !ou or the! ignore a -ro(lem? it is (ound to =orsen or gro= more a=1=ard to handle& If tal1ing a(out it (rings tears? don;t run a=a!& 7ears can (e quite healing& A touch of the hand or a hug in silence can conve! more comfort than an! =ords or advice ever could& @hile (eing a good listener is an im-ortant -art of offering su--ort to !our relative? the! also value a friend =ho can (e honest =ith them& Oou can let !our relative vent hisLher anger? frustration or (itterness? then later at a (etter moment? offer !our honest feed(ac1& 7r! to recogni<e =hen !our relative needs hel- (e!ond =hat !ou can offer and encourage himLher to see1 -rofessional counseling& Finall!? remem(er that the m!asthenic needs to -artici-ate as Hnormall!I and full! as the! can in life& Don;t a(andon all famil! activities? normal conversations? affection and laughter& Remem(er? (efore !ou (ecame a -art of a Hsu--ort s!stem?I !ou =ere and still their aunt or cousinmmmm

#ROGNOSIS
#!!r Criteria a& Duration of illness (& Onset Illness of ?=@ (air ?+@ G!! ?B@ J.sti1icati!n Our -atient has (een diagnosed =ith M!asthenia +ravis for more than a !ear no=& he has (een admitted for a fe= times due to the com-lications led (! her illness& During the first fe= =ee1s u-on the onset of s!m-toms? the -atient continued =or1ing as a cler1& he onl! sought for medical intervention =hen she can no longer (ear the s!m-toms she felt& @ith the -reci-itating factors? our -atient has -oor -rognosis since her age (rac1et falls in middle adulthood A"$ !ears oldB& Considering also that she is a female and such disease is common in their gender& Our -atient =as a(le to com-l! =ith her medications as evidenced (! ta1ing in her medicine on time and

c& Preci-itating Factors d& @illingness to ta1e

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Medications e& Age

f& 3nvironment g& Famil! u--ort

having sufficient financial resources to sustain her medications& M!asthenia +ravis commonl! affects !oung adult =omen? usuall! those under the age of *#& ince our -atient is "$ !ears old? she has a -oor -rognosis =hen age is considered& Our -atient lives in a stressful environment& tress can trigger the remission of s!m-toms& 7he -atient;s famil! is su--ortive& 7he! are al=a!s there =hen she needs them&

Sc!re9 "T"T%T'T%T%T'_ %'L2_%&5/ A-oor 4 fairB ,ased on the data? our -atient got an average score of %&5/ in 2 criteria =hich means -oor to fair -rognosis& In addition? (oth fair and good -rognosis got " criteria =hile the -reci-itating factors? age? and environment got a score of % or -oor -rognosis& @ith this data? our -atient is more susce-ti(le for the recurrence of the disease& If this =ill not (e corrected? this =ill lead to -oor -rognosis& If the -atient is com-liant =ith the treatment? she =ill have a significant im-rovement in her muscle =ea1ness and can e9-ect to live a normal life& If some factors such as stress =ill (e encountered then there is -ossi(le recurrence&

RERERENCES
Doenges? M&3& and Moorhouse? A&C& A"##%B& Nurse;s Poc1et +uide Diagnosis? Interventions and Rationales A3ight 3dB& Fonhson? F&O& A"##*B& 7e9t(oo1 of Medical4 urgical Nursing A7enth 3d&? -& /%54/"*B& Porth? C&M& A"##"B& B Patho-h!siolog! Conce-ts of altered health states A i9th 3d&? -& %%'%4 %%'"B& ilvestri? 8&A& A"##0B& Revie= ford the NC83:4RN e9amination A7hird 3d&? -& $/04$2$B& melt<er? &C& and ,are? ,&+& A"##*B& 7e9t(oo1 of Medical4 urgical Nursing A7enth ed&? -& %$/04%$/5B& tein? A& M& A"##/B& NC83:4RN Revie= AFifth 3d&? -& ""%4"""B& ,onanomi 8? +a<<aniga A& 7o9icological? -harmaco1inetic and meta(olic studies on acet!lc!steine& 3ur F Res-ir Dis? %$5%> 0% A u--l IIIBE */4/%&

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===&emedicine&com ===&m!asthenia&org ===&mgau1&org&u1 ===&=i1i-edia&com ===&=rongdiagnosis&com

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