VERAZON, JAYLORD B.

BSN 3A MYASTENIA GRAVIS NCP

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION/
PATHOPHYSIOLOG
Y
SUBJECTIVE DATA: "INEFECTIVE
NONE BREATHING Thymus gland stay
PATTERN RELATED large and develops
OBJECTIVE DATA: TO RESPIRATORY tumors in adult.
-Tachypnea MUSCLE
-Presence of crackles WEAKNESS"
on both lung field Thymus erroneously
upon auscultation causes immune cells to
-use of accesory produce antibodies that
muscle when breathing attacks the receptor
-orthopnea sites on the voluntary
-cyanosis muscle neuromuscular
junction.
VITAL SIGN
-Respiratory rate- Antibodies produce by
28cpm thymus will bind to the
nicotinic acetylcholine
receptors in muscle
fibers.
Blocking the receptors
sites of acetylcholine
produce by the nerve
that is made up of
cholinergic fibers.
SHORT TERM 1. Place patient with 1. A sitting position SHORT TERM
OBJECTIVE: proper body alignment permits maximum lung OBJECTIVE
After 8hours of for maximum excursion and chest After 8hours of
Nursing Intervention breathing pattern. expansion. Nursing Intervention
the patient will able to 2. Encourage sustained 2. These techniques the patient will able to
* maintains an deep breaths by: promotes deep * maintained an
effective breathing Using demonstration: inspiration, which effective breathing
pattern, as evidenced highlighting slow increases oxygenation pattern, as evidenced
by relaxed breathing at inhalation, holding end and prevents by relaxed breathing at
normal rate and depth inspiration for a few atelectasis. Controlled normal rate and depth
and absence of seconds, and passive breathing methods and absence of
dyspnea. exhalation may also aid slow dyspnea.
* the respiratory rate • respirations in patients * established a good
remains within Utilizing who are tachypneic. respiratory rate within
established limits. incentive spirometer Prolonged expiration limits
* the ABG levels • prevents air trapping. * established a good
return to and remain Requiring the 3. This method relaxes ABG level within
within established patient to yaw muscles and increases limits
limits. 3. Encourage the patient’s oxygen * indicates either
* indicates, either diaphragmatic level. verbally or through
verbally or through breathing for patients 4. This training behavior, feeling
behavior, feeling with chronic disease. improves conscious comfortable when
comfortable when 4. Evaluate the control of respiratory breathing.
breathing. appropriateness of muscles and * reports feeling rested
* reports feeling rested inspiratory muscle inspiratory muscle each day.
each day. training. strength. * performed
* performs 5. Provide respiratory 5. Beta-adrenergic diaphragmatic pursed-
diaphragmatic pursed- medications and agonist medications lip breathing.
lip breathing. oxygen, per doctor’s relax airway smooth * demonstrated a
VERAZON, JAYLORD B. BSN 3A MYASTENIA GRAVIS NCP

* demonstrates orders. muscles and cause maximum lung

Less acetylcholine is maximum lung 6. Avoid high bronchodilation to expansion with
absorbed by the muscle expansion with concentration of open air passages. adequate ventilation.
fiber. Plus, more adequate ventilation. oxygen in patients 6. Hypoxia triggers the * carried out ADLs,
acetylcholine is being * carries out ADLs, with COPD. drive to breathe in the breathing pattern
digest by the enzyme breathing pattern 7. Maintain a clear chronic CO2 retainer remains normal.
acetylcholinesterase. remains normal. airway by encouraging patient. When LONG TERM
patient to mobilize administering oxygen, OBJECTIVE
LONG TERM own secretions with close monitoring is After 3 days of
Muscle weakness in OBJECTIVE successful coughing. very important to Nursing intervertion,
voluntary muscle such After 3 days of nursing 8. Suction secretions, avoid uncertain risings the patient shall have
respiratory muscle. intervention, the as necessary. in the patient’s PaO2, applied techniques that
patient would be able 9. Stay with the patient which could lead to improved breathing
to apply techniques during acute episodes apnea. pattern and be free
that would improve of respiratory distress 7. This facilitates from signs and
breathing pattern and 10. Ambulate patient adequate clearance of symptoms of
be free from signs and as tolerated with secretions respiratory distrees and
symptoms of doctor’s order three 8. This facilitates AEB respiratory rate
respiratory distress. times daily. adequate clearance of within normal range,
11. Encourage secretions. absence of cyanosis,
frequent rest periods 9. This is to clear effective breathing and
and teach patient to blockage in airway. minimal use of
pace activity. 10. This will reduce accesorry muscle
12. Consult dietitian the patient’s anxiety,
for dietary thereby reducing
modifications oxygen demand.
13. Encourage small 11. Ambulation can
frequent meals. further break up and
14. Help patient with move secretions that
ADLs, as necessary. block the airways.
15. Avail a fan in the 12. Extra activity can
room worsen shortness of
16. Encourage social breath. Ensure the
VERAZON, JAYLORD B. BSN 3A MYASTENIA GRAVIS NCP

interactions with patient rests between

others that have strenuous activities.
medical diagnoses of 13. COPD may cause
ineffective breathing malnutrition which can
pattern. affect breathing
17. Educate patient or pattern. Good nutrition
significant other can strengthen the
proper breathing, functionality of
coughing, and respiratory muscles.
splinting methods. 14. This prevents
18. Educate patient crowding of the
about medications: diaphragm.
indications, dosage, 15. This conserves
frequency, and energy and avoids
possible side effects. overexertion and
Incorporate review of fatigue.
metered-dose inhaler 16. Moving air can
and nebulizer decrease feelings of air
treatments, as needed. hunger.
19. Teach patient 17. Talking to others
about: with similar conditions
pursed-lip breathing can help to ease
abdominal breathing anxiety and increase
performing relaxation coping skills.
technique 18. These allow
performing relaxation sufficient mobilization
techniques of secretions.
taking prescribed 19. This information
medications (ensuring promotes safe and
accuracy of dose and effective medication
frequency and administration.
monitoring adverse 20. These measures
effects) allow patient to
VERAZON, JAYLORD B. BSN 3A MYASTENIA GRAVIS NCP

scheduling activities to participate in

avoid fatigue and maintaining health
provide for rest period status and improve
20. Refer patient for ventilation.
evaluation of exercise 21. Exercise promotes
potential and conditioning of
development of respiratory muscles
individualized exercise and patient’s sense of
program. well-being

Establishes arousal
ability or level of
consciousness.

This activity will

further increase
intracranial pressure.
The medication such
as Dextromethorphan
will act to the brain to
reduce the urge to
VERAZON, JAYLORD B. BSN 3A MYASTENIA GRAVIS NCP

cough.