myasthenia gravis crisis, an acute exacerbation of the muscular weakness characterizing the disease, triggered by illness, infection, surgery, emotional stress, or an overdose or insufficiency of anticholinesterase medication. ▪ OBSERVATIONS: Typical signs and symptoms include worsening diplopia or muscle weakness that can progress to respiratory distress accompanied by apnea, extreme fatigue, increased muscular weakness, dysphagia, dysarthria, and fever. The patient may be anxious, restless, irritable, and unable to move the jaws or to raise one or both eyelids. If the condition is caused by anticholinesterase toxicity, then anorexia, nausea, vomiting, abdominal cramps, diarrhea, excessive salivation, sweating, lacrimation, blurred vision, vertigo, and muscle cramps and spasms, as well as general weakness, dysarthria, and respiratory distress may occur. ▪ INTERVENTIONS: Initial treatment is directed to maintaining airway patency. Oxygen with assisted or controlled ventilation is administered. The patient is placed in a bed in which the head is elevated 30 degrees. The withdrawal or reduction of anticholinergic drugs may be ordered, or they may be given to differentiate the kind of crisis. If the eyelids are affected, the eyes may be covered with a patch and soothing eyedrops may be administered. To enable the patient to communicate, the call bell and a pad and pencil are placed within reach. Nourishment is offered between meals, and a daily intake of up to 2000 mL of fluids is encouraged. Walking as tolerated and other activities are planned at the time of the maximum effect of medication. Active or passive range-of-motion exercises of all extremities are performed several times a day, but rest periods are maintained to prevent fatigue and relapse. ▪ PATIENT CARE CONSIDERATIONS: Before discharge the patient is instructed on the importance of taking the prescribed medication with milk, crackers, or bread at the scheduled time and of reporting toxic side effects and symptoms of recurrent or progressive disease. Members of the health care team point out the need to maintain a regular diet, to exercise to tolerance, to rest, and to avoid infections and exposure to hot or cold weather and the use of alcohol and tobacco. Help in planning a schedule that conserves energy for essential activities can enable the patient to be relatively independent and self-sufficient.
