Medical-surgical Nursing Demystified

(^240) Medical-Surgical Nursing Demystified
NURSING DIAGNOSES

• Impaired physical mobility


• Fatigue


• Self-care deficit

NURSING INTERVENTION

• Monitor motor movements for interference with ADLs.


• Encourage activity balanced with rest periods.


• Assess cognitive function for changes, or deterioration.


• Explain to the patient:
  
  
  • Bladder training.
  
  
  • Teach self-catheterization if necessary (for patients with flexic bladder).
  
  
  • Increase fluid intake unless other medical problems contraindicate.
  
  
  • Importance of positioning.
  
  
  • Avoid temperature extremes.
  
  
  • Medication compliance.
  
  
  
  

Myasthenia Gravis

WHAT WENT WRONG?

This is a disorder of the peripheral nervous system involving antibodies that have

been produced by the body; they bind to receptor sites that normally bind acetyl-

choline. This prevents the acetylcholine from binding to the receptor sites on the

skeletal muscle, inhibiting normal muscle contraction in the affected area. The

areas of the body most commonly affected by the autoimmune disease include the

muscles in the eyes, face, lips, tongue, throat, and neck, resulting in weakness and

fatigue of these areas. The disease does not seem to be hereditary, but does have

a family tendency toward autoimmune disorders. The majority of the patients

have a hyperplasia (excessive growth of normal cells) of the thymus gland.

Myasthenia gravis is more likely to develop in young adults and is more common

in women.

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