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Nursing Care Plan | NCP Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS; also known as acute idiopathic demyelinating polyneuropathy) is an acute, rapidly progressing form of polyneuritis that results in a temporary, flaccid paralysis lasting for 4 to 8 weeks. Motor, sensory, and autonomic functions may be involved. The syndrome is characterized by a diffuse inflammation or demyelination (or both) of the ascending or descending peripheral nerves that leads to a viral illness and then paralysis. Although the syndrome is considered to be a medical emergency, over 80% of persons who are affected with Guillain-Barré syndrome recover their functional abilities completely. The remaining individuals have some degree of neurological deficit after recovery from the disease, which results in a chronic disability. Fewer than 5% of patients with Guillain-Barré syndrome die, and usually, death is related to respiratory complications.

Although the exact cause of Guillain-Barré syndrome is unknown, two-thirds of patients who develop it have had a viral or bacterial infection 1 to 3 weeks before the development of symptoms. The most typical site and cause of infections are a lung or intestinal infection caused by Campylobacter jejuni (C. jejuni) or cytomegalovirus (CMV). Infections with Epstein-Barr virus and Mycoplasma pneumoniae are also associated with GBS. Another 10% of patients have had recent surgical procedures during the 4 weeks before GBS developed. Other diseases that have been linked to the development of GBS are lymphoma, human immunodeficiency virus (HIV) disease, gastroenteritis, Hodgkin’s disease, and lupus erythematosus. In some cases, GBS develops after immunization for influenza.
Nursing care plan
Nursing care plan assessment and physical examination
Determine if the patient has had a recent viral illness or surgical procedure. Often, the patient describes a minor upper respiratory or gastrointestinal febrile illness. Many, but not all, patients complain of paresthesia (numbness, prickling, tingling) early in the course of the illness. The patient or family generally seeks assistance when bilateral lower limb weakness begins to spread toward the trunk or has progressed to paralysis of the limbs. Urinary incontinence may be a problem initially, followed by difficulty in swallowing and speaking. Impairment of respiratory functions, the most life-threatening effect of Guillain-Barré syndrome, does not occur until the paralysis has affected all of the peripheral areas and the trunk.

The major neurological sign found in Guillain-Barré syndrome is muscle weakness, but sensory loss, particularly in the legs and later in the arms, often occurs. Although the progression of symptoms is variable, the disease often progresses upward from the legs in 1 to 3 days. To follow the progression of symptoms, test for ascending sensory loss by gently using a pinprick upward from the level of T12 on the vertebral column (level of the iliac crests) to the midscapular point (about T6). Mark the patient’s skin with a pen every 4 hours to document changes. Notify the physician immediately if the level reaches T8 or higher, because muscles at that level are needed for breathing. Patients may also have ocular muscle paralysis, loss of position sense, and diminished or absent reflexes.

The function of cranial nerve VII (facial nerve) may be affected, especially in the later stages of the paralysis. To test for facial nerve weakness, inspect the patient’s face at rest and during conversation. Have the patient raise both eyebrows, smile, frown, puff out the cheeks, and show both upper and lower teeth. If the facial nerve is involved, the patient may have problems talking, chewing, and swallowing.

Patients often have changes in their vital signs. Rapid or slow heart rates and a labile blood pressure may occur because of the effects on the vagus nerve (cranial nerve X), as well as profuse sweating and facial flushing. Patients require continuous cardiac monitoring to assess for dysrhythmias. Although respiratory function may be impaired in the later stages of paralysis, the nurse needs to assess the patency of the airway and adequacy of breathing in order to initiate prompt interventions when necessary.

The patient is alert, but paralyzed, and this leads to considerable fear and anxiety both during the initial stages and throughout the course of the disease. As the paralysis ascends, the patient’s level of anxiety will probably rise. The patient and significant others will need a great deal of emotional support to deal with the health crisis.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to weakness, problems in swallowing, and respiratory muscle paralysis.

Nursing care plan intervention and treatment
During the acute phase of the illness, the patient may be in the intensive care unit, particularly to support pulmonary function with endotracheal intubation and mechanical ventilation. Sequential neurological, cardiopulmonary, and hemodynamic assessments are needed. Some patients have chest physiotherapy ordered, and all require aggressive pulmonary toileting to maintain a patent endotracheal or tracheostomy tube. Most patients need a Foley catheter to manage urinary function. Compression boots limit the risk of thromboembolic complications.

Plasmapheresis (plasma exchange) may be completed during the early stages (first few days) of the syndrome; research suggests that the procedure may reduce the circulating antibodies and shorten the period of paralysis. Care of the patient who is having plasmapheresis includes monitoring the amount of plasma removed and reinfused and monitoring for any reactions to the fluid replacement. Transfusion reactions should not occur because the patient’s own blood is being returned. Complications such as infection and hyptertension require pharmacologic management. Other patients may become hypotensive and require fluid boluses or vasopressors.

The most important interventions center on maintaining a patent airway and adequate breathing. Teach deep-breathing and coughing techniques. Monitor the patient who is mechanically ventilated for airway obstruction. Use deep endotracheal suction to maintain a patent airway, but monitor the patient carefully for dysrhythmias and a dropping oxygen saturation. Because respiratory complications are seen in 35% to 40% of patients, preparation for intubation or eventually a tracheostomy is appropriate. A viable call system for the patient is vital, and the type will depend on the extent of the paralysis. Cardiac dysrhythmias also occur in Guillain-Barré syndrome, so patients require continuous cardiac monitoring.

Provide passive range-of-motion exercises at least twice a day; turn the patient at least every 2 hours, and use splints and pillow supports to keep the limbs in functional positions. Control the environment to limit the risk of injury from falls. Inspect for integrity of the skin. Frequent eye care is necessary for the individual with cranial nerve VII involvement. Protect the cornea with eye shields (some eye specialists may recommend suturing the eyes closed) and provide eye lubricants. Give mouth care at least every 4 hours.

The patient’s psychological state is most important. Use relaxation exercises, include the patient in decision making, and provide frequent explanations of care to decrease the patient’s anxiety. Mood swings are to be expected. Encourage the patient to ventilate fears and anger related to the paralysis and the prognosis. If the patient cannot speak because of endotracheal intubation or paralysis, try to establish communication by having the patient blink once for “yes” and twice for “no.”

Nursing care plan discharge and home health care guidelines
Especially during the recovery period, teach the patient to avoid exposure to further upper respiratory infections. Encourage self-care, but stress the avoidance of fatigue and the importance of frequent planned rest periods. Continue ongoing rehabilitation with physical therapy sessions to teach walking with a cane or walker and to provide active and passive range-of-motion exercises. Teach strengthening exercises for the hands, such as modeling clay or squeezing balls. Teach the patient and family how to manage the transfer from the bed to a wheelchair and from a wheelchair to the toilet or bathtub.

Teach the patient to maintain a high-calorie, high-protein diet and to include at least 2000 mL of fluid intake per day. Avoid constipation by increasing fluids and dietary fiber and using stool softeners as required. Teach the patient to use warm baths to manage muscle pain and diversional activities to decrease boredom during the slow recovery period.
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