Terms in this set (25)
What is Guillain-Barré Syndrome?
acute destruction of the myelin sheath of peripheral nerves due to an autoimmune disorder that results in varying degrees of muscle weakness and paralysis.
-After the accute phase, remyelination occures, re-establishing nerve functions
Three stages that characterize the course of GBS
- initial period - 1-4 wks, onset of symptoms until deterioration stops
-plateau period - several days to 2 wks; no deterioration and no improvement
-recovery period - 4-6m, up to 2 years; remyelination and return of muscle strength
recent within 3 wks:
- acute illness (upper respiratory infection, GI infection
- virus such as Epstein-Barr or cytomegalovirus
- vaccination - swine flu vaccine
Signs and symptoms
-increasing muscle weakness with no recollection of injury
- client report of virus w/in previous 3 wks
-accute progressive muscle weakness and paralysis- begining in lower extremities and moving up
- muscle flacidity w/o muscle atrophy
-paresthesias - creeping/crawling sensations
-cranial nerve symptoms
-signes of resp compromise
- autonomic dysfunction - fluctuating BP, dysrhythmias
EMG - show evidence of denervation after 4+ wks
- WBC - Leukocytosis can develop
- Lumbar puncture - increase in protein w/in cerebral spinal fluid w/o increased cell count
what will a lumbar puncture show?
increase in protein w/in cerebral spinal fluid w/o increased cell count
-monitor resp status
- keep HOB at 45 degrees
-have client turn, cough, deep breath and use incentive spirometer ever 2 hrs
-monitor heart rythms - irregularities and bradycardia
- monitor BP
- assess difficulty articulating words
- assess for difficulty swallowing
-assess pain level
- prevent skin break-down
assist with communication?
alphabet board if can still use hands
assess emotional status
- coping strategies
- provide reassurance - cognative functions are NOT affected
- change position every 2 hrs
- heat and ice
IV Immunoglobulins (IVIg)
Morphine - consider this before giving
respiratory status - monitor carefully for respiratory depression and constipation
- given to suppress attack on immune system
- monitor for side effects - chills, fever, myalgia, possible anaphylaxis or renal failure
given for neuropathic pain
- assess for confusion, depression, drowsiness, ataxia
What is plasmapheresis?
-blood is removed from the body, ran through a separator, and the circulating antibodies are removed from the plasma.
-decreases the attack against the myelin sheath.
-may be done several times over a period of several weeks.
plasmapheresis - pre-procedure nursing actions
Assess vital signs, laboratory values, and weight
plasmapheresis - Intraprocedure nursing actions
- Assess for dizziness and hypotension.
- Maintain patency of shunts during the procedure (one is usually placed
in each upper extremity).
plasmapheresis - Postprocedure nursing actions
- Apply pressure dressing.
-Monitor for infection.
- Assess laboratory values.
- Monitor for the possible complications of hypovolemia, hypokalemia, and hypocalcemia
plasmapheresis -Client Education
Instruct the client that the procedure will typically last 2 to 5 hr.
client care after discharge
- Clients with significant paralysis will be discharged to a rehabilitation facility
- Referrals for assistance of social services, for a home health nurse, home health aide, and in-home physical and occupational
-If not mobile, many adaptations to the
home to make it wheelchair accessible
The client will be free of complications of immobility.
-The client will be able to resume ADLs.
- The client's muscle strength and functioning will return to baseline.
Complications of Guillain-Barré Syndrome
Nusing care for respiratory compromise
Recognize progressing paralysis and be prepared to intervene promptly.
- Nursing Actions:
- Monitor respiratory status (rate and depth of respirations, pulse oximetry, ABGs).
-Have oxygen, suction equipment, and intubation tray readily available.
- Provide assistance in mobilization and removal of secretions.
Items to keep in patient's room
intubation tray readily available
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