ATI, CH11: Guillain-Barre Syndrome
ATI Med-Surge Edition 8.0
Terms in this set (8)
Guillain-Barre Syndrome (GBS)
- this disease develops in relation to acute destruction of the myelin sheath of peripheral nerves due to an autoimmune disorder that results in varying degrees of muscle weakness & paralysis??
- after the acute phase, remyelination occurs, re-establishing nerve functions. However, aggregates of lymphocytes can cause secondary damage, which can delay recovery or result in permanent deficits.
- Three Stages Characterize this disease (?):
*Initial Period - 1-4 weeks; onset of sxs until neurological
*Plateau Period - several days to 2 weeks; no deterioration, & no
*Recovery Period - 4-6 months & up to 2 years; remyelination &
return of muscle strength.
*Etiology is Unknown - evidence indicates a cell-mediated immunologic reaction. A history of a recent viral event is reported in many pts.
- Assessment -
-Recent (w/in 1-3 weeks) history of:
*Acute Illness (Upper resp infection, GI illness).
*Viruses, Epsein-Barr virus (EBV) or Cytomegalovirus
*Vaccination (swin flu vaccine)
- Subjective Data -
*pt reports of increasing weakness w/ no recollection of injury.
*pt report of a virus w/in the previous 1-3 weeks.
- Objective Data -
*Acute progressive muscle weakness & paralysis.
- ascending (initially, bilateral lower extremity muscles are
affected then progresses upward through arms & thorax).
- Recovery is in descending order (initially, face muscles
recover, then improvement progresses downward).
*Muscle Flaccidity w/o muscle atrophy.
*Paresthesias - creeping/crawling sensations across skin.
*Cranial nerve sxs (Diplopia, facial weakness, Dysarthria,
*Signs of Resp Compromise when muscle weakness reaches
*Autonomic Dysfunction (fluctuating BP, dysrhythmias)
Diagnostic Procedures (GBS)
- DIAGNOSTIC PROCEDURES -
1.) Electromyography (EMG) & nerve conduction velocity (NCV).
- shows evidence of denervation after 4+ weeks.
2.) WBC count
- leukocytosis can develop
3.) Lumbar Puncture (LP)
- shows the distinguishing characteristics GBS finding of an
increase in protein w/n the CSF w/o an increase in cell
Collaborative Care (GBS)
- NURSING CARE -
*Monitor resp status (rate & depth of respirations, pulse oximetry,
ABGs). Have oxygen, suction equipment & intubation tray
*Keep the HOB at 45; have the pt turn & cough, deep breathe &
use an incentive spirometer every 2hr; institute chest
physiotherapy if indicated.
*Monitor heart rhythms for irregularities & bradycardia.
*Monitor BP & respond to fluctuations as needed (beta-blocker
administration for hypertension, IV fluids for Hypotension).
*Assess for difficulty articulating words (Dysarthria). Provide an
alphabet board if the pt can still use his hands.
*Assess for difficulty 'swallowing & choking. request swallowing
study be completed if the pt is having difficulty swallowing foods
or liquids. Keep the pt NPO until results are available.
*Assess pain level if pt is experiencing parasthesia. Change
position at least every 2hr & apply ice or heat for discomfort.
*Take measures to prevent skin breakdown. The pt may not be
able to change position or feel pain when skin breakdown is
*Provide comfort measures (frequent repositioning, ice, heat
Medications for (GBS)
- Rx list for (?) -
- an analgesic given for pain & paresthesias.
- Nursing Considerations
*monitor for resp depression & constipation.
*IV Immunoglobulin (IVIg):
- given to suppress attack on immune system.
- Nursing Considerations;
*monitor for side effects, such as chills, fever, myalgia, & for
possible complications including anaphylaxis or renal failur
- given for neuropathic pain.
- Nursing Considerations;
*assess for confusion, depression, drowsiness, & ataxia.
Therapeutic Procedures for (GBS): PLASMAPHERESIS
- The following is a treatment for GBS known as?
- is is a treatment where blood is removed from the body, ran through a separator, & the circulating antibodies are removed from the plasma. This procedure decreases the attack against the myelin sheath. This may be done several times over a period of several weeks.
- NURSING ACTIONS -
- assess vitals, lab values, & weight
- assess for Dizziness & hypotension
- maintain patency of shunts during the procedure (one is
usually placed in each upper extremitiy).
- apply pressure dressing
- monitor for infection
- assess Lab values;
*monitor for possible complications of Hypovolemia,
Hypokalemia, & Hypocalcemia.
- PT EDUCATION -
*instruct the pt that the procedure will typically last 2 - 5 hr.
Client Outcomes for (GBS)
- Client Outcomes -
*The pt will be free of complications of immobility.
*THe pt will be able to resume ADLs.
*the pts muscle strength & functioning will return to baseline.
Complications of (GBS)
- Complications Include -
- Recognize progressing paralysis & be prepared to intervene
- NURSING ACTIONS -
*Monitor resp status (rate/depth of respirations, pulse oximetry,
*Have oxygen, suction equipment & intubation tray available.
*Provide assistance in mobilization & removal of secretions.
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