Nursing Process: The Patient With Guillain-Barré Syndrome

NURSING PROCESS: THE PATIENT WITH GUILLAIN-BARRÉ SYNDROME

Assessment

Ongoing assessment for disease progression is critical. The pa-tient is monitored for life-threatening complications (respiratory failure, cardiac dysrhythmias, DVTs) so that appropriate inter-ventions can be initiated. Because of the threat to the patient in this sudden, potentially life-threatening disease, the nurse must assess the patient’s and family’s ability to cope and their use of appropriate coping strategies.

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, the patient’s major nursing diag-noses may include the following:

·      Ineffective breathing pattern and impaired gas exchange re-lated to rapidly progressive weakness and impending respi-ratory failure

·      Impaired physical mobility related to paralysis

·      Imbalanced nutrition, less than body requirements, related to inability to swallow

·      Impaired verbal communication related to cranial nerve dysfunction

·      Fear and anxiety related to loss of control and paralysis

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include the following:

·      Respiratory failure

·       Autonomic dysfunction

Planning and Goals

The major goals for the patient may include improved respiratory function, increased mobility, improved nutritional status, effec-tive communication, decreased fear and anxiety, and absence of complications.

Nursing Interventions

MAINTAINING RESPIRATORY FUNCTION

Respiratory function can be maximized with incentive spirome-try and chest physiotherapy. Monitoring for changes in vital ca-pacity and negative inspiratory force are key to early intervention for neuromuscular respiratory failure. Mechanical ventilation is required if the vital capacity falls, making spontaneous breathing impossible and tissue oxygenation inadequate.

Parameters for determining the appropriate time to begin me-chanical ventilation include a vital capacity of 12 to 15 mL/kg, downward vital capacity trend over 4 to 6 hours, and an inability to clear secretions (Bella & Chad, 1999). The potential need for mechanical ventilation should be discussed with the patient and family on admission to provide time for psychological prepara-tion and decision-making. Intubation and mechanical ventilation will result in less anxiety if it is initiated on a nonemergent basis to a well-informed patient. The patient may require mechanical ventilation for a long period..

Bulbar weakness that impairs the ability to swallow and clear secretions is another factor in the development of respiratory fail-ure in the patient with Guillain-Barré. Suctioning may be needed to maintain a clear airway.

The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed. Medications are administered or a temporary pacemaker is placed for clinically significant brady-cardia (Winer, 2002).

ENHANCING PHYSICAL MOBILITY

Nursing interventions to enhance physical mobility and prevent the complications of immobility are key to the function and sur-vival of these patients. The paralyzed extremities are supported in functional positions, and passive range-of-motion exercises are performed at least twice daily.

DVT and pulmonary embolism are threats to the paralyzed patient. Nursing interventions are aimed at preventing DVT. Range-of-motion exercises, altering positioning, anticoagulation, thigh-high elastic compression stockings or sequential com-pression boots, and adequate hydration will decrease the risk for DVT.

Padding may be placed over bony prominences such as the el-bows and heels to reduce the risk for pressure ulcers. The need for consistent position changes every 2 hours cannot be overempha-sized. The nurse evaluates laboratory test results that may indi-cate malnutrition or dehydration, both of which increase the risk for pressure ulcers. Collaboration with the physician and dietitian will result in a plan to meet the patient’s nutritional and hydra-tion needs.

PROVIDING ADEQUATE NUTRITION

Paralytic ileus may result from insufficient parasympathetic ac-tivity. In this event, the nurse administers IV fluids and parenteral nutrition as prescribed and monitors for the return of bowel sounds. If the patient cannot swallow due to bulbar paralysis (immobility of muscles), a gastrostomy tube may be placed to ad-minister nutrients. The nurse carefully assesses the return of the gag reflex and bowel sounds before resuming oral nutrition.

IMPROVING COMMUNICATION

Because of paralysis and ventilator management, the patient can-not talk, laugh, or cry and thus has no method for communicating needs or expressing emotion. Establishing some form of com-munication with picture cards or an eye blink system will provide a means of communication. Collaboration with the speech ther-apist may be helpful in developing a communication mechanism that is most effective for a specific patient.

DECREASING FEAR AND ANXIETY

The patient and family are faced with a sudden, potentially life-threatening disease, and anxiety and fear are constant themes for them. The impact of disease on the family will depend on the patient’s age and role within the family. Referral to a support group may provide information and support to the patient and family.

The family may feel helpless in caring for the patient. Me-chanical ventilation and monitoring devices may frighten and intimidate them. Family members often want to participate in physical care; with instruction and support by the nurse, they should be allowed to do so.

In addition to fear, the patient may experience isolation, lone-liness, and lack of control. Nursing interventions that increase the patient’s sense of control include providing information about the condition, emphasizing a positive appraisal of coping resources, and teaching relaxation exercises and distraction techniques. The positive attitude and atmosphere of the multidisciplinary team are important to promote a sense of well-being.

Diversional activities are encouraged to decrease loneliness and isolation. Encouraging visitors, engaging visitors or volun-teers to read to the patient, listening to music or books on tape, and watching television are ways to alleviate the patient’s sense of isolation.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Thorough assessment of respiratory function at regular intervals is essential because respiratory insufficiency and subsequent failure due to weakness or paralysis of the intercostal muscles and di-aphragm may develop quickly. Respiratory failure is the major cause of mortality, which is reported to be as high as 10% to 20%. Vital capacity is monitored frequently and at regular intervals in addition to respiratory rate and the quality of respirations, so that respiratory insufficiency can be anticipated. Decreasing vital ca-pacity associated with weakness of the muscles used in swallowing, which causes difficulty in both coughing and swallowing, indi-cates impending respiratory failure. Signs and symptoms include breathlessness while speaking, shallow and irregular breathing, use of accessory muscles, tachycardia, and changes in respiratory pattern.

Parameters for determining the onset of respiratory failure are established on admission, allowing intubation and the initiation of mechanical ventilation on a nonemergent basis. This also al-lows the patient to be prepared for the procedure in a controlled manner, which reduces anxiety and complications.

Other complications include cardiac dysrhythmias, which ne-cessitate ECG monitoring, transient hypertension, orthostatic hypotension, DVT, pulmonary embolism, urinary retention, and other threats to any immobilized and paralyzed patient. These re-quire monitoring and attention to prevent them and prompt treatment if indicated.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

Patients with Guillain-Barré syndrome and their families are usu-ally frightened by the sudden onset of life-threatening symptoms and their severity. Therefore, teaching the patient and family about the disorder and its generally favorable prognosis is impor-tant (Chart 64-5). During the acute phase of the illness, the patient and family are instructed about strategies they can implement to minimize the effects of immobility and other complications. As function begins to return, family members and other home care providers are instructed about care of the patient and their role in the rehabilitation process. Preparation for discharge is an inter-disciplinary effort requiring family or caregiver education by all team members, including the nurse, physician, occupational and physical therapists, speech therapist, and respiratory therapist.

Continuing Care

Most patients with Guillain-Barré syndrome experience complete recovery. Patients who have experienced total or prolonged paral-ysis require intensive rehabilitation; the extent depends on the pa-tient’s needs. Approaches include a comprehensive inpatient program if deficits are significant, an outpatient program if the patient can travel by car, or a home program of physical and oc-cupational therapy. The recovery phase may be long and will re-quire patience as well as involvement on the part of the patient and family.

During acute care the focus is on obvious needs, issues, and deficits. The nurse needs to remind or instruct patients and fam-ily members of the need for continuing health promotion and screening practices following this initial phase of care.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Maintains effective respirations and airway clearance

a)     Has normal breath sounds on auscultation

b)    Demonstrates gradual improvement in respiratory function

2)    Shows increasing mobility

a)     Regains use of extremities

b)    Participates in rehabilitation program

c)     Demonstrates no contractures and minimal muscle atrophy

3)    Receives adequate nutrition and hydration

a)     Consumes diet adequate to meet nutritional needs

b)    Swallows without aspiration

4)    Demonstrates recovery of speech

a)     Can communicate needs through alternative strategies

b)    Practices exercises recommended by the speech therapist

5)    Shows lessening fear and anxiety

6)    Absence of complications

a)     Breathes spontaneously

b)    Has vital capacity within normal range

c)     Exhibits normal arterial blood gases and oximetry