6 Guillain-Barre Syndrome Nursing Care Plans

Guillain-Barre Syndrome Nursing Care Plans

Guillain-Barre syndrome (GBS) also known as infectious polyneuritis is an autoimmune disease in which there is an acute inflammation of the spinal and cranial nerves manifested by motor dysfunction that predominates over sensory dysfunction. The exact cause is unknown, but it is associated with a previously existing viral infection or immunizations.  Classical clinical manifestation may include ascending and symmetrical motor weakness and absent or diminished reflexes.

The severity of the disease ranges from mild to severe with the course of the disease dependent on the extent of paralysis present at the peak of the condition. Recovery is usually complete and may take weeks or months. The disease most commonly occurs in children between 4 and 10 years of age. Treatment is symptom-dependent with hospitalization required in the acute phase of the disease to observe and intervene for respiratory or swallowing complications.

Nursing Care Plans

Nursing care planning goals for a pediatric client with Guillain-Barre syndrome include improved respiratory function, promotion of physical mobility, prevention of contractures, decreased anxiety and pain, relief of urinary retention, improvement of parental care and prevention of complications.

Here are six (6) nursing care plans (NCP) for Guillain-Barre Syndrome (GBS):

  1. Ineffective Breathing Pattern
  2. Acute Pain
  3. Impaired Physical Mobility
  4. Impaired Urinary Elimination
  5. Anxiety
  6. Risk for Altered Parenting
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Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

May be related to

  • Ascending paralysis
  • Decrease lung

Possibly evidenced by

  • Altered chest expansion
  • Cyanosis
  • Respiratory depth changes
  • Abnormal ABGs

Desired Outcomes

Nursing Interventions Rationale
Assess frequency, symmetry, and depth of breathing. Observed for increased work of breathing and evaluate skin color, temperature, capillary refill. Progressive weakness of both the inspiratory and the expiratory muscles may lead to respiratory distress that may necessitate the need for mechanical ventilation.
Observe for signs of respiratory fatigue such as shortness of breath, decreased attention span, and impaired cough. May indicate neuromuscular respiratory failure or decrease lung capacity.
Auscultate lung sounds for any changes and notifies the physician immediately. Pooling of secretions and increased airway resistance may impede the diffusion of gases resulting in airway complications such as pneumonia.
Assess oxygen saturation and review client’s arterial blood gases results. Determines oxygenation status and provides information about the effectiveness of ventilation given or the need to adjust the parameters.
Keep the head of bed elevated at around 35-45° Increases lung expansion and cough effort minimizes the work of breathing and the risk of aspiration of secretions.
Perform chest physiotherapy which includes postural drainage, chest percussion, chest vibration, turning, deep breathing and coughing exercises. Facilitates mobilization and clearance of airway secretions.
Anticipate the need for mechanical ventilation as ordered. Mechanical ventilation may be required for an extended period to support pulmonary function and adequate oxygenation. Weaning from mechanical ventilation happens when the respiratory muscles can sustain spontaneous respiration and keep adequate tissue oxygenation.
Suction secretions as appropriate, especially if the client is intubated or undergone a tracheostomy. Promotes adequate clearance of secretions and prevents aspiration.
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See Also


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Neurological Care Plans


Nursing care plans for related to nervous system disorders:

Pediatric Nursing Care Plans


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Further Reading


Recommended books and resources:

  1. Nursing Care Plans: Diagnoses, Interventions, and Outcomes
  2. Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
  3. Nursing Diagnoses 2015-17: Definitions and Classification
  4. Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
  5. Manual of Psychiatric Nursing Care Planning
  6. Maternal Newborn Nursing Care Plans
  7. Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
  8. Maternal Newborn Nursing Care Plans