6 Guillain-Barre Syndrome Nursing Care Plans

Ineffective Breathing Pattern

Guillain-Barre syndrome can affect the muscles used for breathing, resulting in a weakened or paralyzed diaphragm, which can lead to an ineffective breathing pattern. This is because the muscles responsible for breathing are not functioning properly, leading to shallow breathing, difficulty taking deep breaths, and an increased risk of respiratory failure.

Nursing Diagnosis

• Ineffective Breathing Pattern

May be related to

• Ascending paralysis
• Decrease lung

Possibly evidenced by

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

Desired Outcomes

• The client will maintain an effective breathing pattern.

Nursing Assessment and Rationales

1. Assess frequency, symmetry, and depth of breathing. Observed for increased work of breathing and evaluate skin color, temperature, and 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.

2. Observe for signs of respiratory fatigue such as shortness of breath, decreased attention span, and impaired cough.
This may indicate neuromuscular respiratory failure or decreased lung capacity.

3. 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.

4. Assess oxygen saturation and review the client’s arterial blood gas results.
Determines oxygenation status and provides information about the effectiveness of ventilation given or the need to adjust the parameters.

Nursing Interventions and Rationales

1. Keep the head of the bed elevated at around 35-45°
Increases lung expansion and cough effort minimizes the work of breathing and the risk of aspiration of secretions.

2. Perform chest physiotherapy which includes postural drainage, chest percussion, chest vibration, turning, deep breathing, and coughing exercises.
Facilitates mobilization and clearance of airway secretions.

3. 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.

4. Suction secretions as appropriate, especially if the client is intubated or has undergone a tracheostomy.
Promotes adequate clearance of secretions and prevents aspiration.