Learn about the nursing diagnosis for guillain-barre syndrome in this nursing care plan guide. Get to know the nursing interventions and nursing management for patients with this condition.
What is Guillain-Barre Syndrome?
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 manifestations 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 depending 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) and nursing diagnosis (NDx) for Guillain-Barre Syndrome (GBS):
- Ineffective Breathing Pattern
- Acute Pain
- Impaired Physical Mobility
- Impaired Urinary Elimination
- Risk for Altered Parenting
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.
- Ineffective Breathing Pattern
May be related to
- Ascending paralysis
- Decrease lung
Possibly evidenced by
- Altered chest expansion
- Respiratory depth changes
- Abnormal ABGs
- 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.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to neurological disorders:
- Alzheimer’s Disease | 15 Care Plans
- Brain Tumor | 3 Care Plans
- Cerebral Palsy | 7 Care Plans
- Cerebrovascular Accident | 12 Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Meningitis | 7 Care Plans
- Multiple Sclerosis | 9 Care Plans
- Parkinson’s Disease | 9 Care Plans
- Seizure Disorder | 4 Care Plans
- Spinal Cord Injury | 12 Care Plans
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