6 Guillain-Barre Syndrome Nursing Care Plans

ADVERTISEMENTS

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) and nursing diagnosis (NDx) for Guillain-Barre Syndrome (GBS):

ADVERTISEMENTS
  1. Ineffective Breathing Pattern
  2. Acute Pain
  3. Impaired Physical Mobility
  4. Impaired Urinary Elimination
  5. Anxiety
  6. Risk for Altered Parenting
ADVERTISEMENTS

Acute Pain

Nursing Diagnosis

May be related to

  • Biologic injuring agent (inflammation of nerves)

Possibly evidenced by

  • Communication of pain descriptors of discomfort in the extremities
  • Guarding behavior
  • Autonomic responses of diaphoresis
  • Alteration in muscle tone
  • Tachypnea, Tachycardia

Desired Outcomes

ADVERTISEMENTS
  • Child rates pain as less than (specify pain rating and scale used).
Nursing InterventionsRationale
Assess level of pain and ability to engage in activities.Determines the extent of pain or presence of progressive paralysis.
Identify the child’s perception of the word “pain” and inquire family members what word the child uses at home; Utilize pain scale appropriate for the child’s age and developmental level.Facilitates better communication between the child/family and nurse.
Administer analgesics based on pain assessment and respiratory status; Monitor side effect after administration.Eliminates or controls pain and provides comfort.
Provide support to extremities and maintain clean, comfortable bed using egg-crate mattress and padding to bony prominences as needed; Reposition client every 2 hours, use good postural alignment, assist with passive ROM.Increases comfort and decreases risks for skin impairment.
Apply a moist warm compress to painful areas as needed.Promotes circulation to the area and relieves pain.
Reassure parents and child that pain
diminishes as motor function slowly
improve or resolved.
Provides information about the length of time pain might be anticipated to continue.
Identify pain preventive measures around the clock; observe for behavioral and physiological signs of pain.Promotes immediate identification of pain which enhances efficient relief of pain.
ADVERTISEMENTS

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

See also

Other recommended site resources for this nursing care plan:

ADVERTISEMENTS

Other nursing care plans related to neurological disorders:

References and Sources

Recommended references and sources for this fracture nursing care plans:

  1. Auer, R., & Riehl, J. (2017). The incidence of deep vein thrombosis and pulmonary embolism after fracture of the tibia: an analysis of the National Trauma DatabankJournal of clinical orthopaedics and trauma8(1), 38-44.
  2. Biz, C., Fantoni, I., Crepaldi, N., Zonta, F., Buffon, L., Corradin, M., … & Ruggieri, P. (2019). Clinical practice and nursing management of pre-operative skin or skeletal traction for hip fractures in elderly patients: a cross-sectional three-institution studyInternational journal of orthopaedic and trauma nursing32, 32-40.
  3. Brent, L., Hommel, A., Maher, A. B., Hertz, K., Meehan, A. J., & Santy-Tomlinson, J. (2018). Nursing care of fragility fracture patientsInjury49(8), 1409-1412.
  4. Buckley, J. (2002). Massage and aromatherapy massage: Nursing art and scienceInternational Journal of Palliative Nursing8(6), 276-280.
  5. Desnita, O., Noer, R. M., & Agusthia, M. (2021, July). Cold Compresses Effect of on Postoperative Orif Pain in Fracture Patients. In KaPIN Conference (pp. 133-140).
  6. DiFazio, R., & Atkinson, C. C. (2005). Extremity fractures in children: when is it an emergency?Journal of pediatric nursing20(4), 298-304.
  7. Griffioen, M. A., Ziegler, M. L., O’Toole, R. V., Dorsey, S. G., & Renn, C. L. (2019). Change in pain score after administration of analgesics for lower extremity fracture pain during hospitalizationPain Management Nursing20(2), 158-163.
  8. Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
  9. Hommel, A., Kock, M. L., Persson, J., & Werntoft, E. (2012). The Patient’s view of nursing care after hip fractureISRN nursing2012. [Link]
  10. Lin, Y. C., Lee, S. H., Chen, I. J., Chang, C. H., Chang, C. J., Wang, Y. C., … & Hsieh, P. H. (2018). Symptomatic pulmonary embolism following hip fracture: A nationwide study. Thrombosis research172, 120-127.
  11. Maher, A. B., Meehan, A. J., Hertz, K., Hommel, A., MacDonald, V., O’Sullivan, M. P., … & Taylor, A. (2012). Acute nursing care of the older adult with fragility hip fracture: an international perspective (Part 1)International Journal of Orthopaedic and Trauma Nursing16(4), 177-194.
  12. McDonald, E., Winters, B., Nicholson, K., Shakked, R., Raikin, S., Pedowitz, D. I., & Daniel, J. N. (2018). Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery. Foot & Ankle International, 39(10), 1135–1140. https://doi.org/10.1177/1071100718782489
  13. McDonald, E., Winters, B., Shakked, R., Pedowitz, D., Raikin, S., & Daniel, J. (2017). Effect of Post-Operative Toradol Administration on Bone Healing After Ankle Fracture Fixation. Foot & Ankle Orthopaedics2(3), 2473011417S000288.
  14. Metsemakers, W. J., Kuehl, R., Moriarty, T. F., Richards, R. G., Verhofstad, M. H. J., Borens, O., … & Morgenstern, M. (2018). Infection after fracture fixation: current surgical and microbiological conceptsInjury49(3), 511-522.
  15. Neri, E., Maestro, A., Minen, F., Montico, M., Ronfani, L., Zanon, D., … & Barbi, E. (2013). Sublingual ketorolac versus sublingual tramadol for moderate to severe post-traumatic bone pain in children: a double-blind, randomised, controlled trial. Archives of disease in childhood98(9), 721-724.
  16. Pan, Y., Mei, J., Wang, L., Shao, M., Zhang, J., Wu, H., & Zhao, J. (2019). Investigation of the incidence of perioperative pulmonary embolism in patients with below-knee deep vein thrombosis after lower extremity fracture and evaluation of retrievable inferior vena cava filter deployment in these patientsAnnals of vascular surgery60, 45-51.
  17. Patterson, J. T., Tangtiphaiboontana, J., & Pandya, N. K. (2018). Management of pediatric femoral neck fractureJAAOS-Journal of the American Academy of Orthopaedic Surgeons26(12), 411-419.
  18. Patzakis, M. J., & Wilkins, J. (1989). Factors influencing infection rate in open fracture woundsClinical orthopaedics and related research, (243), 36-40.
  19. Resch, S., Bjärnetoft, B., & Thorngren, K. G. (2005). Preoperative skin traction or pillow nursing in hip fractures: a prospective, randomized study in 123 patientsDisability and rehabilitation27(18-19), 1191-1195.
  20. Rothberg, D. L., & Makarewich, C. A. (2019). Fat embolism and fat embolism syndromeJAAOS-Journal of the American Academy of Orthopaedic Surgeons27(8), e346-e355.
  21. Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
  22. Wilson, D., & Hockenberry, M. J. (2014). Wong’s Clinical Manual of Pediatric Nursing-E-Book. Elsevier Health Sciences.
Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
  • >