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.
- Ineffective Breathing Pattern
- Acute Pain
- Impaired Physical Mobility
- Impaired Urinary Elimination
- Risk for Altered Parenting
Impaired Urinary Elimination
May be related to
- Neuromuscular impairment
Possibly evidenced by
- Urinary retention
- Client will establish routine urinary elimination patterns.
|Assess progressive degree of paralysis and effect on urinary elimination.||Provides data on the effect of motor dysfunction that travels upward from extremities.|
|Monitor intake and output every 4 to 8 hours and palpate bladder every 2 hours; assess for cloudy, foul-smelling urine.||Provides monitoring of I&O ratio and presence of urinary retention or infection as paralysis progresses.|
|If needed, insert an indwelling urinary catheter to maintain elimination.||Relieves bladder distention and urinary retention.|
|Assist client in urinary elimination rehabilitation program; perform Crede’s maneuver in a gentle manner if indicated.||Promotes urine elimination and return to a normal pattern as soon as possible.|
|Educate parents in the program to restore urinary function.||Supports urinary elimination and return to baseline pattern without retention and possible urinary bladder infection.|
|Instruct parents to maintain fluid intake and monitor output in connection to intake.||Maintains I&O balance and adequate intake to promote urinary output.|
|Instruct to report any reduction or absence of urinary elimination.||Avoids complication of neuromuscular impairment of disease and effect on urinary bladder function.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
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
References and Sources
Recommended references and sources for this fracture nursing care plans:
- 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 Databank. Journal of clinical orthopaedics and trauma, 8(1), 38-44.
- 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 study. International journal of orthopaedic and trauma nursing, 32, 32-40.
- Brent, L., Hommel, A., Maher, A. B., Hertz, K., Meehan, A. J., & Santy-Tomlinson, J. (2018). Nursing care of fragility fracture patients. Injury, 49(8), 1409-1412.
- Buckley, J. (2002). Massage and aromatherapy massage: Nursing art and science. International Journal of Palliative Nursing, 8(6), 276-280.
- 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).
- DiFazio, R., & Atkinson, C. C. (2005). Extremity fractures in children: when is it an emergency?. Journal of pediatric nursing, 20(4), 298-304.
- 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 hospitalization. Pain Management Nursing, 20(2), 158-163.
- Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
- Hommel, A., Kock, M. L., Persson, J., & Werntoft, E. (2012). The Patient’s view of nursing care after hip fracture. ISRN nursing, 2012. [Link]
- 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 research, 172, 120-127.
- 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 Nursing, 16(4), 177-194.
- 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
- 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 Orthopaedics, 2(3), 2473011417S000288.
- 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 concepts. Injury, 49(3), 511-522.
- 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 childhood, 98(9), 721-724.
- 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 patients. Annals of vascular surgery, 60, 45-51.
- Patterson, J. T., Tangtiphaiboontana, J., & Pandya, N. K. (2018). Management of pediatric femoral neck fracture. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 26(12), 411-419.
- Patzakis, M. J., & Wilkins, J. (1989). Factors influencing infection rate in open fracture wounds. Clinical orthopaedics and related research, (243), 36-40.
- Resch, S., Bjärnetoft, B., & Thorngren, K. G. (2005). Preoperative skin traction or pillow nursing in hip fractures: a prospective, randomized study in 123 patients. Disability and rehabilitation, 27(18-19), 1191-1195.
- Rothberg, D. L., & Makarewich, C. A. (2019). Fat embolism and fat embolism syndrome. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(8), e346-e355.
- Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
- Wilson, D., & Hockenberry, M. J. (2014). Wong’s Clinical Manual of Pediatric Nursing-E-Book. Elsevier Health Sciences.