6 Guillain-Barre Syndrome Nursing Care Plans

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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):

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  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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Impaired Urinary Elimination

Nursing Diagnosis

May be related to

  • Neuromuscular impairment

Possibly evidenced by

  • Urinary retention
  • Paralysis

Desired Outcomes

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  • Client will establish routine urinary elimination patterns.
Nursing InterventionsRationale
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.
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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

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Other nursing care plans related to neurological disorders:

References and Sources

Recommended references and sources for this fracture nursing care plans:

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  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]
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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.
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