Notes
Description
- Also known as polyradiculoneuritis.
- It is an acute inflammatory polyneuropathy of the peripheral sensory and motor and nerve roots.
- Affected nerves are demyelinated with possible axonal degeneration.
- It’s exact cause is unknown, Guillain-Barré Syndrome is believed to be an autoimmune disorder that may be triggered by viral infection, Campylobacter diarrheal illness, immunization, or other precipitating event.
- The syndrome is marked by acute onset of symmetric progressive muscle weakness, most often beginning in the legs and ascending to involve the trunk, upper extremities, and facial muscles. Paralysis may develop.
- Complications may include respiratory failure, cardiac arrhythmias, and complications of immobility.
Pathophysiology
GBS results from an autoimmune (cell-mediated and humoral) attack on peripheral nerve myelin proteins ( substances speeding conduction of nerve impulses) . The Schwann cell( which produces myelin in the peripheral nervous system) is paired in GBS, allowing for remyelination in the recovery phase of the disorder.
Causes
Although the exact cause of GBS is unknown, two-thirds of patients who develop it have had a viral or bacterial infection 1 to 3 weeks before the development of symptoms. The most typical site and cause of infections are a lung or intestinal infection caused by Campylobacter jejuni(C. jejuni) or cytomegalovirus (CMV). Infections with Epstein-Barr virus and Mycoplasma pneumoniae are also associated with GBS. Another 10% of patients have had recent surgical procedures during the 4 weeks before GBS developed. Other diseases that have been linked to the development of GBS are lymphoma,human immunodeficiency virus (HIV) disease,gastroenteritis,Hodgkin’s disease, and lupus erythematosus. In some cases,GBS develops after immunization for influenza.
Assessment
- Acute onset (hours to weeks) of progressive, usually ascending muscle weakness and fasciculation, possibly leading to paralysis (maximal weakness is reached within 2 weeks).
- Paresthesia and painful sensations.
- Possible hypoventilation due to chest muscle weakness.
- Difficulty with swallowing, chewing, speech, and gag, indicating fifth (trigeminal) and ninth (glossopharyngeal) cranial nerve movement.
- Reduce or absent deep tendon reflexes, position and vibratory perception.
- Autonomic dysfunction with orthostatic hypotension and tachycardia.
Diagnostic Evaluation
- Lumbar puncture obtains cerebrospinal fluid samples, which reveal low cell count and high protein levels.
- Nerve conduction studies, which allow decreased conduction velocity of peripheral nerves due to demyelination.
- Abnormal laboratory studies may point to prior infection or illness.
Primary Nursing Diagnosis
- Ineffective airway clearance related to weakness,problems in swallowing,and respiratory muscle paralysis
Therapeutic Intervention / Medical Management
- GBS is considered a medical emergency; patient is managed in an intensive care unit.
- Respiratory problems may require mechanical ventilation
- Plasmapheresis (plasma exchange) or intravenous immunoglobulin (IVIG) may be used to limit deterioration or demyelination
- Continuous electrocardiogram (ECG) monitoring: Observe and treat cardiac dysrhythmias and other labile complications of autonomic dysfunction. Tachycardia and hypertension are treated with short acting medication such as alpha-adrenergic blocking agents. Hypotension is manage by increasing the amount of intravenous fluid administered.
Pharmacologic Intervention
- Atrophine may be administered to avoid episodes of bradycardia during endotracheal suctioning and physical therapy. Anticoagulants and thigh-high elastic compression stockings or sequential compression boots may be ordered to prevent thrombosis and pulmonary emboli secondary to immobility.
Nursing Intervention
- Monitor respiratory status through vital capacity measurements, rate and depth of respirations, and breath sounds.
- Monitor level of muscle weakness as it ascends toward respiratory muscles. Watch for breathlessness while talking which is a sign of respiratory fatigue.
- Monitor the patient for signs of impending respiratory failure.
- Monitor gag reflex and swallowing ability.
- Position patient with the head of bed elevated to provide for maximum chest excursion.
- Avoid giving opioids and sedatives that may depress respirations.
- Position patient correctly and provide range-of-motion exercises.
- Provide good body alignment, range-of-motion exercises, and change of position to prevent complications such as contractures, pressure sores, and dependent edema.
- Ensure adequate nutrition without the risk of aspiration.
- Encourage physical and occupational therapy exercises to help the patient regain strength during rehabilitation phase.
- Provide assistive devices as needed (cane or wheelchair) to maximize independence and activity.
- If verbal communication is possible, discuss the patient’s fears and concerns.
- Provide choices in care to give the patient a sense of control.
- Teach patient about breathing exercises or use of an incentive spirometer to reestablish normal breathing patterns.
- Instruct patient to wear good supportive and protective shoes while out of bed to prevent injuries due to weakness and paresthesia.
- Instruct patient to check feet routinely for injuries because trauma may go unnoticed due to sensory changes.
- Urge the patient to maintain normal weight because additional weight will further stress monitor function.
- Encourage scheduled rest periods to avoid fatigue.
Documentation Guidelines
- Respiratory and cardiovascular functions: Patency of airway, description of breathing, vital sign changes with rest or activity
- Neurological functions:Level of paralysis, level of motor and sensory function, level of consciousness
- Bowel and bladder functions:Frequency of voiding,consistency and number of stools
- Pain:Location, duration,precipitating factors,interventions that alleviate pain
- Activity:Strength and motion of extremities,presence of deformities or atrophy and strategies used to manage dysfunction,response to activity
- Skin:Areas of potential or actual breakdown,successful strategies to manage breakdown
Discharge and Home Healthcare Guidelines
- Especially during the recovery period,teach the patient to avoid exposure to further upper respiratory infections. Encourage self-care, but stress the avoidance of fatigue and the importance of frequent planned rest periods. Continue ongoing rehabilitation with physical therapy sessions to teach walking with a cane or walker and to provide active and passive range-of-motion exercises.
- Teach strengthening exercises for the hands,such as modeling clay or squeezing balls. Teach the patient and family how to manage the transfer from the bed to a wheelchair and from a wheelchair to the toilet or bathtub.
- Teach the patient to maintain a high-calorie,high-protein diet and to include at least 2000 mL of fluid intake per day. Avoid constipation by increasing fluids and dietary fiber and using stool softeners as required.
- Teach the patient to use warm baths to manage muscle pain and diversional activities to decrease boredom during the slow recovery period.
Sources:
ADAM for images
Nursingcrib.com
Marilyn Sawyer Sommers, RN, PhD, FAAN , Susan A. Johnson, RN, PhD, Theresa A. Beery, PhD, RN , DISEASES AND DISORDERS A Nursing Therapeutics Manual, 2007 3rd ed
Handbook for Brunner & Suddarth’s, Textbook of Medical-Surgical Nursing, 11th ed.
