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Friday, May 28, 2021

Guillain-Barre syndrome (GBS): Management,Complication,and Nursing Intervention of GBS

 Guillain-Barre syndrome (GBS)

Guillain-Barre syndrome (GBS) is an acute, rapidly progressing, ascending inflammatory demyelinating polyneuropathy of the peripheral sensory and motor nerves and nerve roots. GBS is most often, but not always, characterized by muscular weakness and distal sensory loss or dysesthesias. GBS is the most frequently acquired demyelinating neuropathy. It affects 1 in 100,000 people and must be identified quickly to initiate treatment and decrease life-threatening complications. Usually, GBS occurs a few days or weeks following Symptoms of a respiratory or GI viral infection. Occasionally, surgery or vaccinations will trigger the syndrome. The disorder can develop over the course of hours, days, or weeks. Maximum weakness unusually occurs within the first 2 weeks after symptoms appear, and by the third week of the illness, 90% of all patients are at their weakest. About 30% of those with GBS have residual weakness after 3 years, and the recurrence rate is approximately 3%.

Mortality results from respiratory failure, autonomic disturbance, sepsis, and Complications of immobility and occurs at a rate of about 5% despite intensive medical care.

Pathophysiology and Etiology

  • Believed to be autoimmune disorder that causes acute neuromuscular paralysis due to destruction of the myelin sheath surrounding peripheral nerve axons and subsequent slowing of transmission.
  • Viral infection, immunization, or other event may trigger the autoimmune response.
  • About 30% to 40% of cases are preceded by campylobacter infection, an acute infectious diarrheal illness.
  • Cell-mediated immune reaction is aimed at peripheral nerves, causing demyelination and, possibly, axonal degeneration.

Clinical Manifestations

  • Paresthesias and, possibly, dysthesias.
  • 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.
  • Difficulty with swallowing, speech, and chewing due to cranial nerve involvement.
  • Decreased or absent deep tendon reflexes, position and vibratory perception.
  • Autonomic dysfunction ( increased heart rate and postural hypotension).
  • Decreased vital capacity, depth of respirations, and breath sounds.
  • Occasionally spasm and fasciculations of muscles.

Diagnostic Evaluation GBS

  • History and neurologic exam. Progressive weakness, decreased sensation, decreased deep tendon reflexes.
  • Lumbar puncture for CSF examination- reveals low blood cell count, high protein.
  • Electrophysiologic studies - nerve conduction velocity shows decreased conduction velocity of peripheral nerves.

Management GBS

  • Plasmapheresis is produces temporary reduction of circulating antibodies to reduce the severity and duration of the GBS episode.
  • High-dose immunoglobulin therapy is used to reduce the severity of the episode.
  • ECG monitoring and treatment of cardiac dysrhythmias.
  • Analgesics and muscle relaxants as needed.
  • Intubation and mechanical ventilation if respiratory paralysis develops.

Complications GBS

  • Respiratory failure.
  • Cardiac dysrhythmias.
  • Complications of immobility and paralysis.
  • Anxiety and depression.

Nursing Assessment GBS

  • Assess the pain level due to muscle spasms and dysthesias.
  • Assess cardiac function including orthostatic BPs.
  • Assess respiratory status closely to determine hypoventilation due to weakness.
  • Perform cranial nerve assessment, especially ninth cranial nerve for gag reflex.
  • Assess the motor strength.

Nursing Diagnosis for GBS

  • Ineffective breathing pattern related to weakness of respiratory muscles.
  • Impaired physical mobility related to paralysis.
  • Imbalanced nutrition: less than body requirements related to cranial nerve dysfunction.
  • Chronic pain related to disease pathology.
  • Anxiety-related to communication difficulties and deteriorating physical condition.

Nursing Interventions for GBS

Maintaining Respiration

  • Monitor respiratory status through vital capacity measurements, rate and depth of respirations, breath sounds.
  • Monitor level of weakness as it ascends towards respiratory muscles.
  • Watch for breathlessness while talking, a sign of respiratory fatigue.
  • Maintain calm environment, and position the patient with head of bed elevated to provide for maximum chest excursion.
  • As much as possible, avoid opioids and sedatives that may depress respiration.
  • Monitor the patient for signs of impending respiratory failure; heart rate above 120 or below 70 beats/minute, respiratory rate above 30 breaths/ minute; prepare to intubate.

Avoid Complications of Immobility

  • Position the patient correctly, and provide ROM exercise 
  • Encourage physical and occupational therapy exercises to regain strength during the rehabilitative period.
  • Assess for complications, such as contractures, pressure ulcers, edema of lower extremities, and constipation.
  • Provide assistive devices, as needed, such as cane or wheelchair, for patient to take home.

Promoting Adequate Nutrition

  • Auscultate for bowel sounds, hold enteral feedings if bowel sounds are absent bro prevent gastric distention.
  • Assess chewing and swallowing ability by testing CN V, IX and X; if function is inadequate, provide alternate feeding.
  • During rehabilitation period, encourage a well-balanced, nutritious diet in small, frequent feedings with vitamin supplement if indicated.
  • Recommend referral to dietician for evaluation and proper diet therapy.

Maintaining Communication

  • Develop a communication system with the patient who cannot speak.
  • Have frequent contact with patient, and provide explanation and reassurance, remembering that the patient is fully conscious.
  • Provide some type of patient cell system. Because call lights cannot be activated by the severely weak patient, provide adaptive call light and some type of constant monitoring and surveillance to meet patients needs.
  • Recommended referral to speech therapy for evaluation and treatment.
  • Refer to counselor, social workers, or psychologist to develop coping skills and regain sense of control.

Relieving Pain

  • Administer analgesics as required; monitor for adverse reactions, such as hypotension, nausea and vomiting, and respiratory depression.
  • Provide adjunct pain management therapies, such as therapeutic touch, massage, diversion, guided imagery.
  • Provide explanation to relieve anxiety, which augments pain.
  • Turn the patient frequently to relieve painful pressure areas.

Reducing Anxiet

  • Get to know the patient, and build a trusting relationship.
  • Discuss fears and concerns while verbal communication is possible.
  • Reassure the patient that recovery is probable.
  • Use relaxation techniques such as listening to soft music.
  • Provide choices in care, and give the patient a sense of control.
Referral Lippincott Manual of Nursing

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