What signs symptoms would the nurse expect to assess in a client diagnosed with Guillain

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.

Inhaltsverzeichnis Show

1. Ineffective Breathing Pattern
Ineffective Breathing Pattern
1. Ineffective Breathing Pattern
Recommended Resources
References and Sources
What signs symptoms would the nurse expect to assess in a client diagnosed with Guillain
Which assessment finding is typical for a patient with Guillain
Which assessment data should the nurse assess in the client diagnosed with Guillain
What is the typical presentation of symptoms in a person with Guillain

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 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):

Ineffective Breathing Pattern
Acute Pain
Impaired Physical Mobility
Impaired Urinary Elimination
Anxiety
Risk for Altered Parenting

1. Ineffective Breathing Pattern

Ineffective Breathing Pattern

Nursing Diagnosis

Ineffective Breathing Pattern

May be related to

Ascending paralysis
Decrease lung

Possibly evidenced by

Altered chest expansion
Cyanosis
Respiratory depth changes
Abnormal ABGs

Desired Outcomes

Client will maintain effective breathing pattern.

Nursing Interventions	Rationale
Assess frequency, symmetry, and depth of breathing. Observed for increased work of breathing and evaluate skin color, temperature, capillary refill.	Progressive weakness of both the inspiratory and the expiratory muscles may lead to respiratory distress that may necessitate the need for mechanical ventilation.
Observe for signs of respiratory fatigue such as shortness of breath, decreased attention span, and impaired cough.	May indicate neuromuscular respiratory failure or decrease lung capacity.
Auscultate lung sounds for any changes and notifies the physician immediately.	Pooling of secretions and increased airway resistance may impede the diffusion of gases resulting in airway complications such as pneumonia.
Assess oxygen saturation and review client’s arterial blood gases results.	Determines oxygenation status and provides information about the effectiveness of ventilation given or the need to adjust the parameters.
Keep the head of bed elevated at around 35-45°	Increases lung expansion and cough effort minimizes the work of breathing and the risk of aspiration of secretions.
Perform chest physiotherapy which includes postural drainage, chest percussion, chest vibration, turning, deep breathing and coughing exercises.	Facilitates mobilization and clearance of airway secretions.
Anticipate the need for mechanical ventilation as ordered.	Mechanical ventilation may be required for an extended period to support pulmonary function and adequate oxygenation. Weaning from mechanical ventilation happens when the respiratory muscles can sustain spontaneous respiration and keep adequate tissue oxygenation.
Suction secretions as appropriate, especially if the client is intubated or undergone a tracheostomy.	Promotes adequate clearance of secretions and prevents aspiration.

1. Ineffective Breathing Pattern

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.

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.

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.

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.

What signs symptoms would the nurse expect to assess in a client diagnosed with Guillain

In Guillain-Barré syndrome, the immune system attacks the body's nerves. Symptoms include muscle weakness, pain, tingling and loss of reflexes. Many people need a hospital stay to watch for breathing problems, heart issues, choking and other complications.

Which assessment finding is typical for a patient with Guillain

Most patients with typical GBS present with rapidly progressive bilateral leg weakness with hypo/areflexia in the affected limbs. In rare cases, patients can present with facial, oculomotor, bulbar (i.e. difficulty with swallowing and speaking) weakness, or primary sensory symptoms.

Which assessment data should the nurse assess in the client diagnosed with Guillain

GBS can lead to a decrease in gastric motility and paralytic ileus. Therefore, before starting a scheduled feeding the nurse should always assess for bowel sounds and check gastric residual.

What is the typical presentation of symptoms in a person with Guillain

Early symptoms of GBS include weakness and tingling. People with GBS usually first feel these symptoms in both legs. Some people then have weakness and tingling in their arms and upper body. The weakness can increase until people cannot use some muscles.