6 Guillain-Barre Syndrome Nursing Care Plans

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) for Guillain-Barre Syndrome (GBS):

1. Ineffective Breathing Pattern

Ineffective Breathing Pattern: Inspiration and/or expiration that does not provide adequate ventilation.

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.

2. Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

- Biologic injuring agent (inflammation of nerves)

Possibly evidenced by

- Communication of pain descriptors of discomfort in the extremities
- Guarding behavior
- Autonomic responses of diaphoresis
- Alteration in muscle tone
- Tachypnea, Tachycardia

Desired Outcomes

- Child rates pain as less than (specify pain rating and scale used).

Nursing Interventions	Rationale
Assess level of pain and ability to engage in activities.	Determines the extent of pain or presence of progressive paralysis.
Identify the child’s perception of the word “pain” and inquire family members what word the child uses at home; Utilize pain scale appropriate for the child’s age and developmental level.	Facilitates better communication between the child/family and nurse.
Administer analgesics based on pain assessment and respiratory status; Monitor side effect after administration.	Eliminates or controls pain and provides comfort.
Provide support to extremities and maintain clean, comfortable bed using egg-crate mattress and padding to bony prominences as needed; Reposition client every 2 hours, use good postural alignment, assist with passive ROM.	Increases comfort and decreases risks for skin impairment.
Apply a moist warm compress to painful areas as needed.	Promotes circulation to the area and relieves pain.
Reassure parents and child that pain diminishes as motor function slowly improve or resolved.	Provides information about the length of time pain might be anticipated to continue.
Identify pain preventive measures around the clock; observe for behavioral and physiological signs of pain.	Promotes immediate identification of pain which enhances efficient relief of pain.

3. Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.

May be related to

- Neuromuscular impairment

Possibly evidenced by

- Paralysis
- Inability to purposefully move within physical environment including bed mobility, transfer and ambulation
- Limited ROM
- Decreased muscle strength and control
- Trauma from falls

Desired Outcomes

- Client will have an improved strength and function of the affected extremity.
- Client will demonstrate the use of adaptive devices to increase mobility.

Nursing Interventions	Rationale
Assess motor strength or functional level of mobility.	Understanding the particular level guides the design of best possible management plan.
Monitor nutritional needs as they associate with immobility.	Good nutrition also gives required energy for participating in an exercise or rehabilitative activities.
Place the client in a position of comfort. Provide frequent position changes as tolerated.	Promotes relaxation and prevent the development of decubitus ulcers.
Administer heparin as ordered.	Low ̶ molecular-weight heparin (LMWH) is administered in the prophylaxis of deep vein thrombosis.
Provide padding to bony prominences such as elbow and heels.	Maintain extremity in a physiological position, reduces the risk of pressure ulcers.
Perform active, passive and isotonic range of motion exercises as appropriate.	Improves joint mobility, stimulates circulation and enhance muscle tone.
Evaluate the need for assistive devices and provide a safe environment e.g., bed in low position and side rails up.	Correct utilization of wheelchairs, canes, transfer bars, and other assistance can promote mobility and reduces the risk of falls.
Provide rest periods in between activities. Consider energy-saving techniques.	Rest periods are essential to conserve energy and avoid fatigue.
Assist client and their families to establish goals in participation with activities, exercise and position changes.	Enhances a sense of anticipation of progress or improvement and promotes independence.
Consider the need for home assistance (e.g., physical therapy and occupational therapy).	Formulates a course of treatment with specific interventions to improve muscle function and to retrain in performing activities of daily living (ADLs).

4. Impaired Urinary Elimination

Impaired Urinary Elimination: Disturbance in urinary elimination.

May be related to

- Neuromuscular impairment

Possibly evidenced by

- Urinary retention
- Paralysis

Desired Outcomes

- Client will establish routine urinary elimination patterns.

Nursing Interventions	Rationale
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.

5. Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

- Change in health status and threat to self-concept.

Possibly evidenced by

- Increased apprehension as the condition worsens and paralysis spreads
- Expressed concern and worry about permanent effects of the disease
- Treatments during hospitalization
- Expressed feeling of increased helplessness and uncertainty

Desired Outcomes

- Parents and child verbalize decreased feelings of anxiety.

Nursing Interventions	Rationale
Assess source and level of anxiety, how anxiety is manifested and need for information that will relieve it.	Determines the extent of anxiety and need for interventions, sources may include fear and uncertainty about treatment and recovery, guilt about the presence of illness, possible loss of parental role and responsibility during hospitalizations.
Facilitate expression of concerns and an opportunity to ask inquiries regarding the condition and rehabilitation of the ailing child.	Provides an opportunity to release feelings, secure information needed to overcome anxiety.
Encourage parents to stay with the child and in the care of the child.	Allows for care and support of child instead of increasing anxiety that is caused by absence and lack of knowledge about child’s condition.
Therapeutically communicate with parents and child and answer questions in a calm and honest manner.	Promotes an environment of support.
Assist parents and child to recognize improvements resulting from treatments.	Promotes a positive attitude and optimistic outlook for recovery.
Allow the child to participate in own care depending on ability and degree of paralysis; allow to make informed choices about ADL as soon as possible.	Promotes independence and control and preserves developmental status.
Teach parents and child about disease condition and manifestation.	Provides information to relieve anxiety by knowledge of what to expect.
Discuss each procedure or type of may therapy, effects of any diagnostic tests to parents and child as appropriate to age.	Reduces fear of the unknown which increase anxiety.
Teach parents and child that degree of severity varies but motor weakness and paralysis start with extremities and move upward with the peak reached in 3 weeks and improvement seen by 4 to 8 weeks.	Provides information about the usual course of disease and length of illness.
Clarify any information and answer questions in lay terms and utilize visual aids for reinforcement if helpful.	Prevents unnecessary anxiety resulting from incorrect knowledge or beliefs or inconsistencies in information.

6. Risk for Altered Parenting

Risk for Altered Parenting: At risk for the inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child.

May be related to

- Illness

Possibly evidenced by

- Verbalization of decreased interactions with hospitalized child and inability to provide care
- Lack of control over the situation
- Request for information about parenting skills for long recovery period or permanent residual disability

Desired Outcomes

- Parents will participate in child’s care.

Nursing Interventions	Rationale
Assess for presence of permanent disability or possibility of long-term recovery and effect on parents.	Identifies factors associated with long recovery period.
Encourage parents to express feelings and unmet needs and ability to meet and develop self-expectations.	Identifies potential for social deprivation of parents and development of strategies to achieve realistic expectations.
Encourage and praise positive parental behaviors; support any participation in care or decision-making on behalf of the child.	Reduces anxiety for and enhances learning about child’s needs and care.
Encourage touching and play activities between parents and child.	Enhances comfort and positive parental behaviors.
Teach about physical therapy program including ROM, exercises, gait training, bracing (refer as indicated).	Facilitates muscle recovery and prevents contractures and permanent disability, promotes a sense of confidence and control.
Continue to inform and support parents during the recovery period (provide telephone numbers).	Provides reassurance that recovery is slow and conserves parental emotional reserves.
Refer to Guillain-Barre Syndrome Support Group for assistance or community agencies for support.	Provides information and support from those with experience with the disease.

References and Sources : nurseslabs.com

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