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Objective cues: Ascending paralysis R & L leg weakness Leg muscle weakness uncoordinated movement Paresthesia Loss of pain sensation in legs Tremors
Diagnosis Impaired physical mobility related to decreased strength and endurance secondary to neuromuscular impairment as evidenced by inability to purposefully move, lower legs paralysis and tremors Definition: The state in which an individual experiences limitation of physical movement but is not immobile. It describes an individual with limited use of arm(s) or leg(s) or limited muscle strength. References: •Doenges et al, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span,8th edition,2010 •Carpenito-Moyet,
Handbook of Nursing th Diagnosis,13 edition,2010
Rationale The major pathologic manifestation of Guillain Barré syndrome is segmental demyelination of the peripheral nerves, w/c prevents normal transmission of electrical impulses. The myelin sheath, w/c covers the nerve axons and conducts electrical impulses along the nerve pathways, degenerates. With degeneration comes inflammation, swelling, and patchy demyelination.As myelin is destroyed, the nodes of Ranvier, located at the junctures of myelin sheaths, widen. This delays and impairs impulse transmission along the dorsal and ventral nerve roots. Impairment of dorsal nerve roots affects sensory function, so the patient may experience tingling and numbness. Impairment of ventral nerve roots affects motor function, so the patient may experience muscle weakness, immobility,
Planning Within 2 days of duty, patient will report an increase in strength and endurance of limbs as indicated by the following: • Demonstrate the use of adaptive devices to increase mobility. • Describe rationale for interventions. • Demonstrate measures to increase mobility. • Use safety measures to minimize potential for injury.
Intervention Independent: 1. Continually assess motor function by requesting client to perform certain actions, such as shrug shoulders, spread fingers, and squeeze and release examiner’s hands. 2. Perform or assist with full range of motion (ROM) exercises on all extremities using slow, smooth movements. Include periodic hip hyperextension. 3. Maintain ankles at 90 ° with footboard. Use high-top tennis shoes. Place trochanter rolls along thighs when in bed. 4. Provided support to affective body parts using pillows and roll. 5. Space periods of rest and activity. Encourage client involvement. 6. Investigate sudden onset of dyspnea, cyanosis, and other signs of respiratory distress.
Rationale 1. Continuous motor function assessment helps determine appropriate interventions for the specific motor impairment.
Evaluation Goal partially met. After 2 days of duty patient was able to: • Describe rationale for interventions. • Demonstrate measures to increase mobility such as using walkers. • Use safety measures to minimize potential for injury.
2. ROM exercises enhance circulation, restore or maintain muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy. 3. These measures prevent external rotation of the hip and foot drop.
7. Encourage ambulation for short, frequent walks (at least three times daily), with assistance if unsteady.
4. To maintain body parts function, reduce risk of pressure ulcers and to avoid contractures. 5. Adequate rest and optimal activity prevent fatigue and allows opportunity for maximal efforts and active client participation. 6. Development of pulmonary emboli may be “silent” because pain perception is altered or deep vein thrombosis (DVT) is not readily recognized. 7. To provide progressive mobilization.
Administer medications. as indicated. Encouraged participation in self care and diversional activity. Consult with physical and occupational therapists and rehabilitation team. Dependent: 1. Promote well being and maximize energy production. To enhance self-concept and sense of Independence. Encouraged adequate intake of fluids and nutritious foods.4th ed. 2. Pathophysiology made incredibly easy. Apply anti-embolic hose. 9. Collaboration helps in planning and implementing individualized exercise program. Collaborative: 1. 1. as appropriate.. thus improving vasomotor tone and reducing incidence of thrombus formation and pulmonary emboli. for example: Tizanidine (Zanaflex) 2. leotard.2009 8. or sequential compression devices (SCDs) to legs. Centrally acting adrenergic agonist reduces spasticity. These devices limit pooling of blood in lower extremities or abdomen. 2 . The members of the rehabilitation team identify and develop assistive devices to enhance client’s function and overall independence.and paralysis. 1. 9. References: •Lippincott Williams & Wilkins. 8.
To prevent postural hypotension. To prevent injury or harmful damage. 7. usually in the legs and spreading to the arms and loss of position sense.13th ed. After 4 hrs of nursing interventions. 7. • Relate an intent to practice selected prevention measures Intervention Independent: 1. • Relate intent to practice selected prevention measures such as raising side rails. To promote safe physical environment and individual safety. Keep the sharp objects away from the patient.2010 Rationale Guillain-Barré syndrome causes inflammation and degenerative changes in both the posterior(sensory) and the anterior (motor) nerve roots. 8. To prevent from falling. Reference: •Carpenito-Moyet.2012 Planning After 4 hrs of nursing interventions. 10. 9. patient will relate fewer injuries and less fear of injury with the following criteria: • Identify factors that increase the risk for injury. Precautionary measures when giving warm bath or exposure to extreme temperature. 5. Orient each new admission to surroundings. That can contribute to occurrence of injury. Change the patient’s position slowly. 2. To prevent injury. 3 .Diagnosis Risk for Injury related to altered mobility secondary to Guillain Barré Syndrome Definition: The state in which an individual is at risk for harm because of a perceptual or physiologic deficit. Handbook of Nursing Diagnosis. 3. 2. Discuss importance of self monitoring of condition/emotions. Medical-surgical nursing made incredibly easy.g. Raise side rails and/or lower bed at night. To protect and prevent injury. 8. or maturational age. To identify risk for falls. Evaluation Goal met. 4. Patient may loss sensation to stimuli. To prevent injury from activities requiring alertness. 4.3rd edition. autonomic nerve transmission may be impaired. Educate significant others about the possibility of injury and how to prevent. Assess for the presence of side effects of drugs that may cause vertigo. • Relate an intent to use safety measures to prevent injury (e. That’s why signs of sensory and motor losses occur simultaneously. 3. a lack of awareness of hazards. 6. remove throw rugs or anchor them). Additionally.. in risk for injury: stiffness and pain in the legs and back acute. symmetrical ascending weakness of the limbs.g. Assess clients’ muscle strength. 9. explain the call system. patient was able to relate fewer injuries and less fear of injuries after have been: • Identify factors that increase the risk for injury like sharp objects and hot water. 10. 6. The following progressive manifestations of this disease puts pt. • Relate an intent to use safety measures to prevent injury (e. Provide information regarding disease conditions that may result in increased risk for injury.. and assess the person’s ability to use it. Rationale 1. Reference: •Lippincott Williams & Wilkins. sensory loss. gross and fine motor coordination. remove throw rugs or anchor them). 5.
4 . 9. Note rate and depth of respirations. Handbook of Nursing Diagnosis. 3. excursion.Diagnosis High risk for ineffective breathing pattern related to neuromuscular dysfunction secondary to ascending paralysis Definition: The state in which an individual experiences an actual or potential loss of adequate ventilation related to an altered breathing pattern.cheyne-stokes other irregular patterns.Respiratory involvement occurs rapidly in this form of the disease. After 2 hours of rendering nursing intervention. 2009). patient maintains a normal/ effective breathing pattern as evidenced by normal respiration rate of 18 brths/min. type of breathing pattern: tachypnea. To limit fatigue. Auscultate chest. Prepare to intubate if patient’s impending respiratory failure. Maintained calm environment. Evaluation Goal met. Encouraged adequate rest 7. To provide emergency intubation if in readily accessible location and needed. Assess for abdominal distention 9. and ineffective airway clearance.Hyporeflexia and weakness may progress to tetraplegia. heart rate is above 120 or below 70 bpm and respiratoryrate above 30bpm. decreased ability to cough. 2.13th ed. presence of secretions. periods between activities. Abdominal fullness may impede and muscle spasm. Assisted client to learn 8. diaphragmatic excursion. Demyelination of the nerves that innervate the diaphragm and intercostal muscles results in neuromuscular respiratory failure. Reference: •Carpenito-Moyet. include appropriate ET tubes. As vital capacity Planning Within 2 hours of rendering nursing interventions. Prevention and treatment of respiratory failure is a priority of management. To provide maximum chest bed elevated. noting presence/character of breath sounds. Position patient with head of 4. Monitored for signs of 5. 5. Respiratory difficulties occur as the diaphragm and intercostal muscles become involved. To assess types of breathing pattern so to watch sign of respiratory fatigue. is trapped in the airways and to help patient breath more fresh air through nose. Rationale 1. 8. patient will maintain a normal/effective breathing pattern. Common progression of the disease as it becomes more lifethreatening includes decreases in vital capacity. Respiratory involvement occurs in 50% of patients with ascending GBS (Porth.2010 Rationale Guillain-Barré syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities.thus reducing lung expansion and further compromising respiratory function. 3. 7. 4. Prepared emergency equipment 6. Pursed lip breathing helps get rid breathing exercises such as pursed of the old stale air in your lungs that lip breathing. 2. 6. Intervention Independent: 1. To promote comfort and relaxation. To assess adequacy of air flow and detects presence of adventitious sounds.
11. Contemporary Medical Surgical Nursing. 10. Maximizes arterial oxygenation and aids in prevention of hypoxia. 5 . 10. Avoid or limit prone position when indicated.decreases. Review chest x-rays. 1. If respiratory center is depressed. Additionally.2nd edition. Reposition and turn periodically. Adequate fluid intake liquefies secretions and promotes mobilization and expectoration. Note: Prone position significantly decreases vital capacity and increases risk of respiratory compromise and failure. It helps reduce the risks of complicationssuch as atelectasis and pneumonia. Reveals ventilatory state and signs of developing complications such as atelectasis and pneumonia. increasing weakness of the diaphragm and intercostal muscles occur as innervation decreases. 2.500 to 2. mechanical ventilation may be required. As alterations in respiratory function comprise. Collaborative: 1. Encourage fluids—at least 1. atelectasis and hypoxemia become problematic. 11.000 mL/day.2010 2. patients may experience ineffective airway clearance and ineffective breathing patterns related to the weakness of respiratory muscles. Administer supplemental oxygen. Reference: •Daniels & Nicoll.
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