NURSING CARE PLAN + NURSING
DIAGNOSIS  Respiratory depth changes
NEUROLOGICAL CARE PLANS
WHAT IS GUILLAIN-BARRE
SYNDROME?
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 manifestations
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 depending 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-Bare 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.
6 Nursing Care Plans (NCP) and Nursing
Diagnosis (NDx) for Guillain-Barre Syndrome
1. Ineffective Breathing Pattern
2. Acute Pain
3. Impaired Physical Mobility
4. Impaired Urinary Elimination
5. Anxiety
6. Risk for Altered Parenting
INEFFECTIVE BREATHING PATTERN
Guillain-Barre syndrome can affect the muscles
used for breathing, resulting in a weakened or
paralyzed diaphragm, which can lead to an
ineffective breathing pattern. This is because the
muscles responsible for breathing are not
functioning properly, leading to shallow breathing,
difficulty taking deep breaths, and an increased risk
of respiratory failure.
Nursing Diagnosis
 Ineffective Breathing Pattern
May be related to
 Ascending paralysis
 Decrease lung
Possibly evidenced by
 Altered chest expansion
 Cyanosis
 Abnormal ABGs
Desired Outcomes
 The client will maintain an effective
breathing pattern.
NURSING ASSESSMENT AND RATIONALES
1. Assess frequency, symmetry, and depth of
breathing. Observed for increased work
of breathing and evaluate skin color,
temperature, and 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.
2. Observe for signs of respiratory fatigue
such as shortness of breath, decreased
attention span, and impaired cough
-This may indicate neuromuscular
respiratory failure or decreased lung
capacity.
3. 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.
4. Assess oxygen saturation and review the
client’s arterial blood gas results.
-Determine oxygenation status and provides
information about the effectiveness of
ventilation given or the need to adjust the
parameters.
NURSING INTERVENTIONS AND
RATIONALES
1. Keep the head of the bed elevated at
around 35-45º
-Increase lung expansion and cough effort
minimizes the work of breathing and the risk
of aspiration of secretions.
2. Perform chest physiotherapy which
includes postural drainage, chest
percussion, chest vibration, turning, deep
breathing, and coughing exercises.
-Facilitates mobilization and clearance of
airway secretions.
3. 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.
 4. Suction secretions as appropriate,
especially if the client is intubated or has
undergone a tracheostomy.
-Promotes adequate clearance of secretions
and prevents aspiration.
ACUTE PAIN
Acute pain in patients with Guillain-Barre
syndrome can be caused by nerve damage and
inflammation. The nerves become hypersensitive
due to the demyelination process, resulting in
intense and sudden pain.
Nursing Diagnosis
 Acute pain
May be related to
 Biologic injuring agent (inflammation of
nerves)
Possibly evidenced by
 Communication of pain descriptors of
discomfort in extremities.
 Guarding behavior
 Autonomic responses of diaphoresis
 Alteration in muscle tone
 Tachypnea, Tachycardia
Desired Outcomes
 The child rates pain as less than
(specify pain rating and scale used).
NURSING ASSESSMENT AND RATIONALES
1. Assess the level of pain and ability to
engage in activities.
-Determines the extent of pain or presence
of progressive paralysis.
2. Identify the child’s perception of the word
“pain” and inquire family members about
what word the child uses at home; Utilize
a pain scale appropriate for the child’s
age and developmental level.
-Facilitates better communication between
the child/family and the nurse.
3. Identify pain preventive measures around
the clock; observe behavioral and
physiological signs of pain.
-Promotes immediate identification of pain
which enhances efficient relief of pain.
NURSING INTERVENTIONS AND
RATIONALES
1. Provide support to extremities and
maintain a clean, comfortable bed using
an egg-crate mattress and padding to
bony prominences as needed; Reposition
the client every 2 hours, use good postural
alignment, and assist with passive ROM.
-Increases comfort and decreases risks for
skin impairment.
2. Apply a moist warm compress to painful
areas as needed.
-Promotes circulation to the area and
relieves pain.
3. Reassure parents and child that pain
diminishes as motor function slowly
improves or resolves.
-Provides information about the length of
time pain might be anticipated to continue.
4. Administer analgesics based on pain
assessment and respiratory status;
Monitor side effects after administration.
-Eliminates or controls pain and provides
comfort.
IMPAIRED PHYSICAL MOBILITY
Impaired physical mobility can occur in patients
with Guillain-Barre syndrome due to weakness or
paralysis of muscles. The disease affects the
peripheral nervous system, causing damage to the
myelin sheath that surrounds nerves, leading to
difficulty in movement, coordination, and muscle
weakness.
Nursing Diagnosis
 Impaired Physical Mobility
May be related to
 Neuromuscular impairment
Possibly evidenced by
 Paralysis
 Inability to purposefully move within the
physical environment including bed
mobility, transfer, and ambulation.
 Limited ROM
 Decreased muscle strength and control
 Trauma from falls.
Desired Outcomes
 The client will have improved strength and
function of the affected extremity.
 The client will demonstrate the use of
adaptive devices to increase mobility.
NURSING ASSESSMENT AND RATIONALES
1. Assess motor strength or functional level
of mobility.
-Understanding the particular level guides
the design of the best possible management
plan.
2. Monitor nutritional needs as they
associate with immobility.
-Good nutrition also gives the required
energy for participating in exercise or
rehabilitative activities.
NURSING INTERVENTIONS AND
RATIONALES
 1. Place the client in a position of comfort.
Provide frequent position changes as
tolerated.
-Promotes relaxation and prevents the
development of decubitus ulcers.
Desired Outcomes
 The client will establish routine urinary
elimination patterns.
NURSING ASSESSMENT AND RATIONALES

2. Provide padding to bony prominences 1. Assess the progressive degree of paralysis

such as elbows and heels.
-Maintaining extremities in a physiological
position reduces the risk of pressure ulcers.
3. Perform active, passive, and isotonic
range of motion exercises as appropriate.
-Improves joint mobility, stimulates
circulation, and enhances muscle tone.
4. Evaluate the need for assistive devices
and provide a safe environment e.g., bed
in a 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.
and its effect on urinary elimination.
Provides data on the effect of motor
dysfunction that travels upward from
extremities.
2. 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.

5. Provide rest periods in between activities. NURSING INTERVENTIONS AND

Consider energy-saving techniques. RATIONALES
-Rest periods are essential to conserve
energy and avoid fatigue.
1. Insert an indwelling urinary catheter if
6. Assist client and their families to establish
indicated to maintain elimination.
goals in participation with activities,
-Relieves bladder distention and urinary
exercise, and position changes.
retention.
-Enhances a sense of anticipation of
progress or improvement and promotes
2. Assist client in urinary elimination
independence.
rehabilitation program; perform Crede’s
maneuver in a gentle manner if indicated.
7. Administer heparin as ordered.
-Promotes urine elimination and returns to a
-Low ̶ molecular-weight heparin (LMWH) is
normal pattern as soon as possible.
administered in the prophylaxis of deep vein
thrombosis.
3. Educate parents in the program to restore
urinary function.
8. Consider the need for home assistance
-Supports urinary elimination and return to
(e.g., physical therapy and occupational
baseline pattern without retention and
therapy).
possible urinary bladder infection.
- Formulates a course of treatment with
specific interventions to improve muscle
function and to retrain in performing 4. Instruct parents to maintain fluid intake
activities of daily living (ADLs). and monitor output in connection to
intake.
IMPAIRED URINARY ELIMINATION -Maintains I&O balance and adequate intake
to promote urinary output.
Impaired urinary elimination can occur in patients
with Guillain-Barre syndrome due to the
5. Instruct to report any reduction or
involvement of the autonomic nervous system. The
absence of urinary elimination.
disease can affect the nerves that control bladder
-Avoids complications of neuromuscular
and bowel function, leading to urinary retention,
impairment of disease and effect on urinary
incontinence, and constipation.
bladder function.
Nursing Diagnosis
 Impaired Urinary Elimination ANXIETY
May be related to Anxiety can occur in patients with Guillain-Barre
syndrome due to the sudden onset of symptoms, the
 Neuromuscular impairment
uncertainty of the disease course, and the fear of
Possibly evidenced by potential complications such as respiratory failure
or paralysis. Additionally, patients may experience
 Urinary retention anxiety and stress due to hospitalization and
 Paralysis
separation from their daily routine and support
system.
Nursing Diagnosis
 Anxiety
May be related to
 Uncertainty of the disease course
 Fear of potential complications such as
respiratory failure or paralysis
Possibly evidenced by
 Increased apprehension as the condition
worsens and paralysis spreads
 Expressed concern and worry about the
permanent effects of the disease
 Treatments during hospitalization
 Expressed feelings of increased helplessness
and uncertainty
Desired Outcomes
 The parents and child will verbalize
decreased feelings of anxiety.
NURSING ASSESSMENT AND RATIONALES
1. Assess the 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,
and possible loss of parental role and
responsibility during hospitalizations.
2. 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,
and secure information needed to overcome
anxiety.
NURSING INTERVENTIONS AND
RATIONALES
1. 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.
2. Communicate with parents and child
therapeutically and answer questions in a
calm and honest manner.
-Promotes an environment of support.
3. Assist parents and the child to recognize
improvements resulting from treatments.
-Promotes a positive attitude and optimistic
outlook for recovery.
4. 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.
5. Teach parents and the child about the
disease condition and manifestations.
-Provides information to relieve anxiety by
knowledge of what to expect.
6. Discuss each procedure or type of
therapy, the effects of any diagnostic tests
on parents and child as appropriate to
age.
-Reduces fear of the unknown which
increases anxiety.
7. Teach parents and child that the 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.
8. 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.
RISK FOR ALTERED PARENTING
There is a risk for altered parenting in patients with
Guillain-Barre syndrome, particularly in those who
are caregivers for young children. The disease can
cause weakness or paralysis, resulting in difficulty
with daily activities and responsibilities such as
feeding, bathing, and caring for children. This may
lead to increased stress and anxiety for both the
patient and their family.
Nursing Diagnosis
 Risk for Altered Parenting
May be related to
 Physical limitations and challenges that
may arise due to the patient’s muscle
weakness or paralysis
Possibly evidenced by
 Verbalization of decreased interactions
with the 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
 The parents will participate in the child’s
race
NURSING ASSESSMENT AND RATIONALES
1. Assess for the presence of permanent
disability or the possibility of long-term
recovery and its effect on parents.
-Identifies factors associated with a long
recovery period.
2. Encourage parents to express feelings and
unmet needs and the ability to meet and
develop self-expectations.
-Identifies potential for social deprivation of
parents and development of strategies to
achieve realistic expectations.
NURSING INTERVENTIONS AND
RATIONALES
1. 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 the child’s needs and care.
2. Encourage touching and play activities
between parents and the child.
-Enhances comfort and positive parental
behaviors.
3. Teach about physical therapy programs
including ROM, exercises, gait training,
and bracing (refer to as indicated).
-Facilitates muscle recovery and prevents
contractures and permanent disability,
promoting a sense of confidence and control.
4. Continue to inform and support parents
during the recovery period (provide
telephone numbers).
-Provides reassurance that recovery is slow
and conserves parental emotional reserves.
5. Refer to the Guillain-Barre Syndrome
Support Groups for assistance or
community agencies for support.
-Provides information and support from
those with experience with the disease.
WHAT IS ALZHEIMER’S DISEASE
AND DEMENTIA
Alzheimer’s disease (AD) is a progressive and
irreversible, degenerative, fatal disease and is the
most common form of dementia among older
people. Dementia is a brain disorder that seriously
affects a person’s ability to carry out daily activities.
It usually begins after age 60, and the risk goes up
as you get older. Risk is also higher if a family
member has the disease.
Progression of the disease is done in phases until all
cognitive function is destroyed. Pathologic
consequences include the loss of neurons in
multiple areas of the brain, atrophy with wide sulci
and dilated brain ventricles, and plaques composed
of neurites, astrocytes, and glial cells surrounding
an
amyloid center, and neurofibrillary tangles.
Symptoms of Alzheimer’s Disease result from the
destruction of numerous neurons in the
hippocampus and the cerebral cortex. The enzyme
choline acetyltransferase has a decreased action
with AD patients, which results in impaired
conduction of impulses between the nerve cells
caused
by a lack of acetylcholine production.
Currently, no treatment can stop the progression of
the disease. However, some drugs may help keep
symptoms from getting worse for a limited time.
NURSING CARE PLANS
Nurses play a key role in recognizing dementia
among hospitalized elderly by assessing for signs
during the nursing admission assessment.
Interventions for dementia are aimed at promoting
patient function and independence for as long as
possible. Other important goals include promoting
the patient’s safety, independence in self-care
activities, reducing anxiety and agitation, improving
communication, providing socialization and
intimacy, adequate nutrition, and supporting and
educating the family caregivers.
15 Nursing Care Plans (NCP) and Nursing
Diagnosis (NDx) for patient with Alzheimer’s
Disease and Dementia
1. Impaired Memory
2. Disturbed Thought Process
3. Risk for Injury
4. Chronic Confusion
5. Anxiety
6. Impaired Verbal Communication
7. Self-Care Deficit: Bathing
8. Self-Care Deficit Dressing
9. Self-Care Deficit Toileting
10. Impaired Physical Mobility
11. Disturbed Sleep Pattern
12. Disturbed Sensory Perception
13. Social Isolation
14. Compromised Family Coping
15. Wandering
IMPAIRED MEMORY
Nursing Diagnosis
 Impaired Memory
May be related to
 Alzheimer’s disease process
 Changes in cognitive abilities
 Chemical imbalance in the brain
 Dementia
 Neuronal destruction in the brain
May be evidenced by
 Disorientation to time, place, person, and
circumstance
 Decreased ability to reason or conceptualize
 Inability to reason
 Inability to calculate
 Memory loss
 Decreased attention span
 Easy distractibility
 Inability to follow simple or complex
commands
 Deterioration in personal care and
appearance
 Dysarthria
 Dysphagia
 Convulsions
 Inappropriate social behavior
 Paranoia
 Combativeness
 Inability to cooperate
 Wandering
 Disturbance in judgment and abstract
thoughts
 Explosive behavior
 Illusions, delusions, hallucinations
 Deterioration of intellect
 Loss of sexual drive and desire reduced
control of sexual behavior
 Inappropriate behavior
 Lack of inhibitions
 Hypervigilance or hypo vigilance
 Alteration in sleep pattern
 Lethargy
 Egocentricity
Desired goals and outcomes
 Patient will have appropriate maintenance of
mental and psychological function as long as
possible and reversal of behaviors when
possible.
 Family members will exhibit an
understanding of required care and
demonstrate appropriate coping skills and
utilize community resources.
 Patient will achieve functional ability at his
optimum level with modifications and
alterations within his environment to
compensate for deficits.