UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive, Lahug, Cebu City

COLLEGE OF NURSING

Care In Client with guillian barre syndrome

Submitted by:
Al Gino B. Borinaga
Submitted to :
Mr. Ranilo A. Sabellano RN, MAN.

TABLE OF CONTENTS
Title Page..Page 1

Table of Content....Page 2
Introduction...Page 3-5
General information and Patients Profile..Page 6
Pertinent Nursing History..Page 7
Developmental task.page 8
Gordons Functional Health PatternPage 9-11
Genogram..Page 12
Physical Examination...page 13-15
Laboratory and Diagnostic Findings...Page 16
Summary Of Significant Findings.....Page 17-20
Anatomy and Physiology..Page 21-22
Pathophysiology and Disease Management..Page 23-27
Drug Studies...Page 28-32
Nursing Care Plan....Page 33-38
Discharge Plan.page 39
References.Page 40

INTRODUCTION
GuillainBarr syndrome (GBS), is an acute polyneuropathy, a disorder affecting the
peripheral nervous system. Ascending paralysis, weakness beginning in the feet and hands
and migrating towards the trunk, is the most typical symptom, and some subtypes cause
change in sensation or pain as well as dysfunction of the autonomic nervous system. It can
cause lifethreatening complications, in particular if the respiratory muscles are affected or if
there is autonomic nervous system involvement. The disease is usually triggered by an
infection.
The diagnosis is usually made by nerve conduction studies and with studies of the
cerebrospinal

fluid.

With

prompt

treatment

by

intravenous

immunoglobulins

or

plasmapheresis, together with supportive care, the majority will recover completely. Guillain
Barr syndrome is rare, at 12 cases per 100,000 people annually, but is the most common
cause of acute nontraumarelated paralysis.
physicians Georges Guillain

The syndrome is named after the French

and Jean Alexandre Barr, who described it in 1916. Acute

inflammatory demyelinating polyneuropathy (AIDP) is the most common form of GBS, and
the term is often used synonymously with GBS. It is caused by an autoimmune response
directed against Schwann cell membranes. Miller Fisher syndrome (MFS) is a rare variant
of GBS. Accounting for approximately 5% of GBS cases,

it manifests as a descending

paralysis, proceeding in the reverse order of the more common form of GBS. It usually
affects the eye muscles first and presents with the triad of ophthalmoplegia, ataxia, and
areflexia. The ataxia predominantly affects the gait and trunk, with the limbs relatively
spared. AntiGQ1b antibodies are present in 90% of cases. Acute motor axonal neuropathy
(AMAN), also known as Chinese paralytic syndrome, attacks motor nodes of Ranvier and is
prevalent in China and Mexico. It is probably due to an autoimmune response directed
against the axoplasm of peripheral nerves. The disease may be seasonal and recovery can
be rapid. AntiGD1a antibodies are present. AntiGD3 antibodies are found more frequently
in AMAN.

Acute motor sensory axonal neuropathy (AMSAN) is similar to AMAN but also

affects sensory nerves with severe axonal damage. Like AMAN, it is probably due to an
autoimmune response directed against the axoplasm of peripheral nerves. Recovery is
slow and often incomplete. Acute panautonomic neuropathy is the rarest variant of GBS,
sometimes accompanied by encephalopathy. It is associated with a high mortality rate,
owing to cardiovascular involvement, and associated dysrhythmias. Frequently occurring
symptoms include impaired sweating, lack of tear formation, photophobia, and dryness of
nasal and oral mucosa, itching and peeling of skin, nausea, dysphagia, and constipation
unrelieved by laxatives or alternating with diarrhea.
lethargy,

fatigue,

headache,

and

Initial

decreased initiative

nonspecific

are

followed

symptoms
by

of

autonomic

symptoms

including

orthostatic

lightheadedness,

blurring

of

vision, abdominal pain,

diarrhea, dryness of eyes, and disturbed micturition. The most common symptoms at onset
are related to orthostatic intolerance, as well as gastrointestinal and sudomotor dysfunction
(Suarez et al. 1994).
Parasympathetic

impairment

(abdominal

pain,

vomiting,

constipation,

ileus,

urinary

retention, dilated unreactive pupils; loss of accommodation) may also be observed.

Bickerstaff's brainstem encephalitis (BBE) is a further variant of GuillainBarr syndrome. It
is characterized by acute
consciousness,

hyperreflexia

onset
or

of

ophthalmoplegia,

Babinski's sign.

ataxia,

disturbance

of

The course of the disease can be

monophasic or remittingrelapsing. Large, irregular hyperintense lesions located

mainly in the brainstem, especially in the pons, midbrain and medulla, are described in the
literature. Despite severe initial presentation, BBE usually has a good prognosis. Magnetic
resonance imaging (MRI) plays a critical role in the diagnosis of BBE. A considerable number
of BBE patients have associated axonal GuillainBarr syndrome, indicative that the two
disorders are closely related and form a continuous spectrum.
All forms of GuillainBarr syndrome are autoimmune diseases, due to an immune response
to foreign antigens (such as infectious agents) that is mistargeted at host nerve tissues
instead, a phenomenon called molecular mimicry. The targets of such immune attack are
thought to be gangliosides, compounds naturally present in large quantities in human
peripheral nerve tissues. The most common antecedent infection is the bacterium
Campylobacter jejuni, followed by cytomegalovirus (CMV). However, 60% of cases do not
have a known cause. Some cases may be triggered by the influenza virus, or by an immune
reaction to the influenza virus. There was increased incidence of GuillainBarr syndrome
following influenza immunization during the 19761977 swine flu pandemic;[12] however,
epidemiological studies since

then

have

demonstrated

either

an

extremely small

increased risk following immunization (under 1 additional case per million vaccinations) or
no increased risk. The end result of this autoimmune attack on the peripheral nerves is
damage to the myelin, the fatty insulating layer of
The nerve, and a nerve conduction block, leading to muscle paralysis that may be
accompanied by sensory or autonomic disturbances. In mild cases, nerve axon (the long
slender conducting portion of a nerve) function remains intact and recovery can be rapid if
remyelination occurs. In severe cases, axonal damage occurs, and recovery depends on the
regeneration of this important tissue. Approximately 80% of patients have myelin loss; in the
remaining 20%, the pathological hallmark is axon loss.

GuillainBarr, unlike disorders such

as multiple sclerosis (MS) and Lou Gehrig's disease (ALS), is a peripheral nerve disorder and
does not in general cause nerve damage to the brain or spinal cord.

General Information or Patient's Profile

Name:

A.B.B

Age:

15 years old

Sex:

male

Civil Status:

single

Address:

jagobiao mandaue city

Occupation:

unemployed

Nationality:

Filipino

Religion:

Roman Catholic

Ward and Bed #:

male Medical ward

Date and Time of admission:

Nov1, 2015 12:35am

Admitting Diagnosis:

Guillain Barre Syndrome

Chief Complaints:

pain in the calf of lower right leg, weakness of the

both lower limbs,was Bed ridden after the onset of
weakness.

Pertinent Nursing Health History

History of Present Illness

A 15 yr old male, came to E.R. with complaints of pain in the calf of the right leg on Tuesday,
followed by weakness of the both lower limbs the next day morning. was bed ridden after
the onset of weakness. His bowel and bladder are intact. He is able to feel sensation of
clothes over the lower limbs. He felt heaviness of the limbs. Taken to local hospital was
given treatment. He noticed weakness in the upper limbs also.
Patient was conscious coherent. no pallor ,icterus,clubbing,lymphadenopathy,edema.
His BP is 110/70 mm Hg in supine,100/70 mm Hg on standing. no postural hypotension.
Pulse -82/min regular, all peripheral pulses felt. Respiratory rate -18 /min. breath holding
time able to count up to 45 in single breath.

no
no
no
no
no
no

symptoms of cranial nerve involvement.

h/o fever at the onset of weakness.
h/o recent immunization or no h/o dog bite.
h/o seizures episodes.
h/o similar complaints in the past.
h/o similar complaints in the family.

Previous Hospitalizations
No previous Hospitalization
Family History
No history known history of family diseases
Medical History
No allergy

Category
I.

Before Hospitalization

claims that he doesn't take any takes

medications
multivitamins
prescribed

Health Perception and

Health Maintenance

II.

Nutrition
Metabolism

During Hospitalization
as

Eats twice a day breakfast, he

usually eat half cup of rice,and NPO
fried fish; for Lunch and Supper,
he usually eats rice, fish (most of
the time dried & salted).
Drinks plenty of water, Drinks
alcoholic beverages occasionally

and

III. Elimination

Urinates at least 2x daily; voids Urinates at least 2x daily;

freely; defecates once daily.
voids
freely;
defecation
pattern is once every other
day.

IV. Activity and Exercise

Jogging, walking
basketball are
exercise.

and playing Claims that he cannot move

His way of
that much because of
fatigue
kapoy kaayo akong lawas
as verbalized

V.

Cognition
Perception

VI. Sleep and Rest

VII.

Sexuality
Reproduction

VIII.

Self-Perception
Self-Concept

and Client claims that he does not have able to respond to questions
any memory problems
without any difficulty
able to read and write without any
difficulties
Client claims he used to sleep Stated that he gets 4-5 hours
around 8pm and wake at 5:30am
of sleep every night
to prepare breakfast for her appears lethargic
family

and

and Client claims that he is content Expressed concerns about His

with his life and family even
disease
though sometimes there are
financial problems

IX. Roles and Relationship Client claims that he has a good relationship with his parents
claims that he is very friendly and trustworthy.

X.

Stress Tolerance and

he stated that whenever she had problems, he tells his relatives
Coping
about her problems
he stated that talking to other patients in the ward is therapeutic; it
is provides diversion from feeling of boredom, and pain.

XI. Values and Belief

Client claims that he is a catholic and goes to church with her

whole family when she can. She prays to God before eating and
before going to bed.

The Peripheral Nervous System

The PNS is not as contained as the CNS because it is defined as everything that is not the
CNS. Some peripheral structures are incorporated into the other organs of the body. In
describing the anatomy of the PNS, it is necessary to describe the common structures, the
nerves and the ganglia, as they are found in various parts of the body. Many of the neural
structures that are incorporated into other organs are features of the digestive system;
these structures are known as the enteric nervous system and are a special subset of the
PNS.

Ganglia
A ganglion is a group of neuron cell bodies in the periphery. Ganglia can be categorized, for
the most part, as either sensory ganglia or autonomic ganglia, referring to their primary
functions. The most common type of sensory ganglion is a dorsal (posterior) root
ganglion. These ganglia are the cell bodies of neurons with axons that are sensory endings
in the periphery, such as in the skin, and that extend into the CNS through the dorsal nerve
root. The ganglion is an enlargement of the nerve root. Under microscopic inspection, it can
be seen to include the cell bodies of the neurons, as well as bundles of fibers that are the
posterior nerve root ([link]). The cells of the dorsal root ganglion are unipolar cells,
classifying them by shape. Also, the small round nuclei of satellite cells can be seen
surroundingas if they were orbitingthe neuron cell bodies.
Dorsal Root Ganglion

The cell bodies of sensory neurons, which are unipolar neurons by shape, are seen in this
photomicrograph. Also, the fibrous region is composed of the axons of these neurons that
are passing through the ganglion to be part of the dorsal nerve root (tissue source: canine).
LM 40. (Micrograph provided by the Regents of University of Michigan Medical School
2012)
Spinal Cord and Root Ganglion
The slide includes both a cross-section of the lumbar spinal cord and a section of the dorsal
root ganglion (see also [link]) (tissue source: canine). LM 1600. (Micrograph provided by
the Regents of University of Michigan Medical School 2012)

Another type of sensory ganglion is a cranial nerve ganglion. This is analogous to the
dorsal root ganglion, except that it is associated with a cranial nerve instead of a spinal
nerve. The roots of cranial nerves are within the cranium, whereas the ganglia are outside
the skull. For example, the trigeminal ganglion is superficial to the temporal bone whereas
its associated nerve is attached to the mid-pons region of the brain stem. The neurons of
cranial nerve ganglia are also unipolar in shape with associated satellite cells.
The other major category of ganglia are those of the autonomic nervous system, which is
divided into the sympathetic and parasympathetic nervous systems. The sympathetic
chain gangliaconstitute a row of ganglia along the vertebral column that receive central
input from the lateral horn of the thoracic and upper lumbar spinal cord. Superior to the
chain ganglia are threeparavertebral ganglia in the cervical region. Three other
autonomic ganglia that are related to the sympathetic chain are the prevertebral ganglia,
which are located outside of the chain but have similar functions. They are referred to as
prevertebral because they are anterior to the vertebral column. The neurons of these
autonomic ganglia are multipolar in shape, with dendrites radiating out around the cell body
where synapses from the spinal cord neurons are made. The neurons of the chain,
paravertebral, and prevertebral ganglia then project to organs in the head and neck,
thoracic, abdominal, and pelvic cavities to regulate the sympathetic aspect of homeostatic
mechanisms.
Another group of autonomic ganglia are the terminal ganglia that receive input from
cranial nerves or sacral spinal nerves and are responsible for regulating the parasympathetic
aspect of homeostatic mechanisms. These two sets of ganglia, sympathetic and
parasympathetic, often project to the same organsone input from the chain ganglia and
one input from a terminal ganglionto regulate the overall function of an organ. For
example, the heart receives two inputs such as these; one increases heart rate, and the
other decreases it. The terminal ganglia that receive input from cranial nerves are found in

the head and neck, as well as the thoracic and upper abdominal cavities, whereas the
terminal ganglia that receive sacral input are in the lower abdominal and pelvic cavities.
Terminal ganglia below the head and neck are often incorporated into the wall of the target
organ as a plexus. A plexus, in a general sense, is a network of fibers or vessels. This can
apply to nervous tissue (as in this instance) or structures containing blood vessels (such as a
choroid plexus). For example, the enteric plexus is the extensive network of axons and
neurons in the wall of the small and large intestines. The enteric plexus is actually part of
the enteric nervous system, along with the gastric plexuses and the esophageal plexus.
Though the enteric nervous system receives input originating from central neurons of the
autonomic nervous system, it does not require CNS input to function. In fact, it operates
independently to regulate the digestive system.
Nerves
Bundles of axons in the PNS are referred to as nerves. These structures in the periphery are
different than the central counterpart, called a tract. Nerves are composed of more than just
nervous tissue. They have connective tissues invested in their structure, as well as blood
vessels supplying the tissues with nourishment. The outer surface of a nerve is a
surrounding layer of fibrous connective tissue called the epineurium. Within the nerve,
axons are further bundled intofascicles, which are each surrounded by their own layer of
fibrous connective tissue calledperineurium. Finally, individual axons are surrounded by
loose connective tissue called theendoneurium ([link]). These three layers are similar to
the connective tissue sheaths for muscles. Nerves are associated with the region of the CNS
to which they are connected, either as cranial nerves connected to the brain or spinal nerves
connected to the spinal cord.

Nerve Structure

The structure of a nerve is organized by the layers of connective tissue on the outside,
around each fascicle, and surrounding the individual nerve fibers (tissue source: simian). LM
40. (Micrograph provided by the Regents of University of Michigan Medical School 2012)
Close-Up of Nerve Trunk

Zoom in on this slide of a nerve trunk to examine the endoneurium, perineurium, and
epineurium in greater detail (tissue source: simian). LM 1600. (Micrograph provided by the
Regents of University of Michigan Medical School 2012)

Cranial Nerves
The nerves attached to the brain are the cranial nerves, which are primarily responsible for
the sensory and motor functions of the head and neck (one of these nerves targets organs in
the thoracic and abdominal cavities as part of the parasympathetic nervous system). There
are twelve cranial nerves, which are designated CNI through CNXII for Cranial Nerve, using
Roman numerals for 1 through 12. They can be classified as sensory nerves, motor nerves,
or a combination of both, meaning that the axons in these nerves originate out of sensory
ganglia external to the cranium or motor nuclei within the brain stem. Sensory axons enter
the brain to synapse in a nucleus. Motor axons connect to skeletal muscles of the head or
neck. Three of the nerves are solely composed of sensory fibers; five are strictly motor; and
the remaining four are mixed nerves.
Learning the cranial nerves is a tradition in anatomy courses, and students have always
used mnemonic devices to remember the nerve names. A traditional mnemonic is the
rhyming couplet, On Old Olympus Towering Tops/A Finn And German Viewed Some Hops,
in which the initial letter of each word corresponds to the initial letter in the name of each
nerve. The names of the nerves have changed over the years to reflect current usage and
more accurate naming. An exercise to help learn this sort of information is to generate a
mnemonic using words that have personal significance. The names of the cranial nerves are
listed in [link] along with a brief description of their function, their source (sensory ganglion
or motor nucleus), and their target (sensory nucleus or skeletal muscle). They are listed here
with a brief explanation of each nerve ([link]).
The olfactory nerve and optic nerve are responsible for the sense of smell and vision,
respectively. The oculomotor nerve is responsible for eye movements by controlling four of
theextraocular muscles. It is also responsible for lifting the upper eyelid when the eyes
point up, and for pupillary constriction. The trochlear nerve and the abducens nerve are
both responsible for eye movement, but do so by controlling different extraocular muscles.
Thetrigeminal nerve is responsible for cutaneous sensations of the face and controlling the
muscles of mastication. The facial nerve is responsible for the muscles involved in facial
expressions, as well as part of the sense of taste and the production of saliva.
The vestibulocochlear nerve is responsible for the senses of hearing and balance.

The glossopharyngeal nerve is responsible for controlling muscles in the oral cavity and
upper throat, as well as part of the sense of taste and the production of saliva. The vagus
nerve is responsible for contributing to homeostatic control of the organs of the thoracic
and upper abdominal cavities. The spinal accessory nerve is responsible for controlling
the muscles of the neck, along with cervical spinal nerves. Thehypoglossal nerve is
responsible for controlling the muscles of the lower throat and tongue.
The Cranial Nerves

The anatomical arrangement of the roots of the cranial nerves observed from an inferior
view of the brain.
Three of the cranial nerves also contain autonomic fibers, and a fourth is almost purely a
component of the autonomic system. The oculomotor, facial, and glossopharyngeal nerves
contain fibers that contact autonomic ganglia. The oculomotor fibers initiate pupillary
constriction, whereas the facial and glossopharyngeal fibers both initiate salivation. The
vagus nerve primarily targets autonomic ganglia in the thoracic and upper abdominal
cavities.
Another important aspect of the cranial nerves that lends itself to a mnemonic is the
functional role each nerve plays. The nerves fall into one of three basic groups. They are
sensory, motor, or both (see [link]). The sentence, Some Say Marry Money But My Brother
Says Brains Beauty Matter More, corresponds to the basic function of each nerve. The first,
second, and eighth nerves are purely sensory: the olfactory (CNI), optic (CNII), and
vestibulocochlear (CNVIII) nerves. The three eye-movement nerves are all motor: the
oculomotor (CNIII), trochlear (CNIV), and abducens (CNVI). The spinal accessory (CNXI) and
hypoglossal (CNXII) nerves are also strictly motor. The remainder of the nerves contain both

sensory and motor fibers. They are the trigeminal (CNV), facial (CNVII), glossopharyngeal
(CNIX), and vagus (CNX) nerves. The nerves that convey both are often related to each
other. The trigeminal and facial nerves both concern the face; one concerns the sensations
and the other concerns the muscle movements. The facial and glossopharyngeal nerves are
both responsible for conveying gustatory, or taste, sensations as well as controlling salivary
glands. The vagus nerve is involved in visceral responses to taste, namely the gag reflex.
This is not an exhaustive list of what these combination nerves do, but there is a thread of
relation between them.

Spinal Nerves
The nerves connected to the spinal cord are the spinal nerves. The arrangement of these
nerves is much more regular than that of the cranial nerves. All of the spinal nerves are
combined sensory and motor axons that separate into two nerve roots. The sensory axons
enter the spinal cord as the dorsal nerve root. The motor fibers, both somatic and
autonomic, emerge as the ventral nerve root. The dorsal root ganglion for each nerve is an
enlargement of the spinal nerve.
There are 31 spinal nerves, named for the level of the spinal cord at which each one
emerges. There are eight pairs of cervical nerves designated C1 to C8, twelve thoracic
nerves designated T1 to T12, five pairs of lumbar nerves designated L1 to L5, five pairs of
sacral nerves designated S1 to S5, and one pair of coccygeal nerves. The nerves are
numbered from the superior to inferior positions, and each emerges from the vertebral
column through the intervertebral foramen at its level. The first nerve, C1, emerges between
the first cervical vertebra and the occipital bone. The second nerve, C2, emerges between
the first and second cervical vertebrae. The same occurs for C3 to C7, but C8 emerges
between the seventh cervical vertebra and the first thoracic vertebra. For the thoracic and
lumbar nerves, each one emerges between the vertebra that has the same designation and
the next vertebra in the column. The sacral nerves emerge from the sacral foramina along
the length of that unique vertebra.
Spinal nerves extend outward from the vertebral column to enervate the periphery. The
nerves in the periphery are not straight continuations of the spinal nerves, but rather the
reorganization of the axons in those nerves to follow different courses. Axons from different
spinal nerves will come together into a systemic nerve. This occurs at four places along
the length of the vertebral column, each identified as a nerve plexus, whereas the other
spinal nerves directly correspond to nerves at their respective levels. In this instance, the
word plexus is used to describe networks of nerve fibers with no associated cell bodies.

Of the four nerve plexuses, two are found at the cervical level, one at the lumbar level, and
one at the sacral level ([link]). The cervical plexus is composed of axons from spinal nerves
C1 through C5 and branches into nerves in the posterior neck and head, as well as
the phrenic nerve, which connects to the diaphragm at the base of the thoracic cavity. The
other plexus from the cervical level is the brachial plexus. Spinal nerves C4 through T1
reorganize through this plexus to give rise to the nerves of the arms, as the name brachial
suggests. A large nerve from this plexus is theradial nerve from which the axillary
nerve branches to go to the armpit region. The radial nerve continues through the arm and
is paralleled by the ulnar nerve and the median nerve. Thelumbar plexus arises from all
the lumbar spinal nerves and gives rise to nerves enervating the pelvic region and the
anterior leg. The femoral nerve is one of the major nerves from this plexus, which gives
rise to the saphenous nerve as a branch that extends through the anterior lower leg.
The sacral plexus comes from the lower lumbar nerves L4 and L5 and the sacral nerves S1
to S4. The most significant systemic nerve to come from this plexus is the sciatic nerve,
which is a combination of the tibial nerve and the fibular nerve. The sciatic nerve extends
across the hip joint and is most commonly associated with the condition sciatica, which is
the result of compression or irritation of the nerve or any of the spinal nerves giving rise to
it.
These plexuses are described as arising from spinal nerves and giving rise to certain
systemic nerves, but they contain fibers that serve sensory functions or fibers that serve
motor functions. This means that some fibers extend from cutaneous or other peripheral
sensory surfaces and send action potentials into the CNS. Those are axons of sensory
neurons in the dorsal root ganglia that enter the spinal cord through the dorsal nerve root.
Other fibers are the axons of motor neurons of the anterior horn of the spinal cord, which
emerge in the ventral nerve root and send action potentials to cause skeletal muscles to
contract in their target regions. For example, the radial nerve contains fibers of cutaneous
sensation in the arm, as well as motor fibers that move muscles in the arm.
Spinal nerves of the thoracic region, T2 through T11, are not part of the plexuses but rather
emerge and give rise to the intercostal nerves found between the ribs, which articulate
with the vertebrae surrounding the spinal nerve.

Nerve Plexuses of the Body

There are four main nerve plexuses in the human body. The cervical plexus supplies nerves
to the posterior head and neck, as well as to the diaphragm. The brachial plexus supplies
nerves to the arm. The lumbar plexus supplies nerves to the anterior leg. The sacral plexus
supplies nerves to the posterior leg.

GORDONS
FUNCTIONAL

HEALTH
ASSESSMENT/

LABORATORY
AND

THERAPEUTIC
MANAGEMENT

KEY
NURSING

HEALTH
PATTERN

PHYSICAL
EXAMINATION

: A complete blood

1. Health
Perception and
Health

Objective:

Necrotic
fingers noted

Management
Patterns
Subjective:

DIAGNOSTIC
STUDIES

2.Nutritional
and Metabolic

Objective data:
,
patient Difficulty
swallowing
claims that she noted
upon
has difficulty in eating.
swallowing

3 Activity and
Exercise
Patterns

Ojective:

cannot
move
Subjective:
that
much
maglisod ko lihok because
of
as verbalized.
fatigue
and
stiffness
of
fingers noted
4. sleep and rest
pattern

count (CBC) may

reveal an elevated
white blood cell
count
(WBC).
Electrolyte
levels
may be measured,
and liver function
tests may be done.
Creatinine
phosphokinase
(CPK)
and
erythrocyte
sedimentation rate
(ESR)
may
be
done to evaluate
inflammation.
Recent bacterial or
viral infection is
usually resolved by
the time of GBS
symptom onset, but
precursor
viral
infections
(e.g.,
Epstein-Barr, herpe
s simplex, and HIV)
may
be
documented
by
blood
tests
if
necessary.
Electrodiagnostic
tests,
including electromy
ography (EMG)
and nerve
conduction
velocity (NCV), that
demonstrate
significantly slowed
or
blocked
impulses
support
the
diagnosis.
Slowed
F-wave
responses are the
first
abnormality
chronologically
found
in
NCV
testing. Otherwise,
NCV tests may be
normal for 2 to 3
weeks.
Nerve
conduction velocity
tests show sensory
abnormalities
in
58% to 76% of

PROBLEMS
1. Monitor
respiratory
status
through
vital
capacity
measurements,
rate and depth of
respirations, and
breath sounds.
2. Monitor level of
muscle weakness
as it ascends
toward
respiratory
muscles. Watch
for
breathlessness
while
talking
which is a sign of
respiratory
fatigue.
3. Monitor
the
patient for signs
of
impending
respiratory
failure.
4. Monitor
gag
reflex
and
swallowing
ability.
5. Position patient
with the head of
bed elevated to
provide
for
maximum chest
excursion.
6. Avoid
giving
opioids
and
sedatives
that
may
depress
respirations.
7. Position patient
correctly
and
provide range-ofmotion exercises.

Ineffective
peripheral
tissue
perfusion
related
to
lack of blood
supply
to
extremities

Risk
for
Imbalance
Nutrition
related
to
pain
upon
swallowing

Impaired
physical
Mobility
Related
to
hardening of
the skin and
stiffening of
joints
secondary to
systemic


Putol-putol
akong katug kay
lisud kaayo
i katug dire tungod
sa ka - banha, ka alimuot,
ug sa
pag huna - huna
sa mga prob-lema,
sa akong kahimtang
as
verbalized.

Stated that
he gets 4-5 hours
of
sleep
every
night

Objective data:

frequent
yawning

appears
lethargic

Irritability

Drowsiness
noted

5.Self-Perception
and Self-Concept
mauwaw
kos
akong
condisyon
karon as verbalzed

6.Coping

and Objective data:

Stress Patterns
hardening
of
Subjective cues the skin and
stiffening
of
Mahadlok
ko joints
and
fingers
nga mo grabe
akong sakit as
verbalized

individuals
with
GBS (Davids). A
lumbar
puncture
may be performed
in order to analyze
cerebral spinal fluid
(CSF).
Elevated
protein in the CSF
is seen in most
individuals but may
be normal the first
few
days
after
onset. The CSF cell
count is usually
normal. A muscle
biopsy may be
needed in some
cases
to
differentiate
suspected
GBS
from
myopathy.
Heart irregularities
may be evaluated
by
electrocardiogram.

8. Provide
good
body alignment,
range-of-motion
exercises,
and
change
of
position
to
prevent
complications
such
as
contractures,
pressure
sores,
and
dependent
edema.
9. Ensure adequate
nutrition without
the
risk
of
aspiration.
10. Encourage
physical
and
occupational
therapy
exercises to help
the
patient
regain strength
during
rehabilitation
phase.
11. Provide
assistive devices
as needed (cane
or wheelchair) to
maximize
independence
and activity.
12. If
verbal
communication
is
possible,
discuss
the
patients
fears
and concerns.
13. Provide
choices in care to
give the patient
a
sense
of
control.
14. Teach patient

sclerosis

Distubed
sleep
pattern
related to
uncomfortable sleeping
environment
as
manifested
by day-time
drowsiness,
frequent
yawning,
and
appearing
le-thargic

Disturbed
Body Image
related
to
hardening of
the
skin,
stiffening of
joints
and
fin-gers
secondary to

Objective cues:
-irritability and
discomfort
noted

about breathing
exercises or use
of an incentive
spirometer
to
reestablish
normal breathing
patterns.
15. Instruct
patient to wear
good supportive
and
protective
shoes while out
of bed to prevent
injuries due to
weakness
and
paresthesia.
16. Instruct
patient to check
feet routinely for
injuries because
trauma may go
unnoticed due to
sensory changes.
17. Urge
the
patient
to
maintain normal
weight because
additional weight
will further stress
monitor function.
18. Encourage
scheduled
rest
periods to avoid
fatigue.
.

Pathophysiology

Host
15 Yr old
Male,
Basketball player

Agent
Campylobacter jejuni

Environment
-Nutrition

systemic
sclerosis

Fear related
to
the
disease
process
as
evidenced
by feeling of
helplessness
and
discomfor

Signs and symptoms of

Guillain-Barre syndrome may
include:

Prickling, "pins and

needles" sensations in
your fingers, toes, ankles
or wrists

Weakness in your legs

that spreads to your
upper body

Unsteady walking or
inability to walk or climb
stairs

Difficulty with eye or

facial movements,
including speaking,
chewing or swallowing

Severe pain that may

feel achy or cramp-like
and may be worse at
night

Difficulty with bladder

control or bowel function

Rapid heart rate

Nursing management
1.
Monitor respiratory status through vital
capacity measurements, rate and depth of
respirations, and breath sounds.
2.
Monitor level of muscle weakness as it
ascends toward respiratory muscles. Watch
for breathlessness while talking which is a
sign of respiratory fatigue.
3.
Monitor the patient for signs of
impending respiratory failure.
4.
Monitor gag reflex and swallowing
ability.
5.
Position patient with the head of bed
elevated to provide for maximum chest
excursion.
6.
Avoid giving opioids and sedatives that
may depress respirations.
7.
Position patient correctly and provide
range-of-motion exercises.
8.
Provide good body alignment, range-ofmotion exercises, and change of position to
prevent complications such as contractures,
pressure sores, and dependent edema.
9.
Ensure adequate nutrition without the
risk of aspiration.
10.
Encourage physical and occupational
therapy exercises to help the patient regain
strength during rehabilitation phase.
11.
Provide assistive devices as needed
(cane
or
wheelchair)
to
maximize
independence and activity.
12.
If verbal communication is possible,
discuss the patients fears and concerns.
13.
Provide choices in care to give the
patient a sense of control.
14.
Teach
patient
about
breathing
exercises or use of an incentive spirometer to
reestablish normal breathing patterns.
15.
Instruct
patient
to
wear
good
supportive and protective shoes while out of
bed to prevent injuries due to weakness and
paresthesia.
16.
Instruct patient to check feet routinely
for injuries because trauma may go
unnoticed due to sensory changes.
17.
Urge the patient to maintain normal
weight because additional weight will further
stress monitor function.
18.
Encourage scheduled rest periods to
avoid fatigue.

High risk for Ineffective airway clearance related to impaired ability to cough
Significant
Findings

Scientific Basis

Subjective:
The inflammatory
maglisod
response
to
gihapon ko ug infection
causes
tulon
mura kog tissue edema and
matuk-an
as exudates formation
verbalized
in the lungs, the
Objective:
Difficulty
Breathing noted.

Expected
Outcome

Short
Term:
After 4 hours
of nursing
interventions, t
he client will
be
able
to
maintain
inflammatory
response
can airway
narrow
and patency. Long
potentially obstruct Term: After 1

Interventions

Actual
Outcomes

Delusional clients are

extremely sensitive about
others and can recognize
insincerity. Evasive
comments or hesitation
reinforces mistrust or
delusions.

after 3
days
of
nursepatient
interaction,
the
client
complied
with health
teachings
given
to

Clear, consistent limits

-Difficulty
coughing

bronchial passages
and alveoli
(Med-surg,
p.250)

day of nursing
intervention,
the client will
be
able
to
expectorate
retained
secretions and
maintain
normal
breathing
pattern

provide a secure
structure for the client.

prevent
infection
and
there
were
no
Broken promises reinforce
signs
of
the clients
infection.

mistrust of others.

Probing increases the

clients suspicion and
interferes with the
therapeutic relationship.
When the client has full
knowledge of procedures,
he or she is less likely to
feel tricked by the staff.
Logical argument does
not dispel delusional
ideas and can interfere
with the development of
trust
Collaborative Interventions:
1.Perineal care twice a day
R: To clean site and prevent
infection.

Activity intolerance related to fatigue and difficulty in performing activities in daily Living
Significant
Findings

Scientific Basis

Expected
Outcome

Interventions

Actual
Outcomes

Subjective: dili ko
lihok sa akong
mga lawas
as
verbalized

The first symptoms

of GBS consist of mu
scle weakness (legs
first, then arms, then

Within 3 days
of
nursing
care, client will
participate in

Nursing management
1.
Monitor
respiratory
status through vital capacity
measurements, rate and

After
3
weeks
pt
will be able
to
regain

Objective:
Weak in
appearance
With fatigability
Looks thin in
appearance

face), accompanied
by prickly,tingling se
nsations (paresthesi
as). Symptoms affect
both sides of the bod
y simultaneously, a c
haracteristic that hel
psdistinguish GBS fr
om other causes of
weakness and pares
thesias. Normal refle
xes are first diminish
ed, then lost. Thewe
akness eventually aff
ects all the voluntary
muscles, resulting in
paralysis. When thos
e muscles necessary
forbreathing become
paralyzed, the patien
t must be placed on
a mechanical ventilat
or which takes over t
he function ofbreathi
ng.

preventive
measures,
maintain
optimal
nutrition
and
physical wellbeing,
vmanifest no
signs
of
infection

depth of respirations, and

breath sounds.
2.
Monitor
level
of
muscle weakness as it
ascends toward respiratory
muscles.
Watch
for
breathlessness while talking
which is a sign of respiratory
fatigue.
3.
Monitor the patient
for signs of impending
respiratory failure.
4.
Monitor gag reflex
and swallowing ability.
5.
Position patient with
the head of bed elevated to
provide for maximum chest
excursion.
6.
Avoid giving opioids
and sedatives that may
depress respirations.
7.
Position
patient
correctly and provide rangeof-motion exercises.
8.
Provide good body
alignment, range-of-motion
exercises, and change of
position
to
prevent
complications
such
as
contractures,
pressure
sores,
and
dependent
edema.
9.
Ensure
adequate
nutrition without the risk of
aspiration.
10.
Encourage physical
and occupational therapy
exercises to help the patient
regain
strength
during
rehabilitation phase.
11.
Provide
assistive
devices as needed (cane or
wheelchair) to maximize
independence and activity.
12.
If
verbal
communication is possible,
discuss the patients fears
and concerns.
13.
Provide choices in
care to give the patient a
sense of control.
14.
Teach patient about
breathing exercises or use
of an incentive spirometer
to
reestablish
normal

strength
and
verbalize
understandi
ng
about
the health
teaching
rendered

breathing patterns.
15.
Instruct patient to
wear good supportive and
protective shoes while out of
bed to prevent injuries due
to
weakness
and
paresthesia.
16.
Instruct patient to
check feet routinely for
injuries
because
trauma
may go unnoticed due to
sensory changes.
17.
Urge the patient to
maintain
normal
weight
because additional weight
will further stress monitor
function.
18.
Encourage scheduled
rest periods to avoid fatigue.
Collaborative Interventions:
1.Perineal care twice a day
R: To clean site and prevent
infection.

Imbalanced Nutrition, Less Than Body Requirements related to difficulty chewing, swallowing, fatigue,
limb paralysis.

Significant
Findings
Subjective

Scientific Basis
Data: Dysphagia is

Expected
Outcome

Interventions

Within 3 days
nursing Nursing management
due to abnormal of
Monitor
respiratory
The patient nerve or muscle care, client will 1.
participate
in
status
through
vital
capacity
stated, can control.
It
is

Actual
Outcomes
Oct.
1-3,
2015 after
3 days of
nurse-

common,
for
example,
after
a stroke.

Dysphagia can
compromise nutr
ition and
hydration
and
may
lead
to
aspiration
pneu
Objective
Data:
monia
and dehydration
The
(Med-surg,
inability to
p.250)
perform
not chew
and
swallow.
Patients
say, the
hand can
not be
moved.

the
activity.
Patients
using the
NGT.
Diet food,
nutritional
value.
Weight
loss.
Albumin
and
hemoglobi
n values.
Signs of
malnutritio
n.
The
presence
of nausea.
Intake of
the food
intake is
not in
proportion

preventive
measures,
maintain
optimal
nutrition
and
physical wellbeing,
vmanifest no
signs
of
infection

measurements, rate and

depth of respirations, and
breath sounds.
2.
Monitor
level
of
muscle weakness as it
ascends toward respiratory
muscles.
Watch
for
breathlessness while talking
which is a sign of respiratory
fatigue.
3.
Monitor the patient
for signs of impending
respiratory failure.
4.
Monitor gag reflex
and swallowing ability.
5.
Position patient with
the head of bed elevated to
provide for maximum chest
excursion.
6.
Avoid giving opioids
and sedatives that may
depress respirations.
7.
Position
patient
correctly and provide rangeof-motion exercises.
8.
Provide good body
alignment, range-of-motion
exercises, and change of
position
to
prevent
complications
such
as
contractures,
pressure
sores,
and
dependent
edema.
9.
Ensure
adequate
nutrition without the risk of
aspiration.
10.
Encourage physical
and occupational therapy
exercises to help the patient
regain
strength
during
rehabilitation phase.
11.
Provide
assistive
devices as needed (cane or
wheelchair) to maximize
independence and activity.
12.
If
verbal
communication is possible,
discuss the patients fears
and concerns.
13.
Provide choices in
care to give the patient a
sense of control.
14.
Teach patient about
breathing exercises or use
of an incentive spirometer

patient
interaction,
the
client
complied
with health
teachings
given
to
prevent
infection
and
there
were
no
signs
of
infection
such
as
redness,
swelling,
pain,
and
abnormal
discharges
on
episiorraph
y site

to
reestablish
normal
breathing patterns.
15.
Instruct patient to
wear good supportive and
protective shoes while out of
bed to prevent injuries due
to
weakness
and
paresthesia.
16.
Instruct patient to
check feet routinely for
injuries
because
trauma
may go unnoticed due to
sensory changes.
17.
Urge the patient to
maintain
normal
weight
because additional weight
will further stress monitor
function.
18.
Encourage scheduled
rest periods to avoid fatigue.

Name

Classifica
tion

MECHANISM
OF ACTION

Indication/
Contraindicatio
n

Side Effect

Nursing
Responsibilities

Generic
name:
Mefena
mic Acid
Brand
name:
Ponstel
1 cap
500mg
BID PO

Analgesi
c; Nonsteroidal
antiinflamma
tory drug

Mefenamic
acid binds the
prostaglandin
synthetase
receptors
COX-1 and
COX-2,
inhibiting the
action of
prostaglandin
synthetase.
As these
receptors
have a role as
a major
mediator of
inflammation
and/or a role
for prostanoid
signaling in
activitydependent
plasticity, the
symptoms of
pain are
temporarily
reduced.

Indications:

- Rheumatoid
arthritis
- Mild to moderate
pain
- Dental pain
- Postoperative pain
- Dysmenorrhoea
- Osteoarthritis
- Menorrhagia

Bloody
nose

- Black, tarry
stools
- Blood in the
urine or
stools
- Vomiting
blood
- Red or purple
spots on
Contraindicati
the skin.
Nausea
ons:
- Fatigue
- Inflammatory
- Yellowing of
intestinal
the skin or
diseases
whites of
- Active peptic
the eyes
ulcers
(jaundice)
- Hypersensitivity to
- Excessive
aspirin
tiredness
(acetylsalicylic
Swelling
of
acid) or other
the
face
or
non-steroidal
body
anti- Blisters
inflammatory
- Unexplained
agents
skin rash
- Renal failure
- Wheezing
- Difficulty
breathing
- Chest pain
- Shortness of
breath
- Weakness on
one side of
your body
- Slurred
speech

Assess patients
who develop
severe diarrhea
and vomiting for
dehydration and
electrolyte
imbalance.
1 Discontinue drug
promptly if
diarrhea, dark
stools,
hematemesis,
ecchymoses,
epistaxis, or rash
occur and do not
use again.
Contact
physician.
2 Notify physician if
persistent GI
discomfort, sore
throat, fever, or
malaise occur.
3 Lab tests: With
long-term
therapy (not
recommended)
obtain periodic
complete blood
counts, Hct and
Hgb, and kidney
function tests.

Name

Classifi
cation

Mechanism
of Action

Generi
c
Name:
Multivit
amins
+
FeSO4

Therap
e
u
t
i
c
vitamins
a
n
d
minerals
;
antiane
m
i
c
s

Pharmac
odynamic
s:

Patient
s
Dose:
1 cap
PO OD
Minim
um
Dose:
125 mg
Maxim
um
Dose:
750 mg
Conten
ts:
Fe
sulfate
200
mg,
folic
acid
400
mcg, vit
B1 2
mg, vit
B2 2
mg, vit
B6 2
mg, vit
B12 10
mcg, vit
C 100
mg
Availa
bility:
tablets
: 150
mg,
300
mg,
500 mg
capsul
es: 300
mg,
500 mg
syrups
:250
mg/5ml

Pharma
c
o
logic:
waters
o
l
u
b
l
e
vitamins
;
ir
o
n
supplem
e
n
t
s
Pregna
n
c
y
Catego
r
y
Risk:
A

Chemical
Effects
An
essential
mineral
found in
hemoglobi
n,
myoglobin
, and
many
enzymes.
Enters the
bloodstrea
m and is
transporte
d to the
organs of
the
reticuloen
dothelial
system
(liver,
spleen,
bone
marrow),
where it is
separated
out and
becomes
part of
iron
stores.
Therapeu
tic
Effects:
Prevention
/treatment
of iron
deficiency
Pharmac
okinetics
Absorptio
n:
510% of
dietary
iron is
absorbed
(up to
30% in
deficiency
states).
Therapeuti
cally
administer
ed PO iron
may be
60%

Indication/Co
ntraindicatio
n
General
Indication:
Prevention and
treatment of
iron-vitamin and
dietary
deficiency
anemias. Used
in anemia due
to blood loss
during
menstruation,
infections,
surgery,
delivery,
intoxications,
parasitosis or
other causes
and anemias
during
pregnancy
Contraindicate
d in:
Hemochromatos
is,
hemosiderosis,
or other
evidence of iron
overload;
Anemias not
due to iron
deficiency;
some products
contain alcohol,
tartrazine or
sulfites and
should be
avoided in
patients with
known
intolerance or
hypersensitivity
Precaution:
Use cautiously
in peptic ulcer;
ulcerative colitis
or regional
enteritis
(condition may
be aggravated);
Alcoholism;
Severe hepatic
impairment;
Severe renal
impairment
(oral products);
Pre-existing
cardiovascular
dse; significant
allergies or
asthma;
rheumatoid
arthritis,

Adverse
Effect

Nursing
Responsibilities

CNS:
Before:
seizures,
Monitor blood studies
dizziness,hea
of pt.
dache,

Assess
for intake of
syncope
other multivitamin
products within 2
CV:
hours, may result to
hypotension,
vitamin overdose.
hypertension
, tachycardia Observe proper
dosage of
GI: nausea,
medication to
constipation,
prevent overdose or
dark stools,
toxic effect of the
diarrhea,
drug.
epigastric
Assess for colostomy
pain, GI
or ileostomy.
bleeding,

Note
other drug that
taste
the
pt
are taking to
disorder,
avoid
possible
vomiting
interactions
Verify pt.s identity
Derm:
flushing,
urticaria
During:
Most effectively
Resp: cough,
absorbed if
dyspnea
administered 1 hour
before or 2 hrs after
MS:
meal.
arthralgia,
Take tablets and
myalgia
capsules with a full
glass of water or
Misc:
juice.
staining of
Do not crush or chew
teeth,
anaphylaxis,
enteric-coated
sweating
tablets and do not
open capsules.
Local: pain at Avoid using antacids,
IM site
coffee, tea, dairy
products, eggs within
1 hr after
administration.
Inform pt. about dark,
green or black stools
to avoid panic.

After:
Monitor pt.s blood
studies periodically
thereafter to
determine the level
of effectiveness.
Inform pt of what the
possible adverse
effects that may
occur.
Provide brief
information about
drug and its
indications to be
guided and modify

Discharge Plan
M Instructed immediate relatives to facilitate the patient to continue taking the
drugs prescribed to her on the right time and with the right dose to facilitate
continuity of care
-instructed to contact physician if there are any hypersensitivity with the drugs
given
-encouraged to prevent taking over-the-counter drugs without the physicians
advice
E- Encouraged immediate relatives to facilitate passive exercises and stretching to
exercise muscles
-encouraged him not to carry heavy loads and do not force himself too much to
prevent injury
T- encouraged client to have enough rest and instructed to seek physicians
consultation whenever health problems occurs
H- Encouraged and explained to Her the benefits Breastfeeding and proper hygiene
to promote wellness
O Instructed client to come back for scheduled follow up checkup when he is
discharged
D- Advised patient to eat nutritional foods like fruits and vegetables and to eat a
balanced diet
-instructed to limit eating foods high in fat content and with cholesterol
-instructed to avoid salty foods
S Encouraged client to continue his habits in going to church every Sunday and
always seek Gods help and guidance throughout his life

REFERENCES:
Ulrich & Canales Nursing Care Planning Guides, (7 th ed.)
Brunner & Suddarth. Medical-Surgical Nursing, (13 th ed.).2010
Gulanick & Myers: Nursing Care Plans: Nursing care plans: Diagnosis and
Interventions(8th ed.).Philadelphia, PA: FA Davis Company
Potter, P.A., & Perry, A.G. (2013). Fundamentals of Nursing (13 th ed.).
Philadelphia, PA:F.A. Davis Company
Huether, S.E., & McCane, K.L. (2008). Understanding Pathophysiology (14 th
ed.). St.Louis, MO: Mosby.
Deglin, J.H., & Vallerand, A.H. (2009). Daviss Drug Guide for Nurses (11 th ed.).
Philadelphia, PA: F.A Davis Company
Handbook of Medical-Surgical Nursing (4th ed.). (2006). Philadelphia, PA:
Lippincott, Williams & Wilkins