Anda di halaman 1dari 6

Assessment

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 Barr 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 examiners 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.

and paralysis. References: Lippincott Williams & Wilkins, Pathophysiology made incredibly easy,4th ed.,2009

8. Encouraged participation in self care and diversional activity. 9. Encouraged adequate intake of fluids and nutritious foods. Dependent: 1.Administer medications, as indicated, for example: Tizanidine (Zanaflex) 2. Apply anti-embolic hose, leotard, or sequential compression devices (SCDs) to legs, as appropriate.

8. To enhance self-concept and sense of Independence. 9. Promote well being and maximize energy production.

1. Centrally acting adrenergic agonist reduces spasticity. 2. These devices limit pooling of blood in lower extremities or abdomen, thus improving vasomotor tone and reducing incidence of thrombus formation and pulmonary emboli. 1. Collaboration helps in planning and implementing individualized exercise program. The members of the rehabilitation team identify and develop assistive devices to enhance clients function and overall independence.

Collaborative: 1. Consult with physical and occupational therapists and rehabilitation team.

Diagnosis

Risk for Injury related to altered mobility secondary to Guillain Barr Syndrome Definition: The state in which an individual is at risk for harm because of a perceptual or physiologic deficit, a lack of awareness of hazards, or maturational age. Reference: Carpenito-Moyet, Handbook of Nursing Diagnosis,13th ed,2010

Rationale Guillain-Barr syndrome causes inflammation and degenerative changes in both the posterior(sensory) and the anterior (motor) nerve roots. Thats why signs of sensory and motor losses occur simultaneously. Additionally, autonomic nerve transmission may be impaired. The following progressive manifestations of this disease puts pt. in risk for injury: stiffness and pain in the legs and back acute, symmetrical ascending weakness of the limbs; sensory loss, usually in the legs and spreading to the arms and loss of position sense. Reference: Lippincott Williams & Wilkins, Medical-surgical nursing made incredibly easy,3rd edition,2012

Planning After 4 hrs of nursing interventions, patient will relate fewer injuries and less fear of injury with the following criteria: Identify factors that increase the risk for injury. Relate an intent to use safety measures to prevent injury (e.g., remove throw rugs or anchor them). Relate an intent to practice selected prevention measures

Intervention Independent: 1. Orient each new admission to surroundings, explain the call system, and assess the persons ability to use it. 2. Provide information regarding disease conditions that may result in increased risk for injury. 3. Assess clients muscle strength, gross and fine motor coordination. 4. Change the patients position slowly. 5. Raise side rails and/or lower bed at night. 6. Keep the sharp objects away from the patient. 7. Precautionary measures when giving warm bath or exposure to extreme temperature. 8. Assess for the presence of side effects of drugs that may cause vertigo. 9. Discuss importance of self monitoring of condition/emotions. 10. Educate significant others about the possibility of injury and how to prevent.

Rationale 1. To promote safe physical environment and individual safety. 2. To prevent injury.

Evaluation Goal met. After 4 hrs of nursing interventions, 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. Relate an intent to use safety measures to prevent injury (e.g., remove throw rugs or anchor them). Relate intent to practice selected prevention measures such as raising side rails.

3. To identify risk for falls.

4. To prevent postural hypotension. 5. To prevent from falling. 6. To prevent injury or harmful damage. 7. Patient may loss sensation to stimuli. 8. To prevent injury from activities requiring alertness. 9. That can contribute to occurrence of injury. 10. To protect and prevent injury.

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. Reference: Carpenito-Moyet, Handbook of Nursing Diagnosis,13th ed,2010

Rationale Guillain-Barr syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities.Hyporeflexia and weakness may progress to tetraplegia. Demyelination of the nerves that innervate the diaphragm and intercostal muscles results in neuromuscular respiratory failure. Respiratory involvement occurs in 50% of patients with ascending GBS (Porth, 2009).Respiratory involvement occurs rapidly in this form of the disease. Respiratory difficulties occur as the diaphragm and intercostal muscles become involved. Prevention and treatment of respiratory failure is a priority of management. Common progression of the disease as it becomes more lifethreatening includes decreases in vital capacity, decreased ability to cough, and ineffective airway clearance. As vital capacity

Planning Within 2 hours of rendering nursing interventions, patient will maintain a normal/effective breathing pattern.

Intervention Independent: 1. Auscultate chest, noting presence/character of breath sounds, presence of secretions. 2. Note rate and depth of respirations, type of breathing pattern: tachypnea,cheyne-stokes other irregular patterns. 3. Maintained calm environment.

Rationale 1. To assess adequacy of air flow and detects presence of adventitious sounds. 2. To assess types of breathing pattern so to watch sign of respiratory fatigue.

Evaluation Goal met. After 2 hours of rendering nursing intervention, patient maintains a normal/ effective breathing pattern as evidenced by normal respiration rate of 18 brths/min.

3. To promote comfort and relaxation. 4. Position patient with head of 4. To provide maximum chest bed elevated. excursion. 5. Monitored for signs of 5. Prepare to intubate if patients impending respiratory failure. heart rate is above 120 or below 70 bpm and respiratoryrate above 30bpm. 6. Prepared emergency equipment 6. To provide emergency intubation if in readily accessible location and needed. include appropriate ET tubes. 7. Encouraged adequate rest 7. To limit fatigue. periods between activities. 8. Assisted client to learn 8. Pursed lip breathing helps get rid breathing exercises such as pursed of the old stale air in your lungs that lip breathing. is trapped in the airways and to help patient breath more fresh air through nose. 9. Assess for abdominal distention 9. Abdominal fullness may impede and muscle spasm. diaphragmatic excursion,thus reducing lung expansion and further compromising respiratory function.

decreases, atelectasis and hypoxemia become problematic. Additionally, increasing weakness of the diaphragm and intercostal muscles occur as innervation decreases. As alterations in respiratory function comprise, patients may experience ineffective airway clearance and ineffective breathing patterns related to the weakness of respiratory muscles.

10. Reposition and turn periodically. Avoid or limit prone position when indicated.

11. Encourage fluidsat least 1,500 to 2,000 mL/day.

10. It helps reduce the risks of complicationssuch as atelectasis and pneumonia. Note: Prone position significantly decreases vital capacity and increases risk of respiratory compromise and failure. 11. Adequate fluid intake liquefies secretions and promotes mobilization and expectoration.

Collaborative: 1. Review chest x-rays.

1. Reveals ventilatory state and signs of developing complications such as atelectasis and pneumonia.

2. Administer supplemental oxygen. Reference: Daniels & Nicoll, Contemporary Medical Surgical Nursing,2nd edition,2010

2. Maximizes arterial oxygenation and aids in prevention of hypoxia. If respiratory center is depressed, mechanical ventilation may be required.