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Nursing Care Plan (NCP) for Bell’s Palsy
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Outline
Nursing Care Plan (NCP) for Guillain-Barré Syndrome (GBS)
Lesson Objective for Guillain-Barré Syndrome (GBS)
Upon completion of this nursing care plan for Guillain-Barre, nursing students will be able to:
- Understand the pathophysiology, clinical presentation, and management of Guillain-Barré Syndrome. Students will gain knowledge about the various stages of GBS, recognize early signs and symptoms, understand the principles of medical and nursing management, and be aware of the rehabilitation needs and challenges associated with this condition.
Pathophysiology for Guillain-Barré Syndrome (GBS)
GBS is a rare neurological disorder where the body’s immune system mistakenly attacks part of its peripheral nervous system. This leads to muscle weakness, numbness, and tingling, progressing to paralysis.
- Analogy for Guillain-Barré Syndrome (GBS):
- Imagine the body’s immune system as a security system designed to protect against intruders (like viruses and bacteria). In GBS, this security system mistakenly identifies the body’s own nerve cells as threats and attacks them, leading to nerve damage and resulting symptoms.
Etiology for Guillain-Barré Syndrome (GBS)
It’s often preceded by an infectious illness such as a respiratory infection or gastroenteritis. The exact cause of GBS is unknown, but it is an autoimmune response.
Desired Outcomes for Guillain-Barré Syndrome (GBS)
- Regain muscle strength and function.
- Maintenance of respiratory function.
- Prevention of complications such as pressure ulcers and deep vein thrombosis (DVT).
- Adequate pain management.
- Patient and family education about the disease and its prognosis.
Subjective Data for Guillain-Barré Syndrome (GBS)
- Symptoms of Weakness or Tingling: Patients often report a feeling of weakness or tingling sensations in the legs that may spread to the arms and upper body.
- Pain: Reports of muscle pain or cramps.
- Fatigue: Feelings of extreme tiredness.
- Difficulty with Bladder and Bowel Control: Patients may report changes in bowel and bladder function.
- Breathing Difficulties: Reports of shortness of breath or difficulty breathing.
Objective Data for Guillain-Barré Syndrome (GBS)
- Progressive Muscle Weakness: Observed weakness, often symmetrical and starting in the lower extremities.
- Reflex Changes: Loss of deep tendon reflexes.
- Respiratory Compromise: Signs of respiratory distress or failure.
- Autonomic Dysfunction: Fluctuations in blood pressure or heart rate, sweating abnormalities.
- Abnormal Gait: Difficulty in walking or inability to walk.
Diagnosis for Guillain-Barré Syndrome (GBS)
- Impaired Physical Mobility related to neuromuscular impairment.
- Ineffective Breathing Pattern related to respiratory muscle weakness.
- Acute Pain related to nerve inflammation and damage.
- Anxiety related to disease process and prognosis uncertainty
Nursing Interventions and Rationales for Guillain-Barré Syndrome (GBS)
- Monitor Respiratory Status: Regularly assess respiratory function as GBS can progress to respiratory muscles.
- Rationale: Early detection of respiratory compromise allows for timely intervention.
- Mobility and Physical Therapy: Assist with passive range-of-motion exercises.
- Rationale: To maintain joint flexibility and prevent contractures during the period of paralysis.
- Pain Management: Administer pain medication as prescribed.
- Rationale: Patients may experience significant pain due to nerve inflammation.
- Nutritional Support: Monitor nutritional intake and consider feeding assistance if needed.
- Rationale: GBS can affect swallowing muscles, leading to nutritional challenges.
- Patient Education and Emotional Support: Provide reassurance and information about the condition.
- Rationale: GBS can be frightening due to rapid onset and severity of symptoms.
Evaluation for Guillain-Barré Syndrome (GBS)
- Respiratory Function: Patient maintains adequate ventilation and oxygenation levels without signs of respiratory distress.
- Physical Mobility: Patient demonstrates preserved muscle function and mobility to the greatest extent possible.
- Pain Management: Patient reports pain is controlled at a tolerable level.
- Complication Prevention: Patient remains free from complications associated with immobility and autonomic dysfunction.
- Supportive Care: Patient and family express understanding of the condition, potential outcomes, and available support resources.
References:
Guillain-Barré Syndrome (GBS):
- Van den Berg, B., Walgaard, C., Drenthen, J., Fokke, C., Jacobs, B. C., & Van Doorn, P. A. (2014). Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis. Nature Reviews Neurology, 10(8), 469-482.
- Ropper, A. H., & Samuels, M. A. (2009). Adams and Victor’s Principles of Neurology. McGraw-Hill Medical.
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