Guillian Barre syndrome is an autoimmune attack on the peripheral nerve myelin.The result is acute rapid segmental demylineationof the peripheral nerves and some of the cranial nerves.,producing ascending weakness with dyskinesia(inability to execute voluntary movements)hyporeflexia and parasthesias.
- Idiopathic cause.The causative organisms are campylobacter jejuni,Epstein barr virus,mycoplasma pneumonia,hemophilus influenza,human immune deficiency virus.
PATHOPHYSIOLOGY (step by step progression)1. Due to the etiological factors
2. The infectious organism enters the body
3. The infectious organism contains an amino acid that mimics the peripheral nerve myelin protein
4. The immune system responds to the entry of the infectious organism,but the immune system will not be able to distinguish between the two proteins and destroys the peripheral nerve myelin(the exact location of the attack of the peripheral nervous system is GM1B)
5. Due to the autoimmune attack of the immune system
6. Inflammation and destruction of the myelin occurs
7. Axons will be unable to support the nerve conduction
- Initially weakness and diminished reflexes of the lower extremities
- Hyporeflexia and weakness may progress to tetraplegia
- Demylineation of the nerves innervate the diaphragm and the intercoastal muscles resulting in neuromuscular respiratory failure.
- Sensory symptoms includes parasthesias of the hands and feet and pain related to demylineation of the sensory fibres
- Weakness usually begins in the legs and progresses upward.
- Residual defects are permanent and reflect axonal damage and demylineation
- Optic nerve demylineation results in permanent blindness
- Demylineation of the glossopharyngeal nerve resulting in inability to swallow.
- Vagus nerve dysfunction resulting in cardiovascular disorders,it may include tachycardia,bradycardia and orthostatic hypotension.
ASSESSMENT AND DIAGNOSTIC FINDINGS
- History collection and physical examination.Changes in the vital capacity and respiratory inspiratory force
- Elevated protein levels in CSF evaluation
- Progressive loss of nerve conduction
- This condition is a medical emergency and requires treatment in the intensive car the units.Assessment of the changes in the respiratory function and muscle strength should alert the physician.
- Respiratory therapy and mechanical ventilation may be necessary to relieve the symptoms
- The patient is weaned from mechanical ventilation once the respiratory muscles support spontaneous respirationand maintain adequate tissue oxygenation
- Prevent complications of immobility,these includes use of anticoagualant medications,thick high elastic stockings to prevent thrombosis and pulmonary emboli
- Plasampheresis and IVIG are used to maintain the nerve myelin antibody level.IVIG is the most preferable because it has less side effects
- The cardiographic complication requires continuous electrocardiographic monitoring
- Tachycardia and hypotension is treated with short acting medications like alpha adrenergic medications
- If hypotension is there it should be managed with IV fluids
The patient is monitored for life threatening complications like (respiratory failure,cardiac dysrrythmias,dVT so that appropriate interventions can be initiated.the nurse must assess the patients and family s ability to cope up.
NURSING DIAGNOSISIneffective breathing pattern and impaired gas exchange related to rapidly progressing weakness and impending respiratory failure
- Assess the respiratory pattern of the client.
- Respiratory function is improved by incentive spirometry and chest physiotherapy.
- Monitor for the changes in vital capacity and negative inspiratory force
- Determine the parameters for mechanical ventilation(vital capacity of less than 15 ml/kg,partial pressure of oxygen less than 70mmhg and progressive bulbar weakness.If required mechanical ventilation is initiated.
- Assess the heart rate and blood pressure frequently to assess for autonomic dysfunction.Suctioning is needed to maintain a clear airway.
- Medications are administered and a temporary pacemaker is placed to identify bradycardia.
Impaired physical mobility related to paralysis
- Assess the level of physical mobility of the patient.
- The paralyzed extremities are supported and range of motion exercises are initiated
- Nursing intervention s are aimed at preventing DVT
- Range of motion exercises,position changes,anticoagulation,use of thigh high elastic stockings and adequate hydration is needed to prevent complications of DVT
- Padding should be placed over the bony prominences such as elbows and heels to prevent bed sores.
- The laboratory test results should be evaluated for malnutrition,which may increase the risk of pressure ulcer
- The nurse should collaborate with the dietician for the nutritional requirements of the patient
Imbalanced nutrition less than body requirement related to inability to swallow
- Assess the nutritional requirement of the client
- Assess for the presence of paralytic ileus,if present initiate IV fluids and parenteral feedings should be initiated.Monitor for return of bowel sounds.
- If the patient cannot swallow due to bulbar paralysis,gastrostomy tube is placed to supply nutrients.
- Assess the gag reflex and bowel sounds before administering nutrients.
- Assess the communication level of the patient.
- Establish some forms of communication with picture cards or eye blink system
- Speech therapist should assist in verbal communication
Fear and anxiety related to loss of control and paralysis
- Assess the level of fear and anxiety of the patient as well as the family members.
- Provide psychological support to the patient as well as the family members.
- The family members should be allowed to participate in the physical acre of the patient.
- The patient and the family members should be educated regarding the progress of the disease condition as well as the treatment measurements and reinforcement has to be given.
- The positive attitude of the multidisciplinary team should be encouraging to the patient and the family members.
- Positive reinforcement should be given to the patient and the family members.
- Encourage visitors and friendsEncourage to divert the attention of the client by providing divertional therapy
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
- Thorough assessment of the respiratory function is needed because of the respiratory insufficiency and subsequent failure due to the paralysis of the intercoastal muscles and diaphragm.
- The respiratory rate ,vital capacity,and quality of respiration is monitored at regular intervalsSigns and symptoms of respiratory failure has to be assessed which includes breathlessness while speaking
- shallow and irregular respirationuse of accessory muscles,tachycardia and changes in respiratory pattern.
- Other complications like cardiac dysrrthymias requires ECG monitoring,also monitor for Orthostatic hypotension,DVT,pulmonary embolism,urinary retension etc..