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GBS – Guillain Barre Syndrome – complications, management

Complications

Autonomic Dysfunction

  • Monitoring of autonomic cardiac responses is required so that tachycardia and arrhythmias can be detected early and treatment instituted as necessary.
  • If paralytic ileus occurs, a nasogastric tube is inserted for gastric decompression.
  • An intermittent catheterization program is instituted to relieve urinary retention.
  • Fluid and electrolytes are monitored for imbalance cause by SIADH.

Sleep Dysfunction

  • A disturbed sleep – wakefulness cycle leads to sleep deprivation. The basis for this problem is unclear, but it contributes to the physiologic stress experienced by the patients.

Pain

  • The pain appears to be worse at night.
  • Administering narcotics with a slow IV drip has yielded good results.

Nutrition

  • Patient rapidly loses weight and muscle mass, leading to weakness, fatigue and failure to wean from the ventilator.
  • Nutritional support is aimed at beginning feeding as soon is appropriate for the patients.

Immobility

  • Minidose of heparin are administered to prevent deep vein thrombosis and pulmonary emboli.
  • The use of compression bandage is controversial, because the boot themselves may apply pressure to the sensitive demyelinated peripheral nerves of the leg, leading to palsies.

MANAGEMENT

1 Supportive Care

ICU monitoring: Because of the possibility of rapid progression and neuromuscular respiratory failure, Guillain-Barre syndrome is a medical emergency, requiring intensive care unit management. Careful assessment of changes in motor weakness and respiratory function is needed.

2 Ventilatory Support

Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation. Mechanical ventilation may be required for an extended period. The patient is weaned from mechanical ventilation when the respiratory muscles can again support spontaneous respiration and maintain adequate tissue oxygenation.

Mechanical ventilation usually required if VC (vital capacity)drops below about 14 ml/kg; ultimate risk depending on age, presence of accompanying lung disease, aspiration risk, and assessment of respiratory muscle fatigue.

Tracheostomy may be needed in patients intubated for 2 weeks who do not show improvement.

3 Autonomic dysfunction

Sustained hypertension managed by angiotensin-converting enzyme inhibitor or beta blocking agent. Use short acting intravenous medication for labile hypertension requiring immediate therapy.

Postural hypotension treated with fluid bolus or positioning.

Urinary difficulties may require intermittent catheterization.

4 Nutritional support

Nasogastric tube needed in patients who are intubated or have significant oropharyngeal weakness.

Hyperalimentation may be necessary in patients with ileus.

5 Immune therapy

Plasma exchange (PE) demonstrated to be beneficial if instituted within two weeks of illness. Improvement may occur in mild GBS with as few as 2 exchanges, but most require a minimum of 4 exchanges performed on alternate days.

Intravenous immunoglobulin (IVIg)

When compared to PE, IVIg shown to be as efficacious as PE and with few adverse effects (Sandoglobulin).

Nursing management

Nursing management in the acute phase of GBS includes a comprehensive baseline neurological and respiratory assessment and ongoing monitoring for early recognition of change.

Nursing Assessment

  • Assess pain level due to muscle spasms and dysthesias.
  • Assess cardiac function including orthostatic Blood Pressure.
  • Assess respiratory status closely to determine hypoventilation due to weakness.
  • Perform cranial nerve assessment, especially ninth cranial nerve for gag reflex.
  • Assess motor strength.

Nursing Diagnosis

  1. Ineffective Breathing Pattern related to weakness/paralysis of respiratory muscles
  2. Impaired Physical Mobility related to paralysis
  3. Imbalanced Nutrition: Less Than Body Requirements, related to cranial nerve dysfunction
  4. Impaired Verbal Communication related to intubation, cranial nerve dysfunction
  5. Chronic Pain related to disease pathology
  6. Anxiety related to communication difficulties and deteriorating physical condition

Nursing Interventions

  1. Ineffective Breathing Pattern related to weakness/paralysis of respiratory muscles

Goal: To maintain an effective breathing pattern.

  • Monitor respiratory status through vital capacity measurements, rate and depth of respirations, breath sounds.
  • Monitor level of weakness as it ascends toward respiratory muscles.
  • Watch for breathlessness while talking, a sign of respiratory fatigue.
  • Maintain calm environment, and position patient with head of bed elevated to provide for maximum chest excursion.
  • As much as possible, avoid opioids and sedatives that may depress respirations.
  • Monitor the patient for signs of impending respiratory failure; heart rate above 120 or below 70 beats/minute; respiratory rate above 30 breaths/minute; prepare to intubate.

 

  1. Impaired Physical Mobility related to paralysis

Goal: To avoid Complications of Immobility

  • Position patient correctly, and provide ROM exercises.
  • Encourage physical and occupational therapy exercises to regain strength during the rehabilitative period.
  • Assess for complications, such as contractures, pressure ulcers, edema of lower extremities, and constipation.
  • Provide assistive devices as needed, such as cane or wheelchair, for patient to take home as tolerated.
  • Recommend referral to rehabilitation services or physical therapy for evaluation and treatment.

 

  1. Imbalanced Nutrition: Less Than Body Requirements, related to cranial nerve dysfunction

Goal: To promote Adequate Nutrition

  • Auscultate for bowel sounds; hold enteral feedings if bowel sounds are absent to prevent gastric distention.
  • Assess chewing and swallowing ability by testing Cranial Nerve V and IX; if function is inadequate, provide alternate feeding.
  • During rehabilitation period, encourage a well-balanced, nutritious diet in small, frequent feedings with vitamin supplements if indicated.
  • Recommend referral to dietitian for evaluation and proper diet therapy.

 

  1. Impaired Verbal Communication related to intubation, cranial nerve dysfunction

Goal: To maintain Communication

  • Develop a communication system with patient who cannot speak.
  • Have frequent contact with patient, and provide explanation and reassurance, remembering that patient is fully conscious.
  • Provide some type of patient call system. Because standard call lights cannot be activated by the severely weak GBS patient, provide adaptive call light and/or some type of constant monitoring and surveillance to meet patient’s needs.
  • Recommend referral to speech therapy for evaluation and treatment.
  • Refer to counselor, social workers, or psychologist to develop/enhance coping skills and regain sense of control.

 

  1. Chronic Pain related to disease pathology

Goal: To relieve Pain

  • Administer analgesics as required; monitor for adverse reactions, such as hypotension, nausea and vomiting, and respiratory depression.
  • Provide adjunct pain management therapies, such as therapeutic touch, massage, diversion, guided imagery.
  • Provide explanations to relieve anxiety, which augments pain.
  • Turn the patient frequently to relieve painful pressure areas.

 

  1. Anxiety related to communication difficulties and deteriorating physical condition

Goal: To reduce Anxiety

  • Get to know the patient, and build a trusting relationship.
  • Discuss fears and concerns while verbal communication is possible.
  • Reassure patient that recovery is probable.
  • Use relaxation techniques such as listening to soft music.
  • Provide choices in care, and give patient a sense of control.
  • Enlist the support of significant others.

PATIENT EDUCATION

  • Advise patient and family that acute phase lasts 1 to 4 weeks, then patient stabilizes and rehabilitation can begin; however, convalescence may be lengthy, from 3 months to 2 years.
  • Instruct patient in breathing exercises or use of incentive spirometer to reestablish normal patterns.
  • Teach patient to wear good supportive and protective shoes while out of bed to prevent injuries due to weakness and paresthesia.
  • Instruct patient to check feet routinely for injuries because trauma may go unnoticed due to sensory changes.
  • Reinforce maintenance of normal weight; additional weight will further stress the motor abilities.
  • Encourage the use of scheduled rest periods to avoid over-fatigue.

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