Nursing Diagnosis for Guillain-Barré Syndrome (GBS)
Guillain-Barré syndrome (GBS) |
Guillain-Barre
syndrome (GBS) or also known as acute inflammatory demyelinating
polyneuropathy (AIDP), acute idiopathic polyradiculoneuritis, acute
idiopathic polyneuritis, French Polio, Landry ascending paralysis, and
Landry Guillain Barre syndrome is an autoimmune disease that attacks the
peripheral nervous system; and is usually precipitated by an acute
infectious process. GBS belongs to the group of peripheral neuropathy
diseases.
GBS is spread throughout the world, especially in
developing countries and is the most common cause of acute paralysis.
Incidence is often found in young adults and may increase in the 45-64
year age group. More often found in men than women. A rather high peak
occurs in the 16-25 year age group, but may also develop in any age
group. About half of victims have mild febrile illness 2-3 weeks before
onset. Febrile infections are usually of respiratory or gastrointestinal
origin.
Guillain-Bare Syndrome (GBS) is a clinical syndrome
characterized by the acute onset of symptoms affecting the cranial
nerves. The disease process includes demyelination and degeneration of
the myelin sheath of peripheral and cranial nerves (Sylvia A. Price and
Lorraine M. Wilson, 1995). GBS is a clinical syndrome of unknown cause
involving peripheral and cranial nerves (Suzanne C. Smeltzer and Brenda
G. 2002).
Priguna Sidharta (1985) defines that GBS or idiopathic
types with the characteristics of the type of infection responsible
cannot be determined are usually known as upper respiratory tract
infections only or testinal gastrointestinal infections. Polyneuropathy
manifestations begin to appear 1-3 weeks after the patient recovers from
the primary disease. Examination of the cerebrospinal fluid revealed a
dissociation between the number of cells and protein.
Early
symptoms include: a feeling like pins and needles in the tips of the
toes or hands or numbness in that part of the body. Legs feel heavy and
stiff or hardened, arms feel weak and palms cannot grip tightly or turn
things properly (open locks, open cans, etc.). These early symptoms can
disappear within a few weeks, patients usually do not feel the need for
treatment or it is difficult to explain to the team of doctors to
request further treatment because the symptoms will disappear when
examined.
The primary goal of treating a client with GBS is to
provide maintenance of bodily system function, quickly overcoming
life-threatening crises. Prevent infection and complications of
immobility and provide psychological support for clients and families.
Nursing
assessment of clients with GBS includes a history of disease, physical
examination, diagnostic examination, and psychosocial assessment.
Assessment of GBS complications includes continuous monitoring of the
threat of acute life-threatening respiratory failure. Other
complications include cardiac dysrhythmias, which can be seen by
monitoring the ECG and observing the client for signs of deep vein
thrombosis and pulmonary embolism, which often threaten immobilization
and paralysis.
Possible nursing diagnoses are:
- Ineffective breathing pattern related to rapidly progressive weakness of respiratory muscles and threat of respiratory failure
- Risk for decreased cardiac output related to changes in heart rate, rhythm, and electrical conduction.
- Imbalanced Nutrition: Less Than Body Requirements related to the inability to chew and swallow food.
- Impaired physical mobility related to neuromuscular damage, decreased muscle strength, and decreased consciousness.
- Anxiety related to illness and poor prognosis.
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