Guillain Barre Syndrome (GBS) is a rare autoimmune disorder affecting the peripheral nervous system, causing rapid-onset muscle weakness and sometimes paralysis.
This condition requires immediate medical attention and comprehensive nursing care.
Causes (Related to)
Guillain Barre Syndrome can be triggered by various factors, including:
- Recent viral or bacterial infections
- Recent vaccination
- Surgery
- Trauma
- Pregnancy
- Hodgkin’s lymphoma
Signs and Symptoms (As evidenced by)
Patients with Guillain Barre Syndrome may present with the following signs and symptoms:
Subjective: (Patient reports)
- Muscle weakness or tingling sensations, usually starting in the legs and spreading to the arms and upper body.
- Pain, which can be severe, particularly at night
- Difficulty with eye or facial movements
- Problems with bladder control or digestive function
Objective: (Nurse assesses)
- Progressive symmetric muscle weakness
- Absent or diminished deep tendon reflexes
- Autonomic dysfunction (e.g., fluctuations in blood pressure, heart rate abnormalities)
- Respiratory difficulties
- Paralysis in severe cases
- Abnormal cerebrospinal fluid analysis showing elevated protein levels with normal cell counts
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for patients with Guillain Barre Syndrome:
- The patient will maintain adequate respiratory function
- The patient will demonstrate improved muscle strength and mobility
- The patient will report decreased pain levels
- The patient will maintain stable vital signs and autonomic function
- The patient will achieve optimal nutritional status
- The patient will not develop complications such as deep vein thrombosis or pressure ulcers
- The patient will demonstrate improved psychological well-being and coping skills
Nursing Assessment
- Perform a thorough neurological assessment
Monitor muscle strength, sensory function, and deep tendon reflexes. Grade muscle strength using the Medical Research Council (MRC) scale. - Assess respiratory function
Monitor respiratory rate, depth, and pattern. Assess for respiratory distress or failure signs, as GBS can affect the diaphragm and intercostal muscles. - Evaluate pain levels
A standardized pain scale assesses the patient’s pain intensity and characteristics. - Monitor vital signs
Pay close attention to blood pressure and heart rate, as autonomic dysfunction is common in GBS. - Assess for complications
Check for signs of deep vein thrombosis, pressure ulcers, and infections. - Evaluate psychological status
Assess for signs of anxiety, depression, or fear related to the diagnosis and potential paralysis. - Monitor nutritional status
Assess the patient’s ability to swallow and maintain adequate nutrition. - Perform bladder and bowel assessment.
Monitor for urinary retention or constipation, as GBS can affect these functions.
Nursing Interventions
Maintain respiratory function
- Monitor oxygen saturation and provide oxygen therapy as needed
- Assist with chest physiotherapy and deep breathing exercises
- Prepare for possible intubation and mechanical ventilation in severe cases
Promote mobility and prevent complications
- Implement a turning schedule to prevent pressure ulcers
- Assist with passive range of motion exercises to maintain joint flexibility
- Apply sequential compression devices to prevent deep vein thrombosis
- Manage pain
- Administer pain medications as prescribed
- Provide non-pharmacological pain relief methods such as positioning and relaxation techniques.
Support psychological well-being
- Provide emotional support and education about the condition
- Facilitate communication with family members and the healthcare team
- Refer to mental health professionals if needed
Ensure adequate nutrition
- Assist with feeding or coordinate with the dietitian for alternative feeding methods if necessary.
- Monitor fluid and electrolyte balance
- Manage autonomic dysfunction
- Monitor and report significant changes in vital signs
- Implement measures to prevent orthostatic hypotension
Provide education
- Teach the patient and family about GBS, its progression, and expected recovery process
- Instruct on proper care techniques and how to recognize complications
Nursing Care Plans
Here are five nursing care plans for patients with Guillain Barre Syndrome:
Care Plan 1: Risk for Ineffective Breathing Pattern
Nursing Diagnosis Statement: Risk for Ineffective Breathing Pattern related to neuromuscular weakness affecting respiratory muscles secondary to Guillain Barre Syndrome.
Related factors/causes:
- Neuromuscular impairment
- Respiratory muscle weakness
- Fatigue
Nursing Interventions and Rationales:
- Assess respiratory rate, depth, and pattern every 2-4 hours.
Rationale: Early detection of respiratory compromise allows for prompt intervention. - Monitor oxygen saturation continuously and provide oxygen therapy as needed.
Rationale: Ensures adequate oxygenation and prevents hypoxemia. - Position the patient in a semi-Fowler’s or high Fowler’s position.
Rationale: Promotes optimal lung expansion and eases respiratory effort. - Teach and assist with deep breathing and coughing exercises every 2 hours while awake.
Rationale: Helps maintain airway clearance and prevents atelectasis. - Prepare for possible intubation and mechanical ventilation.
Rationale: Severe cases of GBS may require ventilatory support.
Desired Outcomes:
- The patient will maintain oxygen saturation >92% on room air.
- The patient will demonstrate effective breathing patterns with a respiratory rate between 12-20 breaths per minute.
- The patient will report decreased work of breathing.
Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement: Impaired Physical Mobility related to progressive muscle weakness secondary to Guillain Barre Syndrome as evidenced by inability to perform activities of daily living independently.
Related factors/causes:
- Neuromuscular impairment
- Muscle weakness
- Pain
Nursing Interventions and Rationales:
- Assess muscle strength every shift using the Medical Research Council (MRC) scale.
Rationale: Provides objective measurement of muscle strength progression. - Implement a turning schedule every 2 hours.
Rationale: Prevents pressure ulcers and promotes circulation. - Perform passive range of motion exercises on all extremities every 4 hours while awake.
Rationale: Maintains joint flexibility and prevents contractures. - Assist with gradual mobilization as tolerated, progressing from bed mobility to sitting and standing.
Rationale: Promotes gradual return of muscle strength and prevents deconditioning. - Collaborate with physical and occupational therapists for a comprehensive rehabilitation plan.
Rationale: Ensures a multidisciplinary approach to mobility restoration.
Desired Outcomes:
- Patient will demonstrate improved muscle strength as evidenced by increasing MRC scores.
- Patient will participate in mobility exercises as tolerated.
- Patient will not develop complications related to immobility (e.g., pressure ulcers, contractures).
Care Plan 3: Acute Pain
Nursing Diagnosis Statement: Acute Pain related to nerve inflammation and muscle weakness secondary to Guillain Barre Syndrome as evidenced by the patient’s report of pain intensity 7/10 and grimacing.
Related factors/causes:
- Nerve inflammation
- Muscle weakness and spasms
- Immobility
Nursing Interventions and Rationales:
- Assess pain intensity, location, and characteristics every 4 hours and as needed using a standardized pain scale.
Rationale: Provides a baseline for pain management effectiveness. - Administer prescribed pain medications (e.g., gabapentin, pregabalin) as ordered.
Rationale: Pharmacological management is often necessary for neuropathic pain in GBS. - Implement non-pharmacological pain relief methods such as positioning, relaxation techniques, and distraction.
Rationale: Complements medication and provides additional pain relief. - Apply heat or cold therapy as tolerated and prescribed.
Rationale: It can provide localized pain relief and reduce muscle spasms. - Educate the patient on pain management strategies and the importance of reporting uncontrolled pain.
Rationale: Empower the patient to participate in pain management.
Desired Outcomes:
- The patient will report pain intensity reduced to 3/10 or less within 24 hours.
- The patient will demonstrate the use of non-pharmacological pain relief methods.
- The patient will verbalize understanding of pain management strategies.
Care Plan 4: Risk for Autonomic Dysreflexia
Nursing Diagnosis Statement: Risk for Autonomic Dysreflexia related to autonomic nervous system involvement secondary to Guillain Barre Syndrome.
Related factors/causes:
- Autonomic nervous system dysfunction
- Sensory and motor impairment
- Bladder or bowel distension
Nursing Interventions and Rationales:
- Monitor vital signs, particularly blood pressure and heart rate, every 2-4 hours.
Rationale: Allows early detection of autonomic instability. - Implement measures to prevent orthostatic hypotension (e.g., slow position changes, compression stockings).
Rationale: Reduces the risk of sudden blood pressure drops and associated symptoms. - Assess for bladder distension and implement a bladder management program.
Rationale: Prevents urinary retention, which can trigger autonomic dysreflexia. - Monitor bowel function and implement a bowel management program.
Rationale: Prevents constipation, which can trigger autonomic dysreflexia. - Educate the patient and family about the signs and symptoms of autonomic dysreflexia.
Rationale: Promotes early recognition and prompt reporting of symptoms.
Desired Outcomes:
- The patient will maintain stable vital signs within normal limits.
- The patient will not experience episodes of autonomic dysreflexia.
- The patient will demonstrate proper techniques for position changes to prevent orthostatic hypotension.
Care Plan 5: Anxiety
Nursing Diagnosis Statement: Anxiety related to uncertainty of prognosis and fear of paralysis secondary to Guillain Barre Syndrome as evidenced by expressed worry, restlessness, and increased heart rate.
Related factors/causes:
- Uncertainty about disease progression and recovery
- Fear of paralysis or long-term disability
- Hospitalization and an unfamiliar environment
Nursing Interventions and Rationales:
- Assess anxiety levels using a standardized anxiety scale every shift.
Rationale: Provides objective measurement of anxiety and effectiveness of interventions. - Provide clear, honest information about GBS, its progression, and the expected recovery process.
Rationale: Knowledge can help reduce fear of the unknown and promote coping. - Teach and assist with relaxation techniques such as deep breathing, guided imagery, or progressive muscle relaxation.
Rationale: Helps reduce anxiety and promotes a sense of control. - Encourage expression of feelings and concerns.
Rationale: Allows for emotional ventilation and identification of specific anxiety triggers. - Facilitate communication with family members and arrange for psychological support or counseling if needed.
Rationale: Social support and professional help can significantly reduce anxiety.
Desired Outcomes:
- The patient will report decreased anxiety levels within 48 hours.
- The patient will demonstrate the use of at least one relaxation technique.
- The patient will verbalize understanding of the disease process and expected recovery trajectory.
References
- Dimachkie, M. M., & Barohn, R. J. (2013). Guillain-Barré syndrome and variants. Neurologic Clinics, 31(2), 491-510. https://doi.org/10.1016/j.ncl.2013.01.005
- Hughes, R. A., Swan, A. V., & van Doorn, P. A. (2014). Intravenous immunoglobulin for Guillain-Barré syndrome. Cochrane Database of Systematic Reviews, (9). https://doi.org/10.1002/14651858.CD002063.pub6
- Willison, H. J., Jacobs, B. C., & van Doorn, P. A. (2016). Guillain-Barré syndrome. The Lancet, 388(10045), 717-727. https://doi.org/10.1016/S0140-6736(16)00339-1
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme.
- Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. (Eds.). (2018). Nursing Interventions Classification (NIC). Elsevier Health Sciences.
- Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2018). Nursing Outcomes Classification (NOC): Measurement of Health Outcomes. Elsevier Health Sciences.
- National Institute of Neurological Disorders and Stroke. (2021). Guillain-Barré Syndrome Fact Sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Guillain-Barr%C3%A9-Syndrome-Fact-Sheet
- GBS/CIDP Foundation International. (2021). Guillain-Barré Syndrome (GBS). https://www.gbs-cidp.org/gbs/
