Guillain-Barre Syndrome Nursing Diagnosis

Last updated on January 27th, 2024 at 11:19 am

Guillain-Barré Syndrome (GBS) is a rare neurological disorder characterized by rapid-onset muscle weakness due to damage to the peripheral nervous system.

This complex and unpredictable disease presents a challenge to healthcare professionals, particularly in identifying and managing the different symptoms and complications that may arise.

The pathophysiology of GBS involves an autoimmune response that attacks the peripheral nerves, resulting in varying degrees of muscle paralysis and sensory disturbances.

This can lead to difficulty breathing, swallowing, and coordinating movements, as well as complications such as deep vein thrombosis and infections. Accurate nursing assessment is crucial in identifying the unique needs and potential complications experienced by each GBS patient, which in turn informs appropriate nursing interventions and management strategies.

Nursing diagnoses for GBS patients may include impaired mobility, impaired gas exchange, risk for infection, and pain, among others. These diagnoses require tailored interventions that address the specific needs and challenges faced by affected individuals.

To ensure optimal care, it is essential for nurses to remain up-to-date with evolving knowledge and evidence-based practices regarding GBS treatment and care.

Overview of Guillain Barre Syndrome

Causes

Guillain-Barre Syndrome (GBS) is a rare neurological disorder affecting the peripheral nerves. The exact cause of GBS is not completely understood, but it is often triggered by an infection—such as a respiratory or gastrointestinal illness.

The immune system mistakenly attacks the peripheral nerves, causing inflammation and damage to the myelin sheath, which insulates and protects nerve fibers (called axons). This disrupts the normal functioning of peripheral nerves, leading to the symptoms associated with GBS.

Symptoms

The most common and significant symptom of Guillain-Barre Syndrome is symmetric muscle weakness, which typically begins in the lower extremities and progresses upward through the body. The weakness can vary from mild difficulty walking to complete paralysis. Other symptoms may include:

Decreased or loss of reflexes
Numbness or tingling in the affected muscles
Pain, which can range from mild muscle aches to severe, sharp pain
Fatigue or difficulty breathing, if the muscles involved in respiration are affected

The progression of symptoms is typically rapid, with the greatest weakness occurring within the first two weeks following the onset of symptoms.

Types

There are several types of Guillain-Barre Syndrome, which are classified based on the specific nerves and parts of the nervous system affected. The main types include:

Acute Inflammatory Demyelinating Polyneuropathy (AIDP): This is the most common type of GBS in which the immune system attacks the myelin of the peripheral nerves.
Axonal Guillain-Barre Syndrome: In this type, the axons of the peripheral nerves are directly affected, rather than the myelin. Axonal GBS is further divided into two subtypes: Acute Motor Axonal Neuropathy (AMAN) and Acute Motor Sensory Axonal Neuropathy (AMSAN).
Miller Fisher Syndrome (MFS): A rare variant of GBS, MFS affects the nerves of the eyes and facial muscles, often leading to difficulty with eye movement and facial weakness.

Proper nursing diagnosis and intervention for Guillain-Barre Syndrome are crucial in managing and treating this condition. Understanding the causes, symptoms, and types of GBS allows healthcare professionals to provide the most appropriate care to patients affected by this disorder.

Diagnosis and Assessment

Diagnostic Criteria

Guillain-Barré Syndrome (GBS) is a clinical diagnosis, meaning that its identification is primarily based on the patient’s symptoms and medical history rather than specific test results.

Healthcare providers will look for signs of progressive, symmetrical limb weakness, reduced or absent deep tendon reflexes, and sensory disturbances.

These symptoms usually develop over a few days to weeks. Although there is no single diagnostic test for GBS, other evaluations are performed to confirm the diagnosis and exclude other possible causes.

Tests and Evaluation

Several tests can help support the diagnosis of Guillain-Barré Syndrome and assess its severity. These tests may include:

Electromyography (EMG): EMG measures the electrical activity of muscles and can detect abnormalities in nerve and muscle function, revealing evidence of demyelination or axonal damage.
Nerve conduction studies (NCS): NCS measure the speed at which electrical signals travel along a nerve and can identify slowing or blocking of nerve signals due to demyelination.
Spinal tap (lumbar puncture): A spinal tap involves extracting cerebrospinal fluid (CSF) from the spinal canal for analysis. In GBS patients, CSF often shows elevated protein levels without an increase in white blood cells, a characteristic pattern known as albuminocytologic dissociation.

Differential Diagnosis

One of the challenges in diagnosing GBS is distinguishing it from other conditions that cause similar symptoms. Differential diagnoses may include:

Acute flaccid paralysis (AFP): AFP is a sudden onset of limb weakness, which can be due to numerous causes, including viral infections, spinal cord injury, or toxins. Distinguishing GBS from AFP typically involves evaluating the pattern and progression of symptoms, as well as conducting the aforementioned tests.
Inflammatory demyelinating polyradiculoneuropathy (CIDP): CIDP is another neurological disorder that affects the peripheral nerves, causing weakness and sensory loss. However, CIDP usually develops more gradually than GBS and is often characterized by relapsing and remitting symptoms.

These differential diagnoses and others must be carefully considered to ensure accurate identification and management of Guillain-Barré Syndrome. A thorough clinical assessment, including history-taking and a comprehensive physical examination, is crucial in guiding healthcare providers toward the correct diagnosis and treatment plan for each individual patient.

Causes and Risk Factors

Antecedent Illnesses

Guillain-Barré Syndrome (GBS) has been associated with various antecedent illnesses, including viral and bacterial infections. Some common viral infections linked to GBS are Zika virus, influenza, cytomegalovirus, and HIV. In many cases, these infections may trigger an immune response that leads to GBS.

Similarly, bacterial infections such as Campylobacter jejuni and Mycoplasma pneumoniae have also been implicated in the development of GBS.

Infections and Vaccines

In some instances, GBS has been reported following vaccinations, particularly the influenza vaccine. However, the overall risk of developing GBS after vaccination is low, and the benefits of receiving vaccines often outweigh this risk.

The mechanism linking vaccinations and GBS is not well understood, but it is thought to involve a process known as molecular mimicry, in which the immune system mistakenly targets nerve cells instead of the pathogens present in the vaccine.

Other Factors

Aside from infections and vaccines, GBS has also been linked to other factors such as physical trauma and surgery. Although the exact connection between these factors and GBS is not fully understood, it is believed that these events may trigger an immune response, leading to the development of GBS.

In summary, GBS is a complex disease with various causes and risk factors, including antecedent illnesses, infections, vaccines, and other factors such as physical trauma or surgery.

Understanding these factors can help medical professionals better evaluate and manage patients with GBS, assisting in prompt diagnosis and appropriate treatment.

Nursing Management

Respiratory Care

In managing Guillain-Barré Syndrome (GBS), one of the primary concerns is respiratory failure. Nurses play a vital role in monitoring the patient’s respiratory status and implementing appropriate interventions.

This may include frequent assessment of the patient’s respiratory rate, effort, and oxygen saturation levels. Interventions such as administering supplemental oxygen, suctioning, and positioning the patient to promote optimal lung expansion can be beneficial.

Additionally, collaborating with the healthcare team for potential mechanical ventilation may be necessary in severe cases of respiratory compromise.

GBS patients may experience varying degrees of immobility due to muscle weakness, necessitating nursing interventions to prevent complications. Turning and repositioning the patient every two hours can help in preventing pressure ulcers.

Nurses should also provide assistance with passive and active range-of-motion exercises to maintain joint mobility and muscle strength. Collaborating with physical and occupational therapists is vital in developing an appropriate plan for the patient’s mobilization.

Pain Management

Pain management is crucial for GBS patients as they often experience neuropathic pain. Nurses should regularly assess patients for pain using a numerical or descriptive pain scale. Analgesics such as acetaminophen, NSAIDs, or opioids may be prescribed depending on the severity of pain.

Nonpharmacological interventions, like relaxation techniques and guided imagery, can be implemented alongside pharmacological treatments, providing a comprehensive approach to pain management 3.

Psychological Support

Anxiety, depression, and fear are common in patients diagnosed with GBS due to the sudden onset of symptoms and uncertain prognosis. Nurses play a significant role in providing emotional support and addressing the psychological needs of patients and their families.

Active listening, providing information regarding the patient’s condition, and addressing concerns can offer reassurance and ease anxiety. Involving mental health professionals, like psychologists or psychiatric nurses, may also be beneficial for patients who require further assistance with coping strategies 4.

Treatment Options

Medical Treatments

Several medical treatments are available for Guillain-Barré syndrome patients, with the goal of reducing the severity and duration of the illness. One common treatment is plasma exchange (also known as plasmapheresis), which involves removing harmful antibodies from the blood.

This process can help reduce the immune system’s attack on the peripheral nerves and the myelin sheath, allowing for faster recovery of affected axons.

Another common treatment option is intravenous immunoglobulin therapy (IVIg). IVIg involves administering high doses of immunoglobulin proteins derived from donated blood, which help neutralize harmful antibodies in the patient’s blood.

This treatment has been found to be as effective as plasma exchange in improving the symptoms of Guillain-Barré syndrome.

In addition to these specific treatments, patients may require other medications to manage symptoms and complications such as blood pressure issues and pain management. Neurologists, who specialize in disorders affecting the nervous system, frequently oversee these treatments during hospitalization.

Physical Therapy and Rehabilitation

Physical therapy and rehabilitation are crucial components of the recovery process for Guillain-Barré syndrome patients. As the patient regains their strength and function, physical therapists help develop individualized exercise programs tailored to the patient’s abilities and goals.

Rehabilitation includes:

Gentle stretching and range-of-motion exercises to maintain muscle flexibility and prevent joint stiffness
Gradual muscle strengthening exercises to improve muscle function and reduce muscle atrophy
Balance and coordination exercises to enhance stability and mobility
Endurance training to improve overall stamina

Physical therapists may also provide education on the use of adaptive equipment and strategies to facilitate daily living activities, such as walking, dressing, and bathing. During the rehabilitation phase, a multidisciplinary team typically works together to support the patient’s recovery process, including nurses, occupational therapists, and speech therapists.

Complications and Prognosis

Common Complications

Guillain-Barré Syndrome (GBS) is an autoimmune disease that often develops following a viral infection, such as hepatitis. The complications of GBS can range from mild to severe and may involve various body systems. Some of the most common complications include:

Respiratory function: Many patients with GBS experience difficulty with breathing due to weakness or paralysis of the diaphragm and intercostal muscles. This can lead to respiratory failure, requiring mechanical ventilation.
Cranial nerve involvement: GBS may affect cranial nerves, leading to difficulty with speaking, swallowing, chewing, and vision.
Infections: Patients with GBS are at an increased risk for infections, particularly during the acute phase of the illness. Pneumonia and urinary tract infections are common, often resulting from impaired respiratory function and urinary retention.
Constipation and urinary retention: Autonomic dysfunction in GBS can cause difficulties with bowel and bladder control.
Areflexia: Loss of deep tendon reflexes is a common feature of GBS and can contribute to the overall morbidity and increased risk of injury.

Long-Term Outcomes

The prognosis for patients with GBS varies significantly, with most people experiencing a monophasic course and eventual recovery. However, the time to reach full recovery differs between individuals and can take several months to years. Factors that may influence the long-term outcomes include:

Nadir: The severity of GBS at its worst point, or nadir, can impact the overall prognosis. Patients with a more severe nadir may have a longer and more challenging recovery.
Age: Older patients may experience a slower recovery and are at a higher risk for complications.
Treatment: Early intervention with immunotherapy, such as intravenous immunoglobulin or plasma exchange, can contribute to a better prognosis by reducing the severity and duration of the symptoms[^4^].
Rehabilitation: Active participation in a comprehensive physical and occupational therapy program can help optimize long-term recovery and functional outcomes.

Although most individuals with GBS will eventually recover, some may experience persistent weakness, pain, or sensory disturbances. In rare cases, GBS can lead to significant long-term disability and increased mortality.

Guillain Barré Syndrome Nursing Care Plan

Nursing Diagnoses for Guillain Barré Syndrome

Impaired physical mobility related to muscle weakness and paralysis secondary to Guillain-Barre Syndrome (GBS)
Ineffective breathing pattern related to respiratory muscle weakness caused by Guillain-Barre Syndrome (GBS)
Risk for impaired skin integrity related to immobility and sensory deficits associated with Guillain-Barre Syndrome (GBS)

Expected Outcomes

The patient will demonstrate improved muscle strength and coordination.
The patient will independently perform activities of daily living (ADLs) with minimal assistance.
The patient will achieve safe and functional mobility within the limitations imposed by GBS.
The patient will exhibit improved range of motion in affected muscles.
The patient will maintain a patent airway with clear breath sounds.
The patient will demonstrate effective breathing patterns, with oxygen saturation within the desired range.
The patient will demonstrate adequate ventilation and oxygenation, as evidenced by improved arterial blood gas values.
The patient will be able to effectively use respiratory assistive devices if needed.
The patient will maintain intact skin without the development of pressure ulcers or breakdown.
The patient’s skin will remain free from signs of redness, swelling, or irritation.

Nursing Interventions and Rationales

Collaborate with the physical therapy team to develop a tailored exercise program: This intervention helps improve muscle strength and coordination, promoting mobility and independence.
Assist the patient with range of motion (ROM) exercises: Regular ROM exercises help maintain joint flexibility, prevent contractures, and improve circulation.
Implement safety measures to prevent falls: This includes keeping the environment free from hazards, using assistive devices (e.g., walker, cane), and providing supervision during ambulation.
Educate the patient and caregivers on proper body mechanics and transfer techniques: This knowledge promotes safe movement and minimizes the risk of injury to the patient and caregivers.
Monitor respiratory status closely: Regular assessments of respiratory rate, depth, and breath sounds help detect any deterioration or changes in breathing pattern.
Position the patient in an optimal position for breathing: Elevating the head of the bed or using pillows to prop up the patient can facilitate easier breathing.
Assess the patient’s pain intensity and characteristics: Use pain scales and verbal reports to evaluate the pain experience and tailor interventions accordingly.

Frequently Asked Questions

Priority nursing diagnosis?

The priority nursing diagnosis for patients with Guillain-Barre Syndrome (GBS) often focuses on addressing problems related to mobility and respiratory issues. One of the main concerns is “Impaired Physical Mobility” due to the muscle weakness and paralysis associated with the condition 1.

Key nursing interventions?

Nursing interventions for GBS patients vary depending on the severity of the condition. However, some key interventions include monitoring and managing respiratory status, providing adequate nutritional support, preventing complications related to immobility, and addressing pain management needs 2.

Risk factors?

Risk factors for developing Guillain-Barre Syndrome include recent viral or bacterial infections, vaccinations, surgery, and a history of autoimmune disorders. Additionally, GBS seems to affect more men than women and occurs more frequently in older adults.

Treatment options?

The primary treatment options for GBS include intravenous immunoglobulin (IVIG) and corticosteroids.

These therapies aim to reduce the severity and duration of symptoms while minimizing potential complications. In some cases, plasmapheresis may also be recommended to help filter antibodies from the blood.

Patient education needs?

It is essential to educate GBS patients about their condition, the importance of adhering to prescribed treatments, and the possible complications. Patients should also be informed of potential long-term effects and the need for ongoing rehabilitation and therapy.

Discharge teaching tips?

When preparing a patient with GBS for discharge, it is important to provide guidance on maintaining a safe home environment, managing daily activities, and recognizing signs of potential complications.

Additionally, patients should be encouraged to participate in support groups and maintain contact with healthcare professionals for follow-up care and rehabilitation 6.

References

Best Nursing Books and Resources

These are the nursing books and resources that we recommend.

NurseStudy.net is a participant in the Amazon Services LLC Associates Program. Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. Please see our Privacy Policy

The Nursing Diagnosis Handbook E-Book: An Evidence-Based Guide to Planning Care

This is an excellent reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnoses, it also helps guide the nurse to match the nursing diagnosis to the patient assessment and diagnosis.

This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.

NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023

All introductory chapters in this updated version of a ground-breaking text have been completely rewritten to give nurses the knowledge they require to appreciate assessment, its relationship to diagnosis and clinical reasoning, and the goal and use of taxonomic organization at the bedside.

Nursing Care Plans: Nursing Diagnosis and Intervention

It contains more than 200 care plans that adhere to the newest evidence-based recommendations.

Additionally, it distinguishes between nursing and collaborative approaches and highlights QSEN competencies.

Disclaimer

Please follow your facility’s guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.