Guillain-Barre Syndrome - Disturbed Sensory Perception

Disturbed Sensory Perception
related to:
changes in reception and transmission.

Goal /
Outcomes:
Reveals an awareness of deficits in sensory, mental or maintain general orientation and identify interventions to minimize damage / sensory complications.

Nursing Interventions:

Independent

1. Monitor neurological status on a periodic basis such as the ability to respond to simple commands and responds to pain stimulation.
R /: Development and reappearance of signs and symptoms may vary greatly. These developments are often quite quickly and possibly culminating in a few days / weeks. The healing process begins 2-4 weeks after the process ends and the progression of the disease and most slowly.

2. Provide a safe environment (bed barrier protection against thermal trauma).
R /: Loss of sensation and motor control patients make major concern of caregivers who must maintain a therapeutic environment and prevent trauma.

3. Provide an opportunity for resting on areas that are not susceptible to interference and provide other activities appropriate to the patient's ability boundaries.
R /: Reduce the excessive stimulus and can increase anxiety and minimize great coping skills.

4. Orient the patient returned to the environment as needed.
R /: Helps reduce anxiety and is particularly useful in case of visual impairment.

5. Provide appropriate sensory stimulation, encompass sound of soft music, television (news or a show).
R /: Patients feel isolated due to total paralysis and during the healing phase.

6. Suggest person closest to speak and give a touch of the patient and to maintain engagement with what is happening in the family.
R /: Helping people nearby, felt the mask on the patient's life (decrease feelings of helplessness / no expectations) and decrease patient anxiety during the breakup of the family.

Collaboration

7. Refer every related sources to aid speech therapy.
R /: Increases the healing process / minimize residual symptoms of neurological impairment.

8. Auxiliary perform plasmapheresis as needed.
R /: Handling the throw immunoglobulins, complement, vibrinogen and acute phase proteins that cause disease and respiratory depression in patients.

9. Provide medication as needed.

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Ineffective Breathing Pattern related to Guillain-Barre Syndrome

Nursing Care Plan for Guillain-Barre Syndrome

Nursing Diagnosis : Ineffective breathing pattern
related to:
weakness or paralysis of the respiratory muscles.

Goal / Outcomes:
Demonstrating adequate ventilation with no signs of respiratory distress, and effective breathing pattern.

Nursing Interventions:

Independent

1. Monitor the frequency, depth and symmetry of breathing. Note the increased work of breathing and skin color observations and mucous membranes.
R /: Increased respiratory distress indicate respiratory muscle fatigue and / or paralysis that may require support from mechanical ventilation.

2. Assess for changes in sensation, especially a decrease in the response.
R /: Decreased sensation often (though not always) lead to motor weakness.

3. Note the presence of respiratory fatigue during the talk if the patient is still able to speak.
R /: Is a good indicator of impaired respiratory function / decrease in lung capacity.

4. Auscultation of breath sounds, note the absence of sound or extra sound like crackles.
R /: The increase in airway resistance and accumulation of secretions or would interfere with the gas diffusion process and will lead to respiratory complications (such as pneumonia).

5. Elevate the head of your bed or put the patient in a sitting position leaning.
R /: Improving lung expansion and cough effort, decrease the work of breathing and limit the risk of aspiration of secretions.


Collaboration

6. Perform monitoring of blood gas analysis, pulse oximetry on a regular basis.
R /: Determine the effectiveness of the ventilation now and the need for / effectiveness of the intervention.

7. Perform to review the x-rays.
R /: The change is indicative of pulmonary congestion and or atelectasis.

8. Provide medication or help with the cleaning action of breathing, such as breathing exercises, chest percussion, fibrasi, and postural drainage.
R /: Improved ventilation and decrease atelectasis to mobilize secretions and improving lung expansion alveoili.

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Guillain-Barre Syndrome Care Plan Nursing

Definition of Guillain-Barre Syndrome

Guillain-Barre Syndrome is an autoimmune disease, in which the immunological process directly on the peripheral nervous system.

Guillain-Barre Syndrome (GBS) is an acute disorder of the nervous system, and diffuse the spinal roots and peripheral nerves and sometimes cranial nerve, which usually occurs after an infection.


Etiology of Guillain-Barre Syndrome

The etiology of Guillain-Barre Syndrome is still not yet known with certainty and is still a matter of debate. Scientists have theorized now is a disorder immunobiology, both in the primary immune response and immune-mediated process. Latent period between infection and symptoms polineuritis gives the notion that there is the possibility of a disorder caused by an allergic reaction in response to peripheral nerve. In many cases, the infection was not previously found, except sometimes the peripheral nerves and spinal ventral and dorsal fibers, there were also disturbances in the spinal cord and medulla oblongata.


Some state / diseases that precede and may have something to do with the occurrence of Guillain-Barre Syndrome, among others:

1. Viral or bacterial infection

Guillain-Barre Syndrome often associated with non-specific acute infection. The incidence of cases of Guillain-Barre syndrome associated with this infection approximately between 56% - 80%, ie 1 to 4 weeks before neurological symptoms arise such as upper respiratory infections or gastrointestinal infection. Acute infection associated with GBS:

a. Viruses: CMV, EBV, HIV, varicella-zoster virus, Vaccinia / smallpox, influenza, measles, mumps, rubella, hepatitis, Coxsackie, Echo.
b. Bacteria: Campylobacter, Jejeni, mycoplasma, Pneumonia, Typhoid, Borrelia B, paratyphoid, brucellosis, Chlamydia, Legionella, Listeria.

2. Vaccination.
3. Surgery, anesthesia.
4. Disease systematic, such as malignancy, systemic lupus erythematosus, thyroiditis, and Addison's disease.
5. Pregnancy or during childbirth.
6. Endocrine disorders.


Clinical Manifestations of Guillain-Barre Syndrome

1. The latent period

The time between infection occurs or circumstances preceding and current prodromal onset of neurological symptoms. The length of the latency period ranging from one to 28 days, an average of 9 days. At this latency period no clinical symptoms arise.

2. Symptoms Clinical

a. Paralysis
The main clinical manifestation is paralysis of the muscles of the lower extremity motor neurone type of limb muscles, body and face sometimes. In most patients, paralysis of both lower extremities begins later spread asenderen to the body, upper limbs and cranial nerves. Sometimes it can also be subject to the four limbs simultaneously, and then spreads to the body and cranial nerves. Paralysis of these muscles symmetrical and followed by hyporeflexia or areflexia. Usually the degree of paralysis of the muscles of the proximal portion of the distal portion is heavier, but it can also be as demanding, or more severe distal part of the proximal portion.

b. Impaired sensibility
Paresthesia is usually more pronounced in the distal extremities, face also may be subject to circumoral distribution. Objective sensory deficit is usually minimal and often with patterns of distribution such as socks and gloves. Exteroceptive sensibility is more commonly known than the proprioceptive sensibility. Muscle pain such as pain often encountered after a physical activity.

c. cranial nerves
Cranial nerves are most commonly known is N.VII. Paralysis of facial muscles often begin on one side but then soon became bilateral, so that the weight could be found between the two sides. All cranial nerves may be subject except N. I and N.VIII. Diplopia could occur from involvement N.IV or N.III. When exposed N.IX and N. X will cause a swallowing difficulty, dysphonia, and in severe cases cause respiratory failure due to paralysis of n. laryngeal.

d. Impaired autonomic function
Impaired autonomic function observed in 25% of patients with GBS. The disorder in the form of sinus tachycardia, sinus bradycardia, or more rarely, so red face (facial flushing), hypertension or hypotension fluctuating, episodic loss of sweating or profuse diaphoresis. Urinary retention or urinary incontinence are rare. This rare autonomic disorder that lasts more than one or two weeks.

e. Respiratory failure
Respiratory failure is a major complication that can be fatal if not treated properly. Respiratory failure is caused by paralysis of the diaphragm and the paralysis of the respiratory muscles, which is found in 10-33 percent of patients.

f. Papilledema
Sometimes encountered papilledema, the cause is not known with certainty. Allegedly due to elevation of the protein content in muscles that cause blockage of fluid arachoidales villi that absorption of cerebrospinal fluid is reduced.


Nursing Diagnosis for Guillain-Barre Syndrome

1. Ineffective breathing pattern
related to:
weakness or paralysis of the respiratory muscles.

2. Disturbed Sensory perception
related to:
changes in reception and transmission.

3. Ineffective Tissue perfusion
related to:
autonomic nervous system dysfunction that causes vascular buildup with decreased venous return.

4. Impaired physical mobility
related to:
neuromuscular damage.

5. Imbalanced Nutrition: less than body requirements
related to:
damage affecting neuromuscular reflex swallowing and GI function.

6. Anxiety
related to:
situational crisis.

7. Pain Acute / Chronic
related to:
neuromuscular damage (paresthesias, disestesia)

8. Knowledge Deficit
related to:
less remembering, cognitive limitations.

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