Management of Guillain-Barré Syndrome

I. Definition

•    Guillain-Barré syndrome is an autoimmune attack on the peripheral nerve myelin. The result is acute, rapid segmental demyelination of peripheral nerves and some cranial nerves producing ascending weakness.

II. Risk Factors

•    Antecedent Viral infection (Haemophilus influenza, cytomegalovirus, Epstein-Barr virus)
•    Males between 16 and 25 years of age and between 45 and 60 years of age.
•    Autoimmune
•    Immunizations such as flu vaccine

III. Pathophysiology

•    Guillain-Barré syndrome is the result of a cell-mediated and humoral immune attack on peripheral nerve myelin proteins that causes inflammatory demyelination. With the autoimmune attack, there is an influx of macrophages and other immune-mediated agents that attack myelin, cause inflammation and leave the axon unable to support nerve conduction.

IV. Assessment/Clinical Manifestations/Signs and Symptoms

Autonomic changes
-Tachycardia, bradycardia, hypertension, or othostatic hypotension
-Increased sweating
-Increased salivation

•    Dyskinesia (inability to executive involuntary movements)
•    Weakness usually begins in the legs and progress upward (ascending paralysis)
•    Hyporeflexia (decreased DTRs)
•    Paresthesia (numbness), clumsiness
•    Blindness
•    Inability to swallow (dysphagia) or clear secretions
•    Alternate hypotension/hypertension; feared complication: arrhythmias

V. Medical Management

Guillain-Barré syndrome is a medical emergency, requiring management in an intensive care unit.

•    Respiratory therapy or mechanical ventilation may be necessary to support pulmonary function and adequate oxygenation.
•    Recommend elective intubation before the onset of extreme respiratory muscle fatigue.
•    Prevent complications of immobility. Use of anticoagulant agents and thigh-high elastic compression stockings or sequential compression boots to prevent thrombosis and pulmonary emboli.
•    Plasmapheresis
•    IVIG is currently the therapy of choice because it is associated with fewer side effects.
•    The cardiovascular risks posed by autonomic dysfunction require continuous electrocardiographic (ECG) monitoring.
•    Tachycardia and hypertension are treated with short-acting medications such as alpha-adrenergic blocking agents.
•    Hypotension is managed by increasing the amount of IV fluid administered.

VI. Nursing Diagnosis

•    Ineffective breathing pattern and impaired gas exchange related to rapidly progressive weakness and impending respiratory failure
•    Impaired bed and physical mobility related to paralysis
•    Imbalanced nutrition, less than body requirements, related to inability to swallow
•    Impaired verbal communication related to cranial nerve dysfunction
•    Fear and anxiety related to loss of control and paralysis

VII. Nursing Management

Maintaining respiratory function
•    Monitoring for change in vital capacity and negative inspiratory force are key to early intervention for neuromuscular respiratory failure.
•    The potential need for mechanical ventilation should be discussed with the patient and family on admission, to provide time for psychological preparation and decision-making.
•    Suctioning may be needed to maintain a clear airway.

Enhancing Physical mobility
•    Range-of-motion exercises, position changes, anticoagulation, the use of thigh-high elastic compression stocking or sequential compression boots, and adequate hydration decrease risk for DVT
•    Padding may be placed over bony prominences, such as the elbows and heels to reduce the risk for pressure ulcers. The need for consistent changes every 2 hours cannot be overemphasized.

Providing Adequate nutrition
•    Paralytic ileus may result from insufficient parasympathetic activity. In this event, the nurse administers IV fluids and parenteral nutrition as prescribed and monitors for the return of bowel sounds.
•    If patient cannot swallow due to bulbar paralysis (immobility of muscles), a gastrostomy tube may be placed to administer nutrients.
•    The nurse carefully assesses the return of the gag reflex and bowel sounds before resuming oral nutrition.

Improving communication
•    Because of paralysis, the patient cannot talk, laugh, or cry and therefore has no method for communicating needs or expressing emotion.
•    Establishing some form of communication with picture cards or an eye blink system provides a means of communication.
•    Collaboration with the speech therapist may be helpful in developing a communication mechanism that is most effective for specific patient.

Decreasing fear and anxiety
•    The family may feel helpless in caring for the patient. Mechanical ventilation and monitoring devices may frighten and intimidate them. Family members often want to participate in physical care; with instruction and support by the nurse, they should be allowed to do so.
•    The patient may experience isolation, loneliness and lack of control. Nursing interventions that increase the patient’s sense of control include providing information about the condition, emphasizing a positive appraisal of coping resources and teaching relaxation exercises and distraction techniques.
•    Encouraging visitors, engaging visitors or volunteers to read the patient, listening to music or books on tape, and watching television are ways to alleviate the patient’s sense of isolation.

Monitoring and Managing Potential complications
•    Respiratory rate and quality of respirations, vital capacity is monitored frequently at regular intervals, so that respiratory insufficiency can be anticipated.

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