Guillain-Barre Syndrome is a problem with nervous system. It is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. It causes muscle weakness, loss of reflexes, and numbness or tingling in your arms, legs, face, and other parts of your body. Exactly what triggers Guillain-Barre syndrome is unknown. The syndrome may occur at any age, but is most common in people of both sexes between ages 30 and 50.
Guillain-Barre syndrome may occur along with viral infections such as:
- AIDS
- Herpes simplex
- Mononucleosis
Symptoms of GBS include:
- Numbness or tingling in your hands and feet and sometimes around the mouth and lips.
- Muscle weakness in legs and arms and the sides of your face.
- Trouble speaking, chewing, and swallowing.
- Not being able to move your eyes.
- Back pain.
Emergency symptoms :
- Breathing temporarily stops
- Can't take a deep breath
- Difficulty breathing
- Difficulty swallowing
- Drooling
- Fainting
- Feeling light-headed when standing
Symptoms usually start with numbness or tingling in the fingers and toes. Over several days, muscle weakness in the legs and arms develops. After about 4 weeks, most people begin to get better.
10 Nursing Diagnosis for Guillain-Barre Syndrome
1. Ineffective Breathing Pattern, Ineffective Airway Clearance, Impaired Gas Exchange related to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization.
Characterized by:
Subjective Data:
- The patient said it was hard to breathe.
- Families of patients said that patients experienced loss of consciousness.
Objective Data:
- Patients seen trouble breathing.
- Decreased breath sounds.
- Changes in the value of blood gas analysis.
- Changes in skin color (pale)
- Loss of consciousness.
- Changes in respiratory rate, shortness of breath.
- Accumulation of secretions.
2. Impaired Physical Mobility related to paralysis, ataxia.
Characterized by:
Subjective Data:
- Patients say weakness and paresthesia.
Objective Data:
- The inability to perform the activity.
- Muscle weakness spreads upward.
- Decreased muscle strength.
- Atrophy.
- Sensory loss.
- The loss of tendon reflexes.
3. Risk for Impaired Skin Integrity: pressure sores related to muscle weakness, paralysis, impaired sensation, changes in nutrition, incontinence.
Characterized by:
Subjective Data:
- Patients say weakness and paresthesia.
Objective Data:
- The inability to perform the activity.
- Muscle weakness spreads upward.
- Decreased muscle strength.
- Atrophy.
- Sensory loss.
- The loss of tendon reflexes.
- Changes in nutrition.
- Incontinence.
4. Imbalanced Nutrition, Less Than Body Requirements related to difficulty chewing, swallowing, fatigue, limb paralysis.
Characterized by:
Subjective Data:
- The patient stated, can not chew and swallow.
- Patients say, the hand can not be moved.
Objective Data:
- The inability to perform the activity.
- Patients using the NGT.
- Diet food, nutritional value.
- Weight loss.
- Albumin and hemoglobin values.
- Signs of malnutrition.
- The presence of nausea.
- Intake of the food intake is not in proportion.
5. Impaired Elimination: constipation, diarrhea, related to inadequate food intake, immobilization.
Characterized by:
Subjective Data:
- Patients said they could not defecate or diarrhea.
Objective Data:
- The inability to perform activities / lack of mobilization.
- Muscle weakness spreads upward.
- Decreased muscle strength.
- The pattern of bowel movements in the house.
- Increased or decreased bowel sounds.
- Low-fiber diet.
- Hard or liquid stool.
6. Impaired Verbal Communication related to the VII cranial nerve paralysis, tracheostomy.
Characterized by:
Subjective Data:
- Families of patients said that patients have problems in speaking.
Objective Data:
- Difficulties in communication.
- The use of sign language.
- Facial nerve paralysis.
- The existence of tracheostomy.
7. Ineffective Coping related to the patient's disease state.
Subjective Data:
- Families of patients said that patients have difficulty sleeping.
Objective Data:
- Apathy.
- Sensitive.
- withdraw
8. Knowledge Deficit: patients / families related to disease, treatment, prognosis and treatment.
Characterized by:
Subjective Data:
- Patient / family said they did not know the disease.
Objective Data:
- Patient / family was not cooperative in patient care.
- Patient / family inquire about his illness.
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