Guillain-Barré Syndrome HESI Case Study
The nurse asks Amid
"How can the healthcare team best support your Muslim faith while you are in the hospital?"
The nurse includes the nursing diagnosis
"Impaired physical mobility related to paralysis" in the plan of care.
4. Which intervention should the nurse implement post-procedure? a. Keep Amid in a side-lying position. b. Apply pressure to the puncture site. c. Assess Amid's brachial pulses. d. Increase Amid's fluid intake.
"Increase Amid's fluid intake." Increased fluid intake helps prevent a post-procedure headache which may occur after a lumbar puncture.
15. List the order of interventions the nurse should implement. (Place in numerical order from first action through last action.) Notify the respiratory therapist. Ventilate with a manual resuscitation bag. Request stat arterial blood gases. Auscultate the client's lung sounds.
1. Ventilate with a manual resuscitation bag. 2. Notify the respiratory therapist. 3. Request stat arterial blood gases. 4. Auscultate the client's lung sounds.
After Amid quits fighting the ventilator
Amid's brother asks the nurse, "How will you communicate with my brother?"
A communication system must be established with the use of the client's available abilities. This is extremely difficult if the disease progresses to involvement of the critical nerves.
At the peak of a severe episode the client may be incapable of communicating. The nurse must explain all procedures before doing them and reassure the client that muscle function will return.
Diagnostic Test: Lumbar Puncture
Diagnosis is based primarily on the client's history and clinical signs. Cerebrospinal fluid (CSF) is normal or has a low protein content initially, but after 7 to 10 days it shows an elevated protein level to 700 mg/dl (7 g/L) (normal protein is 15 to 45 mg/dl [0.15 to 0.45 g/L]) with a normal cell count. The healthcare provider schedules Amid for a lumbar puncture for a (CSF) analysis to confirm the diagnosis of Guillain-BarrÉ syndrome.
A Complication Occurs
During the night shift, Amid starts having difficulty breathing. The nurse checks the ventilator and realizes something is wrong but is unable to fix the problem. Amid is in obvious acute respiratory distress.
Meet the Client
Meet the Client: Amid HaqAmid Haq, a 33-year-old Muslim male, and his wife have been visiting Amid's brother in the United States for the past 2 months. Amid has been having trouble walking and has fallen several times because his legs have become weak. He is also having difficulty talking and has experienced some choking episodes. Amid's brother takes Amid to the brother's healthcare provider (HCP), who admits him into the hospital with a diagnosis of rule out Guillain-BarrÉ syndrome.
Tracheostomy Placement
Ten days later Amid is still receiving mechanical ventilation via the endotracheal tube. The healthcare provider has determined that Amid will need a tracheostomy since it is not known how much longer he will require ventilator support. Amid's brother asks, "Why does he need to have this procedure? Is he getting worse?"
The respiratory therapist fixes the ventilator, and Amid is placed back on the ventilator.
The healthcare provider requests stat arterial blood gases (ABG). The ABG results are pH 7.38, PaO2 92, PaCO2 38, and HCO3 24.
The healthcare provider
confirms the diagnosis of Guillain-BarrÉ syndrome and discusses this with Amid, but Amid's family is not in the room.
26. What is the best response by the nurse? a. "I would recommend going straight home. You will be very tired." b. "A visit to the mosque would be just fine; I know your faith is important." c. "Your wife should probably decide if you should visit the mosque." d. "Do you think you are strong enough to make a visit to the mosque?"
"A visit to the mosque would be just fine; I know your faith is important." Amid's Muslim faith is very strong, and visiting the mosque is important to him. He has not been able to visit in more than 2 months, and the nurse should support his spiritual and cultural needs.
21. Which action will the nurse implement? a. Demonstrate the correct technique when giving a bed bath. b. Encourage the UAP to put the bed in the lowest position. c. Instruct the UAP to get another person to help with the bath. d. Provide praise for performing the bath safely for Amid and the UAP.
"Provide praise for performing the bath safely for Amid and the UAP." Raising the opposite side rail addresses Amid's safety to ensure that he will not fall out of bed while being turned. Having the bed in the high position is demonstrating proper body techniques by the UAP.
13. Which action should the nurse implement? a. Tell the wife she must stop crying or she will not be able to visit again. b. Escort Amid's wife out of the room and back to the waiting area. c. Medicate Amid immediately so that he will quit fighting the ventilator. d. Acknowledge the wife's fears and explain about the ventilator and machines.
"Acknowledge the wife's fears and explain about the ventilator and machines." This is a frightening situation and environment, so the nurse should acknowledge the wife's fears and spend time explaining all the machines as well as the intensive care environment. Seeing that his wife's fears are respected and that she is cared for is likely to be the most effective measure to reduce Amid's anxiety and help him relax.
12. Which intervention addressing the mechanical ventilator should be included in the nursing care plan? a. Alternate the position of the endotracheal (ET) tube in the mouth daily. b. Obtain a chest x-ray daily to determine correct position of the ET tube. c. Check daily to ensure that the client's endotracheal cuff is deflated. d. Ensure that 3 fingers can be inserted under the ties securing the ET tube.
"Alternate the position of the endotracheal (ET) tube in the mouth daily." Alternating the ET tube will help prevent the development of a pressure ulcer on the client's tongue.
2. Which assessment intervention will the nurse implement specifically for the diagnosis of Guillain-BarrÉ syndrome? a. Assess deep tendon reflexes. b. Obtain a sterile urine specimen. c. Determine the glucose level. d. Take Amid's vital signs.
"Assess deep tendon reflexes." Hyporeflexia of the lower extremities is the classic clinical manifestation of this syndrome. The paralysis ascends up the lower extremities.
11. Which intervention will the Intensive Care Department nurse implement first? a. Confirm that the ventilator settings are correct. b. Verify that ventilator alarms are functioning properly. c. Assess the respiratory status and pulse oximeter reading. d. Monitor Amid's arterial blood gas results.
"Assess the respiratory status and pulse oximeter reading." Assessment is the first step of the nursing process and the first action the nurse should implement when caring for a client on a ventilator.
17. Which intervention will the nurse implement first? a. Check the tubing for any kinks. b. Suction the client's airway for secretions. c. Manually ventilate the client. d. Sedate the client with a muscle relaxant.
"Check the tubing for any kinks." When peak airway pressure is increased the nurse should implement the intervention that is least invasive for the client. This alarm may sound as the result of a plugged airway, "bucking" the ventilator, decreasing lung compliance, kinked tubing, or pneumothorax.
16. Based on evaluation of the ABG results, which action will the nurse implement? a. Continue to monitor Amid without taking any action. b. Increase the FIO2 rate to 100% oxygen for 10 minutes. c. Suction the client immediately via the end line suction. d. Encourage the client to take slow deep breaths.
"Continue to monitor Amid without taking any action." These arterial blood gases are within normal limits, which means the manual resuscitation was performed correctly and no further action is required.
25. Discharge: Amid works hard during rehabilitation and is able to ambulate with a walker and a cane. He gets tired easily and has regained some of his strength, but he needs some assistance when getting out of the bed and the chair. He has been in the rehabilitation unit for 1 month and is scheduled to be discharged to his brother's home in 2 days.Which intervention should the nurse implement prior to Amid's discharge from the rehabilitation unit? a. Make a referral to the social worker to evaluate the home for safety. b. Show Amid how to perform passive range of motion exercises. c. Arrange to have a Hoyer lift sent to Amid's brother's home. d. Demonstrate proper body mechanics to Amid's wife and brother.
"Demonstrate proper body mechanics to Amid's wife and brother." Since Amid is having difficulty getting out of the bed and the chair, his family should be taught correct techniques to help transfer Amid. This will help prevent injury to both Amid and his family members.
22. Which nursing task(s) can be safely delegated to the (UAP)? Select all that apply. a. Escort a client in a wheel chair to the hospital patio area. b. Take vital signs on an elderly client recovering from hip replacement surgery. c. Determine a client's ability to do range of motion exercises. d. Help feed a client who has had multiple choking episodes. e. Teach a client how to apply a gait belt before ambulating.
"Escort a client in a wheel chair to the hospital patio area." The UAP may escort a client outside as long as the client is stable. "Take vital signs on an elderly client recovering from hip replacement surgery." The UAP can be delegated to perform this task and report the findings to the nurse.
23. The nurse's response will be based on which scientific rationale? a. Full recovery usually occurs within several months to a year after onset of symptoms. b. Most clients with Guillain-Barré syndrome have some type of residual disability. c. The majority of clients with this syndrome end up on mechanical ventilation for life. d. The rehabilitation phase is short, and the client is fully recovered within a month.
"Full recovery usually occurs within several months to a year after onset of symptoms." This is the correct scientific rationale when answering the wife's question.
1. Assessment: Guillain-BarrÉ syndrome is an acute, rapidly progressing, and potentially fatal form of polyneuritis. It affects the peripheral nervous system and results in loss of myelin and edema and inflammation of the affected nerves, causing a loss of neurotransmission to the periphery. The nurse on the medical floor is completing the admission assessment. The client tells the nurse that at first his feet were numb but now his entire legs are numb from his thighs down to his toes.Which question should the nurse ask Amid to support the diagnosis of Guillain-Barré syndrome? a. Were you exposed to anyone with this syndrome prior to coming to the U.S.? b. Have you had any type of cold or stomach virus in the last month? c. Did you receive immunizations prior to coming to the United States? d. Do you take any prescription or over-the-counter medications?
"Have you had any type of cold or stomach virus in the last month?" This syndrome is usually preceded by a respiratory or gastrointestinal infection 1 to 4 weeks prior to the onset of neurologic deficits.
8. How should the nurse respond? a. "According to the privacy law, I cannot discuss this information with you." b. "I will contact Mr. Haq's healthcare provider so that he can explain it to you." c. "I can discuss Amid's condition with his wife but not with you in the room." d. "He has muscle weakness that is traveling up his body and may get worse."
"He has muscle weakness that is traveling up his body and may get worse." Amid's presence in the room can be understood by the nurse as implied consent. Therefore, the nurse can answer the brother's questions and give factual information that is understood by laypersons.
6. Which statement by Amid reflects the Muslim faith? a. I must be able to pray 5 times a day. b. If I die, please face me toward the sun. c. My wife must cleanse my body if I should die. d. I must fast tomorrow because it will be Friday.
"I must be able to pray 5 times a day." The Muslim faith teaches its followers to pray 5 times a day facing toward Mecca.
14. Which statement is the nurse's best response? a. "He will write what he needs on a dry erase board kept at the bedside." b. "I will ask yes or no questions and he can blink once for no and twice for yes." c. "A speech therapist will help us communicate with your brother." d. "We will make sure the call light is available if he needs to call us."
"I will ask yes or no questions and he can blink once for no and twice for yes." Amid will not be able to use his arms due to the paralysis but he can blink his eyes.
18. How should the nurse respond? a. "We are not sure if your brother is getting worse, but he needs a trach." b. "Your brother will be able to talk with you after having this procedure." c. "If the tube stays in his mouth too long it may injure his vocal cords." d. "The tracheostomy procedure will allow Amid to breathe more on his own."
"If the tube stays in his mouth too long it may injure his vocal cords." The endotracheal tube (ET) is placed through the vocal cords into the trachea and can cause damage if left in place too long; a client usually has an ET tube for 10 to 14 days.
9. Which nursing diagnosis will take priority for Amid as the syndrome progresses? a. High risk for injury related to inability to ambulate and transfer safely. b. Fear and anxiety related to hospitalization and loss of control. c. Altered nutrition related to inability to swallow. d. Ineffective breathing pattern related to progressive muscle weakness.
"Ineffective breathing pattern related to progressive muscle weakness." Guillain-BarrÉ syndrome causes ascending paralysis that will cause respiratory failure. Therefore, the diagnosis of ineffective breathing pattern will take priority during the course of the syndrome. Remember Maslow's Hierarchy of Needs.
5. Which action indicates the nurse understands Muslim food and beverage preferences? a. Allow Amid to have one glass of red wine to relax in the evening. b. Instruct Amid's family that they will need to meet Amid's dietary needs. c. Notify the dietary department that Amid cannot eat any pork. d. Help Amid select menu items that do not contain any dairy products.
"Notify the dietary department that Amid cannot eat any pork." The Muslim faith prohibits eating any type of pork.
7. Which action should the nurse implement? a. Implement the prescription as fully as possible based on its legibility. b. Contact the director of nurses to help understand the prescription. c. Verify the prescription during the healthcare provider's routine rounds. d. Notify the healthcare provider immediately to clarify the prescription.
"Notify the healthcare provider immediately to clarify the prescription." If the nurse is unable to clearly read and understand the healthcare provider's prescription, it must be clarified immediately with the person who wrote the prescription.
3. Which intervention will the nurse implement prior to this procedure? a. Keep Amid NPO. b. Instruct Amid not to void. c. Obtain informed consent. d. Place a saline lock in the hand.
"Obtain informed consent." Amid is alert and oriented and has not received any pain medication; therefore, he is capable of signing the consent form allowing this invasive procedure.
24. Which referral is most important for the rehabilitation nurse case manager to implement initially upon Amid's transfer to the rehab unit? a. Guillain-Barré Syndrome Foundation. b. Physical therapist. c. Hospital dietician. d. Home health care services.
"Physical therapist." The physical therapist will help with gait training, muscle building, and transfer techniques. It is essential that this training be started as soon as the client is transferred to the rehab unit to promote early discharge and reduce the risk of injury.
19. Which intervention will the nurse implement when providing tracheostomy care for Amid? a. Ensure that the low pressure tracheostomy cuff is deflated. b. Remove the soiled twill tape before replacing the new twill tape. c. Position the ventilator tubing to ensure minimal pulling on the tube. d. Perform tracheostomy care daily, including removal of the inner cannula.
"Position the ventilator tubing to ensure minimal pulling on the tube." This will reduce the risk of trauma to the trachea.
20. Which assessment data would indicate the client is experiencing a complication secondary to the ventilator? a. The client's urine output is 100 mL in 2 hours. b. The pulse oximeter reading is greater than 95%. c. The client has asymmetrical chest expansion. d. The telemetry shows occasional premature ventricular contractions.
"The client has asymmetrical chest expansion." Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of ventilation.
10. Which long-term goal is written for this nursing diagnosis? a. The client will have no skin breakdown or irritation. b. The client will have minimal muscle atrophy. c. The client will perform active range of motion exercises. d. The client will be turned every 2 hours while awake.
"The client will have minimal muscle atrophy." A client with Guillain-Barré syndrome will not be able to move the extremities during the course of the syndrome. Therefore, preventing muscle atrophy is an appropriate long-term goal.
Later during the shift, the nurse enters Amid's room and meets Amid's brother and Amid's wife, who is in traditional Muslim dress with her face covered.
Amid's brother states, "Amid tells me he has a syndrome but can't explain to me what is going on, can you tell me what is wrong with my brother?"
Communication Skills
After Amid is settled and resting comfortably in the Intensive Care Department, the nurse escorts Amid's wife and brother into his room. Amid's eyes are open, and he is aware of what is going on around him. Amid's wife starts crying uncontrollably, which causes Amid to start fighting the ventilator and crying as well.
The day for Amid's discharge has finally arrived. The nurse escorts Amid, along with his wife and brother, to the car.
Amid asks the nurse, "May I visit the mosque on my way home?"
Throughout the course of the illness, the nurse needs to provide support and encouragement to the family and client. Because residual problems and relapses are uncommon except in the chronic form of the disease, complete recovery can be anticipated. However, it is generally a slow process that takes months or years if axonal degeneration occurs.
Amid continues to improve, is able to breathe without use of the ventilator, and is transferred to the rehabilitation unit with plans to be discharged to his brother's home within the next month.
Management Considerations
Amid is transferred to the medical floor. The unlicensed assistive personnel (UAP) is bathing the client with the bed in a high position with the opposite side rail raised.
Case Outcome
Amid visits the mosque on the way home. He plans to stay with his brother for 2 more months and then return to his home. He was referred to a home healthcare agency and will be receiving weekly visits from the home healthcare nurse and physical therapist. The rehabilitation team expects Amid to make a full recovery within the next year. The expected outcomes are that the client with Guillain-BarrÉ syndrome will: - return to usual level of physical functioning - be free from pain and discomfort - maintain nutritional status
Rehabilitation Care
The nurse assesses Amid and performs bedtime care. Amid's wife asks the nurse, "How long before my husband is back to normal? I miss him so much."
The etiology of this disorder is unknown, but it is believed to be acell-mediated immunologic reaction directed at the peripheral nerves.The syndrome is often preceded by immune system stimulation from aviral infection, trauma, surgery, viral immunizations, humanimmunodeficiency virus (HIV), or lymphoproliferative neoplasms.
The nurse continues to conduct the admission assessment for Amid.
Legal Issues
The nurse is transcribing the healthcare provider's admitting prescriptions. The nurse is having difficulty reading one of the prescriptions.
Cultural/Spiritual Needs
The nurse obtains additional assessment data and plans care related to Amid's cultural needs.
Nursing Diagnosis
The nurse on the medical floor is developing a plan of care for Amid, based on the expected clinical pathway of the syndrome.
The nurse is aware that Amid is at risk for complications secondary to being on the ventilator.
The nurse performs frequent assessments of Amid.
Ventilator Care
Two days after admission, Amid starts complaining of difficulty breathing. His numbness is ascending up his body and affecting his respiratory muscles. He is transferred to the Intensive Care Department and placed on a ventilator for respiratory support. Assessment of the client is the most important aspect of nursing care during the acute phase. The nurse must monitor the ascending paralysis; assess respiratory function; monitor arterial blood gases (ABGs); and assess the gag, corneal, and swallowing reflexes during the routine assessment. Reflexes are usually decreased or absent.
Two hours after Amid is placed back on the ventilator...
the machine alarm goes off and there is an increase in the peak airway pressure.
