Brief Patient History
Mr. A is a 58-year-old Japanese-American admitted to the unit from the emergency department with complaints of paresthesias, lower extremity weakness (onset 2 days ago), and difficulty walking today. Mr. A reports to being in “good health” except for having the flu 3 weeks ago. Mr. A is married and the manager of a local restaurant.
Mr. A is awake, follows commands, and is oriented to person, place, and time. Mr. A is quiet, shows no emotion, avoids all eye contact with the nurse, and only speaks when spoken to. Mr. A verbalizes that he has symmetrical weakness, numbness, and paresthesia in both legs (2 cm above the knee). Within a few hours of admission to the unit, Mr. A is having trouble swallowing, has diminished reflexes, and cannot move his arms or legs to move in bed. Mr. A remains stoic and denies pain.
Mr. A’s vital signs include blood pressure of 142/82 mm Hg, heart rate of 98 beats/min, respiratory rate of 32 breaths/min, temperature of 98.9° F, and SpO2 of 92% on O2 at 2 L/nasal cannula. Cerebral spinal fluid shows protein levels of 15 mg/dL. Electromyography (EMG) and nerve conduction tests reveal reduced nerve conduction and velocity in the lower extremities. Serum sodium, 135 mEq/dL; serum potassium, 4.2 mEq/dL; and serum magnesium, 2.2 mEq/dL.
• Guillain-Barré Syndrome (GBS)
Guillain - Barre syndrome is an autoimmune condition which affects peripheral nerve myeline. As a result there will be a rapid segmental demyelination occurs for peripheral nerve and some cranial nerves. The main symptoms are Dyskinesia- inability to execute voluntary movements ,ascending weakness,hyporeflexia and. parasthesia or numbness.
What major outcomes do you expect to achieve for this patient?
1. maintain a patent airway
2. shows increased mobility
3.decreased fear and anxiety
4.absence of complications
What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
1: Respiratory functions can be improved by spirometry and chest physiotherapy. Continuously monitor the respiratory status such as oxygen saturation and vital capacity.keep mechanical ventilator ready for use
2: This patient has numbness and parasthesia. Passive range of motion exercises should be performed twice daily to improve mobility. Immobility and parastesia may leads to DVT and pulmonary embolism. Position changing and anti- embolism stockings can be used for the patient to avoid risk.
3: Fear and anxiety is common because the patient has an acute
onset.At this point give proper health education about his
condition, emphasizing a positive appraisal on coping resources and
teach him relaxation exercises.
4: identify and manage potential complications such as closely monitor for respiratory pattern,now the vital signs shows elevated blood pressure, there will be a chance of transient hypertension so closely monitor patient vital signs. ECG monitoring is necessary to check for any dysrhythmias.
Interventions should be initiated to promote optimal
functioning, safety, and well-being of the patient?
Safety is very important, because the patient has numbness and weakness.
1.fall risk assessment should perform and check the score every day . Provide safety equipments for mobilization.
2 . change the position every two hours to avoid pressure ulcers.
3 .padding can be applied on the bony prominence.
4: provide adequate nutrition
5. Perform Range of motion exercises which is intermittent and non- fatiguing.
6. encourage patient to do activities of daily living slowly .
7.encourage the patient and family to participate actively in rehabilitation program.
8. Prepare patient and family to manage the acute phase.
What possible learning needs would you anticipate for this patient.
Health education to patient and family plays a key role. Usually
the patient and family frightened by the sudden onset of life
threatening symptoms. Therefore ,teaching the family and patient
about the disorder andits generally favorable prognosis is
: Describe them the disease process of GBS.
: teach them to manage respiratory needs such as suctioning and saturation monitoring .
: demonstrate proper body mechanics.
: practice gait training.
: perform range- of- motion exercises.
: teach them to implement safety measures at home.
: Let them aware how to use community resources.
What cultural and age-related factors may have a bearing on the patient’s plan of care?
culture vary patient to patient,the care giver should be aware
about the visible cultural factors such as language, cloths ,food
habbit and patient intrest in music. Also should aware about non-
visible culture such as communication style, belive, values and
ethics of patient.
The role of patient in family is an another important factor.
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