Medical Surgical Guillain-Barre Syndrom GBS #2

Question

A nurse caring for a client with Guillain-Barré syndrome (GBS) notifies the health care provider of the client’s deteriorating condition. Which of these assessment findings indicate a worsening of Guillain-Barré syndrome?

Answers

  1. Weakness
    • Rationale:

      This answer is not correct because weakness of the body is one of the first major symptoms of this disease. Weakness is usually symmetrical and comes on quickly with GBS.

  2. Paresthesia
    • Rationale:

      This answer is not correct because paresthesia is also an early sign of GBS. Nerve damage ensues when the immune system attacks these nerves, resulting in paresthesia (abnormal sensations of the skin).

  3. Thick green respiratory sputum
    • Rationale:

      This answer is correct because with GBS, respiratory muscle weakness predisposes the client to infections such as pneumonia. Aspiration is thought to be the usual cause of pneumonia in these clients. Weakness of these respiratory muscles increase the chances of aspiration. It is important to anticipate mechanical ventilation with clients who have GBS. Having intubation supplies readily available at the bedside would be good nursing practice.

  4. Lower extremity pain
    • Rationale:

      This answer is not correct because although lower extremity pain may be an early sign, it does not indicate worsening of GBS. Later, there may be complete paralysis so there would be no pain.

Overview

GBS is a neurological autoimmune disease which damages the peripheral nervous system causing muscle weakness and sometimes paralysis. Paralysis of the respiratory muscles occurs, therefore, ventilator support is needed. Thick green respiratory sputum indicates infection which is a complication of the disease.

Explanation

Learning Outcomes

Guillain-Barré is characterized by paralysis, which ascends through the body affecting the peripheral nervous system. Serious complications may occur as a result of the respiratory infection, since the respiratory center is affected and failure may ensue. Monitoring respiratory status is imperative for the client with GBS. Keeping the head of bed elevated, watching for shortness of breath, impaired cough, auscultation of lung sounds, assessing blood oxygen saturation, and arterial blood gases. In some clients, chest physiotherapy may be indicated to mobilize and clear airway secretions. Treatments include plasmapheresis, intravenous immunoglobulin therapy, and corticosteroids.

Test Taking Tip

Weakness, paresthesia, and lower extremity pain are all symptoms of GBS. However, thick green respiratory sputum is not a symptom of GBS; thus indicating an active infection that needs to be addressed.

Video Rationale