Medical Surgical Guillain-Barre Syndrom GBS #3

Question

Which nursing diagnosis is appropriate for the client with Guillain-Barre syndrome?

Answers

  1. Impaired skin integrity
    • Rationale:

      This answer is not correct because GBS does not affect the skin. Impaired skin integrity would become a nursing diagnosis for GBS only if the client becomes immobile from the disease or suffers vascular insufficiency.

  2. Risk for ineffective breathing pattern
    • Rationale:

      This answer is correct because of the possible progression to respiratory failure. GBS causes weakness or paralysis and affects the nerves responsible for breathing. This complication can be life-threatening.

  3. Risk for bleeding
    • Rationale:

      This answer is not correct because hemorrhaging is not a symptom of GBS. The incidence of thrombocytopenia is rare in clients with GBS.

  4. Disturbed body image
    • Rationale:

      This answer is not correct because disturbed body image has no relation to GBS. Disturbed body image is usually a result of a client who has an ileostomy or going through chemotherapy.

Overview

Guillain-barre syndrome is a rare autoimmune disease caused by a virus or an infection with campylobacter which produces harmful antibodies that attack the nerves. GBS can be fatal if left untreated, usually due to paralysis which affects the diaphragm that helps with breathing.

Explanation

Learning Outcomes

Guillain-barre syndrome is a rare autoimmune disease caused by a virus or an infection with campylobacter which produces harmful antibodies that attack the nerves. GBS can be fatal if left untreated, usually due to paralysis which affects the diaphragm that helps with breathing. The immune system destroys the myelin sheath. The myelin sheath is responsible for the electrical impulses transmitted along the nerve cells. The major concern is difficulty breathing. Most people recover in a year. Some people have long-term implications from GBS.

Test Taking Tip

Always know the most important nursing diagnosis for a disease. Refer to the ABCs of triage and Maslow’s Hierarchy of Needs to help you choose.

Video Rationale