GUILLAIN-BARRE' SYNDROME

(affects men/European Americans more)

Pathophys: as a result of demyelination of the peripheral nerves, PROGRESSIVE motor weakness and sensory abnormalities occur. ASCENDING PARALYSIS(from legs and spreads to arms/upperbody). Paralysis can increase to full immobility; may need mech.vent due to weakened respiratory muscles.

*Transmission of electrical impulses from node to node slowed down by demyelinization at Nodes of Ranvier.

*Can be caused by Campylobacter jejuni bacteria infection b/4 symptoms develop.

3 Stages of Acute GBS

~Acute or initial period-1 to 4wks- onset of first symptoms and ends when no futher deterioration occurs.

~Plateau period-several days to 2 weeks

~Recovery phase-usually 4 to 6 months, up to 2 years- coincide with remyelinization -Some pts do not fully recover.

Guillain-Barre' Syndrome: Symptoms

*ASCENDING symmetric muscle weakness--flaccid paralysis

*Decreased or absent DTRs

*Respiratory compromise

*Loss of bowel sounds

*Ataxia

*Parasthesias

*Pain(cramping)

*Facial Weakness

*Dysphagia

*Diplopia

*Difficulty Speaking

*Labile blood pressure

*Cardiac Dysrhythmias

*Tachycardia

GUILLAIN-BARRE SYNDROME:

PHYSICAL ASSESSMENT

*Patient should describe symptoms in chronological order.

*Pain? Paresthesias?

*Sudden onset?

*Signs of Cranial Nerve VII involvement?

(Assess ability to smile, frown, whistle, drink from a straw)

*Difficulty swallowing (CN. IX/X)

*Varying BP, Bradycardia, Heart block?

(Autonomic Dysfunction-->CN. X,Vagus)

GUILLIAN-BARRE' SYNDROME: PSYCHOSOCIAL ASSESSMENT

*Assess ability to cope with illness/anxiety/fear

*Watch for depression through recovery period.

GUILLIAN-BARRE SYNDROME: LAB TESTS

*Lumbar Puncture: CSF

(increased CSF protein w/o an increase in cell count; lymphocyte count is normal)

*High protein levels occur after 1 to 2 weeks of illness, reaching peak at 4 to 6 weeks.

*(other tests)

*Other Tests

1.)Electrophysiologic Studies-EPS- show demyelinating neuropathy.(testing results do not always accurately correspond with level of neuropathy)

2.)MRI/CT used to rule out other causes.

Guillain-Barre' Syndrome: Drug Therapy

Drug Therapy for Guillain-Barre Syndrome

*Plasmapharesis or immunoglobulin(IVIG)-do not combine.

Why? PE removes circulating antibodies thought to be responsible for GBS.

*DO NOT USE CORTICOSTEROIDS unless necessary to treat other conditions.

Plasmapharesis(PE)

*Start PE for nonambulatory adult pt. who seek treatment w/in 4wks of onset of symptoms AND for ambulatory pts seen w/in 2 weeks of onset of symptoms.

Treatment: Pt usually receives 3-4 tx, 1 to 2 days apart.

Nursing Intervention:

Check for shunt patency, assess for bruits q2-4h, Keeping double bulldog clamps at bedside, observing puncture site for bleeding or ecchymosis. To treat paresthesias, add calcium gluconate or chloride to exchange fluids as ordered.

*Give ATROPINE in case of bradycardia

Guillain-Barre' Syndrome: Immunoglobulin(IVIG)

*As effective as plasmapharesis, safer and immediately available*

IVIG(IV Immunoglobulin)

Side effects: chills, mild fever, myalgia, headache, anaphylaxis, aseptic meningitis, acute renal failure, retinal necrosis.

Draw Serum IgA b/4 administration.

Initially start infusion of IVIG slowly and increase rate based on patient's tolerance and hospital protocol.

GUILLAIN-BARRE' SYNDROME: Mgmt of Respiratory Status/Airway

*PRIORITY INTERVENTION FOR GBS PATIENTS*

Respiratory Status/Airway Mgmt: GBS

*Elevate HOB to 45 deg or higher depending on patient needs.

*Place patient on side, to prevent aspiration, log roll of cervical aspiration suspected.

*Monitor for signs of respiratory distress(dyspnea, lack/diminished breath sounds, air hunger, adventitious breath sounds, dec. O2 sat, cyanosis.

*Monitor patient's ability to cough and swallow

*Assess cognitive status, esp. elderly, a decline indicates hypoxia.

*Chest phys by RT

*Frequent position changes w/ breathing exercises(cough/deep breathe) to prevent atelectasis /pneumonia

*Keep ET kit at bedside

Guillain-Barre' Syndrome:Mgmt of Cardiac Dysfunction

GBS: Mgmt of Cardiac Dysfunction

*Place patient on telemetry due to risk for dysrhthmias

*Treat HTN w/Beta blocker or Nitroprusside (Nitropress).

*Treat hypotension with IV fluids and placing patient SUPINE (unless in severe respiratory distress)

*Atropine for bradycardia

GBS: Mobility

*Assess patient's motor function q2-4h w/neuro assessment

*For Safety, assist patient with ambulation, transfer and maintenance of body alignment until able to perform indep.

*Perform ROM exercises q2-4h

*Provide rest b/t activities due to fatigue

*Pt at risk for malnutrition: collab w/nutritionist.

*Weigh pt 3 times/week and check serum albumin levels.

*Turn q2hrs to prevent skin breakdown due to malnutrition.

*To Prevent DVTs-give as ordered Lovenox or Heparin, SCDs, TEDs(remove stockings for 15-30mins q24h)

*Pain is often worse at night

(paresthesias, hyperperesthesia, deep muscle aches, and muscle stiffness)

*Opiates effective for pain mgmt.

*PCA pump or continuous IV drip will be used.

*Also Gabapentin or tricyclic antidepressants

(Older patients due not get tricyclic antidep. cause urinary retention/blurred vision)

*Use nonpharm methods as well(massage, ice, imagery, hypnosis)

Guillain-Barre Syndrome: Promoting Communication

*Collaborate w/Speech Pathologist

*Develop communication system(blink for yes or no; pad for writing requests)

(due to weakened muscles for speech production)

GBS: Emotional Support

*Assess pt for verbal/nonverbal signs of powerlessness, anxiety, fear, and grieving.

*Encourage verbalization of feelings.

*Assess factors affecting pt and family ability to cope.

*Refer to local support groups.