What are the immediate nursing interventions for Guillain-Barré Syndrome (GBS)?

Nursing Interventions for Guillain-Barré Syndrome

Immediate respiratory monitoring is the absolute priority nursing intervention for GBS, with vital capacity measurement and application of the "20/30/40 rule" to identify impending respiratory failure, as up to 30% of patients will require mechanical ventilation. 1, 2

Critical Respiratory Assessment (First Priority)

• Measure vital capacity immediately and serially – patient is at imminent risk of respiratory failure if vital capacity <20 ml/kg, maximum inspiratory pressure <30 cmH₂O, or maximum expiratory pressure <40 cmH₂O 1, 3
• Perform single breath count testing – a count ≤19 predicts the need for mechanical ventilation 1, 3
• Assess for use of accessory respiratory muscles and ability to cough effectively 1, 4
• Monitor for signs of bulbar weakness that compromise airway patency and increase aspiration risk 5
• Obtain arterial blood gas measurements if any respiratory compromise is suspected 1
• Up to 22% of GBS patients require mechanical ventilation within the first week of admission, making this the most life-threatening complication 1

Autonomic Dysfunction Monitoring (Second Priority)

• Perform continuous ECG monitoring for arrhythmias, as cardiovascular and respiratory dysfunction cause up to two-thirds of deaths in GBS 1, 3
• Monitor blood pressure frequently for both hypertension and hypotension episodes 1, 3
• Assess bowel and bladder function regularly for autonomic involvement 1, 4
• Watch for rapid fluctuations in vital signs that indicate severe autonomic instability 1

Neurological Assessment and Documentation

• Assess muscle strength in neck, arms, and legs using the Medical Research Council grading scale 1, 3
• Document functional disability using the GBS disability scale 1, 3
• Monitor for progression of ascending weakness pattern (feet → knees → hips → trunk → arms) 1
• Assess deep tendon reflexes (typically reduced or absent in GBS) 1
• Evaluate swallowing and coughing ability to prevent aspiration 1, 4

Complication Prevention

• Implement deep vein thrombosis prophylaxis – immobilized patients are at high risk 1, 4
• Perform frequent repositioning and use pressure-relieving devices to prevent pressure ulcers 1, 4
• Maintain strict infection control measures, as hospital-acquired infections (pneumonia, urinary tract infections) are common complications 1, 4
• Seven out of 11 mechanically ventilated GBS patients in one study developed ventilator-associated pneumonia and/or sepsis 6

Pain Management

• Recognize that pain is common in GBS and significantly impacts quality of life 4, 3
• Assess pain regularly and treat early, as it can be severe and confusing (may even precede weakness onset) 1, 7
• Provide appropriate analgesia as prescribed 4

Medication Safety

• Avoid administering medications that worsen neuromuscular function: β-blockers, IV magnesium, fluoroquinolones, aminoglycosides, and macrolides 1, 4
• This is a critical nursing responsibility as these medications can precipitate or worsen respiratory failure 1

Psychological Support

• Provide support for anxiety, depression, and hallucinations, which are frequent in GBS patients 1, 4
• Recognize that patients may be fully conscious but completely paralyzed, requiring reassurance and communication support 8
• Educate patient and family about the disease course and expected recovery 8

Coordination of Immunotherapy Administration

• Prepare for and administer intravenous immunoglobulin (IVIg) at 0.4 g/kg body weight daily for 5 consecutive days as prescribed 1, 4, 3
• Monitor for IVIg-related complications during infusion 4
• Recognize that treatment should be initiated as early as possible in the disease course 1, 4

Early Rehabilitation Coordination

• Coordinate with physiotherapists, occupational therapists, speech therapists, and dietitians for early rehabilitation 3
• Facilitate range-of-motion exercises to prevent contractures 3
• Monitor exercise intensity closely, as overwork causes significant fatigue 3

ICU Transfer Criteria Recognition

• Immediately notify physician and prepare for ICU transfer if: evolving respiratory distress with imminent respiratory insufficiency, severe autonomic cardiovascular dysfunction, severe swallowing dysfunction or diminished cough reflex, or rapid progression of weakness 1, 3
• Emergency intubation may lead to life-threatening complications, so early recognition and planned intubation is preferred 5

Common Pitfalls to Avoid

• Respiratory failure can develop rapidly without obvious clinical signs of dyspnea – do not wait for patient complaints 1
• Treatment-related fluctuations occur in 6-10% of patients within 2 months of initial improvement, requiring repeated treatment 1, 4, 3
• About 40% of patients do not show improvement in the first 4 weeks following treatment, which doesn't necessarily indicate treatment failure 4
• Mortality is 3-10%, primarily from cardiovascular and respiratory complications that are potentially preventable with vigilant nursing care 4, 3