BRABALIBINTAWAN

A Case of Guillain-Barre Syndrome

Guillain-Barre Syndrome sometimes Landry's paralysis, is an acute inflammatory demyelinating polyneuropathy (AIDP), a disorder affecting the peripheral nervous system. Ascending paralysis, weakness beginning in the feet and hands and migrating towards the trunk, is the most typical symptom. It can cause life-threatening complications, particularly if the breathing muscles are affected or if there is dysfunction of the autonomic nervous system.The disease is usually triggered by an acute infection. Guillain Barr syndrome is a form of peripheral neuropathy. The diagnosis is usually made by nerve conduction studies. With prompt treatment by intravenous or plasmapheresis, together with supportive care, the majority will recover completely. Guillain Barr syndrome is rare, at 1 2 cases per 100,000 people annually, but is one of the leading causes of acute non-traumarelated paralysis in the world. The group chose this topic because this will help us to know and better understand the syndrome. Because Guillain Barr syndrome is rare, encountering it in a clinical setting is a bit confusing, hence we really have to know the process and progress of the disease and there we depend our nursing responsibilities and interventions. One of the reasons that made the group decided to choose this topic is having known that this is an autoimmune and neurological disease: having the need for further assessments unlike other diseases.

Dorot e

re

s self-c re Deficit

eor

Dorothea Orem believes that therapeutic self-care demand refers to all safe-care activities required to meet existing self-care requisites, or in other words, actions to maintain health and well-being. Self-care theory is based on four concepts: self-care self-care agency, self care requisites, and therapeutic self-care demand. Self-care refers to those activities an individual performs independently throughout life to promote and maintain personal well-being. To Dorothea Orem, self-care agency is the individual s ability to perform self-care activities. It consists of two agents: a self-care agent (the person who performs self-care independentlty0 and a dependent care agent (a person other than the individual who provides the care. We apply this theory because our patient can t do on her own. She needs assistance in her daily living activities from her significant others and other health care team.

Patients Data A. General Data Na e: MVC Ge er: Fe ale A ress: Br . a al c, ta. Mesa ate f Birt : J e 5, 1993 A e: 17 / l Birt lace: Bata es Reli i : Ba tist Nati alit : Fili i cc ati : t e t Ci il tat s: i le Date of Admission: A ril 25, 2 11 11:5 a B. Chief Complain: Nanghihina yung parehong binti ko as verbalized by the patient. (Bilateral L er E tre ities eak ess)

C. History of Present Illness

2 eeks P A, atie t a c l s a tice t at s e alrea e erie ce it f r a fe eeks a ff; set ca t e re e ere t e atie t all s e k e as t at t e c l s ere a ff. eci e t take it f r ra te f r it a et ff after a fe a s. e i t take a e icati t relie e er c l s. ) 1 eek P A, er c l s still ersiste . Patie t t irritate s s e t k Ne ze (5 t st e after 2 ses eca se s e e erie ce izzi ess. After 3 a s, er c l s ere e. e set f t le eak ess it feeli s f 3 a s P A A ril 22, 7a t e atie t a s di a a a as t e atie t descri ed acc a ied it se sati f eedles a d i s. Felt ai i t le s it ai scale f 2/1 . Pai a d t er disc f rts ca t e alle iated e at rest a d a ra ates e e t .No edication as taken. lating ( alk assisted) s e feels ain on er ot leg 2 da s P A, atient ad diffic lt a it a ain scale of 5/1 . Her c rc ate assaged er ot legs, t t e ain re ained. e atient did not take any edication. 1 day P A atient as still e eriencing difficulty in a ulating. e left ar as also feeling eak. e took a ain relie er ut t e ain as ne er relie ed. An our P A, t e atient could no longer a ulate. e felt ain and eakness on er ot legs and left ar it a ain scale of 9/1 . e ent to QMMC accompanied y er mot er and eldest rot er. Consultation as done and patient as advised to e admitted.

D. Past Medical History No allergy, No previous surgery There as no previous hospitalization E. Personal and Social History Ms. Gi i is a second year College student studying at Tuguegarao. he as fifth of eight si lings. he as active in their church and other religious activities. he does not drink alcohol and smoke. he as fond eating read, vegeta les and meat and eats 3 a day ith periods of snacks. he is not fond eating junk foods. he sometimes drinks an average of 2 glasses of ater a day. he as inclined to hear music/sounds. he also loves to play ta le tennis. he mostly sleeps at 1 pm and akes up 6: am.

F. Review of System REVIE F Y TEM ate Taken: April 29, 2 11 Time: 1: pm a.General: (+) eakness (-) fatigue (-) anore ia (-) fever (-) night s eat (-) lumps .Cardiovascular (-) chest pain (-) cough/sputum (-) s elling of ankle (-) palpitation c. Gastrointestinal (-) nausea /vomiting (-) heart urn (+) difficulty in defecation (+) ignores urge to defecate

d. Respiratory ystem

e. Genitourinary

(-) a dominal pain (-) hematemesis, melena (-) jaundice (-) hemoptysis (-) dyspnea (-) tachypnea (-) shortness of reathing (-) anal pain (-) leeding (-) dysuria (-) hematuria (-) headache (-) dizziness (-) lightheadedness (+) paresthesia (+) numbness (+) difficulty in moving lower e tremities (+) weakness of the left arm

f. Nervous ystem

g. Musculoskeletal

G. Physical Assessment Date Taken: April 29, 2 11 Time: 1: pm

General Appearance: Ms. C is tall, has a mesomorphic body type, 17 years old girl who is conscious and coherent. She looks relax while lying in her bed. Her hair is neatly fixed and her clothes are clean. She has a fair skin complexion. Vital signs: BP: 110/70 mmHg RR: 20 breaths per minute PR: 98 beats per minute Temp: 36.9 C

HEAD: Head is proportional to the size of the body. No lumps, masses, scars or areas of tenderness palpated. a. SCALP Scalp is white, clean, and free from masses, lumps, scars, nits, lice and lesions. b. HAIR It is black, evenly distributed and covers the whole scalp, thick and shiny. c. FACE The patient s face is oval. It is symmetrical (facial expression is appropriate to mood/ feeling). There are no involuntary facial movements. EYES Eyes are parallel and evenly placed. They are symmetrical and non-protruding; both eyes are black and clear. a. EYEBROWS Eyebrows are black, symmetrical and slightly thick. The patient can raise and lower the eyebrows symmetrically and without difficulty. It Is evenly distributed and parallel to each other. b. EYELASHES Black evenly distributed and turned outward. c. EYELIDS Symmetrical, color is the same the surrounding skin. No palpable mass. d. CONJUNCTIVA Slightly pale, shiny, moist and transparent. e.SCLERA AND IRIS Sclera is white and clear. Iris is proportional to the size of the eye, round, black and symmetrical.

f. PUPILS Black in color, equal in size, and round. Constricts when looking at near objects and dilates when looking at far objects. g. EYE MOVEMENT Able to move eyes in full Range of Movement. h. FIELD OF VISION When looking straight ahead, the client can see objects in the periphery. i. VISUAL ACUITY Client has 20-20 vision. III. EARS Parallel, symmetrical, proportional to the size of the head. The skin is the same color as the surrounding area, clean. a. EAR CANAL Pinkish, clean with scant amount of cerumen and few cilia. b. HEARING ACUITY Able to hear and repeat whispered words. IV. NOSE Midline, symmetrical and patent V. MOUTH a. GUMS Pinkish, smooth, moist, no swelling/bleeding; no discharge. b. TONGUE Medium in size, pink, moist, shiny and freely movable, no tenderness.

d. SOFT PALATE Is pinkish, smooth and moist. e. HARD PALATE Is slightly pinkish. TONSILS Are light pink, non-inflamed, no exudates. VOICE Is well-modulated and has no hoarseness. VI. NECK: Proportional to the size of the head, symmetrical and straight, no palpable lumps, masses or area of tenderness. A. RANGE OF MOTION Freely movable without difficulty. B. MUSCULAR STRENGTH Symmetrical and able to resist applied force with equal strength. C. THYROID GLAND Gland ascends during swallowing but is not visible. D. LYMPH NODES No palpable masses in the pre-auricular, post-auricular, tonsilar, submandibular, submental, supraclavicular,occipital and cervical area.

E l r is if r , flat ILI S Is flat, siti i ay t t xi i r c ss a sa as t s rr i g ski . EL S S ls s r i t y activ VIII. X ter steri r t tra sverse ia eter i rati f 1:2 I Is strai t. X I y etrical VII.

sy

isis

is.

l r is t

y etrical. ere is l i r retracti ft eI ri reat i . l s, asses r areas f te er ess al ate . Vi rati s are r i e t ver t e areas ear t e r c i. It i creases it t e i te sity f t e v ice. IX. X I I atie t as fair s i , c lete five fi ers i eac a . ails are tra s are t, c vex a t it sli tly ale ail e s a ite tra sl ce t ti s. y etrical fi e air eve ly s istri te it rese ce f fe visi le vei s. l s, asses r areas f te er ess. ef r ities. scles are sli tly fir . a illary refill t r s ac after t sec s.

RANGE F M TI N: ARM : Both Arms in raised in vertical position at the side of the head. Findings: Right arm can perform with relative ease while the left arm with slight difficulty and can be raise up to a limited height SH ULDER: Abduct and adduct Findings: Performs with relative ease. ELB S: Bends and straightens Findings: Right arm can perform with relative ease and fast while the left arm can perform the same but with slower rate than the right arm. FINGERS: E tends and spreads fingers. Makes fist thumb across the knuckles. Findings: Performs with relative ease. Muscle Strength: Left Arm: 4/5 Right Arm: 5/5 X. LOWER EXTREMITIES Fair skin, complete five fingers in each foot. Nails are transparent. Symmetrical fine hair distributed, with absence of varicose veins. Muscles are symmetrical. Length is symmetrical Patient has difficulty in flexing the legs inward. Toenail appears white, color returns immediately as pressure is released (capillary refill is normal). Patient complained of pain upon palpation of both lower extremities with pain scale of 3/10.

RANGE F M TI N A. L ER EXTREMITIES: Abduct (away) can perform with slight difficulty Adduct (towards) can perform with slight difficulty Rotation can perform with slight difficulty B. ANKLE: Fle ion and E tension- can perform with slight difficulty Rotation- can perform with slight difficulty C. TOES: Spreads and iggles can perform with slight difficulty Muscle Strength: 3/5 for both lower e tremities NEUROLOGIAL ASSESSMENT I. Behavioral, Cognitive & Mental Status Patient is alert and coherent, has calm and rela ed behavior upon approached. Able to answer uestions that were asked. Slight facial grimace is present while moving the lower e tremities. She is oriented to time and place; Looks clean with neatly fi ed hair and wears clean hospital gown. II. Intellectual Function A. MEMORY IMMEDIATE Can recall accurately RECENT- Can recall accurately REMOTE- Can recall accurately

B.KNOWLEDGE Has an idea about her illness and all the procedures that was done to her. C.ABSTRACT THINKING Able to e press ideas or concept. D.ASSOCIATION Able to associate. E. JUDGEMENT Able to judge with what she wants or not. III. SENSORY FUNCTION Back of Hands Forearms Upper Arms Lower Arms Dorsal portion of Feet Laterally and Medially touch sensation touch sensation touch sensation touch sensation Light tickling Light tickling

IV. CEREBELLAR FUNCTION Patient can pat hands against thighs Can perform finger to nose tests repeatedly and rhythmically touches the nose Romberg s Test- Sways when not assisted and cannot able to maintain upright posture and foot stands. Patient cannot walk normally V. MOTOR FUNCTION Muscles in the lower e tremities are weaker than normal and can resist little amount of pressure. Muscles in the upper e tremities can perform full range of motion, fle ed and e tend and can resist e ual pressure applied. Able to fle ed arms and can feel the bicep fle ing and tricep e tension . Muscles are firmed. VI.DEEP TENDON REFLEXES BICEP REFLEX: 2+ TRICEP REFLEX: 2+ PATELLAR: 0 PLANTAR REFLEX: 2+ SUPERFICIAL REFLEXES CORNEAL REFLEX: Present GAG REFLEX: Present

VII. CRANIAL NERVES: I.Olfactory : II.Optic : III.Oculomotor :

IV.Trochlear V.Trigeminal

: :

VI.Abducens VII.Facial

: :

Normal -able to identify smells Normal -2 /2 visual acuity Normal - can able to elevate eyelids can able to move eyes full ROM (+) PERRLA Normal -can able to move both eyes downward Normal -S: patient can feel sensation -M: temporal and masseter muscles palpated (muscles for mastication) symmetrical opening of the mouth (+) Corneal Refle Normal -can able to move both eyes laterally Normal -S: able to taste -M: can able to wrinkle forehead, raise eyebrows, smile, show teeth, puff cheeks

Normal -S: able to taste -M: can able to wrinkle forehead, raise eyebrows, smile, show teeth, puff cheeks VIII.Acoustic: Normal -can hear sounds/whisper voices sampled IX.Glossopharyngeal:Normal able to taste; (+) Gag refle ; (+)movement of the pharynx X.Vagus: Normal XI.Accesory: Normal -can able to shrug shoulders and turn the head XII.Hypoglossal: Normal -can able to move tongue full ROM -able to pronounce sounds (d,l,n,t)
y H. Admitting Diagnosis: T/C Guillain-Barre Syndrome

VII.Facial :

I. Course in the Ward Doctor s Orders: April 24, 2011 11:52am

>Pt. admit to PICU >Secure consent for admission and management >NPO >Oxygen inhalation 5 LPM via face mask >Diagnostics: Plain and contrast CT Scan Na, K, Ca U/A HGT non CBC with HPC, BT BUN, Crea

CXR-HPL

>IVF: PNSS 1L to run at 17gtts/min >Monitor v/s 4 and record >Monitor I & O shift and record >Patient inform procedure at this admission >Refer at Neuro Service >WOF signs of respiratory distress >Refer 7pm >For acute flaccid paralysis work-up >Refer

April 25, 2 11 >E/N ophthalmologic findings at this time >No contraindications to LP optha wise 1 : pm >O2 PRN >Maintain on NPO >Refer April 26, 2 11 6am >Resume DAT >PNSS to run 17 gtts/min >Strict I &O shift monitoring and record please uantitatively >Refer 12pm >For EMG-NCV >Facilitate fecalysis of flaccid paralysis work-up

April 27, 2011 6:00am>Still for fecalysis 2:00pm>Still for EMG-NCV

1 :

pm

>Still for stool collection for acute flaccid paralysis work- up

April 29, 2 11 6: am >IVF to follow D5NM 1L to run @ 2 gtts/min >Still for EMG-NCV >Refer 1: pm >Physical Assessment and ROS was done. >V/S was taken and recorded as follows: >BP: 110/70 >Temp.: 36.9C >RR: 20 bpm >PR: 98 bpm

J. Final Diagnosis: Guillain-Barre Syndrome

Review of Related Literature Description Guillain-Barr syndrome (GBS) is a rare disorder in which a person s own immune system damages their nerve cells, causing muscle weakness and sometimes paralysis. GBS can cause symptoms that last for a few weeks. Most people recover fully from GBS, but some people have permanent nerve damage. In very rare cases, people have died of GBS, usually from difficulty breathing. In the United States, for example, an estimated 3,000 to 6,000 people develop GBS each year on average, whether or not they received a vaccination. Causes Many things can cause GBS; about two-thirds of people who develop GBS symptoms do so several days or weeks after they have been sick with diarrhea or a respiratory illness. Infection with the bacterium Campylobacter jejuni is one of the most common risk factors for GBS. People also can develop GBS after having the flu or other infections (such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may develop GBS in the days or weeks after getting a vaccination. Symptoms Symptoms of Guillain-Barr Syndrome include weakness, typically beginning in the legs and progressing upward. The weakness is accompanied by decreased feeling (paresthesia). Reflexes are lost, for example, the hammer to the front of the knee will not induce a kick. In severe cases breathing can be affected enough to require a ventilator and rarely the heart can be affected. The maximal degree of weakness usually occurs within the first 2-3 weeks. After the first clinical manifestations of the disease, the symptoms can progress over the course of hours, days, or weeks.

Treatment There is no known cure for Guillain-Barr syndrome. However, there are therapies that lessen the severity of the illness and accelerate the recovery in most patients. There are also a number of ways to treat the complications of the disease. Currently, plasma exchange (sometimes called plasmapheresis) and high-dose immunoglobulin therapy are used. Both of them are equally effective, but immunoglobulin is easier to administer.

Anatomy and Physiology Muscular system The bodily system that is composed of skeletal, smooth, and cardiac muscle tissue and functions in movement of the body or of materials through the body, maintenance of posture, and heat production. The muscular system consists of muscular cells, the contractile elements with the specialized property of exerting tension during contraction, and associated connective tissues. The three morphologic types of muscles are voluntary muscle, involuntary muscle, and cardiac muscle. The voluntary, striated, or skeletal muscles are involved with general posture and movements of the head, body, and limbs. The involuntary, nonstriated, or smooth muscles are the muscles of the walls of hollow organs of the digestive, circulatory, respiratory, and reproductive systems, and other visceral structures. Cardiac muscle is the intrinsic muscle tissue of the heart. Upon stimulation by an action potential, skeletal muscles perform a coordinated contraction by shortening each sarcomere. The best proposed model for understanding contraction is the sliding filament model of muscle contraction. Actin and myosin fibers overlap in a contractile motion towards each other. Myosin filaments have club-shaped heads that project toward the actin filaments.

Larger structures along the myosin filament called myosin heads are used to provide attachment points on binding sites for the actin filaments. The myosin heads move in a coordinated style, they swivel toward the center of the sarcomere, detach and then reattach to the nearest active site of the actin filament. This is called a rachet type drive system. This process consumes large amounts of adenosine triphosphate (ATP). Energy for this comes from ATP, the energy source of the cell. ATP binds to the cross bridges between myosin heads and actin filaments. The release of energy powers the swiveling of the myosin head. Muscles store little ATP and so must continuously recycle the discharged adenosine diphosphate molecule (ADP) into ATP rapidly. Muscle tissue also contains a stored supply of a fast acting recharge chemical, creatine phosphate which can assist initially producing the rapid regeneration of ADP into ATP. Calcium ions are required for each cycle of the sarcomere. Calcium is released from the sarcoplasmic reticulum into the sarcomere when a muscle is stimulated to contract. This calcium uncovers the actin binding sites. When the muscle no longer needs to contract, the calcium ions are pumped from the sarcomere and back into storage in the sarcoplasmic reticulum here are approximately 639 skeletal muscles in the human body.

Two major groups of skeletal muscles are recognized, somatic (parietal) muscles, which develop from the myotomes, and branchiomeric muscles, which develop in the pharyngeal wall from lateral plate mesoderm. The somatic musculature is subdivided into axial muscles, which develop directly from the myotomes and lie along the longitudinal axis of the body, and appendicular muscles, which develop within the limb bud from mesoderm derived phylogenetically as buds from the myotomes. The muscles of the lower leg are divided into four compartments: anterior (front of leg), lateral (outside of leg), superficial posterior (back of leg, muscles close to surface), and deep posterior (muscles underneath the superficial posterior muscles). Two bones support these muscles: the tibia is the larger bone and located toward the middle of the lower leg (also called the shinbone) and the fibula is the smaller bone, located on the outside of the lower leg.

Four Anterior Compartment Muscle One function of all four muscles in the front of the lower leg is to pull the foot and toes upward (called dorsiflexion). Tibilais anterior is the muscle you feel right next to the shinbone. This muscle also helps turn the foot inward. Extensor digitorum longus and extensor hallucus longus are underneath the tibilais anterior. The extensor hallucus longus extends the big toe, and the extensor digitorum longus extends the other toes. The peroneus tertius is a small muscle at the lower outer part of the front of the lower leg. This muscle helps turn the foot outward. Two Lateral Compartment Muscles The muscles on the outside of the lower leg are the peroneus longus and peroneus brevis. These muscles pull the foot outward (eversion). According to the Anatomy Coloring Book, the peroneus muscles are especially active when walking on the toes or pushing off with the big toe. Three Superficial Posterior Compartment Muscles The two larger superficial posterior compartment muscles (the gastrocnemius and soleus) are commonly called the calf muscles. The gastrocnemius is the outermost the calf muscle. It attaches to bone (femur) above the knee, which means the gastrocnemius helps to bend the knee. It also points the foot (plantarflexion). Underneath the gastrocnemius is the soleus. The soleus is the muscle that gives the calf bulk. It plantar flexes the foot.

Most of the plantaris muscle is in the back of the knee, but the muscle's tendon runs all the way down to the ankle bone (calcaneus). It helps bend the knee and plantar flex the foot. Three Deep Posterior Compartment Muscles The muscles deep in the back of the lower leg help plantar flex the foot. These muscles and their other functions are as follows: - Tibialis posterior helps turn the foot inward. - Flexor hallucus longus flexes the big toe and helps turn the foot inward. - Flexor digitorum longus flexes the other toes and helps turn the foot inward.

ETIOLOGY:

IDIOPATHIC

PATHOPHYSIOLOGY
PRECIPITATING FACTORS: RESPIRATORY INFECTION Influenza like symptoms 2 weeks prior to admission (colds)

ETIOLOGY:

IDIOPATHIC

Infectious organism (Cytomegalovirus, Mycoplasma Pneumoniae) contains an amino acid that mimics the peripheral nerve myelin.

The immune system cannot distinguish between the two proteins and attacks and destroys peripheral nerve myelin that causes inflammatory demyelization. Exact location of the attack within the peripheral nervous system: ganglioside GM1b Influx of macrophages and other immune-mediated agents and attacks the myelin which causes inflammation and destruction Axons unable to support nerve function

Signs and Symptoms:

Lower Extremities Muscle weakness

Diminished reflexes

Paresthesias, Numbness

Impaired physical mobility

Decreased physical mobility
Decreased GI Motility

Risk for injury

Decrease muscle tone (Sphincter muscles of the GI tract)

Retention of stool for a longer period of time

Constipation

Laboratories and Diagnostics Laboratory Results: Chest X-ray (April 25, 20110)
T/c GBS

Result: Examination shows clear lung field. Heart and great vessels are of normal size and configuration. Other chest structures are unremarkable.
Impression: Negative chest x-ray

Clinical Chemistry (April 25, 2011)

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Nahihirapan akong gumalaw as verbalized by the patient Objective: >Reports pain upon movement >Limited range of motion >Decreased movement

Impaired Physical mobility related to decreased muscle strength as evidenced by pain upon movement,limited range of motion, decreased movement and muscle strength of 3/5 in the lower extremities and 4/5 in the left arm RATIONALE: Guillain-Barr Syndrome manifests the following clinical symptoms: ascending flaccid paralysis, diminished reflexes, paresthesia and numbness and it is rapidly progresses to the whole body including the respiratory muscles.

After 8 hours of Nursing interventions the patient will have increase strength and function of affected and compensatory part w/o any reports of pain. 

INDEPENDENT -Supported affected body parts using pillows, foot supports. To maintain position of function and reduce risk of pressure ulcers. To reduce fatigue. To let the patient feel that she can do the activities without hurry Too lessen the boredom of the patient

-Scheduled activities Verbalize with ade uate rest willingness to and periods during the day demonstrate -Provided client with participation in ample time to perform activities mobility related tasks Verbalize understanding of -Encouraged situation and participation in self individual care, divertional treatment regimen activities, recreational and safety activities measures. -Raised the side rails -encouraged patient to do passive range of motion exercises as follows:  Ankle and foot exercises like

After of 8 hours of Nursing interventions the patients has increased strength and function of affected and compensatory part w/o any reports of pain. The pt. verbalized willingness to and demonstrated participation in activities The pt. verbalized of situation and individual treatment regimen and safety measures. The goal was met.

To provide safety Enhances self concept and sense of independence. To improve proper blood circulation and disuse syndrome

Assessment

Diagnosis

Planning

Intervention

Rationale

Evaluation

Because of the flaccid paralysis as a main sign of this syndrome patient can have difficulty in ambulating because of the muscle weakness and discomforts felt.

finger exercises like Finger bends, Finger spreads, and Finger-tothumb touches.

To improve proper blood circulation and disuse syndrome of the hand and fingers To improve proper blood circulation and disuse syndrome of the forearm and wrist To improve proper blood circulation and disuse syndrome of the shoulder and elbow

Forearm and wrist exercise like Wrist rotation and Palm up, palm down.

Shoulder and elbow exercises like Shoulder movement, up and down, Shoulder rotation, Elbow bends, up and down and Elbow bends, side to side.

COLLABORATIVE: Consult with a Physical Therapist to make a plan of care of treatment for the patient For the possible rehabilitation of the patient during or after recovery from the

Assessment

Diagnosis
Constipation related to insufficient physical activity as evidenced by hypoactive bowel sounds (3/min.), difficulty in defecation, and ignores urge to defecate RATIONALE: Decreased physical mobility can result also in decrease GI motility because like other muscles in the body, if not used the muscle tone decreases(sphincter muscles of the GI tract) which leads to stool retention for a longer period of time.

Planning
After 6 hours of nursing intervention patient will have a normal bowel sound and will regain normal pattern of bowel functioning.

Intervention
INDEPENDENT -Determined fluid intake -Palpated abdomen

Rationale
To note deficits. To look for presence of distention and/or masses. For reflecting bowel activity. To improve consistency of stool and facilitate passage through colon. To promote moist/soft stool. To promote timely intervention, enhancing clients independence. To promote peristaltic movement of the GI tract.

Evaluation
After 6 hours of nursing intervention patient has regained normal pattern of bowel functioning and exhibited normal bowel sounds.

Subjective: Ilang araw na akong di dumudumi as verbalized by the patient. Objective: >hypoactive bowel sounds (3/min.) > difficulty in defecation >ignores urge to defecate

-Auscultated abdomen for presence of bowel sounds. -Encouraged to ingest food rich in fiber and bulk.

-Promoted ade uate fluid intake. -Identified specific actions taken if problem recurs.

-Promoted activities that can help in utilizing increase GI mobility (assisted patient to ambulate once in a while) -Assisted through passive range of motion exercises

To promote GI motility

Assessment
Subjective: May weakness at pain sa legs at paa ko lalo na kapag naglalakad. As verbalized by the patient

Diagnosis

Planning
After 2 hours of nursing interventions the patient and significant others will understand the risk factors that contribute to possibility of injury a.Falling from her bed b.Losing control in holding object c.The patient may out of her balance 2. demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury 3. modify environment as indicated to enhance safety 4. be free of injury

Intervention
INDEPENDENT -Monitored vital signs

Rationale

Evaluation
After 2 hours of nursing interventions the patient understood the risk factors that might contribute to possibility of injury a. Falling from her bed b.Losing control in holding object c.The patient may out of her balance

Risk for injury

To have a baseline data for the comparison of any unusual findings To gather data for the evaluation of nursing interventions

RATIONALE: Objective: -decreased lower and upper extremity muscle strength: Left arm:4/5 Right arm:5/5 Both lower extremities: 3/5 -pain on both legs (pain scale of 3/1 ) - noticed patient that she cant walk without assistance. Ms. C, having a problem of impaired physical mobility is also risk to an injury because of falls or any physical bumps that could happen to her most especially because of decreased muscle strength/flaccid paralysis of her upper and lower extremities

- Assessed muscle strength, gross and fine motor coordination. Note individuals general health status. -Provided information regarding clients disease and condition.

To gather data for the evaluation of nursing interventions To provide safety to the patient To provide easier and less tiring ambulation for the patient

-Raised side rails

2. Has demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from injury. 3. Modified environment as indicated to enhance safety. 4. Freed of injury

- Taught patient on how to use assistive devices (cane, walker, grab bars) during ambulation

Assessment

Diagnosis

Planning
5. Patient will demonstrate appropriate use of assistive devices (cane, walker, grab bars)

Intervention
-Encouraged significant others and assisted patient when turning or when needed to grab an object -Instructed significant others of the patient to never leave the patients side or have visiting rotations during confinement

Rationale
To prevent falls or losing control in holding object

Evaluation
5. Patient demonstrated appropriate use of assistive devices.

To prevent falls or any unnecessary accidents that might happen

Discharge Plan
y M Supportive Care y E- Encourage patient and instruct the significant others to assist

the patient to walk within her limits or use assistive devices and provide appropriate resting periods
y y y y y y

Passive range of motion exercise to be performed at least twice daily as follows: Ankle and foot exercises. Like Ankle bends, Ankle rotation, Toe bends, Toe spreads. Hip and leg exercises like Leg movement, side to side, and Leg rotation, in and out. Hand and finger exercises like Finger bends, Finger spreads, and Finger-to-thumb touches. Forearm and wrist exercise like Wrist rotation and Palm up, palm down. Shoulder and elbow exercises like Shoulder movement, up and down, Shoulder rotation, Elbow bends, up and down and Elbow bends, side to side.

yH

Perform activities of daily living with assistance and manage self care like the patient s nutrition, bowel and bladder management. Skin care and adaptive equipment for bathing, hygiene, grooming and dressing.
y Implement safety measures at home. y Increase fiber intake daily to facilitate easy passage of

stool y Increase fluid intake daily to prevent constipation and to keep the patient hydrated

Follow up check-up when symptoms persisted and /or worsen y D Diet as tolerable (DAT)
yO

Prognosis
y

Most of the time recovery starts after the fourth week from the onset of the disorder. Approximately 80% of patients have a complete recovery within a few months to a year, although minor findings may persist, such as areflexia. About 5 10% recover with severe disability, with most of such cases involving severe proximal motor and sensory axonal damage with inability of axonal regeneration. However, this is a grave disorder and despite all improvements in treatment and supportive care, the death rate among patients with this disorder is still about 2 3% even in the best intensive care units. Worldwide, the death rate runs slightly higher (4%), mostly from a lack of availability of life support equipment during the lengthy plateau lasting four to six weeks, and in some cases up to one year, when a ventilator is needed in the worst cases. About 5 10% of patients have one or more late relapses, in which case they are then classified as having chronic inflammatory demyelinating polyneuropathy (CIDP).

y Poor prognostic factors include: 1) age, over 40 years, 2) history

of preceding diarrheal illness, 3) requiring ventilator support, 4) high anti-GM1 titre and 5) poor upper limb muscle strength.