Guillain-Barre Syndrome System Disorder Sheet PDF

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Summary

System disorder sheet for ATI reference...

Description

ACTIVE LEARNING TEMPLATE:

System Disorder

Ryann Starcher ST UDENT NAME _____________________________________ Guillain-Barre Syndrome DISORDER/DISEASE PROCESS __________________________________________________________

Alterations in Health (Diagnosis)

Pathophysiology Related to Client Problem Antibodies attack Schwann cells on the myelin sheath of the axons of the nerves. This causes inflammation and edema which disrupted, nerve transmission becomes abnormal.

An autoimmune reaction that usually follows a primary disorder, especially a viral infection.

REVIEW MODULE CHAPTER ___________

Health Promotion and Disease Prevention Prevention has not been determined yet.

ASSESSMENT

SAFETY CONSIDERATIONS

Risk Factors

Expected Findings

Influenza virus, Cytomegalovirus, Epstein-Barr virus, Zika virus, Hepatitis A, B, C and E, HIV, the virus that causes AIDS, Mycoplasma pneumonia, Trauma, Hodgkin's lymphoma, Rarely, influenza vaccinations or childhood vaccinations, COVID-19 virus, COVID-19 Johnson & Johnson vaccine, Hx of recent surgery, vaccination, malignant diseases, and lupus erythematosus.

Laboratory Tests

Mild to severe ascending muscle weakness, tingling and numbness, or paralysis from the legs upward. Overactive or underactive sympathetic or parasympathetic nervous system (changes in BP and heart rate and rhythm), Changes in respiration muscles, can involve cranial nerves causing difficulty in chewing, talking and swallowing.

Diagnostic Procedures

Lumbar puncture to check elevated CSF protein levels and pressures.

Electromyography (thin-needle electrodes in the muscles to measure nerve activity), Nerve conduction studies.

PATIENT-CENTERED CARE

Nursing Care Observes for signs of respiratory distress using a spirometer for ventilation capacity. Assess for pneumonia (vital signs & lung sounds frequently). Provide skin care and change position every 2 hours, perform active and passive exercises.

Therapeutic Procedures Plamapheresis (removal of plasma from blood and reinfuse cellular components with saline), Intubation if needed, Gastric tube feedings, IV fluids if needed.

ACTIVE LEARNING TEMPLATES

Pneumonia and muscle atrophy, sensitive to touch, cold and heat, fall risk, and increased anxiety.

Complications Medications Gabapentin, TCAs, Opioid analgesics, IV immune globulin-Gamim une N

Client Education Teach patient or caregiver about disorder and what to expect for treatment. Upon discharge rest as needed, continue deep breathing exercises and cough, and apply heat to decrease pain and muscle spasms.

Interprofessional Care Rehabilitation Center, Physical and occupational therapy, Social services, Home health care, Mental health services.

Death, Pneumonia, breathing difficulties, residual numbness or other sensations, heart and BP problems, pain, bowel & bladder function problems, blood clots, pressure sores, relapse....