Académique Documents
Professionnel Documents
Culture Documents
A Case Study
For NCM104
Presented by:
Ariana C. Natiag
Ramadel C. Nervez
Kimberly Nimanand
Fe Padrino
BN3F-Group 3
I. Introduction……………………………………………………………. 3
II. Objectives…………………………………………………………….....4
V. Baseline Data…………………………………………………………....8
VIII. Assessment………………………………………………………….…. 12
X. Pathophysiology…………………………………………….................. 18
XIV. Bibliography……………………………………………………………. 45
I. Introduction
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"We often think of nursing as giving meds on time, checking an X-ray to see if the doctor
needs to be called, or taking an admission at 2:00 a.m. with a smile on our faces. Too often, we
forget all the other things that make our job what it truly is—caring and having a desire to make
a difference." - Erin Pettengill, RN, quoted on RN Modern Medicine
On our third year of being student nurses, we believe that having the passion and love for
our work makes everything easy and fulfilling. Nothing could explain the happiness in our hearts
when we see our patients improving on their health, which gives us more inspiration and
motivation to do better and provide an effective nursing care. We believe that with these values,
we could make a big difference in other people’s lives. With this, we are able to give a brighter
future not only for our own experience, but also for our patients and their loved ones.
As we all know, having the freedom to do what we want makes us happy and enjoy life
even more, but what if one day you’ll wake up paralyzed and unable to move your legs or your
hands? How would you feel about it? This is just one of the complications of Guillain-Barre
syndrome.
Guillain-Barré syndrome is a disorder in which the body's immune system attacks part of
the peripheral nervous system. The first symptoms of this disorder include varying degrees of
weakness or tingling sensations in the legs. In many instances, the weakness and abnormal
sensations spread to the arms and upper body. In these cases, the disorder is life-threatening and
is considered a medical emergency. The patient is often put on a respirator to assist with
breathing.
Guillain-Barré syndrome is rare. Usually Guillain-Barré occurs a few days or weeks after
the patient has had symptoms of a respiratory or gastrointestinal viral infection. Occasionally,
surgery or vaccinations will trigger the syndrome. The disorder can develop over the course of
hours or days, or it may take up to 3 to 4 weeks. No one yet knows why Guillain-Barré strikes
some people and not others or what sets the disease in motion. What scientists do know is that
the body's immune system begins to attack the body itself, causing what is known as an
autoimmune disease. Guillain-Barré is called a syndrome rather than a disease because it is not
clear that a specific disease-causing agent is involved.
As Lasallian nurses, our main goal is to provide care for our patient. Help them cope with
their conditions and be the ones to lighten their minds with every medical procedure that they are
about to face.
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The purpose of this case study is to understand the syndrome, its main cause and how to
treat it to help what our client is going into. The significance of this case study is to help others
in coping up with their health status and as well as to help us understand it well.
We hope that at the end of this study, the reader will be able to understand and to be
aware about this syndrome.
II. OBJECTIVES
A. GENERAL OBJECTIVES
After 5 days of hospital exposure, the student nurses will be able to have a case study
where the nursing process is intensively and extensively utilized in the nursing plan and
care of the patient with Guillain- Barre Syndrome providing the student nurses with a
vivid understanding of the background of the patient’s disease, establish a good
interpersonal relationship with the client, identify the health problem of the client,
perform necessary nursing intervention that could help improve the client’s condition, use
the nursing process as a framework for providing an efficient care.
B. SPECIFIC OBJECTIVES
3. Enumerate the pre-existing and predisposing factors that contribute to the occurrence
of the disease.
5. Recognize the importance of the laboratories examination required for observing the
disease.
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9. Formulate health teachings on medications, exercise, treatment, hygiene, out-patient
and diet.
Immune System
The immune system, which is made up of special cells, proteins, tissues, and organs, defends
people against germs and microorganisms every day. In most cases, the immune system does a
great job of keeping people healthy and preventing infections. But sometimes problems with the
immune system can lead to illness and infection.
The immune system is the body's defense against infectious organisms and other invaders.
Through a series of steps called the immune response, the immune system attacks organisms
and substances that invade our systems and cause disease. The immune system is made up of a
network of cells, tissues, and organs that work together to protect the body.
Peripheral Nerves
The peripheral nervous system consists of more than 100 billion nerve cells that run throughout
the body like strings, making connections with the brain, other parts of the body, and often with
each other. Peripheral nerves consist of bundles of nerve fibers. These fibers are wrapped with
many layers of tissue composed of a fatty substance called myelin. These layers form the myelin
sheath, which speeds the conduction of nerve impulses along the nerve fiber. Nerves conduct
impulses at different speeds depending on their diameter and on the amount of myelin around
them.
The peripheral nervous system has two parts: the somatic nervous system and the autonomic
nervous system.
Somatic Nervous System: This system consists of nerves that connect the brain and spinal cord
with muscles controlled by conscious effort (voluntary or skeletal muscles) and with sensory
receptors in the skin. (Sensory receptors are specialized endings of nerve fibers that detect
information in and around the body.)
Autonomic Nervous System: This system connects the brain stem and spinal cord with internal
organs and regulates internal body processes that require no conscious effort. Examples are the
rate of heart contractions, blood pressure, the rate of breathing, the amount of stomach acid
secreted, and the speed at which food passes through the digestive tract. The autonomic nervous
system has two divisions:
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• Sympathetic division: Its main function is to prepare the body for stressful or emergency
situations—for fight or flight.
• Parasympathetic division: Its main function is to prepare the body for ordinary
situations.
These divisions work together, usually with one activating and the other inhibiting the actions of
internal organs. For example, the sympathetic division increases pulse, blood pressure, and
breathing rates, and the parasympathetic system decreases each of them.
Cranial and Spinal Nerves: Nerves that connect the brain with the
eyes, ears, nose, and throat and with various parts of the head,
neck, and trunk are called cranial nerves. There are 12 pairs of
them. Nerves that connect the spinal cord with other parts of the
body are called spinal nerves. The brain communicates with most
of the body through the spinal nerves. There are 31 pairs of them,
located at intervals along the length of the spinal cord. Several
cranial nerves and most spinal nerves are involved in both the
somatic and autonomic parts of the peripheral nervous system.
• Motor (anterior) nerve root: The motor root emerges from the front of the spinal cord.
Motor nerve fibers carry commands from the brain and spinal cord to other parts of the
body, particularly to skeletal muscles.
• Sensory (posterior) nerve root: The sensory root enters the back of the spinal cord.
Sensory nerve fibers carry sensory information (about body position, light, touch,
temperature, and pain) to the brain from other parts of the body. The sensory nerve fibers
from a specific sensory nerve root carry information from a specific area of the body,
called a dermatome.
After leaving the spinal cord, the corresponding motor and sensory nerve roots join to form a
single spinal nerve. Some of the spinal nerves form networks of interwoven nerves, called nerve
plexuses. In a plexus, nerve fibers from different spinal nerves are sorted and recombined so that
all fibers going to or coming from one area of a specific body part are put together into one nerve
(see Peripheral Nerve Disorders:Plexus Disorders ). There are two major nerve plexuses: the
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brachial plexus, which sorts and recombines nerve fibers traveling to the arms and hands, and the
lumbosacral plexus, which sorts and recombines nerve fibers going to the legs and feet.
III.Definition of Terms
• Guillain Barre Syndrome- a serious disorder that occurs when the body’s defense
(immune) system mistakenly attacks part of the nervous system. This leads to nerve
inflammation that causes muscle weakness
• Crawling skin- it is one specific form of a set of sensations known as paresthesia, which
also include the more common prickling, tingling sensation of pins and needles
• Saltatory conduction- is the propagation of action potentials along myelinated axons from
one node of ranvier to the next node, increasing the conduction velocity of action
potentials without needing to increase the diameter of an axon
• Tidal volume- is the lung volume representing the normal volume of air displaced
between normal inspiration and expiration when extra effort is not applied
• Axon- a long, slender projection of a nerve cell, or neuron that conducts electrical
impulses away from the neuron’s cell body or soma
• Nodes of Ranvier- are the gaps (approximately 1 micrometer in length) formed between
the myelin sheaths generated by different cells
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V. Baseline Data
Name: J.M
Age: 20
Number of Dependents: 0
Gender: Male
Nationality: Filipino
Occupation: student
Admitting Diagnosis: Community Acquired Pneumonia, High risk for Aspiration, Ischemic
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VI. Nursing History
A. Health Maintenance- Perception Pattern
The patient is oriented to time, place, and person. He is knowledgeable as to his
condition and in acquiring such. He tries to regain himself by cooperating in the treatment
regimen and has a strong hope that he would recover as soon as possible.
C. Nutrition Pattern
Before admission, significant others stated that his diet is composed usually of
vegetables, pork, chicken and any other usual foods that we eat and he is funned of eating
junk foods and his meal is always composed of softdrinks. Before he experienced fever,
significant others stated that he ate chicken which does not taste good but still continued to
eat it. During the times that the patient is not feeling well, he doesn’t have time to eat lunch
because of busy schedule in school. His weight before admission is 50kg, but upon staying at
the hospital, it dropped down to 46kg and his mother stated that she thinks, it further
decreased due to his physical condition.
D. Elimination Pattern
Before admission, the client did not experience any problem when it comes to his
urination and defecation. He stated that he urinates to a yellow colored urine usually eight
times a day without any pain or discomfort. He further stated that he defecates daily with no
difficulty. Upon admission, significant others stated that he was attached to a foley catheter
but requested for it to removed due to discomfort and was replaced with diaper. The diaper is
usually fully soaked in about six hours. He experienced difficulty in defecating for about four
days and doctor requested to have suppositories. The client experienced diaphoresis three
weeks prior to admission at OLM and still manifests it upon assessment.
I. Role-Relationship Pattern
His family is composed of 8 members including his mother and father and he is the
2nd child among the 6. He has a good relationship with his family and they are supportive of
one another. Even in his times of illness, his family didn’t think that he is useless and they
are always there to show their love, care, and concern to him. Also, his extended family
members visit him in the hospital and didn’t neglect to support him financially.
a. Childhood Illness
His mother stated that he has no any other serious illness since childhood.
He is well and healthy even though he didn’t completed his immunization
specifically Hepatitis B vaccine.
b. Past Hospitalization
The patient was hospitalized once during his younger days due to diarrhea
which lasted in three days.
c. Family/Social History
The patient’s family has no any other history of genetic diseases except in
his mother side which is hypertension.
VIII. Assessment
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November 8, 2010
A. General Appearance
B. LOC
C. HEENT
D. Cardiovascular
E. Respiratory
F. Gastro-Intestinal Tract
• on OTF 225cc given q3H per NGT bowel sound auscultated at right lower
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• with normoactive bowel sound auscultated at right lower quadrant with the
rate of 8 cpm
• unable to defecate upon initial assessment
G. Genito-Urinary Tract
H. Musculoskeletal
I. Integumentary
November 9, 2010
A. General Appearance
B. LOC
C. HEENT
E. Respiratory
F. Gastro-Intestinal Tract
G. Genito-Urinary Tract
H. Musculoskeletal
I. Integumentary
B. General Appearance
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C. LOC
D. HEENT
E. Cardiovascular
F. Respiratory
G. Gastro-Intestinal Tract
H. Genito-Urinary Tract
I. Musculoskeletal
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• Able to move both upper and lower extremities
J. Integumentary
Serum
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Hemoglobin 143 g/l 120 – 170 g/l Normal Hemoglobin count
is in normal value
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Platelet count 150 – 400.00x10-
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(CBC profile) /L
Significance: The complete blood count is the calculation of the cellular (formed elements) of
blood. It may be a part of a routine check – up or screening, or as a follow up test to monitor
certain treatments. It can also be done as a part of an evaluation based on a patient’s symptoms.
Chest PA
Significance: A chest X-ray is a picture of the chest that shows your heart, lungs, airway, blood
vessels, and lymph nodes. A chest X-ray also shows the bones of your spine and chest, including
your breastbone, ribs, collaboration, and the upper part of your spine. A chest X-ray is the most
common imaging test or X-ray used to find problem inside the chest.
Significance: The erythrocyte sedimentation rate (ESR) is an easy, inexpensive, nonspecific test
that has been used for many years to help detect conditions associated with acute and chronic
inflammation, including infections, cancers, and autoimmune.
ABG
Significance: An arterial blood gas (ABG) test measures the acidity (pH) and the levels of
oxygen and carbon dioxide in the blood from an artery. This test is used to check how well your
lungs are able to move oxygen into the blood and remove carbon dioxide from the blood.
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Laboratory/Diagnostic Result Normal values Interpretation Implication
test
Examination
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Laboratory/Diagnostic Result Normal values Interpretation Implication
test
Microscopic Examination
October 22, 2010
RBC: 3-5/hpf
Pus cells: 6-10/hpf
Epithelial cells: occasional
Mucus thread: many
Bacteria: few
Cast
Hyaline: 0-1/lpf
Crystal
Urates: occasional
RBC: 1-4/hpf
Pus cells: 0.2/hpf
Epithelial cells: occasional
Mucus thread: many
Bacteria: few
Cast
Hyaline: /lpf
Crystal
Urates: few
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Significance: The urinalysis is used as a screening and/or diagnostic tool because it can help
detect substances or cellular material in the urine associated with different metabolic and kidney
disorders.
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114.92mmol/L is in normal
value
Chemistry 1
Significance: For confirming the suspected liver disease. For estimation of the liver damage and
as a guide for treating and knowing the prognosis of the liver disease.
Radiologic Report
Interpretation:
Chest PA SUPINE PORTABLE dated October 25, 2010 compared with the previous
examination dated October 21, 2010 shows interval development of fuzzy densities throughout
both lungs.
There is now haziness in the right lower lung, while the haziness in the left lower lung is
no longer seen.
Endotracheal tube is now seen with its tip above the carina.
Remarks:
Bilateral pulmonary congestion. Concomitant pneumonia in the right lung is not ruled
out.
Significance: A chest X-ray is a picture of the chest that shows your heart, lungs, airway, blood
vessels, and lymph nodes. A chest X-ray also shows the bones of your spine and chest, including
your breastbone, ribs, collarbone, and the upper part of the spine. A chest X-ray is the most
common imaging test or X-ray used to find problems inside the chest.
Clinical Chemistry
November 1, 2010
A/G ratio:
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decreased, may
suggest liver
diseases
A/G ratio:
BIlirubin Adult
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19.00Umol/L in normal value
Significance: A bilirubin test is a diagnostic blood test performed to measure levels of bile
pigment in an individual’s blood serum and to help evaluate liver function
Prothrombin Time
INR 1.15
Significance: Prothrombin time (PT) is a blood test that measures how long it takes blood to
clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to
check whether medicine to prevent blood clots is working.
November 1, 2010
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Examination Result Normal Value Interpretation Implication
Significance: The TSH test is often the test of choice for evaluating thyroid function and/or
symptoms of hyper- or hypothyroidism
X. Pathophysiology
• Trauma Unknown
• Surgery
• Gastrointestinal Illness
• Acute Illness
Immune system starts to destroy the myelin sheath that surrounds the axons
(segmental demyelination)
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XI. Nursing Care Plan 1
31
Ineffective
Airway
Clearance
Source:
Brunner &
Suddarth’s.
Textbook of
Medical-Surgical
Nursing. 12th edition
32
Assessment Nursing Diagnosis Rationale Desired Outcomes Nursing Justification Evaluation
Interventions
Actual Abnormal Impaired physical Precipitating factor: After 40 hours of Independent: After 40 hours of
Findings: mobility related to Guillain-Barré nursing interventions, nursing interventions,
neuromuscular syndrome the client will be able 1. Assist client 1. To promote the client will be able
Subjective: to: reposition self on a optimal level of to:
impairment as
regular schedule function and 1. Goal met.
-“gulpi lang siya indi evidenced by limited 1. Demonstrate prevent Client was able
maka giho sang iya range of motion; diffuse techniques/behaviours 2. Assess nutritional to demonstrate
limited ability to complication.
kamot kag tiil” as inflammation or that enable status and client’s techniques/beha
verbalized by perform gross/fine dymyelination (or resumption of report of energy level. 2. To identify vior that enable
motor skills; activities. resumption of
client’s mother both) of the causative/
difficulty turning. 3. Observe movement activities. He
ascending or 2. Demonstrate contributing factor. was able to do
Risk-Related descending when client is
Definition: techniques/behaviours passive ROM
Factors: peripheral nerves unaware of
that enable safe 2. Goal met.
Limitation in repositioning. observationto note Client was able
-Knowledge deficit any incongruencies 3. To assess
independent, to demonstrate
with reports of functional ability.
-Ecomomic purposeful physical techniques/
Damage to these 3. Maintain position abilities. behavior that
difficulties movement of the nerves makes it hard of function and skin enable safe
body or of one or for them to transmit integrity as evidenced 4. Provide regular 4. To promote
-Family patterns of repositioning
two extremities. signals. by absence of skin care to include optimal level of with the help of
healthcare function and
contractures, pressure area his mother and
Source: Doenges, footdrop, decubitus, prevent relatives
Strength/Wellness: Moorhouse, Murr. management.
and so forth. complication. 3. Goal met.
(2008). “Nurse’s muscles have Client was able
-Family support Collaborative:
Pocket Guide: trouble responding 5. To develop to maintain
-Religious beliefs Diagnoses, position of
to your brain 5. Consult with individual
Prioritized function and
and practices physician or exercise/mobility
Interventions, and skin integrity.
Rationales.” F.A. occupational therapist, program and
He did not have
Davis Company: Weakness or lack of as indicated. identify manifest any of
Philadelphia.11th ed. sensation in the appropriate contractures,
P. 457. mobility devices. footdrop,
legs, which spreads
to the upper part of decubitus,
Source: Doenges, pressure
the body Moorhouse, Murr. ulcers/bed
(2008). “Nurse’s sores. He was33
Pocket Guide: turned every 2
Impaired physical Diagnoses, hours to prevent
mobility these conditions
Prioritized
Assessmet Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions Justification Evaluation
Actual Abnormal Risk for aspiration Precipitating After 40 hours of Independent: After 40 hours of
Findings: related to presence factor: presence nursing interventions, nursing
of endotracheal of endotracheal the client will be able 1. Observe for neck 1. To assess interventions, the
-difficulty of tube. tube to: and facial edema. causative or client will be able
breathing contributing to:
Definition: 1. Experience no 2. Suction as factor. Client
Risk-Related aspiration as needed and avoid with tracheal 1. Goal partially
Factors: At risk for entry of Nasogastric evidenced by triggering gag or bronchial met. Client did
gastrointestinal Tube feedings noiseless mechanism when injury is at not experience
-situation hindering secretions, performing
elevation of the respirations; particular risk aspiration but
oropharyngeal clear breath suction or mouth for airway during
upper body secretions, or solids care.
Positioning sounds, clear, obstruction suctioning, he
-reduced level of or fluids into (improper), odourless and inability voluntarily
tracheobronchial 3. Auscultate lungs
consciousness depressed secretions. sounds to handle coughs out
passages. gag/cough reflex secretion. yellow to
-depressed frequently.
yellow green
cough/gag reflex 4. Assist with 2. To clear
2. Demonstrate colored
Source: Doenges, postural drainage secretion secretion and
-impaired impaired techniques to
Moorhouse, Murr. through changing while reducing was not able to
swallowing swallowing prevent
(2008). “Nurse’s of position (side potential for manifest
aspiration. aspiration of
Strength/Wellness: Pocket Guide: lying) noiseless
Diagnoses, secretion. respirations and
-Family support risk for Collaborative:
Prioritized 3. To determine clear breath
aspiration 3. Identify
Interventions, and 5. Refer to presence of sounds
Rationales.” F.A. causative or risk
factor. physician for secretions/
Davis Company: 2. Goal met.
medical silent Client was able
34
Philadelphia.11th ed. intervention and aspiration. to demonstrate
P. 98. exercise. techniques to
Source: 4. To mobilize prevent
Suddarth’s thickened aspiration such
Medical surgical secretions that as coughing out
manual may interfere of secretions
with and cooperates
swallowing. during suction
Collaborative: 3. Goal met.
5. To strengthen Client was able
muscles and to identify
learn causative or risk
techniques to factor such as
enhance accumulation of
swallowing/re secretions in
duce potential airway passages
aspiration.
Source: Doenges,
Moorhouse, Murr.
(2008). “Nurse’s
Pocket Guide:
Diagnoses, Prioritized
Interventions, and
Rationales.” F.A.
Davis Company:
Philadelphia.11th ed.
35
P. 98-101.
36
NAME OF DOSAGE, MECHANISM INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING
DRUG FREQUENCY, OF ACTION RESPONSIBILITIES
ROUTE
Fluimucil (Acetylcysteine)
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Therapeutic category:
Mucolytic agent
Exerts mucolytic action
through its free sulfhydryl
group which opens up the
disulfide bonds in the
mucoproteins thus lowering
mucous viscosity. The exact
mechanism of action in
acetaminophen toxicity is
unknown. It is thought to act
by providing substrate for
conjugation with the toxic
metabolite.
Dosage: 600mg/tab +50cc
water; Route: NGT;
Frequency: OD
Monitor effectiveness of
therapy and advent of
adverse/allergic effects.
Instruct
patient in appropriate use and
adverse effects to report
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Bibliography
• Hinchliff, Montague and Watson (1996). “Physiology for Nursing Practice”. Harcourt
• http://www.ninds.nih.gov/disorders/gbs/gbs.htm
• http://www.mayoclinic.com/health/guillain-barre-syndrome/DS00413
• http://www.scribd.com/doc/22044205/guillain-barre-syndrome-pathophysiology
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