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Nursing Case Study

Guillain- Barre Syndrome

A Case Study

Presented to the faculty of Nursing

University of St. La Salle

In partial fulfillment of the requirements

For NCM104

Presented by:

Keeshia Marie Magbanua

Rhea Marie V. Montes

Joe Vincent Montinola

Ariana C. Natiag

Ramadel C. Nervez

Kimberly Nimanand

Louella Marie Onday

Fe Padrino

Tess Marie Pagunsan

Rhealine Joy C. Poblete

BN3F-Group 3

March 18, 2011


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Table of Contents

I. Introduction……………………………………………………………. 3

II. Objectives…………………………………………………………….....4

III. Anatomy and Physiology……………………………………………… 5

IV. Definition of Terms……………………………………………………..7

V. Baseline Data…………………………………………………………....8

VI. Nursing History (Gordon’s Functional Health Pattern)…….………..….9

VII. Health History………………………………………………………..... 11

VIII. Assessment………………………………………………………….…. 12

IX. Laboratory and Radiology……………………………………….……...15

X. Pathophysiology…………………………………………….................. 18

XI. Nursing Care Plan……………………………………………….…….. .29

XII. Drug Study……………………………………………………….……. .35

XIII. Health Teaching………………………………………………………. .42

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

After 5 days of case study, the student nurses aim to:

1. Define Guillain- Barre Syndrome.

2. Discuss the anatomy and physiology of the systems involve.

3. Enumerate the pre-existing and predisposing factors that contribute to the occurrence
of the disease.

4. Identify the existing signs and symptoms manifested by the patient.

5. Recognize the importance of the laboratories examination required for observing the
disease.

6. Illustrate the Pathophysiology of Guillain- Barre Syndrome.

7. Create an appropriate Nursing Care Plan for the patient.

8. Determine different drugs essential for the recovery of the patient.

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9. Formulate health teachings on medications, exercise, treatment, hygiene, out-patient
and diet.

III. Anatomy and Physiology

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.

Spinal nerves emerge from the spinal cord through spaces


between the vertebrae. Each nerve emerges as two short branches
(called spinal nerve roots): one at the front of the spinal cord and one at the back.

• 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

• Segmental demyelination- the destruction of myelin between the nodes of ranvier

• 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

• Ophthalmoplegia- paralysis or weakness of the eye muscles

• Areflexia- absence of reflexes

• Ataxia- defective muscle coordination

• 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

Address: Purok Mahinangpanon, Brgy. 5, Silay City, Negros Occidental

Age: 20

Number of Dependents: 0

Birth Date: June 10, 1990

Birth Place: Silay City Hospital

Gender: Male

Marital Status: Single

Religion: Roman Catholic

Educational Level: still in 4th year college

Nationality: Filipino

Occupation: student

Person next to kin: Mother

Date of admission: October 21, 2010, 1:30 pm

Attending physician: Dr. Arthur Ascalon, Dr. Baliguas

Chief Complaint: inability to move

Admitting Diagnosis: Community Acquired Pneumonia, High risk for Aspiration, Ischemic

Hepatitis to consider Guillain- Barre Syndrome

Final Diagnosis: Guillaine- Barre Syndrome

Date of surgery: none

Hospital: Our Lady of Mercy, Male Medical Ward

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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.

E. Activity and Exercise Pattern


Before admission, significant others stated that he likes to sew dress of Barbie dolls
and is not out going and stays only in the house. He is usually the one who does the
household chores such as washing the dishes, arranging the set in the house and a lot more.
Mother verbalized that his son does not engage in exercises.

F. Sleep and Rest Pattern


The patient usually sleeps 10 hours starting from 9 in the evening and he would wake
up at around 7 in the morning. He often has a good sleep due to tiredness because of the
activities in school. Patient doesn’t have siestas or afternoon naps during weekdays but does
during weekends. Two weeks before the admission, the patient only sleeps for about 5 hours
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a day due to the activities in school. He would arrive home 1:00 in the morning and would
wake up 7:00am to go back to school again. Furthermore, during those days he has already
experiencing flu but tolerated it. During admission, he complained that he can’t sleep well
due to the environment and noise.

G. Cognitive- Perception Pattern


The client responds to non-verbal stimuli. When asked, he would show that he would
agree or disagree by nodding his head since he cannot speak due to endotracheal tube. He is
still in 4th year college taking up Hospitality Management.

H. Self Perception- Self Concept Pattern


His mother stated that he is comfortable of himself and has a strong self-esteem. He is
confident of whom he is and has trust but during admission, he thought of himself as
worthless because of his condition but he is trying his best to recover from his illness so that
he can continue to his normal way of living by submitting himself to necessary and important
treatment.

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.

J. Sexuality and Reproductive Pattern


He is single and didn’t experience any relationship with opposite sex. He doesn’t
engage in any sexual contact and not productive.

K. Coping- Stress Pattern


His mother stated that his hobby of sewing dresses of Barbie doll makes him relaxed
and entertained. He would go to sleep right after a long hour of school activities. If he has
problems, he would talk to his friends as well as with his family members.

L. Values and Beliefs Pattern


They are Roman Catholic and they only believe that there is only one God and they
have a strong faith on Him. He doesn’t have any other beliefs or rituals.

VII. Health History


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1. History of Present Illness
Significant others stated that his son first experienced fever and he took it for
granted and still continued to go to school until such time that he can no longer tolerate
his condition.
Two weeks prior, patient was admitted and it was treated as typhoid, was
admitted for eight days in Silay Hospital.
One day prior, patient complaint of inability to move both upper and lower
extremities associated with vomiting, nausea, negative fever, difficulty of breathing and
seizure. There is persistence of signs and symptoms noted.

2. Past Health History

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

• 20 years old male adult


• Neat and clean physically
• With tidy hair
• With systemic jaundice noted

B. LOC

• awake, lying on bed in semi fowler’s position


• responsive and conscious to both verbal and non verbal stimuli and in
painful stimuli
• with GCS of 11 as evaluated

C. HEENT

• Pupils Equally Round and Reactive to Light and Accommodation


• with pale conjunctiva
• icteric sclerae
• with patent NGT for feeding inserted at right narynx
• with nasal flaring noted
• face symmetrical

D. Cardiovascular

• With ongoing IVF bottle#21 D5NM 1Lx60cc/hr infusing well at Right


cephalic vein with remaining solution of 280cc
• with strong palpable pulse at the rate of 90 bpm
• with BP = 100/80mmHg taken at Left arm in fowler’s position
• with good capillary refill of less than 2 seconds
• attached to pulse oximeter of 92 bpm

E. Respiratory

• With ET attached to mechanical vent with specific parameters of FIO2-


40%, back-up rate- 18, tidal vokume-300 on AC node
• With respiratory rate of 30 cpm
• with wheezing and crackles noted upon auscultation on both lung fields
• with symmetrical rise and fall of chest wall

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

• With diaper not fully soaked upon initial assessment


• With an average of 2 diaper change per shift approximately 150 cc

H. Musculoskeletal

• Unable to move; assistance needed


• Able to move both upper and lower extremities minimally

I. Integumentary

• warm to touch with temperature of 36.9°C


• with good skin turgor
• with pale mucous membrane as noted
• Hair well groomed, nail beds symmetrical and complete number of teeth
as noted

November 9, 2010

A. General Appearance

• 20 years old male adult


• Neat and clean physically
• With tidy hair

B. LOC

• awake, lying on bed


• responsive and conscious to both verbal and non verbal stimuli
• with GCS of 11 as evaluated

C. HEENT

• Pupils Equally Round and Reactive to Light and Accommodation


• with pale conjunctiva
• icteric sclerae
• with patent NGT for feeding inserted at right narynx
• face symmetrical
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D. Cardiovascular

• With ongoing IVF bottle#22 D5NM 1Lx60cc/hr infusing well at Right


cephalic vein with remaining solution of 350cc
• with strong palpable pulse at the rate of 90 bpm
• with BP = 100/80mmHg taken at Left arm in fowler’s position
• with good capillary refill of less than 2 seconds
• attached to pulse oximeter of 92 bpm

E. Respiratory

• With ET attached to mechanical vent with specific parameters of FIO2-


40%, back-up rate- 18, tidal vokume-300 on AC node
• With respiratory rate of 30 cpm
• with wheezing noted upon auscultation on both lung fields
• with symmetrical rise and fall of chest wall

F. Gastro-Intestinal Tract

• on OTF 225cc given q3H per NGT


• unable to defecate upon initial assessment

G. Genito-Urinary Tract

• With diaper not fully soaked upon initial assessment

H. Musculoskeletal

• Unable to move; assistance needed

I. Integumentary

• warm to touch with temperature of 36.8°C


• with good skin turgor with pale mucous membrane as noted

November 10, 2010

B. General Appearance

• 20 years old male adult


• Neat and clean physically
• With tidy hair

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C. LOC

• awake, lying on bed in fowler’s position


• conscious and responsive to both verbal and non verbal stimuli
• with GCS of 11 as evaluated

D. HEENT

• Pupils Equally Round and Reactive to Light and Accommodation


• with pale conjunctiva
• icteric sclerae
• with patent NGT for feeding inserted at right narynx
• face symmetrical

E. Cardiovascular

• With ongoing IVF bottle#23 D5NM 1Lx60cc/hr infusing well at Right


cephalic vein with remaining solution of 250cc
• with strong palpable pulse at the rate of 88 bpm
• with BP = 90/70mmHg taken at Left arm in fowler’s position
• with good capillary refill of less than 2 seconds
• attached to pulse oximeter of 82 bpm

F. Respiratory

• With ET attached to mechanical vent with specific parameters of FIO2-


40%, back-up rate- 18, tidal vokume-300 on AC node
• With respiratory rate of 30 cpm
• with crackles noted upon auscultation on both lung fields
• with symmetrical rise and fall of chest wall

G. Gastro-Intestinal Tract

• on OTF 225cc given q3H per NGT


• with normoactive bowel sound of 6cpm auscultated at right abdomen
• unable to defecate upon initial assessment

H. Genito-Urinary Tract

• With diaper not fully soaked upon initial assessment

I. Musculoskeletal

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• Able to move both upper and lower extremities

J. Integumentary

• cool to touch with temperature of 36.6°C


• with good skin turgor with pale mucous membrane as noted

IX. Laboratory and Radiology

Serum

October 21, 2010

Examination Result Normal Value Interpretation Implication

Creatinine 61.88 mmol/l 53.0 – Normal Creatinine level


114.92mmol/ is in normal
value

Potassium 4.30mmol/l 3.6 – 5.1mmol/l Normal Potassium level


is in normal
value

Sodium 137.60mmol/l 137 – 146mmol/l Normal Sodium level is


in normal value

Examination Result Normal Value Interpretation Implication

Creatinine 0.7 mg/dl 0.6 – 1.3 mg/dl Normal Creatinine level


is in normal
value

Potassium 4.3 mg/dl 3.6 – 5.1 mg/dl Normal Potassium level


is in normal
value

Sodium 137 mg/dl 137 – 145 mg/dl Normal Sodium level is


in normal value

Significance: This test measures the kidney function

Complete Blood Count

October 21, 2010

Examination Result Normal Value Interpretation Implication

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Hemoglobin 143 g/l 120 – 170 g/l Normal Hemoglobin count
is in normal value

Hematocrit 0.41 L/L 0.40 – 0.54 Normal Hematocrit count


is in normal value

RBC 4.48 4.60 – 6.00x10- Decreased RBC is decreased,


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/L may suggest
anemia

WBC 8.6 5.00 – 10.00x10- Normal WBC count is in


9
/L normal value

Segmenters 0.63 0.50 – 0.70 Normal Segmenters is in


normal value

Lymphocytes 0.37 0.20 – 0.40 Normal Lymphocytes is in


normal value

Platelet count 563 150.00 – Increased Platelet count is


(CBC profile) 400.00x10-9/L increased, may
suggest
myeloproliferative
disorder and
thromboembolism

October 26, 2010

Examination Result Normal Value Interpretation Implication

Hemoglobin 141 g/L 120 – 170 g/L Normal Hemoglobin


count is in
normal value

Hematocrit 0.40 L/L 0.40 – 0.54 Decreased Hematocrit is


decreased, may
suggest anemia

RBC 4.26 4.60 – 6.00x10- Decreased RBC is decreased


12
/L may suggest
anemia

WBC 9.1 5.00 – 10.00x10- Normal WBC count is in


9
/L normal value

Segmenters 0.76 0.50 – 0.70 Increased Segmenters


increased, may
suggest viral
infection

Lymphocytes 0.24 0.20 – 0.40 Normal Lymphocyte is in


normal value

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Platelet count 150 – 400.00x10-
9
(CBC profile) /L

October 27, 2010

Examination Result Normal Value Interpretation Implication

Hemoglobin 134 g/L 120 – 170 g/L Normal Hemoglobin


count is in
normal value

Hematocrit 0.39 L/L 0.40 – 0.54 Decreased Hematocrit is


decreased, may
suggest anemia

RBC 4.09 4.60 – 6.00x10- Decreased RBC is decreased


12
/L may suggest
anemia

WBC 8.9 5.00 – 10.00x10- Normal WBC count is in


9
/L normal value

Segmenters 0.74 0.50 – 0.70 Increased Segmenters


increased, may
suggest viral
infection

Lymphocytes 0.26 0.20 – 0.40 Normal Lymphocyte is in


normal value

Platelet count 150 – 400.00x10-


9
(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.

October 22, 2010

Examination Result Normal Value Interpretation Implication

ASO titer Positive <200 IU/mL Increased May suggest


streptococcal
infection

Chest PA

October 21, 2010


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Chest PA sitting shows hazy infiltrates in the lower lung

Heart is not enlarged

No other remarkable findings to note

Remarks: Left lower lung pneumonia

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.

October 22, 2010

Examination Result Normal Value Interpretation Implication

ESR result 86 mm/hr 0.00 - Increased ESR increased,


10.00mm/hr may suggest
marker of
infection or
inflammation in
the body.

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

October 22, 2010

Set-up: MV/Mode: AC FIO2 at 100% RR 20bpn Vt 350mL

Examination Result Normal Value Interpretation Implication

pH 7.41 7.35 – 7.45 Normal pH level is in


normal value

pCO2 40 mmHg 35 – 45 mmHg Normal pCO2 level is in


normal value

pO2 325 mmHg 80 – 100 mmHg Increased pO2is increased,


may suggest
Increased oxygen
levels in the
inhaled air and
polycythemia

HCO3 25.1mEq/L 22 – 26 mEq/L Normal HCO3 level is in


normal value

B.E. 0.6 mEq/L +/- 2 mEq/L Increased B.E is increased,


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may suggest Loss
of buffer base,
hemorrhage,
diarrhea, ingestion
of alkali

O2 Sat. 100% 97% Increased O2 sat. Is


increased, may
suggest deep or
rapid breathing
occurs and
inspired oxygen
levels are
increased, such as
breathing from a
100% axygen
source

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.

Laboratory/Diagnostic Result Normal values Interpretation Implication


test

Urinalysis (10/22/10) Color: Straw Color: Straw Normal The urine is


normal in color.

Transparency Transparency: Abnormal Hazy urine


Clear could mean that
mucus,
phosphates,
Physical bacteria, pus, or
fats are spilling
properties
into your urine.

pH: 5.0 pH: 7.0 Decreased The urine had


slight acidity.

Specific Specific Normal The urine’s


Gravity: 1.015 Gravitiy: concentration is
1.003-1.030 normal.

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Laboratory/Diagnostic Result Normal values Interpretation Implication
test

Urinalysis (10/22/10) Color: Dark Color: Straw Abnormal


yellow

Transparency: Transparency: Abnormal Hazy urine


Slightly hazy Clear could mean that
mucus,
phosphates,
bacteria, pus, or
fats are spilling
into your urine.
Physical
pH: 5.0 pH: 7.0 Decreased The urine had
properties slight acidity.

Specific Specific Normal The urine’s


Gravity: 1.015 Gravitiy: concentration is
1.003-1.030 normal.

Laboratory/Diagnostic Result Normal values Interpretation Implication


test

Urinalysis (10/22/10) Albumin: - Normal Presence of


Albumin is not
- noted

Sugar: - Normal Presence of


sugar is not
- noted
Chemical

Examination

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Laboratory/Diagnostic Result Normal values Interpretation Implication
test

Urinalysis (10/22/10) Albumin: - Normal Presence of


Albumin is not
- noted

Sugar: - Normal Presence of


Chemical sugar is not
- noted
Examination

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

October 22, 2010

RBC: 1-4/hpf
Pus cells: 0.2/hpf
Epithelial cells: occasional
Mucus thread: many
Bacteria: few
Cast
Hyaline: /lpf

Crystal
Urates: few

22
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.

October 24, 2010

Examination Result Normal Value Interpretation Implication

Sodium 141.20mmol/L 137-146mmol/L Normal Sodium level is


in normal value

Examination Result Normal Value Interpretation Implication

Sodium 141.2mmol/L 137-145mmol/L Normal Sodium level is


in normal value

October 26, 2010

Examination Result Normal Value Interpretation Implication

Creatinine 79.56mmol/L 53.0- Normal Creatinine level


114.92mmol/L is in normal
value

Potassium 3.35mmol/L 3.6-5.1mmol/L Decreased Potassium level


is decreased, may
suggest
hypokalemia

Sodium 139.8mmol/L 137-146mmol/L Normal Sodium level is


in normal value

October 27, 2010

Examination Result Normal Value Interpretation Implication

Creatinine 53.04mmol/L 53.0- Normal Creatinine level

23
114.92mmol/L is in normal
value

Potassium 2.75mmol/L 3.6-5.1mmol/L Decreased Potassium level


is decreased, may
suggest
hypokalemia

Sodium 141mmol/L 137-146mmol/L Normal Sodium level is


in normal value

Significance: This test measures the kidney functions.

Chemistry 1

October 25, 2010

Test CU (result) SI (result) CU (normal SI (normal Interpretation Implication


value) value)

SGPT 215U/L 215 U/L 0.41U/L 0.41U/L Increased SGPT is


increased,
may suggest
liver
damage
such as
hepatitis

October 30, 2010

Test CU (result) SI (result) CU (normal SI (normal Interpretation Implication


value) value)

SGPT 364 U/L 364 U/L 0.41U/L 0.41U/L Increased SGPT is


increased,
may suggest
liver
24
damage
such as
hepatitis

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

Exam taken: Chest PA

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

Examination Result Normal Value Interpretation Implication

A/G ratio:

Total Protein 77g/L 63-82g/L Normal Total protein is


in normal value

Albumin 34.90g/L 35-50g/L Decreased Albumin is

25
decreased, may
suggest liver
diseases

Globulin 42.10g/L 23-30g/L Increased Globulin is


increased, may
suggest infection
and hepatitis

A/G ratio 0.80 1.10-2.50 Decreased A/G ratio is


decreased, may
suggest liver or
kidney disorder

Examination Result Normal Value Interpretation Implication

A/G ratio:

Total Protein 7.70g/dL 6.30-8.20g/dL Normal Total protein is


in normal value

Albumin 3.49g/dL 3.50-5g/dL Decreased Albumin is


decreased, may
suggest liver
diseases

Globulin 4.21g/dL 2.30-3g/dL Increased Globulin is


increased, may
suggest infection
and hepatitis

A/G ratio 0.80 1.10-2.50 Decreased A/G ratio is


decreased, may
suggest liver or
kidney disorder

Significance: To detect any liver or kidney disease

BIlirubin Adult

Examination Result Normal Value Interpretation Implication

Total bilirubin 13.00 Umol/L 0.00- Normal Total bilirubin is

26
19.00Umol/L in normal value

Direct bilirubin 10.00 Umol/L 0.00-5.00Umol/L Increased Direct bilirubin is


increased, may
suggest hepatitis

Indirect 3.00Umol/L 0.00- Normal Indirect bilirubin


bilirubin 14.10Umol/L is in normal
value

Examination Result Normal Value Interpretation Implication

Total bilirubin 0.76mg/dL 0.00-1.11mg/dL Normal Total bilirubin is


in normal value

Direct bilirubin 0.58mg/dL 0.00-0.29mg/dl Increased Direct bilirubin is


increased, may
suggest hepatitis

Indirect 0.18mg/dL 0.00-0.82mg/dL Normal Indirect bilirubin


bilirubin is 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

Examination Result Normal Value Interpretation Implication

Patient 13.7 9.15-11.28 secs Increased Patient is


increased

INR 1.15

% activity 63.2 More than 70% Decreased % activity is


decreased

NPM 10.22 sec Normal NPM is in


normal value

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
27
Examination Result Normal Value Interpretation Implication

TSH 1.335UIU/ml 0.49-4.67UIU/ml Normal TSH is in normal


value

Significance: The TSH test is often the test of choice for evaluating thyroid function and/or
symptoms of hyper- or hypothyroidism

X. Pathophysiology

Precipitating Factors: Predisposing


Factors:

• Trauma Unknown

• Surgery

• Immunization 1 to 3 weeks before the onset

• Gastrointestinal Illness

• Acute Illness

• Viral infection and respiratory tract infection

Entrance of pathogens (bacterial and viral)


in the body

Pathogens invade the immune


system

Limited malfunction of the immune

Immune system starts to destroy the myelin sheath that surrounds the axons
(segmental demyelination)

Affects salutatory conduction (leaping of impulses from


node to node)

Dispersion of Slow conduction Conduction


Impulses velocities Block 28
Affects cranial, motor nerves, myelinated pain, touch, temperature, nerve fibers, and
sensory functions
Brain, may receive inappropriate
sensory signals

Descending Ascending Milter Fisher


GBS GBS Variant

-Weakness of face or - -Opthalmoplegia,


bulbar muscle of the Opthalmopleg areflexia, severe
jaw, ia, diplopia, ataxia, inability to
sternocleidomastoid functional smile, frown whistle,
muscle, muscle of blindness, drink from a straw,
tongue, pharynx and numbness dysphagia, paralysis
larynx. in hands, of larynx, inability to
decrease or cough, gag or
-Progress downward to absent deep swallow,
involve limbs,
hypertensive or
breathlessness during
Note: All bold text are manifested hypotensive
by the patient

29
XI. Nursing Care Plan 1

ASSESSMENT NURSING RATIONALE DESIRED NURSING JUSTIFICATION EVALUATION


DIAGNOSIS OUTCOME INTERVENTIONS
Actual Abnormal Ineffective Airway Precipitating After 40 hours of Independent: After 40 hours of
Findings: Clearance related Factor: nursing intervention,  Position head  To open or nursing intervention,
to excessive, Presence of my client will be able in semi maintain the client was able
 RR= 30 thickened mucus disease to: fowler’s open to:
 PR= 90 secretions and position airway in at 1. Goal met.
 Attached to presence of rest or
1. Maintain airway appropriate Client able to
mechanical disease as Guillain compromis
evidenced by CAP patency for age or breath
ventilator ed
having of rhonchi, Barre condition properly, his
 Excessive individual
alterations in Syndrome tube was
sputum In  To clear
laboratory results airway suctioned and
upon vasion
(Chest PA) and is  Suction when cleaned from
suctioning
attached to Of tracheal/oral excessive time to time
 Cold and
clammy
mechanical immune prn or viscous and he
ventilator bacteria secretions undergone
skin
system starts in 2. Expectorate or are process of
 Laboratory
Definition: the clear secretions blocking weaning.
results to destroy
Inability to clear readily airway 2. Goal met.
Chest Pa lungs
secretions or  To take Client able to
October the myelin  Elevate head
obstructions from advantage
21,2010 sheath that of cough out
the respiratory of gravity
Remarks: Left
tract to maintain
surrounds bed/change secretions
lower lung Chest Pa decreasing and
a clear airway position pressure on
pneumonia the axons
every 2 hours participates
showed the
Source: Doenges E., of many and prn when he is
October 25, diaphragm
Moorhouse M., haziness 3. Demonstrate and told during
2010 peripheral in behaviours to suctioning.
Remarks: Geisller-Murr A., enhancing
both improve or 3. Goal met.
Bilateral Nurse’s Pocket drainage
nerves lung maintain clear Client made
pulmonary Guide 11th edition. areas of/ventilatio
congestion p. 77 airway  Assist with n to use of
use of different gestures as
nerves lung means to
30
Risk Factors: there is respiratory segments communicate
 Infection cannot devices and  To maintain when he
accumulation adequate
 Retained treatments experiences
transmit of
secretions airways, difficulty in
secretions
 Presence of signals in improve breathing.
artificial the respiratory
airway efficiently function
 Position and gas
Strength factor: lungs
appropriately exchange
• Good family
support  To help
muscles begin facilitate in
• Good to lose their Collaborative: the entry of
participation in ability to
 Give air
treatment regimen respond to
the brain's expectorants
• Strong Faith in commands or  To promote
God ronchi bronchodilato wellness
rs as ordered
and Source: Doenges
crackles E., Moorhouse M.,
Weakness Geisller-Murr A.,
heard Nurse’s Pocket
or paralysis Guide 11th edition. p.
upon
of spread
77-81
auscultation
to the
in both
muscles that lung
fields
control
breathing

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.

XII. Drug Study

36
NAME OF DOSAGE, MECHANISM INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING
DRUG FREQUENCY, OF ACTION RESPONSIBILITIES
ROUTE

Generic Name: Dosage:  Hypertension,  Contraindicated • Allergic: 1. Do not


Metropolol 50mg/tab  Competitively alone or with with sinus pharyngitis, discontinue drug
Route: NGT blocks beta- other drugs, bradycardia (HR erythematous abruptly after
Brand Name: adrenergic especially less than 45 bpm); rash, fever, sore long-term
AstraZeneca Frequency: receptors in diuretic. second or third throat, therapy.
BID the heart and  Immediate- degree heart block laryngospasm 2. Give drug with
Classification: juxtaglomerula release tablets (PR interval more • CNS: dizziness, food to facilitate
Antihypertensive; r apparatus, and injection: than 0.24 sec), vertigo, tinnitus, absorption.
Beta1-selective decreasing the Prevention of cardiogenic shock, fatigue, emotional 3. Provide
adrenergic blocker influence of reinfarction in heart failure depression, continual cardiac
the MI patients who  Use cautiously with paresthesias, sleep monitoring for
sympathetic are asthma or COPD disturbances, patients
nervous hemodynamicall hallucinations, receiving the
system on y stable or disorientation, drug.
these tissues within 3-10 days memory loss,
and the of acute MI. slurred speech
excitability of  Long-term • CV: heart failure,
the heart, treatment of cardiac
decreasing angina pectoris. arrhythmias,
cardiac output  Tropol-XL only; peripheral
and the release treatment of vascular
of rennin, and stable, insufficiency,
lowering BP; symptomatic claudication,
acts in CNS to heart failure of CVA, pulmonary
reduce ischemic, edema,
sympathetic hypertensive, or hypotension
outflow and cardiomyopathic • Dermatologic: rash,
vasoconstricto origin. pruritis, sweating,
r tone. dry skin
• EENT: eye
irritation, dry
eyes,
conjunctivitis,
blurred vision
37
• GI: gastric pain,
flatulence,
constipation,
diarrhea, nausea,
XIII. Health Teaching Plan

Medication Exercises Treatment Hygiene Outpatient Diet

 Levofloxacin (Levocin) 1. Teach client 1. Oral Hygiene 1. Have adequate Osteorized


 Fluoroquinolone/anti - infective breathing - Tooth rest and should Feeding on strict
 Inhibits the enzyme DNA exercises • Tracheostomy brushing maintain aspiration
gyrase in susceptible gram- • to deepen  to bypass an
- Mouth healthy diet to
precaution- give
negative and gram-positive breathing and washing promote
airway that has recovery. feeding via
aerobic and anaerobic bacteria, for better lung
expansion become obstructed 2. Personal Hygiene 2. Continue nasogastric tube
interfering with bacterial DNA
synthesis How?  to remove a. Skin care- apply medications
 Dosage: 1cap 500mg, Route: lotion to prescribed by
• Place hands on fluid that has built up moisturize the the doctor.
PO, Frequency: OD
the border of rib in the upper airway, skin 3. Instruct family
 Tell patient to stop taking drug
and contact prescriber if he cage particularly in the b. Bathing- removes to return to
experiences signs or symptoms • Inhale through throat and trachea dirt and dead attending
of hypersensitivity reaction nose and exhale epithelial cells physician for a
(windpipe)
(rash, hives, or other skin trough mouth from the surface scheduled
• Do this at least  to assist with of skin, reducing check-up.
reactions) or severe diarrhea
(which may indicate 10 times every breathing by the chance of 4. Continue mild
pseudomembranous colitis). time patient is delivering oxygen to infection exercise
awake c. Hair care- regimen for
 Check vital signs, especially the lungs brushing and faster recovery.
blood pressure. Too-rapid
2. Ambulate from • Fluid/IVF combing the hair Avoid
infusion can cause hypotension.
stimulates strenuous
38
 Closely monitor patients with time to time circulation of exercises.
therapy – for
renal insufficiency. • To improve blood in the scalp 5. Advise to report
circulation hydration and to d. Eye care- soften to the physician
 Monitor blood glucose level
closely in diabetic patients. replace loss fluids dried secretions if any sign of
and electrolytes using tap clean complications
 Metropolol (AstraZeneca) 3. Do passive water, wipe from occur
- D5NM inner to outer
 Antihypertensive; Beta1- ROM
selective adrenergic blocker • Also to • Medications canthus
 Competitively blocks beta- improve e. Ear care- clean
- Anti
adrenergic receptors in the circulation the pinna with
infective moist wash cloth
heart and juxtaglomerular
apparatus, decreasing the 4. Have Enough - Antihyperten f. Nose care- clean
influence of the sympathetic rest nasal secretions
sive
nervous system on these to provide relief to by blowing the
tissues and the excitability of the pain felt - Mucolytic nose gently with
the heart, decreasing cardiac Agents soft tissue
output and the release of g. Hand washing
- Multivitamin h. Regular change of
rennin, and lowering BP; acts
s clothing
in CNS to reduce sympathetic
outflow and vasoconstrictor i. Environmental
tone. Sanitation
 Dosage: 50mg/tab; Route:
NGT; Frequency: BID
 Provide continual cardiac
monitoring for patients
receiving the drug.
 Do not discontinue drug
abruptly after long-term
therapy.
 Give drug with food to
facilitate absorption.

 Fluimucil (Acetylcysteine)
39
 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

 Multiple vitamins (KREBB C)


 Multivitamin
 Dietary supplement for the
treatment and prevention of
vitamin deficiencies. These
vitamins are necessary for
normal growth and
development. Many act as
coenzymes or catalysts in
40
numerous metabolic processes.
 Dosage: 1 cap; Route: NGT;
Frequency: OD
 Instruct patient to report
adverse effects of the drug.

41
Bibliography

• Brunner and Suddarth’s. “Medical Surgical Nursing. Lippincott Williams and

Wilkins”. 12th Edition. Volume II. Pp.1966 – 1970

• Hinchliff, Montague and Watson (1996). “Physiology for Nursing Practice”. Harcourt

Brace and Company. 2nd Editoin. p281

• Doenges, et.al (2006). “Nurses Pocket Guide: Diagnoses, Interventions and

Rationales”. F.A. Davis Company: Philadelphia. 11th Edition.pp98-101, 70-73, 77-81

• 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

42