{
  "name": "Guillain-Barré Syndrome",
  "slug": "guillain-barre",
  "url": "https://nursingplex.com/care-plans/guillain-barre",
  "category": "Neurological",
  "summary": "Ascending paralysis; respiratory monitoring, VTE prevention and rehab planning.",
  "nursing_diagnoses": [
    "Ineffective breathing pattern",
    "Impaired physical mobility",
    "Anxiety"
  ],
  "overview": [
    "Guillain-Barré syndrome is an acute autoimmune polyneuropathy in which the immune system attacks peripheral nerve myelin, usually one to three weeks after a respiratory or gastrointestinal infection — Campylobacter jejuni is the classic trigger.",
    "Weakness is symmetric and ascending, starting in the legs and moving upward, with loss of deep tendon reflexes early. Progression can be alarmingly fast, reaching maximum in two to four weeks, and about a third of patients need mechanical ventilation when the paralysis reaches respiratory muscles.",
    "Autonomic instability adds a second danger: swings between hypertension and hypotension, tachycardia and bradycardia, ileus and urinary retention. Treatment is plasmapheresis or IVIG — not corticosteroids — plus intensive supportive care, and most patients eventually recover substantial function over months."
  ],
  "key_facts": [
    {
      "label": "Number one nursing priority",
      "text": "Respiratory monitoring — serial vital capacity and negative inspiratory force, not just pulse oximetry, which falls late."
    },
    {
      "label": "Intubation triggers",
      "text": "Vital capacity below about 15–20 mL/kg, rising CO2, weak cough or inability to count to 20 in one breath."
    },
    {
      "label": "Pattern",
      "text": "Ascending symmetric weakness with areflexia; sensation and cognition are largely preserved."
    },
    {
      "label": "Treatment",
      "text": "Plasmapheresis or IV immunoglobulin; corticosteroids are not effective."
    },
    {
      "label": "Autonomic swings",
      "text": "Expect labile blood pressure and arrhythmias; move and suction slowly and monitor continuously."
    },
    {
      "label": "Recovery",
      "text": "Descending recovery over weeks to months, often with residual fatigue and weakness."
    }
  ],
  "nursing_priorities": [
    "Continuously monitor and support ventilation.",
    "Detect and manage autonomic instability.",
    "Prevent VTE, pressure injury, contracture and aspiration.",
    "Control neuropathic pain.",
    "Maintain communication and reduce fear in a paralyzed but fully aware patient.",
    "Support prolonged rehabilitation."
  ],
  "assessment": {
    "subjective": [
      "Onset and progression of weakness and how far up the body it has moved",
      "Shortness of breath, difficulty swallowing or speaking",
      "Paresthesia, deep aching and burning pain",
      "Recent gastrointestinal or respiratory illness or vaccination",
      "Fear, helplessness and understanding of the expected course"
    ],
    "objective": [
      "Serial vital capacity, negative inspiratory force, respiratory rate and cough strength",
      "Ascending motor weakness mapped by level with each assessment and absent deep tendon reflexes",
      "Cranial nerve involvement: facial weakness, dysphagia, dysarthria, diplopia",
      "Blood pressure and heart rate variability, arrhythmias and orthostatic changes",
      "Bowel sounds, abdominal distention, bladder volume and urinary retention",
      "CSF showing high protein with normal cell count; nerve conduction studies",
      "Skin, calves and joint range for immobility complications"
    ],
    "related_factors": [
      "Autoimmune demyelination of peripheral nerves after infection",
      "Respiratory muscle paralysis",
      "Autonomic nervous system involvement",
      "Prolonged immobility and dependence",
      "Impaired swallowing and cough"
    ]
  },
  "goals": [
    "The client will maintain adequate ventilation, or will be intubated electively before respiratory failure.",
    "The client will maintain hemodynamic stability without untreated arrhythmia.",
    "The client will remain free of VTE, pressure injury, aspiration and contracture.",
    "The client will report pain at 3/10 or lower.",
    "The client will communicate needs effectively using an established method.",
    "The client will participate in rehabilitation as strength returns."
  ],
  "interventions": [
    {
      "title": "Respiratory surveillance",
      "points": [
        "Measure vital capacity and negative inspiratory force every 2–4 hours during progression and trend the values.",
        "Keep intubation equipment at the bedside and escalate before the patient is in distress.",
        "Assess cough, secretion clearance and swallowing; keep suction available and hold oral intake if swallowing is unsafe.",
        "Reposition and use chest physiotherapy to prevent atelectasis and pneumonia."
      ]
    },
    {
      "title": "Autonomic and hemodynamic care",
      "points": [
        "Maintain continuous cardiac monitoring during the acute phase.",
        "Change position slowly and avoid sudden movements or vigorous suctioning that can trigger bradycardia.",
        "Treat hypotension with fluids and hypertension cautiously with short-acting agents, since swings reverse quickly.",
        "Monitor for ileus, urinary retention and temperature instability."
      ]
    },
    {
      "title": "Treatment and complication prevention",
      "points": [
        "Administer IVIG with attention to infusion rate, hydration, renal function and allergic reaction, or support plasmapheresis with line care and volume monitoring.",
        "Give VTE prophylaxis, compression devices and passive range of motion at least twice daily.",
        "Use pressure-redistribution surfaces, reposition every two hours and protect heels and sacrum.",
        "Maintain nutrition with enteral feeding when swallowing is impaired and monitor weight."
      ]
    },
    {
      "title": "Pain, communication and psychological care",
      "points": [
        "Treat neuropathic pain with gabapentin or pregabalin plus adjuncts; positioning and gentle massage help deep aching.",
        "Establish a reliable communication method early — eye blinks, letter boards or communication devices — before speech is lost.",
        "Explain every procedure; the patient hears and understands even when unable to respond.",
        "Provide reassurance about the expected recovery and involve family in orientation and stimulation."
      ]
    }
  ],
  "patient_teaching": [
    "Explain that weakness typically peaks within two to four weeks, then improves gradually over months.",
    "Explain why breathing tests are done so often and what the numbers mean.",
    "Teach family what the patient can perceive and how to communicate with them.",
    "Prepare for a long rehabilitation with physical and occupational therapy.",
    "Report new weakness, breathing difficulty or swallowing trouble immediately after discharge.",
    "Expect residual fatigue and pace return to work and activity accordingly."
  ]
}