U Assessment

HISTORY. Determine if the patient has had a recent viral illness or surgical procedure. Often, the patient describes a minor upper respiratory or gastrointestinal febrile illness. Many, but not all, patients complain of paresthesia (numbness, prickling, tingling) early in the course of the illness. The patient or family generally seeks assistance when bilateral lower limb weakness begins to spread toward the trunk or has progressed to paralysis of the limbs. Urinary incontinence may be a problem initially, followed by difficulty in swallowing and speaking. Impairment of respiratory functions, the most life-threatening effect of GBS, does not occur until the paralysis has affected all of the peripheral areas and the trunk.

PHYSICAL EXAMINATION. The major neurological sign found in GBS is muscle weakness, but sensory loss, particularly in the legs and later in the arms, often occurs. Although the progression of symptoms is variable, the disease often progresses upward from the legs in 1 to 3 days. To follow the progression of symptoms, test for ascending sensory loss by gently using a pinprick upward from the level of T12 on the vertebral column (level of the iliac crests) to the midscapular point (about T6). Mark the patient's skin with a pen every 4 hours to document changes. Notify the physician immediately if the level reaches T8 or higher, because muscles at that level are needed for breathing. Patients may also have ocular muscle paralysis, loss of position sense, and diminished or absent reflexes.

The function of cranial nerve VII (facial nerve) may be affected, especially in the later stages of the paralysis. To test for facial nerve weakness, inspect the patient's face at rest and during conversation. Have the patient raise both eyebrows, smile, frown, puff out the cheeks, and show both upper and lower teeth. If the facial nerve is involved, the patient may have problems talking, chewing, and swallowing.

386 Guillain-Barré Syndrome

Patients often have changes in their vital signs. Rapid or slow heart rates and a labile blood pressure may occur because of the effects on the vagus nerve (cranial nerve X), as well as profuse sweating and facial flushing. Patients require continuous cardiac monitoring to assess for dysrhythmias. Although respiratory function may be impaired in the later stages of paralysis, the nurse needs to assess the patency of the airway and adequacy of breathing in order to initiate prompt interventions when necessary.

PSYCHOSOCIAL. The patient is alert, but paralyzed, and this leads to considerable fear and anxiety both during the initial stages and throughout the course of the disease. As the paralysis ascends, the patient's level of anxiety will probably rise. The patient and significant others will need a great deal of emotional support to deal with the health crisis.

Diagnostic Highlights

Test Normal Result

Abnormality with Condition

Explanation

Cerebrospinal fluid Protein: 15-45 (CSF) assay mg/dL; glucose: 40-80 mg/dL; erythrocytes: 0-10/^L; leukocytes: 0-10/^L

Increase In CSF protein without an increase in cell count; lymphocytes might be present but are usually <20/^l

High protein levels (as high as 500 mg/dL) are often noted 1-2 wk of illness; peak at 4-6 wk

Other Tests: White blood cell counts showing mild leukocytosis, electromyography, pulmonary function tests, arterial and venous blood gases, blood cultures.

0 0

Post a comment