Nursing Care Plan for Guillain-Barre Syndrome
Nursing Diagnosis : Ineffective breathing pattern
related to:
weakness or paralysis of the respiratory muscles.
Goal / Outcomes:
Demonstrating adequate ventilation with no signs of respiratory distress, and effective breathing pattern.
Nursing Interventions:
Independent
1. Monitor the frequency, depth and symmetry of breathing. Note the increased work of breathing and skin color observations and mucous membranes.
R /: Increased respiratory distress indicate respiratory muscle fatigue and / or paralysis that may require support from mechanical ventilation.
2. Assess for changes in sensation, especially a decrease in the response.
R /: Decreased sensation often (though not always) lead to motor weakness.
3. Note the presence of respiratory fatigue during the talk if the patient is still able to speak.
R /: Is a good indicator of impaired respiratory function / decrease in lung capacity.
4. Auscultation of breath sounds, note the absence of sound or extra sound like crackles.
R /: The increase in airway resistance and accumulation of secretions or would interfere with the gas diffusion process and will lead to respiratory complications (such as pneumonia).
5. Elevate the head of your bed or put the patient in a sitting position leaning.
R /: Improving lung expansion and cough effort, decrease the work of breathing and limit the risk of aspiration of secretions.
Collaboration
6. Perform monitoring of blood gas analysis, pulse oximetry on a regular basis.
R /: Determine the effectiveness of the ventilation now and the need for / effectiveness of the intervention.
7. Perform to review the x-rays.
R /: The change is indicative of pulmonary congestion and or atelectasis.
8. Provide medication or help with the cleaning action of breathing, such as breathing exercises, chest percussion, fibrasi, and postural drainage.
R /: Improved ventilation and decrease atelectasis to mobilize secretions and improving lung expansion alveoili.
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