51455701 Guillain Barre

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

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March 18, 2011

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

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I. Introduction

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.

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.

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

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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:

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.

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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

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.

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http://www.merck.com/mmhe/sec06/ch095/ch095d.html#MMHE_06_095_02

II. 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: MC

Address:

Age: 63

Birth Date:

Birth Place:

Gender: Male

Marital Status: Single

Religion: Roman Catholic

Educational Level: undergraduate

Nationality: Filipino

Occupation: student

Attending physician:

Chief Complaint: inability to move

Admitting Diagnosis: Community Acquired Pneumonia, to consider Guillain- Barre

Syndrome

Final Diagnosis: Guillaine- Barre Syndrome

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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.

A. 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.

B. 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.

C. 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.

D. 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.

E. 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.

F. 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.

G. 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.

H. 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.

I. 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.

J. 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.

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VII. Health History

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.

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VIII. Assessment

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 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

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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

D. Cardiovascular With ongoing IVF bottle#22 D5NM 1Lx60cc/hr infusing well at Right cephalic


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

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20 years old male adult Neat and clean physically With tidy hair

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


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 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, 201013

Examination Result Normal Value Interpretation Implication

Creatinine 61.88 mmol/l 53.0 – 114.92mmol/

Normal Creatinine level 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


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


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-

12/LDecreased RBC is decreased,

may suggest anemia

WBC 8.6 5.00 – 10.00x10-

9/LNormal WBC count is in

normal value

Segmenters 0.63 0.50 – 0.70 Normal Segmenters is in normal value

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Lymphocytes 0.37 0.20 – 0.40 Normal Lymphocytes is in normal value

Platelet count (CBC profile)

563 150.00 – 400.00x10-9/L

Increased Platelet count is increased, may

suggest myeloproliferative

disorder and thromboembolism

October 26, 2010


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-

12/LDecreased RBC is

decreased may suggest anemia

WBC 9.1 5.00 – 10.00x10-


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


150 – 400.00x10-

9/L

October 27, 2010


Hemoglobin 134 g/L 120 – 170 g/L Normal Hemoglobin count is in

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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-

12/LDecreased RBC is

decreased may suggest anemia

WBC 8.9 5.00 – 10.00x10-


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


150 – 400.00x10-

9/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


ASO titer Positive <200 IU/mL Increased May suggest streptococcal infection

Chest PA

October 21, 2010

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

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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


ESR result 86 mm/hr 0.00 - 10.00mm/hr

Increased ESR increased, 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


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

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

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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 test

Result Normal values Interpretation Implication

Urinalysis (10/22/10)

Physical

properties

Color: Straw Color: Straw Normal The urine is normal in color.

Transparency Transparency: Clear

Abnormal Hazy urine could mean that mucus, phosphates, bacteria, pus, or fats are spilling into your urine.

pH: 5.0 pH: 7.0 Decreased The urine had slight acidity.

Specific Gravity: 1.015

Specific Gravitiy:

1.003-1.030

Normal The urine’s concentration is normal.



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Physical

properties

Color: Dark yellow

Color: Straw Abnormal

Transparency: Slightly hazy

Transparency: Clear

Abnormal Hazy urine could mean that mucus, phosphates, bacteria, pus, or fats are spilling into your urine.

pH: 5.0 pH: 7.0 Decreased The urine had slight acidity.

Specific Gravity: 1.015

Specific Gravitiy:

1.003-1.030

Normal The urine’s concentration is normal.




Chemical

Examination

Albumin:

-

- Normal Presence of Albumin is not

noted

Sugar:

-

- Normal Presence of sugar is not

noted

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Chemical

Examination

Albumin:

-

- Normal Presence of Albumin is not

noted

Sugar:

-

- Normal Presence of sugar is not

noted

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

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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.

October 24, 2010


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

in normal value



in normal value

October 26, 2010


Creatinine 79.56mmol/L 53.0-

114.92mmol/L

Normal Creatinine level

is in normal

value

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

is decreased, may

suggest

hypokalemia


in normal value

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October 27, 2010


Creatinine 53.04mmol/L 53.0-

114.92mmol/L

Normal Creatinine level

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

value)

SI (normal

value)

Interpretation Implication

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

increased,

may

suggest

liver

damage

such as

hepatitis

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October 30, 2010

Test CU (result) SI (result) CU (normal

value)

SI (normal

value)

Interpretation Implication

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

increased,

may

suggest

liver

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

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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:

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

in normal value

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

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


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

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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


Total bilirubin 13.00 Umol/L 0.00-

19.00Umol/L

Normal Total bilirubin is

in normal value

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

is increased, may

suggest hepatitis

Indirect

bilirubin

3.00Umol/L 0.00-

14.10Umol/L

Normal Indirect bilirubin

is in normal

value


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

bilirubin

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

is in normal

value

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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


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


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

26

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

27

Limited malfunction of the immune system

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 Impulses Slow conduction velocities Conduction Block

Affects cranial, motor nerves, myelinated pain, touch, temperature, nerve fibers, and sensory functions

Brain, may receive inappropriate sensory signals

Milter Fisher VariantDescending GBS Ascending GBS

-Weakness of face or bulbar muscle of the jaw, sternocleidomastoid muscle, muscle of tongue, pharynx and larynx.

-Progress downward to involve limbs, breathlessness during speech, shallow respirations, decrease tidal volume.

-Opthalmoplegia, diplopia, functional blindness, numbness in hands, decrease or absent deep tendon reflexes

-Opthalmoplegia, areflexia, severe ataxia, inability to smile, frown whistle, drink from a straw, dysphagia, paralysis of larynx, inability to cough, gag or swallow, hypertensive or hypotensive episodes, orthostatic hypotension, bradycardia, heart block, asystole.

Entrance of pathogens (bacterial and viral) in the body

Pathogens invade the immune system

Note: All bold text are manifested by the patient

XI. Nursing Care Plan 1

ASSESSMENT NURSING DIAGNOSIS RATIONALE DESIRED OUTCOME NURSING INTERVENTIONS

JUSTIFICATION EVALUATION

Actual Abnormal Findings:

RR= 30 PR= 90 Attached to

mechanical ventilator

Excessive sputum upon suctioning

Cold and clammy skin

Laboratory results

Chest PaOctober 21,2010Remarks: Left lower lung pneumonia

October 25, 2010Remarks: Bilateral pulmonary congestion

Risk Factors: Infection Retained

Ineffective Airway Clearance related to excessive, thickened mucus secretions and presence of disease as evidenced by having of rhonchi, alterations in laboratory results (Chest PA) and is attached to mechanical ventilator

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Source: Doenges E., Moorhouse M., Geisller-Murr A., Nurse’s Pocket Guide 11th edition. p. 77

Precipitating Factor: Presence of disease

Guillain CAPBarre Syndrome Invasion Ofimmune bacteriasystem starts in theto destroy lungsthe myelin sheath that surrounds Chest Pathe axons showedof many haziness peripheral in bothnerves lung areas

nerves there iscannot accumulationtransmit of secretionssignals in the efficiently lungs

muscles begin to lose their ability to respond to

After 40 hours of nursing intervention, my client will be able to:

1. Maintain airway patency

2. Expectorate or clear secretions readily

3. Demonstrate behaviours to improve or maintain clear airway

Independent: Position head

in semi fowler’s position appropriate for age or condition

Suction tracheal/oral prn

Elevate head of bed/change position every 2 hours and prn

Assist with

To open or maintain open airway in at rest or compromised individual

To clear airway when excessive or viscous secretions are blocking airway

To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of/ventilation to different lung segments

To maintain adequate airways, improve

After 40 hours of nursing intervention, the client was able to:

1. Goal met. Client able to breath properly, his tube was suctioned and cleaned from time to time and he undergone process of weaning.

2. Goal met. Client able to cough out secretions and participates when he is told during suctioning.

3. Goal met. Client made use of

28

secretions Presence of

artificial airway

Strength factor: Good family

support Good

participation in treatment regimen

Strong Faith in God

the brain's commands ronchi and cracklesWeakness heard or paralysis uponof spread auscultationto the in bothmuscles that lung fieldscontrol breathing

Ineffective Airway Clearance

Source:Brunner & Suddarth’s. Textbook of Medical-Surgical Nursing. 12th edition

use of respiratory devices and treatments

Position appropriately

Collaborative: Give

expectorants or bronchodilators as ordered

respiratory function and gas exchange

To help facilitate in the entry of air

To promote wellness

Source: Doenges E., Moorhouse M., Geisller-Murr A., Nurse’s Pocket Guide 11th edition. p. 77-81

gestures as means to communicate when he experiences difficulty in breathing.

29

Assessment Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions

Justification Evaluation


Subjective:

-“gulpi lang siya indi maka giho sang iya kamot kag tiil” as verbalized by client’s mother

Risk-Related Factors:

-Knowledge deficit

-Ecomomic difficulties

-Family patterns of healthcare

Strength/Wellness:

-Family support

-Religious beliefs and practices

Impaired physical mobility related to neuromuscular impairment as evidenced by limited range of motion; limited ability to perform gross/fine motor skills; difficulty turning.

Definition:

Limitation in independent, purposeful physical movement of the body or of one or two extremities.

Source: Doenges, Moorhouse, Murr. (2008). “Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.” F.A.

Precipitating factor: Guillain-Barré syndrome

diffuse inflammation or

dymyelination (or both) of the ascending or descending

peripheral nerves

Damage to these nerves makes it hard for them to transmit

signals.

muscles have trouble responding

to your brain

After 40 hours of nursing interventions, the client will be able to:

1. Demonstrate techniques/behaviours that enable resumption of activities.

2. Demonstrate techniques/behaviours that enable safe repositioning.

3. Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth.

Independent:

1. Assist client reposition self on a regular schedule

2. Assess nutritional status and client’s report of energy level.

3. Observe movement when client is unaware of observationto note any incongruencies with reports of abilities.

4. Provide regular skin care to include pressure area management.

Collaborative:

5. Consult with physician or occupational therapist,

1. To promote optimal level of function and prevent complication.

2. To identify causative/ contributing factor.

3. To assess functional ability.

4. To promote optimal level of function and prevent complication.

5. To develop individual exercise/mobility program and


1. Goal met. Client was able to demonstrate techniques/behavior that enable resumption of activities. He was able to do passive ROM

2. Goal met. Client was able to demonstrate techniques/ behavior that enable safe repositioning with the help of his mother and relatives

3. Goal met. Client was able to maintain position of function and skin integrity.

30

Davis Company: Philadelphia.11th ed. P. 457. Weakness or lack of

sensation in the legs, which spreads to the upper part of

the body

Impaired physical mobility

Source:

Black and Hawks. Medical-Surgical Nursing

as indicated. identify appropriate mobility devices.

Source: Doenges, Moorhouse, Murr. (2008). “Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.” F.A. Davis Company: Philadelphia.11th ed. P. 459-460.

He did not have manifest any of contractures, footdrop, decubitus, pressure ulcers/bed sores. He was turned every 2 hours to prevent these conditions

31

Assessmet Nursing Diagnosis Rationale Desired Outcomes Nursing Interventions Justification Evaluation


-difficulty of breathing

Risk-Related Factors:

-situation hindering elevation of the upper body

-reduced level of consciousness

-depressed cough/gag reflex

-impaired swallowing

Strength/Wellness:

-Family support

Risk for aspiration related to presence of endotracheal tube.

Definition:

At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or solids or fluids into tracheobronchial passages.

Source: Doenges, Moorhouse, Murr. (2008). “Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.” F.A. Davis Company: Philadelphia.11th ed.

Precipitating factor: presence of endotracheal tube

Nasogastric Tube feedings

Positioning (improper), depressed

gag/cough reflex

impaired swallowing

risk for aspiration


1. Experience no aspiration as evidenced by noiseless respirations; clear breath sounds, clear, odourless secretions.

2. Demonstrate techniques to prevent aspiration.

3. Identify causative or risk factor.

Independent:

1. Observe for neck and facial edema.

2. Suction as needed and avoid triggering gag mechanism when performing suction or mouth care.

3. Auscultate lungs sounds frequently.

4. Assist with postural drainage through changing of position (side lying)

Collaborative:

5. Refer to physician for medical intervention and exercise.

1. To assess causative or contributing factor. Client with tracheal or bronchial injury is at particular risk for airway obstruction and inability to handle secretion.

2. To clear secretion while reducing potential for aspiration of secretion.

3. To determine presence of secretions/ silent aspiration.

4. To mobilize


1. Goal partially met. Client did not experience aspiration but during suctioning, he voluntarily coughs out yellow to yellow green colored secretion and was not able to manifest noiseless respirations and clear breath sounds

2. Goal met. Client was able

32

P. 98.

Source: Suddarth’s Medical surgical manual

thickened secretions that may interfere with swallowing.

Collaborative:

5. To strengthen muscles and learn techniques to enhance swallowing/reduce potential aspiration.

Source: Doenges, Moorhouse, Murr. (2008). “Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales.” F.A. Davis Company: Philadelphia.11th ed. P. 98-101.

to demonstrate techniques to prevent aspiration such as coughing out of secretions and cooperates during suction

3. Goal met. Client was able to identify causative or risk factor such as accumulation of secretions in airway passages

33

XII. Drug Study

NAME OF DRUG

DOSAGE, FREQUENCY,

ROUTE

MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECT NURSING RESPONSIBILITIES

Generic Name:Metropolol

Brand Name:AstraZeneca

Classification: Antihypertensive; Beta1-selective adrenergic blocker

Dosage: 50mg/tabRoute: NGT Frequency: BID

Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of rennin, and lowering BP; acts in CNS to reduce

Hypertension, alone or with other drugs, especially diuretic.

Immediate-release tablets and injection: Prevention of reinfarction in MI patients who are hemodynamically stable or within 3-10 days of acute MI.

Long-term treatment of angina pectoris.

Tropol-XL only; treatment of stable, symptomatic heart failure of ischemic,

Contraindicated with sinus bradycardia (HR less than 45 bpm); second or third degree heart block (PR interval more than 0.24 sec), cardiogenic shock, heart failure

Use cautiously with asthma or COPD

Allergic: pharyngitis, erythematous rash, fever, sore throat, laryngospasm

CNS: dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep disturbances, hallucinations, disorientation, memory loss, slurred speech

CV: heart failure, cardiac arrhythmias, peripheral vascular insufficiency, claudication, CVA, pulmonary edema,

1. Do not discontinue drug abruptly after long-term therapy.

2. Give drug with food to facilitate absorption.

3. Provide continual cardiac monitoring for patients receiving the drug.

34

sympathetic outflow and vasoconstrictor tone.

hypertensive, or cardiomyopathic origin.

hypotension Dermatologic:

rash, pruritis, sweating, dry skin

EENT: eye irritation, dry eyes, conjunctivitis, blurred vision

GI: gastric pain, flatulence, constipation, diarrhea, nausea, vomiting, anorexia, ischemic colitis, renal and mesenteric arterial thrombosis, retroperitoneal thrombosis, retroperitoneal fibrosis, hepatomegaly, acute pancreatitis

GU: impotence, decreased libido, dysuria, Peyronie’s disease, nocturia, frequent urinitaion

MS: joint pain, arthralgia, muscle

35

cramp Respiratory:

bronchospasm, dyspnea, cough, bronchial obstruction, nasal stuffiness, rhinitis, pharyngitis

Other: decreased exercise tolerance, development of ANA, hyperglycemia or hypoglycaemia, elevated serum transaminase, alkaline phosphate

36

NAME OF DRUG

DOSAGE, FREQUENCY,

ROUTE

MECHANISM OF ACTION


Generic Name:Levofloxacin

Brand Name:Levocin

Classification: Antibiotic; Fluoroquinolone

Dosage: 500mg/tabRoute: NGT Frequency: OD

Bactericidal: interferes with DNA by inhibiting DNA gyrase replication in susceptible gram-negative and gram-positive bacteria, preventing cell reproduction.

Treatment of adults with Community Acquired pneumonia, bacterial sinusitis caused by susceptible bacteria including multidrug resistant strains

Treatment of acute exacerbation of chronic bronchitis caused by susceptible bacteria

Treatment of nosocomial pneumonia due to methicillin-sensitive Staphylococcus aureus,

Contraindicated with allergy to fluoroquinolones

Use cautiously with renal impairment, seizures

CNS: headache, dizziness, insomnia, fatigue, somnolence, blurred vision

GI: nausea, vomiting, dry mouth, constipation, flatulence, abnormal liver function

GU: abnormal renal function, acute renal failure, UTI, urine retention

Hematologic: elevated BUN, serum creatinine and alkaline phosphatise, neutropenia, anemia

Other: fever, rash, photosensitivity, muscle and joint

1. Arrange for culture and sensitivity tests before beginning therapy

2. Continue therapy as indicated for condition being treated

3. Ensure that patient is well hydrated during course of therapy.

4. Discontinue drug at any sign of hypersensitivity or at complaint of tendon pain, inflammation, or rupture

5. Monitor clinical response; if no improvement is seen or a relapse

37

Pseudomonas strains, Serratia E.coli, Klebsiella, Haemophilus influenza, Streptococcus pneumoniae

tenderness, increase serum glucose

occurs, repeat culture and sensitivity test

38

NAME OF DRUG

DOSAGE, FREQUENCY,

ROUTE

MECHANISM OF ACTION


Generic Name:Fluimucil

Brand Name:Acetylcysteine

Classification: Therapeutic category:Mucolytic agent

Dosage: 600mg/tab +50cc water

Route: NGT Frequency: OD

Exerts mucolytic

action through its

free sulfhydryl

group which opensup 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.

Treatment of respiratory affections characterized by thick and viscous hypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonary emphysema, mucoviscidosis and bronchiectasis.

Severe hypertension;

severe. Coronary artery

disease, hypersensitivity to

pseudoedephrine,

acrivastine or any

component; renal

impairment

Rarely, urticaria,

bronchospasm, nausea,

vomiting. Aerosol

treatment: Rhinitis,

stomatitis.

1. Monitor effectiveness of therapy and advent of adverse/allergic effects.

2. Instruct

patient in appropriate

use and adverse effects

to report

39

NAME OF DRUG

DOSAGE, FREQUENCY,

ROUTE

MECHANISM OF ACTION


Generic name: Multiple vitamins

Brand Name:KREBB C

Classification: Multivitamin

Dosage: 1 cap

Route: NGT Frequency: OD

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 numerous metabolic processes.

Multivitamins are used to provide vitamins that are not taken in through the diet. Multivitamins are also used to treat vitamin deficiencies (lack of vitamins) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions.

Contraindicated to patients with alcohol intolerance, hypersensitivity to preservatives, colorants or additives including tartrazine, saccharine, and aspartame.

GU: urine discoloration

Others: allergic reactions to preservatives, additives or colorants

1. Instruct patient to report adverse effects of the drug.

40

XIII. Health Teaching Plan

Medication Exercises Treatment Hygiene Outpatient Diet

Levofloxacin (Levocin) Fluoroquinolone/anti -

infective Inhibits the enzyme DNA

gyrase in susceptible gram-negative and gram-positive aerobic and anaerobic bacteria, interfering with bacterial DNA synthesis

Dosage: 1cap 500mg, Route: PO, Frequency: OD

Tell patient to stop taking drug and contact prescriber if he experiences signs or symptoms of hypersensitivity reaction (rash, hives, or other skin reactions) or severe diarrhea (which may indicate pseudomembranous colitis).

Check vital signs, especially blood pressure. Too-rapid infusion can cause hypotension.

Closely monitor patients with renal insufficiency.

Monitor blood glucose level

1. Teach client breathing exercises

to deepen breathing and for better lung expansion

How?

Place hands on the border of rib cage

Inhale through nose and exhale trough mouth

Do this at least 10 times every time patient is awake

2. Ambulate from time to time

To improve circulation

Tracheostomy

to bypass an airway

that has become

obstructed

to remove fluid that

has built up in the

upper airway,

particularly in the

throat and trachea

(windpipe)

to assist with

breathing by

delivering oxygen to

the lungs

Fluid/IVF

therapy – for

hydration and to

replace loss

fluids and

electrolytes

1. Oral Hygiene- Tooth

brushing- Mouth

washing

2. Personal Hygienea. Skin care- apply

lotion to moisturize the skin

b. Bathing- removes dirt and dead epithelial cells from the surface of skin, reducing the chance of infection

c. Hair care- brushing and combing the hair stimulates circulation of blood in the scalp

d. Eye care- soften dried secretions

1. Have adequate rest and should maintain healthy diet to promote recovery.

2. Continue medications prescribed by the doctor.

3. Instruct family to return to attending physician for a scheduled check-up.

4. Continue mild exercise regimen for faster recovery. Avoid strenuous exercises.

5. Advise to report to the physician if

Osteorized Feeding on strict aspiration precaution- give feeding via nasogastric tube

41

closely in diabetic patients.

Metropolol (AstraZeneca) Antihypertensive; Beta1-

selective adrenergic blocker Competitively blocks beta-

adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of rennin, and lowering BP; acts in CNS to reduce sympathetic outflow and vasoconstrictor tone.

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) Therapeutic category:

Mucolytic agent

3. Do passive ROM

Also to improve circulation

4. Have Enough rest

to provide relief to the pain felt

- D5NM

Medications

- Anti infective

- Antihypertensive

- Mucolytic Agents

- Multivitamins

using tap clean water, wipe from inner to outer canthus

e. Ear care- clean the pinna with moist wash cloth

f. Nose care- clean nasal secretions by blowing the nose gently with soft tissue

g. Hand washingh. Regular change

of clothingi. Environmental

Sanitation

any sign of complications occur

42

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.

Instructpatient 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 numerous metabolic

43

processes. Dosage: 1 cap; Route: NGT;

Frequency: OD Instruct patient to report

adverse effects of the drug.

44

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

45

http://www.scribd.com/doc/22044205/guillain-barre-syndrome-pathophysiology

http://www.mayoclinic.com/health/guillain-barre-syndrome/DS00413

http://www.ninds.nih.gov/disorders/gbs/gbs.htm

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