The highest priority for a patient with Guillain-Barre syndrome (GBS) and respiratory compromise is preparation for immediate endotracheal intubation and mechanical ventilation. This addresses the life-threatening failure of the ventilatory pump.
Key Clinical Reasoning:
- Pathophysiology: Ascending demyelination weakens the diaphragm and intercostal muscles, causing neuromuscular respiratory failure. This is a pump problem, not a lung tissue problem.
- Priority: Securing the airway takes absolute precedence over supportive measures like positioning or spirometry, which do not prevent apnea from progressive muscle weakness.
- Pharmacology: Corticosteroids are not standard of care for GBS and do not reverse the acute neuromuscular blockade.
Nursing Actions:
- Continuously monitor vital capacity, negative inspiratory force, and single breath count to detect declining function.
- Assemble intubation equipment and have emergency medications (e.g., sedatives, paralytics) at the bedside.
- Notify the rapid response team and respiratory therapy early; do not wait for complete decompensation.
- After intubation, confirm placement with end-tidal CO2 detection and secure the tube.
NCLEX Tip: In neuromuscular emergencies, airway and breathing always come first. Do not be distracted by interventions that treat inflammation or promote lung expansion when the respiratory muscles are failing.