A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing progressive muscle weakness. Which nursing intervention should be the highest priority to ensure patient safety?
A 45-year-old patient diagnosed with Guillain-Barré syndrome is admitted to the medical unit. The patient reports numbness and tingling in both hands and feet that began 3 days ago, with progressive weakness now affecting the lower extremities. Vital signs are stable, but the patient expresses anxiety about the worsening symptoms.
1Encourage active range of motion exercises to prevent muscle atrophy
2Provide emotional support and reassurance about the recovery process
3Monitor respiratory function and maintain airway patency✓ 정답
4Administer prescribed pain medications for neuropathic discomfort
해설
Respiratory monitoring is the highest priority safety intervention for patients with Guillain-Barré syndrome due to the risk of ascending paralysis affecting respiratory muscles, which can lead to respiratory failure. Other options are important but secondary to immediate safety.
In Guillain-Barré syndrome (GBS), an acute immune-mediated polyradiculoneuropathy, the classic presentation is a symmetric, ascending weakness that can progress to the muscles of respiration. The foundational principle of nursing care for this condition is that GBS is a major cause of neuromuscular respiratory failure globally [1]. As the paralysis ascends, it can involve the diaphragm and intercostal muscles, leading to ineffective ventilation and a life-threatening emergency. Therefore, the highest priority nursing intervention is derived directly from the Airway, Breathing, Circulation (ABC) framework.
Why Respiratory Monitoring is the Priority
The other listed interventions are all appropriate components of holistic care for a patient with GBS, but they do not address the most immediate threat to life. The primary danger is not a contracture, a deep vein thrombosis, or pain, but rather the insidious onset of respiratory failure. The case reports underscore this reality. One case describes a patient managed in a stepdown unit with close respiratory monitoring, which was the specific intervention that prevented progression to respiratory failure and the need for intensive care unit (ICU) admission [2]. In a resource-limited setting without access to invasive ventilation, a structured framework was built around noninvasive respiratory support and intensive nursing care to manage respiratory failure successfully [1]. These examples demonstrate that vigilant, continuous assessment of respiratory function—including vital capacity, negative inspiratory force, and signs of hypoxia or hypercapnia—is the cornerstone of patient safety. The nurse must be prepared to escalate care and assist with mechanical ventilation the moment clinical indicators show the patient can no longer protect their own airway or ventilate adequately.
Integrating the Evidence into Practice
For the NCLEX-RN examinee, this question highlights the critical distinction between a routine intervention and a life-saving priority. While performing passive range of motion exercises, monitoring for deep vein thrombosis, and managing pain are all within the nurse's scope for a patient with immobility and neuropathic discomfort, they are secondary to ensuring the patient is breathing. The evidence confirms that even in a case where a patient did not ultimately require ICU admission, the decision to provide close respiratory monitoring was the key safety net [2]. The nurse’s clinical judgment must focus on the predictable trajectory of ascending paralysis: what begins as leg weakness can rapidly become diaphragmatic weakness. A systematic assessment of respiratory rate, depth, breath sounds, and the patient’s ability to cough and clear secretions provides the data necessary to prevent respiratory arrest, which is the most catastrophic outcome of GBS.
References (research sources)
[1]
High-Dependency Care Without Mechanical Ventilation for Severe Guillain-Barré Syndrome in a Rural Low-Income Setting.Research articleNotghi L, Little L, Chin J. (2026) · DOI: 10.1155/crcc/1700879
[2]
Guillain-Barré Syndrome Following Seasonal Coronavirus (HCoV-229E) Infection: A Case Managed Without Intensive Care.Case reportWeldearegay G, Aghabekyan T, Arif A, Salvani J. (2026) · DOI: 10.7759/cureus.107360
Clinical Management of Respiratory Risk in Guillain-Barré Syndrome
Assessment and Monitoring
Perform serial bedside pulmonary function tests, specifically forced vital capacity (FVC) and negative inspiratory force (NIF), every 2-4 hours during the progressive phase.
Monitor for clinical signs of impending respiratory failure: dyspnea, tachypnea, use of accessory muscles, paradoxical abdominal breathing, staccato speech, and inability to count to 20 in a single breath.
Continuously monitor oxygen saturation and end-tidal CO2 if available; be aware that pulse oximetry alone may not detect early hypoventilation, especially if supplemental oxygen is administered.
Assess bulbar function by evaluating the patient's ability to swallow, handle oral secretions, and the quality of their cough; an ineffective cough indicates a high risk for aspiration and secretion retention.
Intervention Thresholds and Actions
Notify the rapid response team or intensivist immediately if FVC falls below 20 mL/kg (or roughly less than 1.0-1.5 L in an adult) or NIF is weaker than -30 cm H2O, as these are strong indicators for elective intubation.
Prepare for elective endotracheal intubation before a crisis occurs; intubation under controlled circumstances is far safer than an emergency crash intubation in a hypoxic, fatiguing patient.
Keep emergency airway equipment (bag-valve-mask, suction, endotracheal tubes, laryngoscope) at the bedside at all times.
Position the patient with the head of bed elevated 30-45 degrees to optimize diaphragmatic excursion and reduce the work of breathing, unless contraindicated.
Multidisciplinary Care and Communication
Establish clear communication with the medical team regarding respiratory parameters and any subtle changes in the patient's neurological status.
Consult respiratory therapy early for assistance with monitoring and secretion management techniques, including chest physiotherapy and cough assist devices.
Involve the patient and family in discussions about the potential need for mechanical ventilation, framing it as a temporary supportive measure while the disease runs its course.
If the patient is transferred to an ICU, ensure a structured handoff that includes the trajectory of FVC decline, bulbar function status, and the patient's expressed anxieties.
Guillain-Barré syndrome — An acute inflammatory demyelinating polyradiculoneuropathy where the immune system attacks peripheral nerves, causing symmetric ascending paralysis.
Ascending paralysis — A pattern of weakness that begins in the distal lower extremities and progresses upward, potentially involving the trunk, arms, and respiratory muscles.
ABC framework — A nursing priority-setting framework that ranks Airway, Breathing, and Circulation as the most critical assessments for patient safety.
Respiratory failure in GBS — A life-threatening complication caused by weakness of the diaphragm and intercostal muscles, leading to hypoventilation and inability to clear secretions.
Vital capacity — The maximum amount of air a person can expel from the lungs after a maximum inhalation, used to monitor respiratory muscle strength in GBS.