A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing ascending paralysis. Which nursing intervention should be the highest priority to ensure patient safety?
1Perform passive range of motion exercises every 2 hours to prevent contractures
2Monitor for signs of deep vein thrombosis and apply sequential compression devices
3Assess pain levels frequently and administer prescribed analgesics as needed
4Continuously monitor respiratory status and prepare for potential mechanical ventilation✓ 정답
해설
Respiratory monitoring is the highest priority because ascending paralysis can rapidly lead to respiratory failure, which is life-threatening. Other interventions are important but secondary to maintaining adequate ventilation.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Guillain-Barré syndrome (GBS), an acute autoimmune disorder that causes demyelination of peripheral nerves. The hallmark is ascending paralysis, which starts in the lower extremities and moves upward. The most critical and life-threatening complication is respiratory failure, which occurs when the paralysis ascends to involve the nerves controlling the diaphragm and intercostal muscles.
Answer Rationale: Key Point! In any patient with a condition that can impair the airway, breathing, or circulation (ABCs), the Airway and Breathing always take precedence. For GBS, the priority is to continuously monitor respiratory status (rate, depth, effort, oxygen saturation, vital capacity) and be prepared for mechanical ventilation. Respiratory failure is the leading cause of mortality in GBS, making this intervention the highest priority for patient safety.
Distractor Analysis:
Option 1 (Passive ROM): While preventing contractures and maintaining joint mobility is an important part of long-term care and rehabilitation for a paralyzed patient, it is not the highest priority when a life-threatening condition like respiratory failure is imminent.
Option 2 (DVT monitoring/SCDs): Immobility from paralysis puts the patient at high risk for deep vein thrombosis (DVT), and applying sequential compression devices is a key preventive measure. However, this addresses a potential complication of immobility, not the primary, immediate threat from the disease process itself.
Option 3 (Pain assessment/analgesics): Patients with GBS often experience significant neuropathic pain. Managing this pain is crucial for comfort and reducing anxiety, but it does not supersede the need to maintain a patent airway and adequate gas exchange.
Related Concepts: The nursing process requires prioritization based on Maslow's Hierarchy of Needs and the ABCs. Physiological needs (airway, breathing, circulation) always come before safety, comfort, or rehabilitative needs. In neurological emergencies, think "Airway, Breathing, Circulation, Disability (Neurological)"—the "Disability" assessment here directly leads to the threat to "Breathing."
Respiratory status – paralysis ascends to diaphragm/intercostals.
Myasthenia Gravis (MG)
Fluctuating weakness, worsens with activity (fatigability)
Airway & Respiratory status – risk of myasthenic crisis with bulbar (swallowing) and respiratory muscle weakness.
Amyotrophic Lateral Sclerosis (ALS)
Mixed UMN & LMN signs, progressive
Airway & Respiratory support – eventual respiratory muscle failure; also prioritize communication as bulbar muscles weaken.
Anatomy, Physiology & Pharmacology Points
Physiology: Respiratory drive depends on the phrenic nerve (C3-C5) to stimulate the diaphragm and intercostal nerves (T1-T11) for chest wall movement. Ascending paralysis that reaches these spinal levels causes respiratory failure.
Pharmacology: First-line treatments for GBS are IV immunoglobulin (IVIG) or plasmapheresis. These therapies modulate the immune response but do not reverse paralysis immediately, so vigilant supportive care (like respiratory monitoring) remains paramount.
Memory Tips
Acronym: GBS = "Got Breathe? Soon!" – Reminds you that the urgent need is to ensure they can breathe soon, as paralysis ascends.
Visualize: Picture paralysis climbing like water up a ladder from the toes to the chest. When it hits the chest (respiratory muscles), it's an emergency.
High-Frequency NCLEX Topics
The NCLEX loves to test prioritization in patients with neurological conditions that threaten the ABCs. GBS is a classic example. You must be able to distinguish between a correct nursing action and the most important or priority action. Always apply the ABC framework first.
Watch Out for Question Variations!
From Symptom to Action: "The nurse notes a patient with GBS has a vital capacity of 12 mL/kg and increasing shortness of breath. What is the nurse's priority action?" (Answer: Prepare for/assist with intubation and mechanical ventilation).
Change in Focus: "A patient with GBS is receiving IVIG. Which finding requires immediate intervention?" (Options might include headache, chills, flushing vs. declining oxygen saturation. The respiratory finding is the priority).
Discharge Planning: For a recovering GBS patient, priority teaching shifts to preventing complications of immobility (skin breakdown, contractures) and recognizing signs of relapse.
Nursing Clinical Practice GuideClinical Scenario: You are assigned to care for Mr. Johnson, a 45-year-old admitted two days ago with progressive weakness in his legs, diagnosed with Guillain-Barré syndrome. This morning, he reports feeling "like a heavy weight is on my chest" and that it's harder to take a deep breath.
Nursing Intervention Strategy:
Assessment (Immediate & Continuous):
Respiratory: Count respiratory rate for a full minute. Observe for paradoxical breathing (abdomen moves in while chest expands out), use of accessory neck muscles, nasal flaring. Auscultate lung sounds. Monitor SpO2 continuously. Check vital capacity (VC) and negative inspiratory force (NIF) per protocol (e.g., every 2-4 hours). A VC < 20 mL/kg or a rapid decline signals impending failure.
Neurological: Perform a focused neuro check. Document the highest level of paralysis (e.g., "weakness now present in hip flexors," "facial muscles weak"). Check gag and cough reflexes, as bulbar involvement impairs airway protection.
Autonomic: Monitor for autonomic instability – labile blood pressure, tachycardia/bradycardia, which is common in GBS.
Planning & Implementation:
Priority: Prepare for Intubation: Ensure the crash cart and intubation tray are nearby. Notify the respiratory therapist and the provider of the patient's declining status. Have suction equipment ready at the bedside (weak gag/cough reflex increases aspiration risk).
Safety: Keep the bed in low position with side rails up. Place call light within patient's reach (if hand strength allows).
Comfort & Communication: As respiratory distress increases, anxiety will rise. Provide calm, clear explanations. Use a communication board if speech becomes difficult.
Patient Safety and Precautions:
Never Delay Respiratory Support: Do not wait for cyanosis or extreme bradycardia to act. Early intubation is safer than emergency intubation.
Suction with Caution: If suctioning is needed, pre-oxygenate and limit suction time to 10-15 seconds to prevent hypoxia and vagal stimulation (which can cause severe bradycardia in GBS).
Medication Alert: Avoid drugs that can worsen neuromuscular blockade or respiratory depression, such as aminoglycoside antibiotics, magnesium, and certain sedatives, unless absolutely necessary and with extreme caution.
Nursing Procedure & Medication FlowMonitoring for Respiratory Failure in GBS:
Obtain baseline vital capacity (VC) and negative inspiratory force (NIF) on admission.
Monitor VC/NIF every 4-8 hours in stable phase, increasing to every 2-4 hours (or more) with any sign of progression or respiratory complaint.
SpO2 < 92% on room air or increasing oxygen requirement
Document trends meticulously. A downward trend is more significant than a single value.
A Word from Your Senior Nurse
"Guillain-Barré syndrome is one of those 'don't take your eyes off them' conditions. Your most important tool is your own observation. That subtle increase in respiratory rate, the new use of neck muscles to breathe, the soft voice, the patient's report of 'just feeling winded' – these are your early warning signs long before the monitor alarms. In clinicals and on the NCLEX, thinking 'ABCs first' will guide you right 99% of the time. With GBS, your vigilance in monitoring breathing isn't just a task; it's the intervention that can save a life. You are the frontline guardian watching for the climb of that paralysis."
Guillain-Barré Syndrome — An acute autoimmune disorder causing inflammatory demyelination of peripheral nerves, leading to ascending flaccid paralysis and areflexia.
Ascending Paralysis — A pattern of muscle weakness that begins in the lower extremities and progresses upward to the trunk, arms, and cranial nerves; characteristic of GBS.
Vital Capacity — The maximum amount of air a person can expel from the lungs after a maximum inhalation. In GBS, a VC < 20 mL/kg is a critical indicator of impending respiratory failure.
Mechanical Ventilation — The use of a machine to move air in and out of the lungs for a patient who is physically unable to breathe adequately on their own. A key life-saving intervention in GBS.
Autonomic Instability — Dysfunction of the autonomic nervous system, common in GBS, manifesting as labile blood pressure, cardiac arrhythmias, and diaphoresis.