Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on a medical-surgical unit caring for Mr. Johnson, a 45-year-old diagnosed with GBS two days ago. He initially had tingling in his feet, which has progressed to weakness in his legs. During your shift, you note his speech is slightly slurred, and he reports feeling short of breath.
Nursing Intervention Strategy:- 1AssessmentImmediately perform a focused respiratory assessment. Check respiratory rate, depth, and pattern. Listen to lung sounds. Measure his vital capacity (VC) and negative inspiratory force (NIF) per unit protocol. Check oxygen saturation via pulse oximetry. Assess for use of accessory neck and abdominal muscles.
- 2ActionIf VC is decreasing (e.g., from 30 mL/kg to 18 mL/kg) or respirations are shallow and rapid, this is a medical emergency. Stay with the patient, call for help, and notify the physician/respiratory therapist immediately. Elevate the head of the bed to ease breathing. Have the intubation tray, bag-valve-mask, and suction equipment at the bedside.
- 3Ongoing CareFor dysphagia, initiate aspiration precautions (NPO, consult speech-language pathology). Implement strict turn schedules and pressure ulcer prevention. Provide passive range-of-motion exercises. Manage pain, which is often severe and neuropathic.
Patient Safety and Precautions:
* Airway Protection: If bulbar symptoms are present, do NOT give oral food/medications until a swallow evaluation is completed.
* Autonomic Monitoring: Monitor for and report severe blood pressure fluctuations (hypertension or hypotension) and cardiac arrhythmias.
* Immobility Complications: Implement DVT prophylaxis (sequential compression devices, anticoagulants as ordered) and meticulous skin care.
Nursing Procedure & Medication Flow
Monitoring Respiratory Status:
* Frequency: Measure VC and NIF every 2-4 hours in the acute phase, or more frequently if deteriorating.
* Procedure: Coach the patient to take a maximal inhalation and exhale fully into the spirometer. For NIF, instruct them to inhale maximally against a closed valve.
* Critical Values: VC < 20 mL/kg, NIF > -30 cm H2O, or rapid decline in values warrant immediate notification.Administering IV Immunoglobulin (IVIG):
* Pre-medication: Administer diphenhydramine and acetaminophen as ordered to prevent infusion-related reactions (fever, chills, headache).
* Monitoring: Start infusion slowly, monitor vital signs frequently. Watch for severe reactions like anaphylaxis, thrombosis, or renal impairment (check BUN/Cr).
A Word from Your Senior Nurse
"With GBS patients, your assessment skills are their lifeline. The weakness creeps up silently. One minute they're talking to you, and the next, they can't take a deep breath. Don't just chart 'SOB' (short of breath)—get the objective data: count their respirations, measure that vital capacity, listen to their lung bases. Catching the descent in respiratory function early is what allows for a controlled intubation in the ICU instead of a crash situation. On the NCLEX and at the bedside, remember: breathing always comes first. Your vigilance makes all the difference in their recovery journey."