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.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Guillain-Barré syndrome (GBS). GBS is an acute autoimmune disorder where the body's immune system attacks the peripheral nerves, leading to ascending paralysis. The most critical complication is Key Point!respiratory failure due to paralysis of the respiratory muscles (diaphragm and intercostals). Therefore, the nurse's highest priority is always airway, breathing, and circulation (ABCs).
Answer Rationale: Option ③ is correct because it directly addresses the Key Point!life-threatening risk. Monitoring respiratory function includes assessing respiratory rate, depth, pattern, oxygen saturation (SpO2), and vital capacity (VC). A vital capacity below 15-20 mL/kg or a rapid decline signals impending respiratory failure, requiring immediate intervention like intubation and mechanical ventilation. Maintaining airway patency is the foundational safety measure.
Distractor Analysis:
Watch out for confusion! Option ① (Encourage active ROM) is incorrect and potentially harmful in the acute, progressive phase of GBS. Forcing activity can worsen fatigue and is not the priority when respiratory failure is imminent. Passive ROM is used to prevent contractures.
Option ② (Provide emotional support) is a valuable psychosocial intervention but is secondary to physiological safety needs (Maslow's Hierarchy).
Option ④ (Administer pain meds) addresses a common symptom (neuropathic pain) but does not take precedence over the risk of respiratory arrest.
Related Concepts: The nursing priority follows the ABC (Airway, Breathing, Circulation) framework. In GBS, autonomic dysfunction can also cause labile blood pressure and cardiac arrhythmias, making continuous cardiac monitoring important after securing the airway.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse for Mr. Johnson, a 45-year-old with GBS whose weakness has progressed from his feet to his knees over 24 hours. He is on a medical-surgical floor with continuous pulse oximetry.
Nursing Intervention Strategy:
1AssessmentPerform a focused respiratory assessment every 1-2 hours. Key actions: Count respirations for a full minute, listen for breath sounds, assess for use of accessory muscles, ask "Can you take a deep breath for me?" Monitor SpO2. Collaborate with respiratory therapy for serial vital capacity (VC) and negative inspiratory force (NIF) measurements – a declining trend is a red flag.
2Planning & ImplementationHave emergency equipment (suction, bag-valve-mask, intubation tray) at the bedside. Position the patient for optimal lung expansion (semi-Fowler's). Initiate deep breathing and coughing exercises, but assist as weakness increases. Plan for possible transfer to the ICU.
3Patient Education & EvaluationExplain the purpose of frequent checks to reduce anxiety. Evaluate the effectiveness of interventions by stable respiratory parameters and prevention of respiratory distress.
Patient Safety and Precautions: Never leave a patient with rapidly progressing GBS unattended for long. Be vigilant for signs of autonomic dysreflexia (severe hypertension, bradycardia). Use caution with opioids for pain due to risk of respiratory depression.
Nursing Procedure & Medication FlowRespiratory Monitoring Procedure:
1. Assess respiratory rate, rhythm, and effort.
2. Auscultate lung sounds bilaterally (listen for diminished sounds or crackles).
3. Check SpO2 via pulse oximetry.
4. Inquire about shortness of breath or difficulty swallowing (dysphagia).
5. Document findings and report any deterioration immediately.Medication Note: First-line treatment for GBS is IV immunoglobulin (IVIG) or plasmapheresis. These aim to halt the immune attack. Administer IVIG as per protocol, monitoring for infusion reactions (fever, chills, flushing).
A Word from Your Senior Nurse
"With GBS, you are literally racing against the paralysis. Your most important tool is your stethoscope and your watchful eyes. Catching a drop in vital capacity from 30 mL/kg to 18 mL/kg before the patient becomes short of breath is the difference between a planned intubation and a code blue. Always think ABCs first – it will guide you to the right priority every single time."
Guillain-Barré Syndrome — An acute autoimmune polyneuropathy causing demyelination of peripheral nerves, leading to ascending paralysis. Often preceded by a viral or bacterial infection.
Ascending Paralysis — A hallmark of GBS where muscle weakness begins in the lower extremities (feet/legs) and progresses upward to the trunk, arms, and cranial nerves.
Vital Capacity — The maximum amount of air a person can expel from the lungs after a maximum inhalation. In GBS, a VC < 15-20 mL/kg or a rapid decline indicates impending respiratory failure.
Autonomic Dysfunction — A complication of GBS involving instability of the autonomic nervous system, manifesting as labile blood pressure, cardiac arrhythmias, ileus, or diaphoresis.
IV Immunoglobulin — A first-line treatment for GBS. It is a pooled antibody product thought to modulate the immune system and halt the autoimmune attack on nerves.