A nurse is caring for a client with Guillain-Barré syndrome who is experiencing ascending paralysis that has progressed to the thoracic level. The client reports difficulty breathing and appears anxious. Which nursing action should be the highest priority?
The client reports difficulty breathing and appears anxious.
1Administer prescribed anxiolytic medication to reduce anxiety
2Position the client in high Fowler's position to improve comfort
3Prepare for immediate endotracheal intubation and mechanical ventilation✓ 정답
4Encourage deep breathing exercises and use of incentive spirometer
해설
In Guillain-Barré syndrome, ascending paralysis to the thoracic level compromises respiratory muscles, making immediate airway management the priority. Other options address anxiety, comfort, or breathing exercises but do not manage the life-threatening respiratory failure.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing action for a patient with Guillain-Barré syndrome (GBS) who is showing signs of impending respiratory failure. GBS is an acute autoimmune disorder causing demyelination of peripheral nerves, leading to ascending symmetric paralysis. When paralysis ascends to involve the thoracic nerves, it compromises the intercostal muscles and diaphragm, which are essential for breathing. The symptoms of "difficulty breathing" and "anxiety" are classic signs of Key Point!hypoxia and respiratory distress, not just psychological anxiety. The priority is always Airway, Breathing, Circulation (ABC).
Answer Rationale: The correct answer is to Key Point!prepare for immediate endotracheal intubation and mechanical ventilation. In GBS, respiratory muscle weakness can progress rapidly to complete respiratory failure. The nurse's recognition of this progression to the thoracic level, coupled with the client's subjective and objective signs (difficulty breathing, anxiety), signals an immediate need for securing the airway and providing ventilatory support. This is a life-saving intervention.
Distractor Analysis:
- Watch out for confusion! Option ① (Administer anxiolytic) is dangerous. The anxiety is likely secondary to hypoxia. Sedating the patient could depress the respiratory drive further, worsening the crisis.
- Option ② (High Fowler's position) may provide minimal comfort but does not address the underlying problem of neuromuscular respiratory failure. It is a supportive measure, not a priority intervention.
- Option ④ (Deep breathing exercises) is ineffective and potentially exhausting for a patient whose respiratory muscles are becoming paralyzed. It does not support or replace inadequate ventilation.
Related Concepts: Nursing management of GBS focuses on vigilant respiratory assessment (vital capacity, negative inspiratory force), monitoring for autonomic instability (blood pressure fluctuations, cardiac arrhythmias), and providing comprehensive supportive care, including prevention of complications like deep vein thrombosis (DVT), pressure ulcers, and aspiration.
Concept SummaryGuillain-Barré Syndrome (GBS): Acute inflammatory demyelinating polyneuropathy. Autoimmune attack on peripheral nerves → ascending paralysis. Priority Concern: Respiratory failure due to paralysis of respiratory muscles (diaphragm, intercostals). Key Assessment: Monitor Vital Capacity (VC) (normal >15-20 mL/kg). A VC < 10-15 mL/kg indicates need for ventilatory support. Also monitor O2 saturation, arterial blood gases (ABGs), and work of breathing. Primary Treatment: Plasmapheresis (Plasma exchange) or IV immunoglobulin (IVIG) to modulate immune response.
Side-by-Side Comparison!
Administer anticholinesterase meds (e.g., pyridostigmine), prepare for intubation
Chronic Obstructive Pulmonary Disease (COPD)
Airflow obstruction & air trapping
Administer bronchodilators, low-flow O2, monitor for CO2 retention
Anatomy, Physiology & Pharmacology PointsPhysiology: Breathing requires the diaphragm (innervated by phrenic nerve, C3-C5) and intercostal muscles (thoracic nerves). Ascending paralysis that reaches the thoracic level directly threatens these muscles. Pharmacology - Caution!: Avoid respiratory depressants (e.g., opioids, benzodiazepines) in patients with neuromuscular weakness unless intubated and mechanically ventilated.
Memory TipsABCs of GBS: Ascending paralysis, Breathing failure is the big threat, Critical care needed. When to Intubate? Think "T for Thoracic and Tube". Paralysis to Thoracic level = Think about EndoTracheal tube.
High-Frequency NCLEX Topics
GBS is a classic NCLEX topic focusing on priority-setting (ABCs) and recognizing signs of respiratory compromise. Expect questions on monitoring parameters (vital capacity), understanding disease progression, and differentiating anxiety from hypoxia.
Watch Out for Question Variations!
- Instead of "highest priority action," the question may ask: "The nurse should assess which parameter first?" → Answer: Respiratory status (rate, depth, O2 sat, vital capacity).
- A question may present lab values: "Arterial Blood Gas shows pH 7.25, PaCO2 55 mmHg" → This indicates respiratory acidosis from hypoventilation, reinforcing the need for ventilation.
- A question may test knowledge of autonomic dysfunction in GBS (e.g., managing labile blood pressure or bradycardia).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a neurology unit. Your patient, Mr. Johnson, diagnosed with GBS three days ago, now states, "I feel like I can't get a full breath," and is using accessory neck muscles to breathe. His paralysis, which started in his feet, has now reached his mid-abdomen. He appears pale, diaphoretic, and anxious.Nursing Intervention Strategy:
1Immediate Assessment (Do not leave the room)Call for help using the call bell. Assess respiratory rate, depth, and pattern. Check oxygen saturation via pulse oximetry. Auscultate lung sounds. Ask the patient to count to 10 in one breath (a simple bedside test for vital capacity).
2Priority ActionBased on signs of respiratory distress and known disease progression, anticipate the need for intubation. Inform the rapid response team or physician immediately. Have the intubation tray and mechanical ventilator ready at the bedside.
3Supportive Care While Awaiting IntubationApply supplemental oxygen via non-rebreather mask. Position in high Fowler's to maximize chest expansion. Provide calm, clear communication to the patient and family. Do not leave the patient unattended.
Patient Safety and Precautions:
1Neverattribute anxiety in a GBS patient solely to psychological causes; always rule out hypoxia first.
2ContraindicationAvoid administering sedatives or opioids that could further suppress respiratory effort.
3Key MonitoringSerial measurements of forced vital capacity (FVC) and negative inspiratory force (NIF) are standard of care to objectively track respiratory decline.
Nursing Procedure & Medication FlowPre-Intubation Preparation:
1. Ensure suction is set up and functioning at the bedside.
2. Gather equipment: laryngoscope, endotracheal tubes of various sizes, stylet, 10cc syringe, tape, bag-valve-mask (BVM) device connected to oxygen.
3. Administer pre-intubation medications as ordered (e.g., sedative and paralytic) only when the intubating clinician is ready.Post-Intubation Care:
1. Verify tube placement by auscultating bilateral breath sounds and confirming end-tidal CO2.
2. Secure the tube. Set ventilator parameters per order (often starting with Assist-Control mode).
3. Provide meticulous oral care and suctioning per protocol to prevent ventilator-associated pneumonia (VAP).
A Word from Your Senior Nurse
"In neurology, we say 'watch the belly, save the brain.' For GBS, we watch the respiratory muscles to save the life. That patient's anxiety is their body screaming for air. Your most critical skill here is not a procedure, but clinical judgment—connecting the dots between the disease process (ascending paralysis) and the clinical signs (difficulty breathing). On the NCLEX and at the bedside, never get distracted by a symptom like anxiety; always ask yourself, 'What's the underlying physiological cause?' That thinking will make you a safe and exceptional nurse."
Guillain-Barré Syndrome — An acute autoimmune disorder causing demyelination of peripheral nerves, leading to ascending symmetric paralysis and areflexia.
Ascending Paralysis — A pattern of muscle weakness that begins in the lower extremities and moves upward toward 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. A key parameter monitored in GBS to assess respiratory muscle strength.
Mechanical Ventilation — The use of a machine to move air in and out of the lungs when a patient cannot breathe effectively on their own, often required in GBS with respiratory involvement.
Plasmapheresis — A treatment for GBS that involves removing the patient's plasma (which contains harmful antibodies) and replacing it with donor plasma or a substitute.