A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing respiratory compromise. Which nursing intervention should be the highest priority?
1Administer prescribed corticosteroids to reduce inflammation
2Position the patient in high Fowler's position to maximize lung expansion
3Prepare for immediate endotracheal intubation and mechanical ventilation✓ 정답
4Encourage deep breathing exercises and use of incentive spirometer
해설
In Guillain-Barré syndrome, respiratory compromise is a life-threatening emergency requiring immediate intervention. Preparing for intubation and mechanical ventilation is the priority to maintain oxygenation, while other options are supportive but not emergent.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with Guillain-Barré syndrome (GBS) experiencing respiratory compromise. GBS is an acute autoimmune disorder causing demyelination of 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). When a GBS patient shows signs of compromise, it is a medical emergency.
Answer Rationale: The correct answer is ③ Prepare for immediate endotracheal intubation and mechanical ventilation. The priority in nursing is always the ABCs (Airway, Breathing, Circulation). In GBS, respiratory muscle weakness can progress rapidly to complete failure. Signs of compromise (e.g., tachypnea, use of accessory muscles, decreased oxygen saturation, difficulty speaking) indicate that supportive measures like positioning or breathing exercises are no longer sufficient. Key Point! Preparing for intubation and mechanical ventilation is the immediate, life-saving intervention to secure the airway and support breathing until the patient recovers.
Distractor Analysis:
Watch out for confusion!① Administer prescribed corticosteroids to reduce inflammation: While inflammation is part of GBS pathophysiology, corticosteroids are not the standard first-line treatment and are often ineffective. The primary treatments are Intravenous immunoglobulin (IVIG) or Plasmapheresis. More importantly, administering medication is not the priority when the patient's breathing is immediately threatened.
Watch out for confusion!② Position the patient in high Fowler's position to maximize lung expansion: This is a supportive measure for patients with mild dyspnea but is inadequate for true respiratory compromise. It does not address the core problem of neuromuscular paralysis.
Watch out for confusion!④ Encourage deep breathing exercises and use of incentive spirometer: These are excellent for preventing atelectasis and maintaining lung function in a stable patient. However, if the patient is already in respiratory compromise, they likely lack the muscle strength to perform these exercises effectively. This intervention is too late and insufficient for the emergent situation.
Related Concepts: The management of GBS revolves around monitoring for and managing complications. Key assessments include vital capacity and negative inspiratory force to objectively measure respiratory decline. Autonomic instability (labile blood pressure, cardiac arrhythmias) is another major concern. Nursing care focuses on supportive measures: preventing complications of immobility (pressure ulcers, DVTs), managing pain, and providing nutritional support, all while prioritizing respiratory surveillance.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse for Mr. Johnson, a 45-year-old admitted 3 days ago with progressive weakness in his legs, now spreading to his arms. He was diagnosed with GBS. During your morning assessment, you note his speech is slightly slurred, he's using his neck muscles to breathe, his respiratory rate is 28 breaths/min, and his oxygen saturation is 92% on room air. He reports feeling "like I can't get a full breath."
Nursing Intervention Strategy:
1Immediate Assessment & CommunicationAuscultate lung sounds. Check vital capacity at the bedside (a drop below 15-20 mL/kg or 1 L is a critical warning sign). Immediately notify the physician and respiratory therapist. Your report should be specific: "Patient with GBS showing signs of respiratory distress: tachypnea, accessory muscle use, low SpO2, subjective dyspnea."
2Prepare for IntubationWhile awaiting the physician, gather the emergency intubation cart, ensure the suction is working, and prepare the ventilator. Have sedatives and paralytics (per protocol/order) ready. This is the action described in the correct answer.
3Supportive Care Post-IntubationOnce intubated, provide meticulous ventilator care: monitor settings, suction PRN using sterile technique, prevent ventilator-associated pneumonia (VAP), and provide frequent oral care. Continue comprehensive neurological and autonomic assessments.
Patient Safety and Precautions: Never leave a GBS patient with signs of respiratory compromise alone. Do not assume positioning or breathing exercises will suffice. Be aware of the risk of autonomic dysreflexia—handle the patient gently, avoid sudden position changes, and monitor for arrhythmias.
1IVIG (Intravenous Immunoglobulin)Administered over 2-5 days. Monitor for side effects like flu-like symptoms, headache, and rare anaphylaxis. Infuse slowly per protocol.
2PlasmapheresisRemoves antibodies from the blood. Nursing care involves monitoring vascular access, blood pressure during the procedure, and for signs of hypocalcemia (tingling, muscle cramps) from the citrate anticoagulant.
Respiratory Monitoring Parameters:
- Vital Capacity (VC): Normal: 65-75 mL/kg. Critical: < 15-20 mL/kg or < 1 L.
- Negative Inspiratory Force (NIF): Normal: -80 to -100 cm H2O. Critical: > -20 to -30 cm H2O (less negative).
A Word from Your Senior Nurse
"With GBS, you are in a race against the ascending paralysis. Your most important tool is your assessment skills. That slight slur in speech, the look of anxiety in their eyes, the belly moving paradoxically instead of the chest—these are your early warnings. On the NCLEX, they love to test your ability to prioritize. Remember: Airway and Breathing always come first, before any medication or comfort measure. In real life, catching that decline early and acting swiftly can prevent a full respiratory arrest. Think 'ABCs' for every priority question until it's second nature!"
Guillain-Barré Syndrome — An acute autoimmune disorder causing demyelination of peripheral nerves, leading to ascending symmetric 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. A key objective measure to monitor for impending respiratory failure in GBS.
Intravenous Immunoglobulin — A primary treatment for GBS. It is thought to work by modulating the immune system and neutralizing pathogenic antibodies.
Autonomic Dysfunction — A complication of GBS involving instability of the autonomic nervous system, manifesting as labile blood pressure, cardiac arrhythmias, ileus, and diaphoresis.