Priorities in the first 72 hours
Guillain-Barré syndrome (GBS) produces weakness that can keep ascending for days to weeks. The early nursing plan therefore centers on three threats: respiratory failure, pressure injury, and venous thromboembolism (VTE). The correct set is statements 1, 3 and 4: measuring vital capacity and negative inspiratory force, turning every 2 hours with heel off-loading, and applying intermittent pneumatic compression. Respiratory monitoring is the top priority because ascending weakness can reach the diaphragm and intercostal muscles.
Respiratory monitoring
Vital capacity and negative inspiratory force measure the strength of the breathing muscles and fall before oxygen saturation drops. Pulse oximetry can stay normal until late, so it is not a reliable early warning in neuromuscular weakness. Serial measurements as ordered show the trend, and a falling value prompts the team to plan elective intubation before a crisis. The nurse also watches for a weak cough, difficulty swallowing, and a soft voice, which signal risk to the airway.
Immobility: skin and clots
A client who cannot move his legs lies still for long periods, which loads the sacrum and heels and slows venous return. Turning every 2 hours and floating the heels off the mattress relieve pressure on bony prominences. Intermittent pneumatic compression devices mimic the calf muscle pump and reduce stasis in the deep veins. Immobility in GBS carries a high risk of venous thromboembolism, so mechanical prophylaxis belongs in the plan, often together with prescribed pharmacologic prophylaxis.
Why corticosteroids are excluded
Statement 2 is the trap. Although GBS is immune-mediated, trials have shown that corticosteroids are not effective in GBS, and they are not part of standard treatment. The disease-modifying treatments are intravenous immunoglobulin (IVIG) and plasma exchange, which shorten the course when started early. Any option containing methylprednisolone is therefore wrong. Option 1 (1 and 3) omits compression devices; options 3 and 4 include corticosteroids and also leave out respiratory monitoring or turning.
| Statement | Include? | Reason |
|---|
| 1. Vital capacity and NIF | Yes | Detects respiratory muscle weakness early |
| 2. IV methylprednisolone | No | Corticosteroids are not effective in GBS |
| 3. Turning and heel off-loading | Yes | Prevents pressure injury |
| 4. Pneumatic compression | Yes | Prevents venous thromboembolism |
Key point! In GBS, plan for breathing, skin, and clots. Treatment is immunoglobulin or plasma exchange, never corticosteroids alone.