# A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing respiratory compromise. Which nursing intervention should be the highest priority?

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## 문제

A nurse is caring for a patient with Guillain-Barré syndrome who is experiencing respiratory compromise. Which nursing intervention should be the highest priority?

## 보기

1. Administer prescribed corticosteroids to reduce inflammation
2. Position the patient in high Fowler's position to maximize lung expansion
3. Prepare for immediate endotracheal intubation and mechanical ventilation **✔ 정답**
4. Encourage deep breathing exercises and use of incentive spirometer

**정답: 3**

## 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.

## 심화 해설

Clinical Priority in Ascending Paralysis

In Guillain-Barré syndrome (GBS), an acute immune-mediated polyradiculoneuropathy, the classic presentation is a symmetric, ascending weakness that can progress to the muscles of respiration. The foundational principle of nursing care for this condition is that GBS is a major cause of neuromuscular respiratory failure globally [1]. As the paralysis ascends, it can involve the diaphragm and intercostal muscles, leading to ineffective ventilation and a life-threatening emergency. Therefore, the highest priority nursing intervention is derived directly from the Airway, Breathing, Circulation (ABC) framework.

Why Respiratory Monitoring is the Priority

The other listed interventions are all appropriate components of holistic care for a patient with GBS, but they do not address the most immediate threat to life. The primary danger is not a contracture, a deep vein thrombosis, or pain, but rather the insidious onset of respiratory failure. The case reports underscore this reality. One case describes a patient managed in a stepdown unit with close respiratory monitoring, which was the specific intervention that prevented progression to respiratory failure and the need for intensive care unit (ICU) admission [2]. In a resource-limited setting without access to invasive ventilation, a structured framework was built around noninvasive respiratory support and intensive nursing care to manage respiratory failure successfully [1]. These examples demonstrate that vigilant, continuous assessment of respiratory function—including vital capacity, negative inspiratory force, and signs of hypoxia or hypercapnia—is the cornerstone of patient safety. The nurse must be prepared to escalate care and assist with mechanical ventilation the moment clinical indicators show the patient can no longer protect their own airway or ventilate adequately.

Integrating the Evidence into Practice

For the NCLEX-RN examinee, this question highlights the critical distinction between a routine intervention and a life-saving priority. While performing passive range of motion exercises, monitoring for deep vein thrombosis, and managing pain are all within the nurse's scope for a patient with immobility and neuropathic discomfort, they are secondary to ensuring the patient is breathing. The evidence confirms that even in a case where a patient did not ultimately require ICU admission, the decision to provide close respiratory monitoring was the key safety net [2]. The nurse’s clinical judgment must focus on the predictable trajectory of ascending paralysis: what begins as leg weakness can rapidly become diaphragmatic weakness. A systematic assessment of respiratory rate, depth, breath sounds, and the patient’s ability to cough and clear secretions provides the data necessary to prevent respiratory arrest, which is the most catastrophic outcome of GBS.References (research sources)

- [1]High-Dependency Care Without Mechanical Ventilation for Severe Guillain-Barré Syndrome in a Rural Low-Income Setting.Research articleNotghi L, Little L, Chin J. (2026) · DOI: 10.1155/crcc/1700879

- [2]Guillain-Barré Syndrome Following Seasonal Coronavirus (HCoV-229E) Infection: A Case Managed Without Intensive Care.Case reportWeldearegay G, Aghabekyan T, Arif A, Salvani J. (2026) · DOI: 10.7759/cureus.107360

## 임상 시나리오

Clinical Priority for Respiratory Compromise in Guillain-Barre Syndrome

The highest priority for a patient with Guillain-Barre syndrome (GBS) and respiratory compromise is preparation for immediate endotracheal intubation and mechanical ventilation. This addresses the life-threatening failure of the ventilatory pump.

**Key Clinical Reasoning:**

- **Pathophysiology:** Ascending demyelination weakens the diaphragm and intercostal muscles, causing neuromuscular respiratory failure. This is a pump problem, not a lung tissue problem.

- **Priority:** Securing the airway takes absolute precedence over supportive measures like positioning or spirometry, which do not prevent apnea from progressive muscle weakness.

- **Pharmacology:** Corticosteroids are not standard of care for GBS and do not reverse the acute neuromuscular blockade.

**Nursing Actions:**

- Continuously monitor vital capacity, negative inspiratory force, and single breath count to detect declining function.

- Assemble intubation equipment and have emergency medications (e.g., sedatives, paralytics) at the bedside.

- Notify the rapid response team and respiratory therapy early; do not wait for complete decompensation.

- After intubation, confirm placement with end-tidal CO2 detection and secure the tube.

**NCLEX Tip:** In neuromuscular emergencies, airway and breathing always come first. Do not be distracted by interventions that treat inflammation or promote lung expansion when the respiratory muscles are failing.

## 핵심 개념

- **Guillain-Barre syndrome** — Acute immune-mediated polyneuropathy causing ascending demyelination and potential neuromuscular respiratory failure.
- **Respiratory compromise** — Inadequate ventilation due to weakened diaphragm and intercostal muscles, leading to hypoventilation and apnea risk.
- **Endotracheal intubation** — Placement of a tube into the trachea to establish a definitive airway and provide mechanical ventilation.
- **Mechanical ventilation** — Machine support that takes over the work of breathing when the ventilatory pump fails.
- **Ventilatory pump failure** — Inability of the respiratory muscles to maintain adequate alveolar ventilation, distinct from lung tissue disease.

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