NURSING CARE PLAN

DATE ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

5.11.19 Objective data : Acute onset of To 1..Assess motor 1..To determine 1. Patient has loss of motor Muscle power
>..Ascending paralysis progressive muscle increase function for motor appropriate function in upper and score :
1st day >..Both lower limbs weakness related mobility impairment. interventions for lower limbs measured by
... .. . muscle weakness to decreased of limbs specific motor muscle power score. Upper limbs –
4/5
> Uncordinated strength and and impairment
....movement secondary to minimize Lower limbs –
> Paresthesia neuromuscular potential 2..Assist for 2..It enhances 2.Passive ROM exercise of 0/5
impairment as for injury. passive exercise circulation, upper, lower limbs is done
evidenced by with full range of maintain muscle in each shift.
inability to motion (ROM) on tone and joint
purposefully move, all extremities. mobility.
lower limbs
paralysis and 3..Maintain ankles 3. To prevent 3. Both feet are supported
tremors. at 90 with foot drop with pillow to prevent foot
footboard. drop.

4. Provide support 4. To maintain 4. Patient is provided air

to affective body body part mattress and limbs are
parts using pillows. function and rested on pillows.
reduce risk of
pressure ulcer

5. Monitor for 5.If pulmonary 5.Physical examination is

sudden onset of emboli or deep done in each shift to rule
dyspnea, cyanosis, vein thrombosis out complications.
respitatory distress. develops that
may lead to
complications.
DATE ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

6. Administer IVIG 6. It is a drug of 6. Ing IVIG 10 gm with

as prescribed. choice in 500 ml NS is administered
autoimmune per day for 3 days.
disorder

7.Encourage 7.To provide 7. Patient is intubated so

ambulation for progressive only passive exercise is
short, frequent mobilization. done.
walks with
assistance.

5.11.19 Objective data : Acute pain related To relief 1.Assist with ROM 1.To reduce pain 1. ROM is done in each Pain reduces to
 Pain score 6/10 to alteration in pain exercises and joint shift. some extent as
1st day muscle tone, stiffness evidenced by
 Guarding sign
pain score 4/10.
 Limited paresthesia as
movement evidenced by 2.Provide back rub 2.It reduces pain 2. Back rub with oil is
patient’s written 2nd hourly or atleast alteration of provided 2nd hourly
complain of painful once in each shift sensory neurons,
sensation. provides muscle
relaxation

3. Provide calm 3. To soothen 3. Ventilator alarms are

and quiet and as a attended each time to
environment. diversional avoid disturbances.
therapy

4.Administer 4. To reduce 4.Tab PCM 500 mg is

analgesics as pain given with ryles tube feed
prescribed by
doctor.
DATE ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

6.11.19 Objective data : Ineffective Patient 1. .Auscultate 1. To assess 1.On auscultation crackles Patients
 Patients ABG breathing pattern will be chest, character of adequacy of air is present respiratory
2nd day level shows low related to able to breath sounds, flow and needs are met on
paO2 level. neuromuscular maintain presence of presence of time as
evidenced by
dysfunction and effective secretions. breath sound.
Spo2 – 98%.
 Thick secretions chest muscle breathing
present in weakness pattern. 2. Monitor rate and 2. To assess 2.Resp rate – 24/min
respiratory tract secondary to depth of types of Normal preathing pattern
ascending paralysis respirations, type breathing ...present
as evidenced by of breathing pattern pattern, signs of
hypoventilation, (cheyne-strokes, respiratory
paO2 – 69.8, tachypnea) failure.

3. Position patient 3. To promote 3.Patient’s head end is 45

with head of bed effective chest elevated and neck
elevated (45 ) expansion supported with pillow.

4. Monitor signs of 4. To provide 4.Patient is under

impending emergency ventilator support with
respitratory failure intubation if Fio2 – 100 %
(Heart rate needed.
>120b/min, or
< 30b/min.

5. Suction 5. To promote 5.Endotracheal tube

secretions as clearance of suction is done 2nd hourly
appropriate. secretions and and as and when required.
prevent
aspiration.
DATE ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL IMPLEMENTATION EVALUATION

6. Review chest x- 6. It reveals 6. Chest X-ray shows no

rays and perform ventilator state lung infection like
chest and signs of pneumonia or atelectasis.
physiotherapy developing
complications
such as
atelectasis and
pneumonia.

6.11.19 Subjective data : Risk for impaired At the end 1. Assess skin 1.Skin is prone 1.Bony prominences are Patient had
Patient reported, skin integrity of the care integrity, noting to breakdown intact with no redness. intact skin on
2nd day related to complete patient colour, moisture, when client is bony
Objective data : bed rest. maintains texture and bedridden prominences
 Dry skin intact skin. temperature.
 Poor turgor
 Bedsore 2.Maintain good 2.To maintain 2.Patient is provided air
skin care, keeping good skin mattress and 2nd hourly
skin clean and integrity back care.
lubricated with
lotion as needed.

3.Turn patient’s 3. It improves 3. Side-lateral position is

position second skin circulation provided to patient 2nd
hourly. and reduces hourly and documented in
pressure time on nursing care plan
bony
prominences

4.Keep bed clothes 4.To prevent 4.To prevent skin irritation

 dry and free of skin irritation and rednes
wrinkles, crumbs

7.11.19 Objective data: Imbalanced To 1.Perform 1.To improve 1.Obtain nutritional Patient is given
 On 2nd hourly nutrition less than improve nutritional nutritional food history from patients wife. timely RT feed
3rd day ryles tube feed body requirement dietary assessment for the intake. with mouth
related to pattern patient. care.
inadequate food
intake as evidenced 2.Provide 2nd 2.To provide 2.Patient is given 200 ml
by appearance hourly ryles tube nutrition ryles tube feed 2nd hourly.
(depressed feed to the patient.
periorbital area)
3.Add nutritional 3.To provide High protein 1 scoop is
supplement with required protein. added in each feed.
ryles tube feed as
instructed by
dietician.

4.Aspirate gastric 4.To check feed 4. Last gastric aspirate is

content 4th hourly tolerance 10 ml.

5.Monitor for 5. To check feed 5. Patient passess stool

diarrhea or tolerance twice a day in diaper.
vomiting, (quantity,
abdominal constituents)
distension,
abdominal cramps

6.Provide mouth 6.Avoid 6.Chlorhexidine mouth

care in each shift. halitosis and wash is used for patient.
increase appetite
HEALTH EDUCATION :

Seek medical care immediately if –

 Swallowing difficulty
 Shortness of breath
 Difficulty in moving any part of body

Diet
 patient is a
 To avoid food such as oily foods, caffeine and spicy foods
 To consume milk twice in a day.
 Drink fluids to prevent dehydration and avoid plain water in large quantity.
 Donot eat food high in fat, sugar and salt.

Physical activity and exercise

 Advised the patient to avoid excessive work and exposure to sunlight

 Encourage the patient to go for morning and evening walk
 Advised to avoid sports in public place.
 Advised to do lip breathing in the morning.
 Encourage the patient to avoid any accident or sharp objects during his activity.

Medication

 Encourage the patient to take medication on time and not to skip his medication.
 Taught the patient not to take any medication without the physician prescription.
Prevention from complication

 Encourage the patient to come for check-up if any abnormality found in his body
 To check his routine LFT, KFT blood levels.
 To take proper medication at the time .

Home care and follow up

 Encourage to maintain his personal hygiene.

 Avoid consumption of alcohol and drugs
 To avoid sedentary lifestyle.
 Encourage the patient to come for regular health check-up after the discharges

Conclusion

Guillain Barre syndrome is an acute process of post-infectious etiology with multiple sources and triggering events. The most common symptom
is peripheral neuropathy and weakness, leading to respitatory compromise. Treatment primarily consists of supportive care. IVIg is an IgG
concentrate used to hasten time to recovery.
REFERENCE
 Judith HopferDeglin, April Hazard Vellerand, Davis’s Drug Guide for Nurses 12edition , 2010 publisher Robert G.Martone
Page no. 245-246.124.156.

 K D Tripathi MD, (2015), Essentials of Medical Pharmacology (7th edition), pages – 787 to 797 and pages – 849 to 856.

 Mosby’s Drug Consult for Nurses,(2006), 2nd edition, pages – 17 to 38.