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8/6/2019 Case Press Power Point

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BRABALIBINTAWANA Case of Guillain-Barre Syndrome


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Guillain-Barre Syndrome sometimes Landry's paralysis, is an acute

inflammatory demyelinating polyneuropathy (AIDP), a disorder affecting

the peripheral nervous system. Ascending paralysis, weakness beginning in the feetand hands and migrating towards the trunk, is the most typical symptom. It can

cause life-threatening complications, particularly if the breathing muscles are

affected or if there is dysfunction of the autonomic nervous system.The disease is

usually triggered by an acute infection. GuillainBarr syndrome is a form

of peripheral neuropathy.The diagnosis is usually made by nerve conduction studies. With prompt

treatment by intravenous or plasmapheresis, together with supportive care, the

majority will recover completely. GuillainBarr syndrome is rare, at 12 cases

per 100,000 people annually, but is one of the leading causes of acute non-trauma-

related paralysis in the world.

The group chose this topic because this will help us to know and betterunderstand the syndrome. Because GuillainBarr syndrome is rare, encountering

it in a clinical setting is a bit confusing, hence we really have to know the process

and progress of the disease and there we depend our nursing responsibilities and

interventions. One of the reasons that made the group decided to choose this topic

is having known that this is an autoimmune and neurological disease: having theneed for further assessments unlike other diseases.


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Dorot e re s self-c re Deficit eor

Dorothea Orem believes that therapeutic self-care demand refersto all safe-care activities required to meet existing self-care requisites, or

in other words, actions to maintain health and well-being. Self-care

theory is based on four concepts: self-care self-care agency, self care

requisites, and therapeutic self-care demand.Self-care refers to those activities an individual performs independently

throughout life to promote and maintain personal well-being.

To Dorothea Orem, self-care agency is the individuals ability to perform

self-care activities. It consists of two agents: a self-care agent (the person

who performs self-care independentlty0 and a dependent care agent (aperson other than the individual who provides the care.

We apply this theory because our patient cant do on her own. She needs

assistance in her daily living activities from her significant others and

other health care team.


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Patients Data

A. General Data

Na e: MVC

Ge er: Fe ale

A ress: Br . a al c, ta. Mesa

ate f Birt : J e 5, 1993A e: 17 / l

Birt lace: Bata es

Reli i : Ba tist

Nati alit : Fili i

cc ati : t e t

Ci il tat s: i le

Date of Admission: A ril 25, 2 11 11:5 a

B. Chief Complain:

Nanghihina yung parehong binti ko as verbalized by the patient.

(Bilateral L er E tre ities eak ess)


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F. Review of System

REVIE F YT

EMate Taken: April 29, 2 11

Time: 1: pm

a.General: (+) eakness

(-) fatigue

(-) anore ia

(-) fever(-) night s eat

(-) lumps

.Cardiovascular (-) chestpain

(-) cough/sputum

(-) s ellingof ankle(-)palpitation

c. Gastrointestinal (-) nausea /vomiting

(-) heart urn

(+) difficulty indefecation

(+) ignores urge todefecate


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(-) a dominalpain

(-) hematemesis, melena(-) jaundice

d. Respiratory ystem (-) hemoptysis

(-) dyspnea

(-) tachypnea

(-) shortness of reathing

e. Genitourinary (-) analpain

(-) leeding

(-) dysuria

(-) hematuria

f.Nervous ystem

(-) headache(-) dizziness

(-) lightheadedness

(+)paresthesia

(+) numbness

g. Musculoskeletal (+) difficulty inmoving lower e tremities

(+) weakness of the left arm


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G. Physical Assessment

Date Taken: April 29, 2 11

Time: 1: pm

General Appearance:

Ms. C is tall, has a mesomorphic body type, 17 years old girl who is consciousand coherent. She looks relax while lying in her bed. Her hair is neatly fixed and

her clothes are clean. She has a fair skin complexion.

Vital signs:

BP: 110/70 mmHg

RR: 20 breaths per minutePR: 98 beats per minute

Temp: 36.9C


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f. PUPILS

Black in color, equal in size, and round. Constricts when looking at near objects and dilates

when looking at far objects.

g. EYE MOVEMENT

Able to move eyes in full Range of Movement.h. FIELD OF VISION

When looking straight ahead, the client can see objects in the periphery.

i. VISUAL ACUITY

Client has 20-20 vision.

III. EARS

Parallel, symmetrical, proportional to the size of the head. The skin is the same color as the

surrounding area, clean.

a. EAR CANALPinkish, clean with scant amount of cerumen and few cilia.

b. HEARING ACUITYAble to hear and repeat whispered words.IV. NOSEMidline, symmetrical and patentV. MOUTH

a. GUMSPinkish, smooth, moist, no swelling/bleeding; no discharge.

b. TONGUEMedium in size, pink, moist, shiny and freely movable, no tenderness.


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d. SOFT PALATE

Is pinkish, smooth and moist.

e. HARD PALATE

Is slightly pinkish.

TONSILS

Are light pink, non-inflamed, no exudates.

VOICE

Is well-modulated and has no hoarseness.

VI. NECK:

Proportional to the size of the head, symmetrical and straight, no palpable lumps, masses or

area of tenderness.

A. RANGE OF MOTIONFreely movable without difficulty.

B. MUSCULAR STRENGTHSymmetrical and able to resist applied force with equal strength.

C. THYROID GLANDGland ascends during swallowing but is not visible.

D. LYMPH NODESNo palpable masses in the pre-auricular, post-auricular, tonsilar, submandibular,submental, supraclavicular,occipital and cervical area.


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RANGE F M TI N:

ARM : BothArms in raised invertical position at the side of the head.

Findings: Right armcanperformwith relative ease while the left armwith slight difficulty andcanbe raise up to a limitedheight

SH ULDER: Abduct and adduct

Findings: Performs with relative ease.

ELB S: Bends and straightens

Findings: Right armcanperformwith relative ease and fast while the left armcanperform the

samebut with slower rate than the right arm.FINGERS: E tends and spreads fingers. Makes fist thumb across the knuckles.

Findings: Performs with relative ease.

Muscle Strength: Left Arm: 4/5

Right Arm: 5/5

X. LOWER EXTREMITIESFair skin, complete five fingers in each foot. Nails are transparent. Symmetricalfine hair distributed, with absence of varicose veins. Muscles are symmetrical. Length issymmetrical Patient has difficulty in flexing the legs inward. Toenail appears white, colorreturns immediately as pressure is released (capillary refill is normal). Patient complainedof pain upon palpation of both lower extremities with pain scale of 3/10.


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RANGE F M TI N

A. L ER EXTREMITIES: Abduct (away) canperformwith slight difficulty

Adduct (towards) canperformwith slight difficulty

Rotationcanperformwith slight difficulty

B. ANKLE: Fle ion and E tension- canperformwith slight difficulty

Rotation- canperformwith slight difficulty

C. TOES: Spreads and igglescanperformwith slight difficulty

Muscle Strength: 3/5 forboth lower e tremities

NEUROLOGIAL ASSESSMENT

I. Behavioral, Cognitive & Mental Status

Patient is alert andcoherent, has calm and rela edbehaviorupon approached. Able to answer

uestions that were asked. Slight facial grimace is present while moving the lower e tremities.

She is oriented to time andplace; Looks cleanwithneatly fi edhair andwears cleanhospitalgown.

II. Intellectual FunctionA. MEMORY

IMMEDIATE Can recall accuratelyRECENT- Can recall accurately

REMOTE- Can recall accurately


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B.KNOWLEDGE

Has an idea abouther illness and all t

heprocedures t

hat was done to

her.C.ABSTRACTTHINKING

Able to e press ideas orconcept.

D.ASSOCIATION

Able to associate.

E. JUDGEMENT

Able to judge withwhat she wants ornot.

III. SENSORY FUNCTION

Back of Hands touch sensationForearms touch sensationUpper Arms touch sensationLower Arms touch sensationDorsal portion of Feet Light ticklingLaterally and Medially Light tickling


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IV. CEREBELLAR FUNCTION

Patient canpat hands against thighs

Canperform finger tonose tests repeatedly and rhythmically touches the nose

RombergsTest- Sways whennot assisted andcannot able tomaintainuprightposture and foot

stands.

Patient cannot walknormally

V. MOTOR FUNCTION

Muscles in the lower e tremities are weaker thannormal andcan resist little amount ofpressure.

Muscles in the upper e tremities canperform full range ofmotion, fle ed and e tend andcanresist e ualpressure applied.

Able to fle ed arms andcan feel thebicep fle ing and tricep e tension .

Muscles are firmed.

VI.DEEP TENDON REFLEXESBICEP REFLEX: 2+

TRICEP REFLEX: 2+PATELLAR: 0PLANTAR REFLEX: 2+

SUPERFICIAL REFLEXESCORNEAL REFLEX: PresentGAG REFLEX: Present


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VII. CRANIALNERVES:

I.Olfactory : Normal -able to identify smellsII.Optic : Normal -2 /2 visual acuity

III.Oculomotor : Normal - can able to elevate eyelids

can able tomove eyes full ROM

(+) PERRLA

IV.Trochlear : Normal -can able tomove both eyes downward

V.Trigeminal : Normal -S:patient can feel sensation-M: temporal andmassetermusclespalpated

(muscles formastication)

symmetrical openingof the mouth

(+) Corneal Refle

VI.Abducens : Normal -can able tomove both eyes laterally

VII.Facial : Normal -S: able to taste-M: can able towrinkle forehead, raise

eyebrows, smile, show teeth, puffcheeks


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I. Course in the Ward

Doctors Orders:

April 24, 2011

11:52am

>Pt. admit to PICU>Secure consent for admission andmanagement

>NPO

>Oxygen inhalation 5 LPM via face mask

>Diagnostics:

Plain andcontrast CTScan

Na, K, Ca

U/A

HGTnon

CBC with HPC, BT

BUN, Crea


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CXR-HPL

>IVF: PNSS 1L to run at 17gtts/min

>Monitorv/s 4 and record

>Monitor I & O shift and record

>Patient informprocedure at this admission>Refer atNeuro Service

>WOF signs of respiratorydistress

>Refer

7pm>For acute f laccid paralysis work-up

>Refer


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1 : pm >Still for stool collection for acute flaccidparalysis work- up

April 29, 2 11

6: am

>IVF to followD5NM 1L to run @ 2 gtts/min

>Still for EMG-NCV

>Refer

1: pm >Physical Assessment and ROS was done.

>V/S was taken and recorded as follows:

>BP: 110/70

>Temp.: 36.9C

>RR: 20 bpm

>PR: 98 bpm

J. Final Diagnosis: Guillain-Barre Syndrome


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Review of Related Literature

Description

Guillain-Barr syndrome (GBS) is a rare disorder in which a persons own immune system

damages their nerve cells, causing muscle weakness and sometimes paralysis. GBS can cause

symptoms that last for a few weeks. Most people recover fully from GBS, but some people have

permanent nerve damage. In very rare cases, people have died ofGBS, usually from difficulty

breathing. In the United States, for example, an estimated 3,000 to 6,000 people develop GBS

each year on average, whether or not they received a vaccination.

Causes

Many things can cause GBS; about two-thirds of people who develop GBS symptoms

do so several days or weeks after they have been sick with diarrhea or a respiratory

illness. Infection with the bacterium Campylobacter jejuni is one of the most common riskfactors for GBS. People also can develop GBS after having the flu or other infections

(such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may

develop GBS in the days or weeks after getting a vaccination.

SymptomsSymptoms of Guillain-Barr Syndrome include weakness, typically beginning in the

legs and progressing upward. The weakness is accompanied by decreased feeling(paresthesia). Reflexes are lost, for example, the hammer to the front of the knee will notinduce a kick. In severe cases breathing can be affected enough to require a ventilator andrarely the heart can be affected. The maximal degree of weakness usually occurs within thefirst 2-3 weeks.After the first clinical manifestations of the disease, the symptoms can progress over the

course of hours, days, or weeks.


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Anatomy and PhysiologyMuscular system

The bodily system that is composed of skeletal, smooth, and cardiac muscle tissueand functions in movement of the body or of materials through the body, maintenance of

posture, and heat production.

The muscular system consists of muscular cells, the contractile elements with the

specialized property of exerting tension during contraction, and associated connective

tissues. The three morphologic types of muscles are voluntary muscle, involuntary

muscle, and cardiac muscle. The voluntary, striated, or skeletal muscles are involvedwith general posture and movements of the head, body, and limbs. The involuntary,

nonstriated, or smooth muscles are the muscles of the walls of hollow organs of the

digestive, circulatory, respiratory, and reproductive systems, and other visceral

structures. Cardiac muscle is the intrinsic muscle tissue of the heart. Upon stimulation by

an action potential, skeletal muscles perform a coordinated contraction by shortening

each sarcomere.T

he best proposed model for understanding contraction is the slidingfilament model of muscle contraction. Actin and myosin fibers overlap in a contractile

motion towards each other. Myosin filaments have club-shaped heads that project

toward the actin filaments.


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Larger structures along the myosin filament called myosin heads are used to

provide attachment points on binding sites for the actin filaments. The myosin headsmove in a coordinated style, they swivel toward the center of the sarcomere, detachand then reattach to the nearest active site of the actin filament. This is called arachet type drive system. This process consumes large amounts of adenosinetriphosphate (ATP).

Energy for this comes from ATP, the energy source of the cell. ATP binds to

the cross bridges between myosin heads and actin filaments. The release of energypowers the swiveling of the myosin head. Muscles store little ATP and so mustcontinuously recycle the discharged adenosine diphosphate molecule (ADP) intoATP rapidly. Muscle tissue also contains a stored supply of a fast acting rechargechemical, creatine phosphate which can assist initially producing the rapidregeneration of ADP into ATP.

Calcium ions are required for each cycle of the sarcomere. Calcium isreleased from the sarcoplasmic reticulum into the sarcomere when a muscle isstimulated to contract. This calcium uncovers the actin binding sites. When themuscle no longer needs to contract, the calcium ions are pumped from the sarcomereand back into storage in the sarcoplasmic reticulum here are approximately 639skeletal muscles in the human body.


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FourAnteriorCompartment Muscle

One function of all four muscles in the front of the lower leg is to pull the foot and toes

upward (called dorsiflexion).

Tibilais anterior is the muscle you feel right next to the shinbone. This muscle also helpsturn the foot inward.

Extensor digitorum longus and extensor hallucus longus are underneath the tibilais

anterior. The extensor hallucus longus extends the big toe, and the extensor digitorum

longus extends the other toes.

The peroneus tertius is a small muscle at the lower outer part of the front of the lower

leg. This muscle helps turn the foot outward.Two Lateral Compartment Muscles

The muscles on the outside of the lower leg are the peroneus longus and

peroneus brevis. These muscles pull the foot outward (eversion). According to the

Anatomy Coloring Book, the peroneus muscles are especially active when walking on

the toes or pushing off with the big toe.Three

Sup

erficialPo

steri

orC

ompartm

ent

Muscles

The two larger superficial posterior compartment muscles (the gastrocnemius andsoleus) are commonly called the calf muscles. The gastrocnemius is the outermost the calfmuscle. It attaches to bone (femur) above the knee, which means the gastrocnemius helpsto bend the knee. It also points the foot (plantarflexion).Underneath the gastrocnemius is the soleus. The soleus is the muscle that gives the calfbulk. It plantar flexes the foot.


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Most of the plantaris muscle is in the back of the knee, but the muscle's tendon runs all

the way down to the ankle bone (calcaneus). It helps bend the knee and plantar flex thefoot.

Three Deep PosteriorCompartment Muscles

The muscles deep in the back of the lower leg help plantar flex the foot. These

muscles and their other functions are as follows:

- Tibialis posterior helps turn the foot inward.- Flexor hallucus longus flexes the big toe and helps turn the foot inward.

- Flexor digitorum longus flexes the other toes and helps turn the foot inward.


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PATHOPHYSIOLOGY

ETIOLOGY:

IDIOPATHIC

PRECIPITATING FACTORS:RESPIRATORY INFECTIONInfluenza like symptoms 2weeks prior to admission

(colds)

ETIOLOGY:

IDIOPATHIC

Infectious organism(Cytomegalovirus,

Mycoplasma Pneumoniae)

contains an amino acid thatmimics the peripheral nerve

myelin.


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The immune system cannotdistinguish between the two

proteins and attacks and destroysperipheral nerve myelin that causes

inflammatory demyelization.

Exact location of the attack withinthe peripheral nervous system:

ganglioside GM1b

Influx of macrophages and otherimmune-mediated agents and attacks

the myelin which causesinflammation and destruction

Axons unable to support nervefunction


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Signs and Symptoms:

LowerExtremities

Muscleweakness

Diminishedreflexes

Paresthesias,Numbness

Impairedphysicalmobility

Risk forinjury

Decreased physicalmobility

Decreased GI Motility


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Decrease muscle tone (Sphinctermuscles of the GI tract)

Retention of stool for a longer period of time

Constipation


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Laboratories and Diagnostics

Laboratory Results:

ChestX-ray (April 25, 20110)

T/c GBS

Result: Examination shows clear lung field.

Heart and great vessels are of normal size andconfiguration.

Other chest structures are unremarkable.Impression:Negative chest x-ray


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Clinical Chemistry (April 25, 2011)


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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

Nahihirapan akonggumalaw as

verbalizedby the

patient

Objective:

>Reportspainupon

movement

>Limited range of

motion

>Decreased

movement

Impaired Physical

mobility related to

decreasedmuscle

strength as evidenced

bypainupon

movement,limited

range ofmotion,

decreasedmovement

andmuscle strength

of 3/5 in the lower

extremities and 4/5 in

the left arm

RATIONALE:

Guillain-Barr

Syndrome manifests

the followingclinical

symptoms: ascending

flaccidparalysis,

diminished reflexes,

paresthesia and

numbness and it is

rapidlyprogresses to

the wholebody

including the

respiratorymuscles.

After 8 hours of

Nursing interventions

thepatient will have

increase strength and

functionof affected and

compensatorypart w/o

any reports ofpain.

Verbalize

willingness to and

demonstrateparticipation in

activities

Verbalize

understandingof

situation and

individual

treatment regimen

and safetymeasures.

INDEPENDENT

-Supported affectedbodyparts using

pillows, foot supports.

-Scheduled activities

with ade uate rest

periods during the day

-Providedclient with

ample time toperform

mobility related tasks

-Encouraged

participation in self

care, divertional

activities, recreational

activities

-Raised the side rails

-encouragedpatient to

dopassive range of

motion exercises as

follows:

Ankle and foot

exercises like

Tomaintainpositionof

function and

reduce riskof

pressure ulcers.

To reduce

fatigue.

To let the patientfeel that she can

do the activities

without hurry

Too lessen the

boredomof the

patient

Toprovide safety

Enhances self

concept and

sense of

independence.

To improve

properbloodcirculation and

Afterof 8 hours of

Nursing interventions

thepatients has

increased strength and

functionof affected

andcompensatorypart

w/o any reports of

pain.

Thept. verbalized

willingness to anddemonstrated

participation in

activities

Thept. verbalized of

situation and

individual treatment

regimen and safety

measures.

The goal was met.


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Because of the flaccid

paralysis as a main

signof this syndrome

patient canhave

difficulty in

ambulatingbecause of

the muscle weakness

anddiscomforts felt.

finger exercises like

Fingerbends, Finger

spreads, and Finger-to-

thumb touches.

Forearm andwrist

exercise like Wrist

rotation and Palm

up,palmdown.

Shoulder and

elbow exercises

like Shoulder

movement, up and

down, Shoulder

rotation, Elbow

bends, up and

down and Elbow

bends, side to

side.

COLLABORATIVE:

Consult with a Physical

Therapist tomake a

planofcare of

To improve

properblood

circulation and

disuse syndrome

of the hand and

fingers

To improve

properblood

circulation and

disuse syndromeof the forearm

andwrist

To improve

properblood

circulation and

disuse syndrome

of the shoulder

and elbow

For thepossible

rehabilitationof

thepatient duringor after recovery


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Subjective:

Ilang araw na akong

di dumudumi as

verbalizedby thepatient.

Objective:

>hypoactivebowel

sounds (3/min.)

>difficulty in

defecation

>ignores urge to

defecate

Constipation related

to insufficient

physical activity as

evidencedby

hypoactivebowelsounds (3/min.),

difficulty in

defecation, and

ignores urge to

defecate

RATIONALE:

Decreasedphysical

mobilitycan resultalso indecrease GI

motilitybecause like

othermuscles in the

body, ifnot used the

muscle tone

decreases(sphincter

muscles of the GI

tract) which leads to

stool retention for a

longerperiodof

time.

After 6 hours of

nursing intervention

patient will have a

normalbowel sound

andwill regainnormal

patternofbowel

functioning.

INDEPENDENT

-Determined fluid

intake

-Palpated abdomen

-Auscultated abdomen

forpresence ofbowel

sounds.

-Encouraged to ingest

food rich in fiber and

bulk.

-Promoted ade uate

fluid intake.

-Identified specific

actions taken if

problem recurs.

-Promoted activities

that canhelp in

utilizing increase GI

mobility (assisted

patient to ambulate

once in a while)

-Assisted through

passive range of

motion exercises

Tonote deficits.

To look for

presence ofdistention and/or

masses.

For reflecting

bowel activity.

To improve

consistencyof

stool and

facilitate passagethroughcolon.

Topromote

moist/soft stool.

Topromote

timely

intervention,

enhancing

clients

independence.

Topromote

peristaltic

movement of the

GI tract.

Topromote GI

motility

After 6 hours of

nursing intervention

patient has regained

normalpatternof

bowel functioningand exhibitednormal

bowel sounds.


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A Di i Pl i I i R i l E l i


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5. Patient will

demonstrate

appropriate use of

assistive devices

(cane, walker, grab

bars)

-Encouraged

significant others and

assistedpatient when

turningorwhenneeded tograb an

object

-Instructed significant

others of thepatient to

never leave the

patients side orhave

visiting rotations

duringconfinement

Toprevent falls

or losingcontrol

inholdingobject

Toprevent falls

or any

unnecessary

accidents that

might happen

5. Patient

demonstrated

appropriate use of

assistive devices.


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Discharge Plan

yM Supportive Care

y E- Encourage patient and instruct the significant others to assistthe patient to walk within her limits or use assistive devices andprovide appropriate resting periodsy Passive range of motion exercise to be performed at least twice daily

as follows:

y Ankle and foot exercises. Like Ankle bends, Ankle rotation, Toebends, Toe spreads.y Hip and leg exercises like Leg movement, side to side, and Leg

rotation, in and out.y Hand and finger exercises like Finger bends, Finger spreads, and

Finger-to-thumb touches.

y Forearm and wrist exercise like Wrist rotation and Palm up, palmdown.y Shoulder and elbow exercises like Shoulder movement, up and

down, Shoulder rotation, Elbow bends, up and down and Elbowbends, side to side.


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y H Perform activities of daily living with assistance

and manage self care like the patients nutrition, boweland bladder management. Skin care and adaptiveequipment for bathing, hygiene, grooming anddressing.

y

Implement safety measures at home.y Increase fiber intake daily to facilitate easy passage of

stool

y Increase fluid intake daily to prevent constipation and tokeep the patient hydrated

y O Follow up check-up when symptoms persisted and/or worsen

y D Diet as tolerable (DAT)


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Prognosis

y Most of the time recovery starts after the fourth week from theonset of the disorder. Approximately 80% of patients have acomplete recovery within a few months to a year, although minorfindings may persist, such as areflexia. About 510% recover withsevere disability, with most of such cases involving severe proximalmotor and sensory axonal damage with inability of axonalregeneration. However, this is a grave disorder and despite allimprovements in treatment and supportive care, the death rateamong patients with this disorder is still about 23% even in thebest intensive care units. Worldwide, the death rate runs slightlyhigher (4%), mostly from a lack of availability of life supportequipment during the lengthy plateau lasting four to six weeks, andin some cases up to one year, when a ventilator is needed in the

worst cases. About 510% of patients have one or more late relapses,in which case they are then classified as having chronicinflammatory demyelinating polyneuropathy(CIDP).

y Poor prognostic factors include: 1) age, over 40 years, 2) historyof preceding diarrheal illness, 3) requiring ventilator support, 4)high anti-GM1 titre and 5) poor upper limb muscle strength.


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