C.B. is a single, self-employed 54-year-old man. Three weeks ago, he saw his primary care
provider because of symptoms of fatigue, myalgia, fever, and chills, which were accompanied
by a hacking cough. He was diagnosed with viral influenza. Today he has weakness,
numbness, and tingling of both lower extremities, which is progressing into his upper body.
His brother brought him to the emergency department after recognizing the seriousness of his
illness. The attending physician immediately suspects Guillain-Barré syndrome (GBS).
1. Describe the cause of GBS.
Guillain-Barré syndrome (GBS) is a rare and serious autoimmune disorder that affects the
peripheral nervous system. It can cause muscle weakness, numbness, and tingling that typically
start in the legs and progress upward to the arms and upper body. In severe cases, GBS can lead
to paralysis and respiratory failure, requiring immediate medical intervention. Guillain-Barré
syndrome (GBS) is an autoimmune disorder in which the body's immune system mistakenly
attacks the myelin sheath that covers the nerves in the peripheral nervous system. This leads to
inflammation and damage to the nerves, disrupting the transmission of nerve impulses and
causing muscle weakness, numbness, and tingling. The exact cause of GBS is not fully
understood, but it is often triggered by a preceding infection or vaccination. The immune
system may produce antibodies against the infection, which then cross-react with the myelin
sheath, causing damage to the nerves.
2. What factors in C.B.’s history support a diagnosis of GBS?
C.B.'s history supports a diagnosis of Guillain-Barré syndrome (GBS) based on several factors:
Recent infection: Three weeks before the onset of his current symptoms, C.B. was diagnosed
with viral influenza. GBS is often preceded by a bacterial or viral infection.
Progressive weakness and numbness: C.B. has weakness, numbness, and tingling in both lower
extremities, which is progressing to his upper body. This is a hallmark feature of GBS, as the
muscle weakness typically starts in the legs and progresses upward.
Time course of symptoms: C.B.'s current symptoms developed several weeks after his initial
infection, which is consistent with the time course of GBS. The onset of symptoms can range
from days to weeks after the initial infection.
Age: GBS can affect individuals of all ages, but it is more common in older adults. C.B. is 54 years
old, which is a risk factor for GBS.
3. Describe the clinical manifestations of GBS.
Numbness and tingling: This is often the first symptom of GBS, and it typically starts in the toes
and fingers before spreading to the legs and arms.
Loss of reflexes: GBS can cause a decrease or loss of reflexes, which can be an important
diagnostic clue.
Difficulty with coordination: GBS can affect coordination, making it difficult to walk, stand, or
perform other tasks that require fine motor skills.
Pain: Many people with GBS experience pain, which can be severe and difficult to manage.
Respiratory problems: In severe cases, GBS can lead to respiratory failure and the need for
mechanical ventilation.
Autonomic dysfunction: GBS can affect the autonomic nervous system, leading to symptoms
such as changes in blood pressure, heart rate, and sweating
4. How is GBS diagnosed, and what tests would you expect to be performed?
Nerve conduction studies (NCS): These tests measure the speed at which electrical signals travel
through the nerves. In GBS, NCS may show decreased conduction velocity and prolonged distal
latencies, which are consistent with demyelination.
Electromyography (EMG): This test measures the electrical activity of the muscles and can help
distinguish between GBS and other neuromuscular disorders.
Lumbar puncture (LP): This test involves the insertion of a needle into the lower back to collect
cerebrospinal fluid (CSF), which surrounds the brain and spinal cord. In GBS, CSF may show
elevated protein levels without an increase in white blood cells.
Blood tests: Blood tests may be performed to look for evidence of recent infection, such as
elevated levels of certain antibodies or inflammatory markers.
Imaging tests: Imaging tests, such as magnetic resonance imaging (MRI), may be performed to
rule out other possible causes of symptoms, such as spinal cord compression.
5. What is your immediate concern for C.B. and why?
My immediate concern for C.B. would be the progression of his symptoms and the potential for
respiratory failure. Guillain-Barré syndrome (GBS) can cause rapidly progressive weakness that
can spread to the respiratory muscles, leading to respiratory failure and the need for
mechanical ventilation.
Given that C.B.'s weakness, numbness, and tingling have progressed from his lower extremities
to his upper body, it is possible that his respiratory muscles are also affected. Therefore, it is
important to monitor his breathing closely and provide supportive care as needed to prevent
respiratory failure.
Additionally, if the diagnosis of GBS is confirmed, early treatment with immunoglobulin therapy
or plasmapheresis may help to reduce the severity and duration of symptoms and prevent
complications. Therefore, it is important to initiate treatment promptly once the diagnosis is
confirmed.
6. What assessment findings would tell you this is occurring?
Assessment findings that would indicate respiratory muscle involvement and potential
respiratory failure in a patient with Guillain-Barré syndrome (GBS) include:
Shortness of breath or difficulty breathing: The patient may complain of feeling short of breath
or may appear to be working harder to breathe.
Respiratory rate: The patient's respiratory rate may be elevated, indicating increased effort to
breathe.
Use of accessory muscles: The patient may use accessory muscles, such as the muscles in the
neck or between the ribs, to help with breathing.
Cyanosis: The patient's skin or lips may appear bluish, indicating a lack of oxygen.
Decreased oxygen saturation: Oxygen saturation levels may be low, indicating a lack of oxygen in
the blood.
Abnormal blood gas values: Arterial blood gas (ABG) values may show
elevated carbon dioxide (CO2) levels above 45 mmHg, indicating respiratory acidosis
decreased oxygen (O2) levels, below 80 mmHg, indicating hypoxemia,
7. Which set of arterial blood gases would be consistent with the presence of this
complication?
a. pH 7.50, Pco2 52 mm Hg
b. pH 7.35, Pco2 40 mm Hg
c. pH 7.25, Pco2 60 mm Hg
This is because the pH is decreased (acidosis) and the PaCO2 is increased (hypercapnia),
which are both characteristic of respiratory failure. A high PaCO2 level indicates that the
lungs are not adequately removing carbon dioxide from the blood, leading to respiratory
acidosis.
d. pH 7.51, Pco2 31 mm Hg
8. Which assessment finding, if present, would require your immediate intervention?
a. Diaphoresis
b. Slurred speech
If slurred speech is present, it would require immediate intervention.
Slurred speech can be a sign of neurological involvement, which can be a serious
complication in Guillain-Barré syndrome (GBS). It may indicate impaired motor function
or cranial nerve involvement, which can affect the ability to speak and swallow.
Hypoglossal nerve (CN XII): Controls the movements of the tongue, which are essential
for articulating speech sounds.
Glossopharyngeal nerve (CN IX): Innervates the pharynx, which is important for
swallowing and speaking.
Vagus nerve (CN X): Innervates the larynx, which contains the vocal cords and is
essential for producing speech sounds.
Facial nerve (CN VII): Innervates the muscles of the face, including those used in facial
expressions and in shaping the mouth for speech.
c. Facial flushing
d. Urinary retention
Case study progress
Shortly after arrival, C.B. becomes completely paralyzed and requires endotracheal intubation
and mechanical ventilation. He is transferred to the neurologic ICU for further support.
9. What are the goals of medical management in GBS?
Provide supportive care: Patients with severe GBS may require mechanical ventilation, as in the
case of C.B. This helps to maintain adequate oxygenation and ventilation and to prevent
respiratory failure. Other supportive measures may include monitoring vital signs, providing
nutritional support, and managing pain and discomfort.
Treat the underlying cause: Although the exact cause of GBS is not known, it is often preceded
by an infection, such as a respiratory or gastrointestinal infection. Treating the underlying
infection may help to alleviate symptoms of GBS.
Manage complications: Patients with GBS are at risk of complications such as pneumonia, deep
vein thrombosis, and pressure ulcers. Careful monitoring and management of these
complications can help to prevent further morbidity and mortality.
Administer immunomodulatory therapy: Several treatments have been shown to be effective in
reducing the duration and severity of GBS symptoms, including intravenous immunoglobulin
(IVIG) and plasma exchange (also known as plasmapheresis). These treatments work by
modulating the immune response and reducing inflammation.
Promote rehabilitation: Once the acute phase of GBS has passed, patients may require
rehabilitation to regain strength and function. Physical therapy, occupational therapy, and
speech therapy may all be part of a comprehensive rehabilitation plan.
10. Describe the collaborative care patients generally receive in the ICU for GBS.
Neurologist: A neurologist is typically involved in the diagnosis and management of GBS. In the
ICU, the neurologist may provide guidance on the use of intravenous immunoglobulin (IVIG) and
plasma exchange (plasmapheresis), which are the primary treatments for GBS.
Critical care physician: A critical care physician is responsible for the overall management of the
patient's care in the ICU. This may include monitoring vital signs, managing the patient's airway
and breathing, and addressing any complications that arise.
Respiratory therapist: Patients with severe GBS may require mechanical ventilation to maintain
adequate oxygenation and ventilation. A respiratory therapist is responsible for managing the
ventilator and monitoring the patient's respiratory status.
Physical therapist: Once the acute phase of GBS has passed, patients may require physical
therapy to regain strength and function. A physical therapist can develop a rehabilitation plan
tailored to the patient's needs and abilities.
Occupational therapist: Patients with GBS may experience weakness and numbness in their
hands and arms, which can make it difficult to perform activities of daily living. An occupational
therapist can work with the patient to develop strategies for managing these difficulties.
Speech therapist: Some patients with GBS may experience difficulty with speech and
swallowing, particularly if the cranial nerves are affected. A speech therapist can work with the
patient to develop strategies for improving communication and managing swallowing
difficulties.
Nutritionist: Patients with GBS may require nutritional support, particularly if they are unable to
eat or drink normally. A nutritionist can develop a plan to ensure the patient receives adequate
nutrition while in the ICU.
11. What are the overall goals of nursing care for C.B. at this time?
The overall goals of nursing care for C.B. with Guillain-Barré syndrome (GBS) in the neurologic
ICU would be to prevent complications, support respiratory function, and promote
rehabilitation.
Preventing complications is critical in GBS as patients are at increased risk of developing
complications such as infections, pressure ulcers, deep vein thrombosis, and muscle
contractures due to immobilization. Nursing interventions to prevent these complications may
include turning and positioning the patient every two hours, administering prophylactic
anticoagulants, monitoring for signs of infection, and performing frequent skin assessments.
GBS can affect respiratory function, and patients may require mechanical ventilation to support
breathing. Close monitoring of oxygenation, ventilation, and vital signs is essential to prevent
complications such as hypoxia and respiratory failure.
Rehabilitation is an important aspect of GBS management as it can help patients regain their
strength and function. Nursing interventions to promote rehabilitation may include passive
range of motion exercises to prevent muscle contractures, early ambulation when the patient is
stable enough, and referral to physical and occupational therapy.
12. The attending physician states C.B. will begin either IV immune globulin or
plasmapheresis. What is plasmapheresis?
Plasmapheresis, also known as plasma exchange, is a procedure in which the liquid portion of
the blood (plasma) is separated from the blood cells and removed from the body. This process
can be done using a machine called a centrifuge or by passing the blood through a series of
filters. Once the plasma is removed, it is replaced with a substitute solution such as albumin or
saline.
The purpose of plasmapheresis in the treatment of GBS is to remove the antibodies that are
attacking the myelin sheath around the nerves. By removing these antibodies, the hope is that
the immune system will stop attacking the nerves and the symptoms of GBS will improve.
The purpose of IV immune globulin (IVIG) in the treatment of GBS is to provide the patient with
additional antibodies that can help to regulate the immune system and reduce the
inflammation that is damaging the nerves. IVIG is a solution that is made from donated human
blood plasma and contains a high concentration of immunoglobulins (antibodies). When
administered intravenously, IVIG can help to neutralize the harmful antibodies that are attacking
the myelin sheath around the nerves and reduce the severity of GBS symptoms.
IVIG is usually given over the course of several days in the hospital under the supervision of a
healthcare professional. The treatment may be repeated several times depending on the
patient's response and the severity of the illness.
13. You are concerned about the possibility of disuse syndrome related to C.B.’s paralysis.
Describe an outcome of nursing care for C.B., and 4 independent nursing interventions you
would implement to meet that outcome.
Disuse syndrome is a set of physiologic and functional changes that occur as a result of
prolonged bed rest or immobility. It can affect multiple body systems, including the
musculoskeletal, cardiovascular, respiratory, and gastrointestinal systems. Some of the
consequences of disuse syndrome include muscle weakness and atrophy, decreased aerobic
capacity, impaired circulation, and gastrointestinal disturbances. Disuse syndrome can lead to
significant morbidity and mortality, especially in critically ill patients who require prolonged
periods of bed rest and mechanical ventilation.
Outcome: The patient will maintain muscle strength and range of motion despite paralysis.
Independent nursing interventions:
Perform range-of-motion exercises every 2-4 hours to promote circulation and prevent
contractures. Passive range-of-motion exercises can be performed when the patient is unable to
move actively.
Encourage and assist with turning and repositioning every 2 hours to prevent pressure ulcers
and promote blood flow to all areas of the body.
Use sequential compression devices (SCDs) or intermittent pneumatic compression (IPC) devices
to promote circulation and prevent deep vein thrombosis (DVT).
Use splints or braces as indicated to maintain proper body alignment and prevent contractures.
By implementing these interventions, the patient will be less likely to experience muscle
weakness, joint stiffness, or muscle atrophy associated with disuse syndrome. The patient will
also have a lower risk of developing complications such as pressure ulcers and DVT.
14. How would performing passive ROM exercises benefit C.B. from a cardiovascular
perspective?
a. ROM will help prevent C.B. from developing contractures.
b. Keeping his muscles active will assist in maintaining muscle tone.
c. ROM is an effective way to help prevent VTE.
Performing passive range of motion (ROM) exercises in C.B. can help prevent venous
thromboembolism (VTE) by promoting blood circulation and preventing blood pooling in
the lower extremities. VTE is a common complication in patients with immobilization or
prolonged bed rest, and it can be life-threatening if the blood clot dislodges and travels
to the lungs (pulmonary embolism). Therefore, performing passive ROM exercises can
help prevent this serious complication and promote cardiovascular health.
d. The stretching motion accompanying ROM will decrease C.B.’s pain.
15. Name 5 interventions you would implement to meet the expected outcome of
maintaining skin integrity.
Turning and repositioning C.B. every 2 hours to relieve pressure and prevent pressure ulcers.
Assessing C.B.'s skin regularly, at least every shift, for signs of breakdown or injury, such as
redness, blisters, or abrasions.
Using appropriate support surfaces, such as a pressure-relieving mattress or cushion, to
distribute pressure and reduce the risk of pressure ulcers.
Ensuring that C.B. is clean and dry, particularly in areas prone to sweating or moisture buildup,
to prevent skin maceration and breakdown.
Using moisture barriers or skin protectants, such as petroleum jelly or zinc oxide, to protect
C.B.'s skin from irritation and breakdown due to incontinence or other sources of moisture.
16. What is foot drop? How can it be prevented?
Foot drop is a condition where a person is unable to lift the front part of their foot, causing it to
drag on the ground while walking. It is caused by a weakness or paralysis of the muscles that lift
the foot and toes upward. This can be caused by a variety of conditions, such as nerve damage,
muscle or nerve disorders, spinal cord injury, or brain injury. It is commonly seen in patients
with neurological conditions such as Guillain-Barré syndrome, spinal cord injury, and stroke.
To prevent foot drop, there are several interventions that can be implemented, including:
Regularly repositioning the patient to avoid prolonged pressure on the feet.
Using a footboard or a foam wedge to keep the foot in a neutral position. Proper positioning
and the use of braces can help prevent foot drop by maintaining the ankle and foot in a neutral
position. The position of the foot is maintained to keep the toes pointing upward, which
lengthens the calf muscles (gastrocnemius / ga·straak·nee·mee·uhs and the soleus) and
decreases the tension on the Achilles tendon. This prevents shortening of the calf muscles,
which can contribute to foot drop.
Using ankle-foot orthosis (AFO) or braces to help maintain proper alignment and support the
foot and ankle.
Providing regular range-of-motion exercises to maintain joint flexibility and muscle strength.
Encouraging the patient to sit up and dangle their feet over the edge of the bed, which can help
stimulate blood flow and muscle activity.
17. How would C.B.’s nutritional needs be met?
I would anticipate implementing TPN to prevent complication while GB is paralyzed and on
mechanical ventilation. Lack of peristalsis, ileus in the stomach and colonic atony could lead to a
buildup of food or waste, causing discomfort, distention, and other complications such as
malnutrition, sepsis, and bowel perforation.
18. What evaluative parameters would you use to determine whether C.B.’s nutritional needs
were being met?
Body weight: Regular monitoring of C.B.'s body weight can help determine if he is gaining or
losing weight and if his nutritional needs are being met.
Serum albumin levels: Serum albumin is a protein made by the liver that can indicate the overall
nutritional status of a person. Low levels of serum albumin may indicate malnutrition.
Prealbumin levels: Prealbumin is a protein made in the liver that has a shorter half-life than
serum albumin. Monitoring prealbumin levels can provide more up-to-date information on
C.B.'s nutritional status.
Intake and output records as well as electrolyte status. Keeping accurate records of C.B.'s intake
(including enteral or parenteral nutrition) and output (including urine and stool output) can help
determine if he is meeting his nutritional needs
Clinical assessment: Regular clinical assessment can help identify signs of malnutrition, such as
muscle wasting, poor skin turgor, and slow wound healing.
19. What interventions can you implement to help decrease C.B.’s fear and anxiety?
Select all that apply.
a. Speak calmly to him when providing care. Speaking calmly can help to decrease C.B.'s
anxiety and create a calming environment. It also promotes trust between the patient and the
healthcare team.
b. Administer continuous intravenous sedation.
c. Limit visitors only to immediate family members. Limiting visitors to immediate family
members can help to decrease C.B.'s stress and anxiety. It can also help to control the
environment and promote rest.
d. Continually reassure him that his needs are being met. Continually reassuring C.B. that his
needs are being met can help to decrease his anxiety and promote trust in the healthcare
team.
e. Use a communication system that allows C.B. to let his needs be known. Using a
communication system that allows C.B. to let his needs be known can help to decrease his
frustration and anxiety. It can also promote a sense of control and autonomy, which can be
important for his emotional well-being.
20. C.B.’s brother asks how long C.B. will be paralyzed. How should you respond?
As a nurse, it is important to be honest and transparent with the patient and their family
members. However, in this case, it is difficult to predict how long C.B. will be paralyzed as the
recovery process from GBS can vary widely from person to person. It is important to explain to
C.B.'s brother that GBS is a complex condition that affects everyone differently and that
recovery is often unpredictable. It is important to encourage C.B.'s brother to focus on the
positive aspects of his brother's progress and reassure him that the healthcare team is doing
everything possible to support C.B.'s recovery. It may also be helpful to provide education about
GBS and the recovery process, and encourage the family to ask questions and voice their
concerns.