Impaired Physical Mobility - NCP for Guillain-Barre Syndrome
Nursing Care Plan for Guillain-Barre Syndrome
Guillain-Barre syndrome or GBS is a severe inflammatory disorder of the peripheral nerves.
Guillain-Barre Syndrome is an inflammatory disorder in which the body's immune system attacks the nerves, causing severe weakness and numbness and eventually leading to muscular paralysis.
The symptoms of Guillain-Barre syndrome are lack of feeling, weakness or itchiness in arms or legs, and possible loss of feeling and movement in the upper body, face, arms and legs. The symptoms can remain in this phase and can cause little difficulty in walking. However, in some cases the illness can progress resulting in entire paralysis of arms and legs.
Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular damage
Goals:
To maintain the position of function with no complications (contractures, pressure sores).
Outcomes:
Clients can improve the strength and function of the affected part
Nursing Interventions and Rationale:
1. Assess motor strength / functional ability by using a scale of 0-5.
R / Define the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.
2. Give the patient a position that causes a sense of comfort. Make changes to the position on a regular schedule as needed on an individual basis.
R / Reduce fatigue, increase relaxation. Reduce the risk of ischemia / damage to the skin.
3. Chock extremities and joints with a pillow.
R / Maintain extremity in a physiological position, prevent contractures.
4. Perform passive range of motion exercises. Avoid active exercise during the acute phase.
R / Stimulates circulation, improve muscle tone and increase joint mobilization.
5. Coordinate care provided and the period of uninterrupted rest.
R / Excessive use of muscles can increase the time it takes to remielinisasi, arena may extend the time for healing.
6. Encourage you to do the exercise that continues to be developed and depend on individual tolerance.
R / exercise activities in the affected areas gradually improved / fixed, improve organ function normally and have a positive psychological effect
7. Give lubrication / oil artificially within their needs.
R / Prevent from drying the client's body.
Collaboration
1. Confirm with / refer gets physical therapy / occupational therapy.
R / Helpful in creating individual muscle strength / exercise conditioned and running training programs and identify tools to maintain the mobilization and independence in performing daily activities.
Guillain-Barre syndrome or GBS is a severe inflammatory disorder of the peripheral nerves.
Guillain-Barre Syndrome is an inflammatory disorder in which the body's immune system attacks the nerves, causing severe weakness and numbness and eventually leading to muscular paralysis.
The symptoms of Guillain-Barre syndrome are lack of feeling, weakness or itchiness in arms or legs, and possible loss of feeling and movement in the upper body, face, arms and legs. The symptoms can remain in this phase and can cause little difficulty in walking. However, in some cases the illness can progress resulting in entire paralysis of arms and legs.
Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular damage
Goals:
To maintain the position of function with no complications (contractures, pressure sores).
Outcomes:
Clients can improve the strength and function of the affected part
Nursing Interventions and Rationale:
1. Assess motor strength / functional ability by using a scale of 0-5.
R / Define the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.
2. Give the patient a position that causes a sense of comfort. Make changes to the position on a regular schedule as needed on an individual basis.
R / Reduce fatigue, increase relaxation. Reduce the risk of ischemia / damage to the skin.
3. Chock extremities and joints with a pillow.
R / Maintain extremity in a physiological position, prevent contractures.
4. Perform passive range of motion exercises. Avoid active exercise during the acute phase.
R / Stimulates circulation, improve muscle tone and increase joint mobilization.
5. Coordinate care provided and the period of uninterrupted rest.
R / Excessive use of muscles can increase the time it takes to remielinisasi, arena may extend the time for healing.
6. Encourage you to do the exercise that continues to be developed and depend on individual tolerance.
R / exercise activities in the affected areas gradually improved / fixed, improve organ function normally and have a positive psychological effect
7. Give lubrication / oil artificially within their needs.
R / Prevent from drying the client's body.
Collaboration
1. Confirm with / refer gets physical therapy / occupational therapy.
R / Helpful in creating individual muscle strength / exercise conditioned and running training programs and identify tools to maintain the mobilization and independence in performing daily activities.