Page 259 - Critical Care Nursing Demystified

244 CRITICAL CARE NURSING DeMYSTIFIED

promote healing and tissue repair by improving blood flow to the site of
injury. Patients with rapidly progressing paralysis can also benefit from plas-
mapheresis, which involves plasma exchanges to wash away or remove the
antibodies that cause GBS. The administration of immune globulin (IVIG)
is also beneficial as a treatment modality. Full muscular strength does even-
tually occur in cases of Guillain-Barré, but recovery could take many months
up to 1 year, in which case extensive physical therapy and rehabilitation are
required.

1 and 4 Nursing Diagnosis Expected Outcomes
Impaired mobility related to mus- Patient will have increased muscle strength
cle flaccidity and paralysis Patient will regain full level of mobility

Nursing Interventions
Provide passive range of motion exercises several times daily within the pa-
tient’s level of tolerance.
Provide massages alternating between heat and cold applications to maintain
muscle tone. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
Initiate gentle stretching and active assisted exercises.
Teach the patient a sequence of stretching and active range-of-motion exer-
cises as patient’s condition stabilizes.
Closely monitor and control episodes of pain with appropriate analgesic
therapy.
Assess and prevent signs of skin breakdown through frequent change in
position and adequate nutrition.
Gradually increase patient’s level of mobility and exercise as patient’s condi-
tion strengthens.
Monitor for signs of muscular atrophy and contractions.

1 and 4 Nursing Diagnosis Expected Outcomes
Fear and anxiety related to Patient will understand the concept of the
uncertain status of recovery disease
Patient will have a positive outlook regard-
ing the outcome of his or her illness