Page 491 - ACCCN's Critical Care Nursing

468 P R I N C I P L E S A N D P R A C T I C E O F C R I T I C A L C A R E

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the severity of the disease. GBS has three phases – acute, muscles, presence of paradoxical respiration and
plateau, and recovery – each stage lasting from days to integrity of upper airway reflexes), ABG data and chest
weeks and in recovery to months and years. The patient radiography determine levels of fatigue in both the
presents with: acute stage (for intubation and ventilation) and
rehabilitation (weaning) stage. Long-term ventilation
● symmetrical weakness, diminished reflexes, and
upward progression of motor weakness. A history of increases the risk of ventilator-acquired pneumonia
a viral illness in the previous few weeks suggests the (VAP), and routine surveillance for VAP is vital.
diagnosis ● Cardiovascular assessment is important, as serious
● changes in vital capacity and negative inspiratory tachyarrhythmias and bradyarrhythmias and destabi-
force, which are assessed to identify impending neu- lising fluctuations in blood pressure caused by
romuscular respiratory failure. autonomic impairment are prevalent. This feature is
common during fatigue, sleep and states of dehydra-
Indications for ICU admission include the following: tion. Often, autonomic dysfunction is worst in the
ventilatory insufficiency, severe bulbar weakness threat- early stages of a nosocomial infection. 112
ening pulmonary aspiration, autonomic instability, or ● Cranial nerve assessment and dermatome (for sensory)
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coexisting general medical factors, and often a combi- and muscle strength assessment assist in mapping the
nation of factors, are present. The incidence of respiratory progression, severity and rehabilitation of the disease
failure requiring mechanical ventilation in GBS is approxi- and determining the risk of aspiration. Pain (espe-
mately 30%. cially neuropathic) is particularly common in GBS
during changes in myelination, and can be difficult to
Ventilatory failure is primarily caused by inspiratory 113
muscle weakness, although weakness of the abdominal treat. Assessment will include all aspects as indi-
and accessory muscles of respiration, retained airway cated for the long-term immobile, intubated, venti-
secretions leading to pulmonary aspiration and atelecta- lated and neuromuscular-impaired patient.
sis are all contributory factors. The associated bulbar
weakness and autonomic instability reinforce the need Independent practice
for control of the airway and ventilation. When caring for a neuromuscular-impaired patient, a
Acute motor and sensory axonal neuropathy, the acute structured care plan is essential for continuity of care and
axonal form of GBS, usually presents with a rapidly devel- should involve the patient and family. This is of particular
oping paralysis developing over hours, and a rapid devel- importance in the long-term recovery phase, where the
opment of respiratory failure requiring tracheal intubation provision of sleep, good nutrition and prevention of the
and ventilation. PaCO 2 may remain constant until just complications of immobility (noso comial infections,
before intubation, emphasising the importance of not DVT, integument and muscular we akening, adequate
relying purely on arterial blood gas analysis to make deci- nutrition and constipation) is important:
sions regarding intubation. ● Endotracheal and pharyngeal suction can be demand-
Recently sensory involvement in relation to pain has been ing (weakened upper airway reflexes), and sputum
studied asserting the clinical observation of pain ranging plugging and retention requires frequent reposition-
from mild to severe in the acute and rehabilitant phases. ing and physiotherapy.
Chronic pain is often present in survivors of GBS. 110 ● Routine daily gentle exercise as part of a flexible
program improves wellbeing and strength.
There may be total paralysis of all voluntary muscles of ● Fatigue must be avoided, as autonomic nerve dysfunc-
the body, including the cranial musculature, the ocular tion, deafferent pain syndromes, muscle pain and
muscles and the pupils. Prolonged paralysis and incom- depression can be exacerbated.
plete recovery are more likely, and prolonged ventila- ● Suctioning, coughing, bladder distension, constipa-
tory support may be necessary. Walgaard and colleagues tion and the Valsalva manoeuvre can also aggravate
found that GBS patients who experience rapid disease autonomic nerve dysfunction instability.
progression, bulbar dysfunction, bilateral facial weak- ● Therapeutic massage, warm and cold packs and
ness or autonomic nerve dysfunction were more likely careful positioning contribute to comfort and pain
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to require mechanical ventilation. Tracheostomy is management.
usually performed within 2 weeks, and mechanical ven- ● The patient’s surroundings should be pleasant and
tilation is delivered in a supportive mode with minimal presentable, especially during long recovery.
yet adequate sedation and pain management. ● Communication techniques need to be refined to
prevent fatigue and frustration.
Nursing practice ● Patience, tolerance, empathy, humour and family
Assessment and understanding of neuromuscular weak- involvement assist the patient in psychological resil-
ness through motor and sensory neurological assess- ience and recovery.
ment is vital in the acute care and rehabilitation of GBS
patients: Collaborative management
● Comprehensive respiratory assessment (level of In the acute phase, accurate diagnosis and timely ven-
overall patient comfort, frequency and depth of tilatory support are provided by effective communica-
breathing, forced vital capacity, use of accessory tion between primary and in-hospital care providers.