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Nursing Diagnosis Risk for Impaired Skin Integrity - Nursing Care Plan for Guillain-Barre Syndrome

Guillain-Barre syndrome is a serious disorder that occurs when the body's defense (immune) system mistakenly attacks part of the nervous system. This leads to nerve inflammation that causes muscle weakness and other symptoms.

Symptoms of Guillain-Barre syndrome include:

•     Numbness or tingling in your hands and feet and sometimes around the mouth and lips.
•     Muscle weakness in your legs and arms and the sides of your face.
•     Trouble speaking, chewing, and swallowing.
•     Not being able to move your eyes.
•     Back pain.

Symptoms usually start with numbness or tingling in the fingers and toes. Over several days, muscle weakness in the legs and arms develops. After about 4 weeks, most people begin to get better.

You may need to be treated in the hospital for the first few weeks. This is because GBS can be deadly if weakness spreads to muscles that control breathing, heart rate, and blood pressure.

Signs and tests

A history of increasing muscle weakness and paralysis may be a sign of Guillain-Barre syndrome, especially if there was a recent illness.

A medical exam may show muscle weakness and problems with involuntary (autonomic) body functions, such as blood pressure and heart rate. The examination will also show that reflexes, such as the "ankle or knee jerk," are decreased or missing.

There may be signs of decreased breathing caused by paralysis of the breathing muscles.

The following tests may be ordered:

•     Cerebrospinal fluid sample ("spinal tap")
•     ECG
•     Electromyography (EMG) tests the electrical activity in muscles
•     Nerve conduction velocity test
•     Pulmonary function tests

Nursing Diagnosis : Risk for Impaired Skin Integrity : dekubitus related to kelemahan otot, paralisis, gangguan sensasi, perubahan nutrisi, inkontinensia.

Expected outcomes:

• Patients retain the skin remains dry and intact.
• Maintaining depressed area remains dry and intact, free of pressure sores.

Intervention:

1. Assess motor function and sensation every 4 hours.
R /: muscle paralysis can occur quickly with a pattern that has been rising.

2. Assess the patient's degree of dependence.
R /: To identify patients in need of ADL ability.

3 . Monitor depressed area.
R /: Identifying early signs of pressure sores.

4. Keep the bed, lake remains clean, tight and dry.
R /: Laken, wet, dirty, matted facilitate the occurrence of pressure sores.

5. Monitor intake and output of nutrients.
R /: inadequate nutrition reduce the risk of pressure sores.

6. Perform over the position every 2 hours.
R /: Smooth distressed parts of blood flow.

7. Perform ROM.
R /: Preventing atrophy.