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BRABALIBINTAWANA Case of Guillain-Barre Syndrome
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Guillain-Barre Syndrome sometimes Landry's paralysis, is an acute
inflammatory demyelinating polyneuropathy (AIDP), a disorder affecting
the peripheral nervous system. Ascending paralysis, weakness beginning in the feetand hands and migrating towards the trunk, is the most typical symptom. It can
cause life-threatening complications, particularly if the breathing muscles are
affected or if there is dysfunction of the autonomic nervous system.The disease is
usually triggered by an acute infection. GuillainBarr syndrome is a form
of peripheral neuropathy.The diagnosis is usually made by nerve conduction studies. With prompt
treatment by intravenous or plasmapheresis, together with supportive care, the
majority will recover completely. GuillainBarr syndrome is rare, at 12 cases
per 100,000 people annually, but is one of the leading causes of acute non-trauma-
related paralysis in the world.
The group chose this topic because this will help us to know and betterunderstand the syndrome. Because GuillainBarr syndrome is rare, encountering
it in a clinical setting is a bit confusing, hence we really have to know the process
and progress of the disease and there we depend our nursing responsibilities and
interventions. One of the reasons that made the group decided to choose this topic
is having known that this is an autoimmune and neurological disease: having theneed for further assessments unlike other diseases.
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Dorot e re s self-c re Deficit eor
Dorothea Orem believes that therapeutic self-care demand refersto all safe-care activities required to meet existing self-care requisites, or
in other words, actions to maintain health and well-being. Self-care
theory is based on four concepts: self-care self-care agency, self care
requisites, and therapeutic self-care demand.Self-care refers to those activities an individual performs independently
throughout life to promote and maintain personal well-being.
To Dorothea Orem, self-care agency is the individuals ability to perform
self-care activities. It consists of two agents: a self-care agent (the person
who performs self-care independentlty0 and a dependent care agent (aperson other than the individual who provides the care.
We apply this theory because our patient cant do on her own. She needs
assistance in her daily living activities from her significant others and
other health care team.
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Patients Data
A. General Data
Na e: MVC
Ge er: Fe ale
A ress: Br . a al c, ta. Mesa
ate f Birt : J e 5, 1993A e: 17 / l
Birt lace: Bata es
Reli i : Ba tist
Nati alit : Fili i
cc ati : t e t
Ci il tat s: i le
Date of Admission: A ril 25, 2 11 11:5 a
B. Chief Complain:
Nanghihina yung parehong binti ko as verbalized by the patient.
(Bilateral L er E tre ities eak ess)
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F. Review of System
REVIE F YT
EMate Taken: April 29, 2 11
Time: 1: pm
a.General: (+) eakness
(-) fatigue
(-) anore ia
(-) fever(-) night s eat
(-) lumps
.Cardiovascular (-) chestpain
(-) cough/sputum
(-) s ellingof ankle(-)palpitation
c. Gastrointestinal (-) nausea /vomiting
(-) heart urn
(+) difficulty indefecation
(+) ignores urge todefecate
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(-) a dominalpain
(-) hematemesis, melena(-) jaundice
d. Respiratory ystem (-) hemoptysis
(-) dyspnea
(-) tachypnea
(-) shortness of reathing
e. Genitourinary (-) analpain
(-) leeding
(-) dysuria
(-) hematuria
f.Nervous ystem
(-) headache(-) dizziness
(-) lightheadedness
(+)paresthesia
(+) numbness
g. Musculoskeletal (+) difficulty inmoving lower e tremities
(+) weakness of the left arm
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G. Physical Assessment
Date Taken: April 29, 2 11
Time: 1: pm
General Appearance:
Ms. C is tall, has a mesomorphic body type, 17 years old girl who is consciousand coherent. She looks relax while lying in her bed. Her hair is neatly fixed and
her clothes are clean. She has a fair skin complexion.
Vital signs:
BP: 110/70 mmHg
RR: 20 breaths per minutePR: 98 beats per minute
Temp: 36.9C
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f. PUPILS
Black in color, equal in size, and round. Constricts when looking at near objects and dilates
when looking at far objects.
g. EYE MOVEMENT
Able to move eyes in full Range of Movement.h. FIELD OF VISION
When looking straight ahead, the client can see objects in the periphery.
i. VISUAL ACUITY
Client has 20-20 vision.
III. EARS
Parallel, symmetrical, proportional to the size of the head. The skin is the same color as the
surrounding area, clean.
a. EAR CANALPinkish, clean with scant amount of cerumen and few cilia.
b. HEARING ACUITYAble to hear and repeat whispered words.IV. NOSEMidline, symmetrical and patentV. MOUTH
a. GUMSPinkish, smooth, moist, no swelling/bleeding; no discharge.
b. TONGUEMedium in size, pink, moist, shiny and freely movable, no tenderness.
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d. SOFT PALATE
Is pinkish, smooth and moist.
e. HARD PALATE
Is slightly pinkish.
TONSILS
Are light pink, non-inflamed, no exudates.
VOICE
Is well-modulated and has no hoarseness.
VI. NECK:
Proportional to the size of the head, symmetrical and straight, no palpable lumps, masses or
area of tenderness.
A. RANGE OF MOTIONFreely movable without difficulty.
B. MUSCULAR STRENGTHSymmetrical and able to resist applied force with equal strength.
C. THYROID GLANDGland ascends during swallowing but is not visible.
D. LYMPH NODESNo palpable masses in the pre-auricular, post-auricular, tonsilar, submandibular,submental, supraclavicular,occipital and cervical area.
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RANGE F M TI N:
ARM : BothArms in raised invertical position at the side of the head.
Findings: Right armcanperformwith relative ease while the left armwith slight difficulty andcanbe raise up to a limitedheight
SH ULDER: Abduct and adduct
Findings: Performs with relative ease.
ELB S: Bends and straightens
Findings: Right armcanperformwith relative ease and fast while the left armcanperform the
samebut with slower rate than the right arm.FINGERS: E tends and spreads fingers. Makes fist thumb across the knuckles.
Findings: Performs with relative ease.
Muscle Strength: Left Arm: 4/5
Right Arm: 5/5
X. LOWER EXTREMITIESFair skin, complete five fingers in each foot. Nails are transparent. Symmetricalfine hair distributed, with absence of varicose veins. Muscles are symmetrical. Length issymmetrical Patient has difficulty in flexing the legs inward. Toenail appears white, colorreturns immediately as pressure is released (capillary refill is normal). Patient complainedof pain upon palpation of both lower extremities with pain scale of 3/10.
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RANGE F M TI N
A. L ER EXTREMITIES: Abduct (away) canperformwith slight difficulty
Adduct (towards) canperformwith slight difficulty
Rotationcanperformwith slight difficulty
B. ANKLE: Fle ion and E tension- canperformwith slight difficulty
Rotation- canperformwith slight difficulty
C. TOES: Spreads and igglescanperformwith slight difficulty
Muscle Strength: 3/5 forboth lower e tremities
NEUROLOGIAL ASSESSMENT
I. Behavioral, Cognitive & Mental Status
Patient is alert andcoherent, has calm and rela edbehaviorupon approached. Able to answer
uestions that were asked. Slight facial grimace is present while moving the lower e tremities.
She is oriented to time andplace; Looks cleanwithneatly fi edhair andwears cleanhospitalgown.
II. Intellectual FunctionA. MEMORY
IMMEDIATE Can recall accuratelyRECENT- Can recall accurately
REMOTE- Can recall accurately
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B.KNOWLEDGE
Has an idea abouther illness and all t
heprocedures t
hat was done to
her.C.ABSTRACTTHINKING
Able to e press ideas orconcept.
D.ASSOCIATION
Able to associate.
E. JUDGEMENT
Able to judge withwhat she wants ornot.
III. SENSORY FUNCTION
Back of Hands touch sensationForearms touch sensationUpper Arms touch sensationLower Arms touch sensationDorsal portion of Feet Light ticklingLaterally and Medially Light tickling
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IV. CEREBELLAR FUNCTION
Patient canpat hands against thighs
Canperform finger tonose tests repeatedly and rhythmically touches the nose
RombergsTest- Sways whennot assisted andcannot able tomaintainuprightposture and foot
stands.
Patient cannot walknormally
V. MOTOR FUNCTION
Muscles in the lower e tremities are weaker thannormal andcan resist little amount ofpressure.
Muscles in the upper e tremities canperform full range ofmotion, fle ed and e tend andcanresist e ualpressure applied.
Able to fle ed arms andcan feel thebicep fle ing and tricep e tension .
Muscles are firmed.
VI.DEEP TENDON REFLEXESBICEP REFLEX: 2+
TRICEP REFLEX: 2+PATELLAR: 0PLANTAR REFLEX: 2+
SUPERFICIAL REFLEXESCORNEAL REFLEX: PresentGAG REFLEX: Present
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VII. CRANIALNERVES:
I.Olfactory : Normal -able to identify smellsII.Optic : Normal -2 /2 visual acuity
III.Oculomotor : Normal - can able to elevate eyelids
can able tomove eyes full ROM
(+) PERRLA
IV.Trochlear : Normal -can able tomove both eyes downward
V.Trigeminal : Normal -S:patient can feel sensation-M: temporal andmassetermusclespalpated
(muscles formastication)
symmetrical openingof the mouth
(+) Corneal Refle
VI.Abducens : Normal -can able tomove both eyes laterally
VII.Facial : Normal -S: able to taste-M: can able towrinkle forehead, raise
eyebrows, smile, show teeth, puffcheeks
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I. Course in the Ward
Doctors Orders:
April 24, 2011
11:52am
>Pt. admit to PICU>Secure consent for admission andmanagement
>NPO
>Oxygen inhalation 5 LPM via face mask
>Diagnostics:
Plain andcontrast CTScan
Na, K, Ca
U/A
HGTnon
CBC with HPC, BT
BUN, Crea
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CXR-HPL
>IVF: PNSS 1L to run at 17gtts/min
>Monitorv/s 4 and record
>Monitor I & O shift and record
>Patient informprocedure at this admission>Refer atNeuro Service
>WOF signs of respiratorydistress
>Refer
7pm>For acute f laccid paralysis work-up
>Refer
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1 : pm >Still for stool collection for acute flaccidparalysis work- up
April 29, 2 11
6: am
>IVF to followD5NM 1L to run @ 2 gtts/min
>Still for EMG-NCV
>Refer
1: pm >Physical Assessment and ROS was done.
>V/S was taken and recorded as follows:
>BP: 110/70
>Temp.: 36.9C
>RR: 20 bpm
>PR: 98 bpm
J. Final Diagnosis: Guillain-Barre Syndrome
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Review of Related Literature
Description
Guillain-Barr syndrome (GBS) is a rare disorder in which a persons own immune system
damages their nerve cells, causing muscle weakness and sometimes paralysis. GBS can cause
symptoms that last for a few weeks. Most people recover fully from GBS, but some people have
permanent nerve damage. In very rare cases, people have died ofGBS, usually from difficulty
breathing. In the United States, for example, an estimated 3,000 to 6,000 people develop GBS
each year on average, whether or not they received a vaccination.
Causes
Many things can cause GBS; about two-thirds of people who develop GBS symptoms
do so several days or weeks after they have been sick with diarrhea or a respiratory
illness. Infection with the bacterium Campylobacter jejuni is one of the most common riskfactors for GBS. People also can develop GBS after having the flu or other infections
(such as cytomegalovirus and Epstein Barr virus). On very rare occasions, they may
develop GBS in the days or weeks after getting a vaccination.
SymptomsSymptoms of Guillain-Barr Syndrome include weakness, typically beginning in the
legs and progressing upward. The weakness is accompanied by decreased feeling(paresthesia). Reflexes are lost, for example, the hammer to the front of the knee will notinduce a kick. In severe cases breathing can be affected enough to require a ventilator andrarely the heart can be affected. The maximal degree of weakness usually occurs within thefirst 2-3 weeks.After the first clinical manifestations of the disease, the symptoms can progress over the
course of hours, days, or weeks.
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Anatomy and PhysiologyMuscular system
The bodily system that is composed of skeletal, smooth, and cardiac muscle tissueand functions in movement of the body or of materials through the body, maintenance of
posture, and heat production.
The muscular system consists of muscular cells, the contractile elements with the
specialized property of exerting tension during contraction, and associated connective
tissues. The three morphologic types of muscles are voluntary muscle, involuntary
muscle, and cardiac muscle. The voluntary, striated, or skeletal muscles are involvedwith general posture and movements of the head, body, and limbs. The involuntary,
nonstriated, or smooth muscles are the muscles of the walls of hollow organs of the
digestive, circulatory, respiratory, and reproductive systems, and other visceral
structures. Cardiac muscle is the intrinsic muscle tissue of the heart. Upon stimulation by
an action potential, skeletal muscles perform a coordinated contraction by shortening
each sarcomere.T
he best proposed model for understanding contraction is the slidingfilament model of muscle contraction. Actin and myosin fibers overlap in a contractile
motion towards each other. Myosin filaments have club-shaped heads that project
toward the actin filaments.
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Larger structures along the myosin filament called myosin heads are used to
provide attachment points on binding sites for the actin filaments. The myosin headsmove in a coordinated style, they swivel toward the center of the sarcomere, detachand then reattach to the nearest active site of the actin filament. This is called arachet type drive system. This process consumes large amounts of adenosinetriphosphate (ATP).
Energy for this comes from ATP, the energy source of the cell. ATP binds to
the cross bridges between myosin heads and actin filaments. The release of energypowers the swiveling of the myosin head. Muscles store little ATP and so mustcontinuously recycle the discharged adenosine diphosphate molecule (ADP) intoATP rapidly. Muscle tissue also contains a stored supply of a fast acting rechargechemical, creatine phosphate which can assist initially producing the rapidregeneration of ADP into ATP.
Calcium ions are required for each cycle of the sarcomere. Calcium isreleased from the sarcoplasmic reticulum into the sarcomere when a muscle isstimulated to contract. This calcium uncovers the actin binding sites. When themuscle no longer needs to contract, the calcium ions are pumped from the sarcomereand back into storage in the sarcoplasmic reticulum here are approximately 639skeletal muscles in the human body.
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FourAnteriorCompartment Muscle
One function of all four muscles in the front of the lower leg is to pull the foot and toes
upward (called dorsiflexion).
Tibilais anterior is the muscle you feel right next to the shinbone. This muscle also helpsturn the foot inward.
Extensor digitorum longus and extensor hallucus longus are underneath the tibilais
anterior. The extensor hallucus longus extends the big toe, and the extensor digitorum
longus extends the other toes.
The peroneus tertius is a small muscle at the lower outer part of the front of the lower
leg. This muscle helps turn the foot outward.Two Lateral Compartment Muscles
The muscles on the outside of the lower leg are the peroneus longus and
peroneus brevis. These muscles pull the foot outward (eversion). According to the
Anatomy Coloring Book, the peroneus muscles are especially active when walking on
the toes or pushing off with the big toe.Three
Sup
erficialPo
steri
orC
ompartm
ent
Muscles
The two larger superficial posterior compartment muscles (the gastrocnemius andsoleus) are commonly called the calf muscles. The gastrocnemius is the outermost the calfmuscle. It attaches to bone (femur) above the knee, which means the gastrocnemius helpsto bend the knee. It also points the foot (plantarflexion).Underneath the gastrocnemius is the soleus. The soleus is the muscle that gives the calfbulk. It plantar flexes the foot.
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Most of the plantaris muscle is in the back of the knee, but the muscle's tendon runs all
the way down to the ankle bone (calcaneus). It helps bend the knee and plantar flex thefoot.
Three Deep PosteriorCompartment Muscles
The muscles deep in the back of the lower leg help plantar flex the foot. These
muscles and their other functions are as follows:
- Tibialis posterior helps turn the foot inward.- Flexor hallucus longus flexes the big toe and helps turn the foot inward.
- Flexor digitorum longus flexes the other toes and helps turn the foot inward.
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PATHOPHYSIOLOGY
ETIOLOGY:
IDIOPATHIC
PRECIPITATING FACTORS:RESPIRATORY INFECTIONInfluenza like symptoms 2weeks prior to admission
(colds)
ETIOLOGY:
IDIOPATHIC
Infectious organism(Cytomegalovirus,
Mycoplasma Pneumoniae)
contains an amino acid thatmimics the peripheral nerve
myelin.
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The immune system cannotdistinguish between the two
proteins and attacks and destroysperipheral nerve myelin that causes
inflammatory demyelization.
Exact location of the attack withinthe peripheral nervous system:
ganglioside GM1b
Influx of macrophages and otherimmune-mediated agents and attacks
the myelin which causesinflammation and destruction
Axons unable to support nervefunction
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Signs and Symptoms:
LowerExtremities
Muscleweakness
Diminishedreflexes
Paresthesias,Numbness
Impairedphysicalmobility
Risk forinjury
Decreased physicalmobility
Decreased GI Motility
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Decrease muscle tone (Sphinctermuscles of the GI tract)
Retention of stool for a longer period of time
Constipation
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Laboratories and Diagnostics
Laboratory Results:
ChestX-ray (April 25, 20110)
T/c GBS
Result: Examination shows clear lung field.
Heart and great vessels are of normal size andconfiguration.
Other chest structures are unremarkable.Impression:Negative chest x-ray
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Clinical Chemistry (April 25, 2011)
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Nahihirapan akonggumalaw as
verbalizedby the
patient
Objective:
>Reportspainupon
movement
>Limited range of
motion
>Decreased
movement
Impaired Physical
mobility related to
decreasedmuscle
strength as evidenced
bypainupon
movement,limited
range ofmotion,
decreasedmovement
andmuscle strength
of 3/5 in the lower
extremities and 4/5 in
the left arm
RATIONALE:
Guillain-Barr
Syndrome manifests
the followingclinical
symptoms: ascending
flaccidparalysis,
diminished reflexes,
paresthesia and
numbness and it is
rapidlyprogresses to
the wholebody
including the
respiratorymuscles.
After 8 hours of
Nursing interventions
thepatient will have
increase strength and
functionof affected and
compensatorypart w/o
any reports ofpain.
Verbalize
willingness to and
demonstrateparticipation in
activities
Verbalize
understandingof
situation and
individual
treatment regimen
and safetymeasures.
INDEPENDENT
-Supported affectedbodyparts using
pillows, foot supports.
-Scheduled activities
with ade uate rest
periods during the day
-Providedclient with
ample time toperform
mobility related tasks
-Encouraged
participation in self
care, divertional
activities, recreational
activities
-Raised the side rails
-encouragedpatient to
dopassive range of
motion exercises as
follows:
Ankle and foot
exercises like
Tomaintainpositionof
function and
reduce riskof
pressure ulcers.
To reduce
fatigue.
To let the patientfeel that she can
do the activities
without hurry
Too lessen the
boredomof the
patient
Toprovide safety
Enhances self
concept and
sense of
independence.
To improve
properbloodcirculation and
Afterof 8 hours of
Nursing interventions
thepatients has
increased strength and
functionof affected
andcompensatorypart
w/o any reports of
pain.
Thept. verbalized
willingness to anddemonstrated
participation in
activities
Thept. verbalized of
situation and
individual treatment
regimen and safety
measures.
The goal was met.
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Because of the flaccid
paralysis as a main
signof this syndrome
patient canhave
difficulty in
ambulatingbecause of
the muscle weakness
anddiscomforts felt.
finger exercises like
Fingerbends, Finger
spreads, and Finger-to-
thumb touches.
Forearm andwrist
exercise like Wrist
rotation and Palm
up,palmdown.
Shoulder and
elbow exercises
like Shoulder
movement, up and
down, Shoulder
rotation, Elbow
bends, up and
down and Elbow
bends, side to
side.
COLLABORATIVE:
Consult with a Physical
Therapist tomake a
planofcare of
To improve
properblood
circulation and
disuse syndrome
of the hand and
fingers
To improve
properblood
circulation and
disuse syndromeof the forearm
andwrist
To improve
properblood
circulation and
disuse syndrome
of the shoulder
and elbow
For thepossible
rehabilitationof
thepatient duringor after recovery
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Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:
Ilang araw na akong
di dumudumi as
verbalizedby thepatient.
Objective:
>hypoactivebowel
sounds (3/min.)
>difficulty in
defecation
>ignores urge to
defecate
Constipation related
to insufficient
physical activity as
evidencedby
hypoactivebowelsounds (3/min.),
difficulty in
defecation, and
ignores urge to
defecate
RATIONALE:
Decreasedphysical
mobilitycan resultalso indecrease GI
motilitybecause like
othermuscles in the
body, ifnot used the
muscle tone
decreases(sphincter
muscles of the GI
tract) which leads to
stool retention for a
longerperiodof
time.
After 6 hours of
nursing intervention
patient will have a
normalbowel sound
andwill regainnormal
patternofbowel
functioning.
INDEPENDENT
-Determined fluid
intake
-Palpated abdomen
-Auscultated abdomen
forpresence ofbowel
sounds.
-Encouraged to ingest
food rich in fiber and
bulk.
-Promoted ade uate
fluid intake.
-Identified specific
actions taken if
problem recurs.
-Promoted activities
that canhelp in
utilizing increase GI
mobility (assisted
patient to ambulate
once in a while)
-Assisted through
passive range of
motion exercises
Tonote deficits.
To look for
presence ofdistention and/or
masses.
For reflecting
bowel activity.
To improve
consistencyof
stool and
facilitate passagethroughcolon.
Topromote
moist/soft stool.
Topromote
timely
intervention,
enhancing
clients
independence.
Topromote
peristaltic
movement of the
GI tract.
Topromote GI
motility
After 6 hours of
nursing intervention
patient has regained
normalpatternof
bowel functioningand exhibitednormal
bowel sounds.
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A Di i Pl i I i R i l E l i
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Assessment Diagnosis Planning Intervention Rationale Evaluation
5. Patient will
demonstrate
appropriate use of
assistive devices
(cane, walker, grab
bars)
-Encouraged
significant others and
assistedpatient when
turningorwhenneeded tograb an
object
-Instructed significant
others of thepatient to
never leave the
patients side orhave
visiting rotations
duringconfinement
Toprevent falls
or losingcontrol
inholdingobject
Toprevent falls
or any
unnecessary
accidents that
might happen
5. Patient
demonstrated
appropriate use of
assistive devices.
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Discharge Plan
yM Supportive Care
y E- Encourage patient and instruct the significant others to assistthe patient to walk within her limits or use assistive devices andprovide appropriate resting periodsy Passive range of motion exercise to be performed at least twice daily
as follows:
y Ankle and foot exercises. Like Ankle bends, Ankle rotation, Toebends, Toe spreads.y Hip and leg exercises like Leg movement, side to side, and Leg
rotation, in and out.y Hand and finger exercises like Finger bends, Finger spreads, and
Finger-to-thumb touches.
y Forearm and wrist exercise like Wrist rotation and Palm up, palmdown.y Shoulder and elbow exercises like Shoulder movement, up and
down, Shoulder rotation, Elbow bends, up and down and Elbowbends, side to side.
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y H Perform activities of daily living with assistance
and manage self care like the patients nutrition, boweland bladder management. Skin care and adaptiveequipment for bathing, hygiene, grooming anddressing.
y
Implement safety measures at home.y Increase fiber intake daily to facilitate easy passage of
stool
y Increase fluid intake daily to prevent constipation and tokeep the patient hydrated
y O Follow up check-up when symptoms persisted and/or worsen
y D Diet as tolerable (DAT)
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Prognosis
y Most of the time recovery starts after the fourth week from theonset of the disorder. Approximately 80% of patients have acomplete recovery within a few months to a year, although minorfindings may persist, such as areflexia. About 510% recover withsevere disability, with most of such cases involving severe proximalmotor and sensory axonal damage with inability of axonalregeneration. However, this is a grave disorder and despite allimprovements in treatment and supportive care, the death rateamong patients with this disorder is still about 23% even in thebest intensive care units. Worldwide, the death rate runs slightlyhigher (4%), mostly from a lack of availability of life supportequipment during the lengthy plateau lasting four to six weeks, andin some cases up to one year, when a ventilator is needed in the
worst cases. About 510% of patients have one or more late relapses,in which case they are then classified as having chronicinflammatory demyelinating polyneuropathy(CIDP).
y Poor prognostic factors include: 1) age, over 40 years, 2) historyof preceding diarrheal illness, 3) requiring ventilator support, 4)high anti-GM1 titre and 5) poor upper limb muscle strength.
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