Guillan Barre Syndrome Nursing Care Plans

Guillan Barre Syndrome Nursing Care Plans 

Nursing Diagnosis :

01.Ineffective airway clearance related to presence of artificial airway and retained secretions as evidenced by presence of copious drooling oral secretions, tracheal secretions, basal crepitations on auscultation.

02. Ineffective breathing pattern related to neuromuscular dysfunction as evidenced by dyspnea and increased respiratory rate.

03. Acute pain related to biological and physical injury agents as evidenced by facial grimacing indicating pain in the legs.

04. Impaired bed mobility related to

05. Impaired verbal communication related to physical barrier as evidenced by inability to speak and use facial expressions.

06. Bathing self care deficit related to neuromuscular impairement as evidenced by the inability access bathroom.

07. Feeding self care deficit related to neuromuscular impairement as evidenced by the inability swallow and chew.

08. Toileting self care deficit related to neuromuscular impairement as evidenced by the inability get to toilet.

09. Dressing self care deficit related to neuromuscular impairement as evidenced by the inability to put on necessary clothing.

10. Risk for aspiration related to presence of endotracheal tube and feeding tube.

11. Risk for infection related to continuous bladder drainage.

12.Risk for disuse syndrome related to paralysis secondary to guillan barre syndrome.

13. Risk for impairement skin integrity related to physical immobilisaiton.

14. Risk for vascular trauma related to the presence of venous catheter in in site.