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.
