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Client Dx: Guillain-Barre Syndrome with Miller Fisher Variant Age: 64 Allergies: Aspirin, Motrin
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Guillain-Barre Syndrome with Miller Fisher Variant
PATHOPHYSIOLOGY of diagnosed disease: (From text)
Guillain-Barre Syndrome is a rare auto-immune disorder that damages a persons nerve cells which causes muscle weakness and
paralysis at times. Symptoms normally last a few weeks and people recover fully but it can leave long-term nerve damage. In rare
cases, it has can cause death due to difficulty breathing. It effects 3000-6,000 people a year in the US.
Miller Fisher Variant is a variant form of Guillain-Barre Syndrome. This variant effects the eye muscles causing abnormal muscle
coordination, paralysis and blindness. It effects about 5% of people with Guillain-Barre Syndrome.
Guillain-Barre Syndrome and Flu Vaccine. (2015, October). In Centers for Disease Control and Prevention. Retrieved from
http://www.cdc.gov/flu/protect/vaccine/guillainbarre.htm
NINDS Miller Fisher Syndrome Information Sheet. (2015, July). In National Institute of Neurological Disorders and Stroke.
Retrieved from http://www.ninds.nih.gov/disorders/miller_fisher/miller_fisher.htm
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Symptoms of tingling and weakness starts in the feet and legs and spreads to the upper body and arms. Symptoms also include
prickling sensation, unsteady gait, inability to walk, difficulty with eye or facial movements, blindness, difficulty speaking, chewing
and swallowing, severe pain, decreased bladder and bowel control, rapid HR, high or low BP, difficulty breathing.
Guillain-Barre Syndrome: Symtoms. (1998). In Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/guillain
barre-syndrome/basics/symptoms/con-20025832
CLIENTS SYMPTOMS of the diagnosed disease include:
Weakness and tingling in fingers that was spreading up arms to chest, partial blindness and ptosis.
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): 175.26 cm Weight (actual or estimated): 63.50 kg
Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5): 66.68 kg
Does this client have characteristics of a well-nourished person? Yes
No ______
Explain your answer: His electrolyte levels are within a normal range, his protein is low and glucose is high. His overall physical
appearance is healthy and appropriate.
STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress.
Stress management strategies are unknown. Nothing was clearly charted and no family was present at the time to ask and patient was
unable to communicate. His room was kept quiet though.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnosis that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Ineffective Breathing r/t respiratory muscle weakness and decreased cough reflex.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Patient was experiencing weakness in the chest, SOB, decreased cough reflex.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Be able to tolerate breathing on own during spontaneous wake session, keep breathing patterns and levels at an effective rate and
pattern, stimulate cough reflex.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Assess and monitor effective breathing including ABG levels, SpO2, ventilator settings and skin color.
2. Suction secretions and clear any airway blockage as needed.
3. Perform spontaneous wake sessions 1x per day to evaluate breathing capability on own.
#2 NURSING DIAGNOSIS (problem r/t)
Impaired Physical Mobility r/t weakness in upper extremities and spreading.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Unable to perform ADLs, unable to move on own, weakness.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Be able to do hand/foot push/pulls, move extremities on own when instructed to.
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1. Perform passive ROM.
2. Test hand/foot push/pull strengths 3x per day to test improvement.
3. Assess sensation and weakness in body.
COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
He would stop breathing.
How would you know this is happening?
He would not be breathing on his own anymore, cyanotic.
What will you do if this happens?
Call a code blue, start CPR, intubate.
EVALUATION:
Was the patient able to achieve the objectives identified on the first clinical day? yes
If no, list new objectives.
no
n/o
Did you choose the appropriate nursing diagnosis on the first clinical day? yes
If no, list nursing diagnosis that would have been more appropriate.
no
REASON PRESCRIBED
(Drug Classification
What is it treating?)
NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse reactions,
preparation & administration
concerns)
Atorvastatin 10mg
PO QHS
Chlorhexidine 1 application
Topical QID
Docusate 10ml
Feeding Tube BID
Stool Softener
Prevent Constipation
Famotidine 20mg
PO BID
Histamine H2-Receptor
Antagonist
Inhibits Acid Reflux
Heparin 1ml
SubQ Q8H
Anticoagulant
Prevent Blood Clots
Levothyroxine 50mcg
PO Daily
Osmotic Laxative
Prevents Constipation
Fluid Electrolyte
Used to flush IV lines
Fentanyl 1ml
IVP Q2H PRN
Opioid
Pain/Sedation
Fluid Electrolyte
Fluid Bolus
Fentanyl 250ml
IV Continuous Drip
Opioid
Pain/Sedation
Propofol 100ml
IV Continuous Drip
Hypnotic/Amnestic Agent
Sedation
Fluid Electrolyte
Hydration
List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications)
and provide the patient values for each test. Explain why they are pertinent for this patient.
2.
List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased
or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test
Patient Values
Glucose
122
Chloride
97
BUN
23
Calcium
8.7
Protein
5.5
AST
51
pH ART
7.46
Hgb
13
Hct
39
RBC
4.05
Analysis of Values
Slightly increased. Pt on TPN and immobile.