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CRITICAL THINKING SUMMARY

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.

PSYCHOSOCIAL STAGE OF DEVELOPMENT


What is the clients developmental stage? He is in the adulthood age, the conflict of generativity vs. stagnation, and Care for the
virtue.

Has he/she met the necessary accomplishments? Yes __X___ No _____


Explain
He has a career and has a family involvement. The main accomplishments of this stage are work and family and he has both of them.
How is this illness affecting the clients ability to meet these necessary accomplishments?
This illness is not affecting him from meeting these accomplishments. This illness is temporary and he is expected to make a full
recovery within a few weeks. He can get back to family and work and continue to meet other accomplishments and enjoy life.

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.

Were the interventions appropriate? yes no n/o


If no, list more appropriate interventions.

no

PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS


MEDS/IVS/TX/DIET
(Include dose, route,
frequency)

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

HMG CoA reductase inhibitor


(STATIN)
Lowers cholesterol levels
Antiseptic Antibacterial
Oral Care Mouth Wash

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

Synthetic Thyroid Hormone


Treats Hypothyroidism

Polyethylene Glycol 17Gm


PO BID

Osmotic Laxative
Prevents Constipation

Sodium Chloride 3ml


IVP Q8H

Fluid Electrolyte
Used to flush IV lines

Fentanyl 1ml
IVP Q2H PRN

Opioid
Pain/Sedation

Sodium Chloride 250ml


IV PRN

Fluid Electrolyte
Fluid Bolus

Fentanyl 250ml
IV Continuous Drip

Opioid
Pain/Sedation

Propofol 100ml
IV Continuous Drip

Hypnotic/Amnestic Agent
Sedation

Sodium Chloride 120ml


IV Continuous Drip

Fluid Electrolyte
Hydration

Liver Disease, Kidney Disease,


Stroke, Weakness, Tiredness
Increase in staining of teeth/oral
surfaces, increase in calculus
formation, alteration in taste
Loose stools, Abdominal Pain,
Nausea, Vomiting, Bowel
Obstruction
History of Ulcers, Liver Disease,
Kidney Disease, Stomach
Cancer, Long QT Syndrome,
Chest Pain
Uncontrolled bleeding, high
blood pressure, bleeding
disorders, liver disease, severe
lack of platelets
Thyrotoxicosis, heart disease,
CAD, history of blood clots,
diabetes, anemia, osteoporosis,
pituitary gland disorder, adrenal
gland disorder, heart attack
Bowel obstruction, Kidney
problems, Nausea, Vomiting,
Abdominal Pain
IV blockage, Infiltration,
swelling, redness, pain
Breathing problems, lung
disease, head or brain injury,
Liver or Kidney disease, slow
HR
Electrolyte imbalance, Blood
pressure problems, liver disease,
fluid build-up, fluid retention,
CHF, Low salt diet
Breathing problems, lung
disease, head or brain injury,
Liver or Kidney disease, slow
HR
Seizures, high cholesterol,
dizziness, drowsiness, head-ach
feeling
Electrolyte imbalance, Blood
pressure problems, liver disease,
fluid build-up, fluid retention,
CHF, Low salt diet

PATIENT DATA FROM


YOUR ASSESSMENT
(What data is important to know
before & after giving)
Monitor Cholesterol Levels,
Know medical history, give
through feeding tube
Mouth condition

Loose stools, bowel sounds and


activity
Acid reflux/heartburn, Chest
Pain, Know Medical History,
give through feeding tube
PTT levels, Platelet levels, signs
of bleeding or bruising

T4 levels, Know medical


history, glucose level, chest pain

Loose stools, bowel sounds and


activity
Patent flush, Pain at site,
Infiltration, leaking, swelling,
redness, lung sounds
BP, HR, RR, Breathing, Pain
level, Sedation level, SOB, chest
pain
Electrolyte levels, Urine Output
and characteristics, Hydration
status, BP, HR
BP, HR, RR, Breathing, Pain
level, Sedation level, SOB, chest
pain
Sedation level, know medical
history
Electrolyte levels, Urine Output
and characteristics, Hydration
status, BP, HR

Analysis of Diagnostic Tests


DIRECTIONS:
1.

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

Level is 1 point high caused by the kidneys


working slower due to TPN and
immobilization.
This level is normal. Just monitored due to a
Calcium infusion given during
plasmapheresis.
Level is low caused by being on TPN and
body not absorbing it properly.

AST

51

Level is high caused by the liver


metabolizing all the medications.

pH ART

7.46

Level is .01 point high. This is caused by


being on the ventilator.

Hgb

13

Level is 1 point low caused by being on


plasmapheresis.

Hct

39

Level is low caused by having a decreased


RBC and being on plasmapheresis.

RBC

4.05

Level is low caused by being on


plasmapheresis.

Narrative Charting Sample

Analysis of Values
Slightly increased. Pt on TPN and immobile.

Level is 1 point low caused by the high


volumes of fluids being given.

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