Question

Initial Discussion Post:

Select one (1) of the following Nursing Diagnoses:

Impaired Spontaneous Ventilation

Impaired Swallowing

Care Giver Role Strain

Address the following:

Is the nursing diagnoses that you selected appropriate for the patient with a diagnosis of myasthenia gravis, Guillain-Barre syndrome or both? Explain your answer.

Provide an outcome for the nursing diagnosis that you selected making sure that is specific to the needs of the patient with myasthenia gravis or Guillain-Barre syndrome.

Identify two (2) interventions that will help your patient with myasthenia gravis or Guillain-Barre syndrome reach the outcome for the nursing diagnosis.

Answer 1

I have selected the nursing diagnosis as - Impaired Spontaneous Ventilation .

• Yes, the selected nursing diagnosis is appropriate for both myasthenia gravis and Guillain-Barre syndrome.

• Myasthenia Gravis (MG) is a type of autoimmune disorder, a neuromuscular disease that usually results to muscle weakness and fatigue primarily in the face. The patients with MG , experience ineffective breathing pattern and impaired gas exchange due to the neuromuscular weakness of the respiratory muscles and throat.
  

Desired Outcome -

The patient will maintain an oxygen saturation of >92% and a respiratory rate of 12-20 with ADL’s.

Nursing intervention -

1.Assess for signs of activity intolerance. Ask client to rate perceived exertion.

Rationale - Dyspnea on exertion, palpitations, headaches, or dizziness or patient states increased exertion level, are all signs of activity intolerance and decreased tissue oxygenation.

2.Monitor pulse oximetry and report O2 saturation <92%.

Rationale - O2 sat of <92% indicates the need to supplement oxygen.

3.. Encourage deep breathing exercises and administer oxygen if indicated.

Rationale - Increases oxygen delivery to the body.

• Guillain-Barre syndrome (GBS) is an autoimmune disease in which there is an acute inflammation of the spinal and cranial nerves manifested by motor dysfunction that predominates over sensory dysfunction. The patient with GBS has Ineffective Breathing Pattern, Ineffective Airway Clearance, Impaired Gas Exchange due to respiratory muscle weakness or paralysis, decreased cough reflex, immobilization and is evidenced by altered chest expansion, cyanosis, respiratory depth changes, abnormal ABGs.

Desired Outcome - Client will maintain effective breathing pattern.

Nursing intervention -

1. Assess frequency, symmetry, and depth of breathing. Observed for increased work of breathing and evaluate skin color, temperature, capillary refill.

Rationale - Progressive weakness of both the inspiratory and the expiratory muscles may lead to respiratory distress that may necessitate the need for mechanical ventilation.

2. Observe for signs of respiratory fatigue such as shortness of breath, decreased attention span, and impaired cough.

Rationale - May indicate neuromuscular respiratory failure or decrease lung capacity.

3. Keep the head of bed elevated at around 35-45°

Rationale - Increases lung expansion and cough effort minimizes the work of breathing and the risk of aspiration of secretions.

4. Perform chest physiotherapy which includes postural drainage, chest percussion, chest vibration, turning, deep breathing and coughing exercises.

Rationale - Facilitates mobilization and clearance of airway secretions.