Question

A client with Guillain-Barre syndrome has paralysis of the extremities and requires mechanical ventilation, the client is not blinking. what itervention shour the nurse take?

A.Assess signs of intracranial pressure

B.Arouse client to stimuli blinking

C.Encourage fluids

D.Protect cornea with lubricant and eye shield

Answer 1

Correct answer - option D

Explanation

1. This condition is characterized by areflexia.
2. Therefore, the corneal reflex will be absent.
3. This patient is unable to blink
4. This makes the eye susceptible exposure keratitis.
5. Therefore it is important for the nurse to start eye care with lubricant and eye shield.

Incorrect answer

Option A - GBS doesnt occur due to increase intracranial tension.

Option B - GBS patient wont be able to blink eye-lids due to motor weakness.

Option C - patient is on mechanical ventilation. So the fluid infusion should be dictated by urine output and insensible fluid loss. Avoid fluid overload.

• Gillian Barrie syndrome is a condition characterized by acute inflammatory polyradiculopathy.
• The Classical presentation includes ascending paralysis and areflexia. This usually follows an acute infection.
• The pathophysiology includes immune- mediated demyelination of the myelinated neurons.
• Clinical feature:
  • Ascending motor weakness ( starts with food drop and lower limb weakness. Respiratory muscle involvement is a late manifestation)
  • Areflexia ( progression is from normoreflexia to hyporeflexia to areflexia)
  • Autonomic, cranial nerve involvement and sensory involvement may be present.
• Lumbar puncture should elevated protein levels compared to the cells. Cell count more than 50 mono nuclear cells makes diagnosis of GBS is less likely