Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide • Review laboratory reports and other testing: o Lumbar puncture: CSF will have elevated protein levels and increased cell counts o CBC with differential: Will show leukocytosis o EMG nerve conduction: After four weeks, this test will show denervation Nursing diagnosis for Guillain-Barre syndrome: • Impaired gas exchange related to respiratory depression, secondary to muscle weakness • Ineffective airway clearance related to inability to cough, secondary to weakness • Ineffective breathing pattern related to weakness of respiratory muscles • Risk for impaired skin integrity related to immobility • Fall risk related to flaccid muscles Nursing interventions for Guillain-Barre syndrome: • Monitor oxygen saturations and arterial blood gasses • Continue to check vital signs every four hours • Check neurological status frequently, focusing on cranial nerves • Encourage to turn, cough, and deep breath every two hours and assist with turning if needed • Give medications per MD order: pain control and immunoglobulin; side effects of immunoglobulin are fever and chills • Prepare to assist MD with plasmaphereses. This procedure replaces the plasma that contains antibodies. Side effects include hypovolemia, hypocalcemia, and hypokalemia. Check site of administration frequently for patency. Expected outcomes for Guillain-Barre syndrome: • Demonstrates increased mobility with no evidence of falls or injuries • Demonstrates adequate ventilation and effective breathing • Demonstrates ability to clear secretions • Maintains skin integrity with no signs of breakdown

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