Reduction of Risk Potential Q 6
The LPN/LVN, under your supervision, is providing nursing care for a patient with GBS. What observation would you instruct the LPN/LVN to report immediately?
A. Complaints of numbness and tingling.
B. Facial weakness and difficulty speaking.
C. Rapid heart rate of 102 beats per minute.
D. Shallow respirations and decreased breath sounds.
Correct Answer: D. Shallow respirations and decreased breath sounds
The priority interventions for the patient with GBS are aimed at maintaining adequate respiratory function. These patients are at risk for respiratory failure, which is urgent. Upon presentation, 40% of patients have a respiratory or oropharyngeal weakness. Ventilatory failure with required respiratory support occurs in up to one-third of patients at some time during the course of their disease.
Option A: These findings should be reported to the nurse but it is not an urgent matter. The typical patient with Guillain-Barré syndrome (GBS), which in most cases will manifest as acute inflammatory demyelinating polyradiculoneuropathy (AIDP), presents 2-4 weeks following a relatively benign respiratory or gastrointestinal illness with complaints of finger dysesthesias and proximal muscle weakness of the lower extremities.
Option B: Facial weakness and difficulty of speaking are common signs of GBS and must be reported, but it is not a priority. The classic clinical picture of weakness is ascending and symmetrical in nature. The lower limbs are usually involved before the upper limbs. Proximal muscles may be involved earlier than the more distal ones. Trunk, bulbar, and respiratory muscles can be affected as well.
Option C: A rapid heart rate is important and should be reported to the nurse, but it is not life-threatening. Autonomic nervous system involvement with dysfunction in the sympathetic and parasympathetic systems can be observed in patients with GBS.