Silliman University College of Nursing D u m a g u e t e C I t y, P h I l I p p I n e s

GUILLAIN-BARRE SYNDROME (GBS)

Definition of terms

Areflexia
absence of reflexes

Ataxia
impaired ability to coordinate movement

Dyskinesia
an impairment of the ability to execute voluntary movements

Hyporeflexia
decreased reflex reactions

Parasthesias
any subjective sensation experienced as numbness, tingling or a pins and needles feeling.

Quadriplegia
paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord.

Myelin
is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites.

Nerve
is a cordlike organ that is part of the PNS. They vary in size, but each of them consists of bundles of peripheral axons that may be myelinated or not and are enclosed by successive wrappings of connective tissue.

Guillain-Barre Syndrome
Also known as Infectious Polyneuritis. An autoimmune attack on the peripheral nerve myelin Two peak time periods: 1. late adolescence 2. young adulthood

 Results to acute, rapid segmental demyelination of peripheral nerves and some cranial nerves, producing ascending weakness with dyskinesia (inability to execute voluntary movements), hyporeflexia, and paresthesias (numbness).

 First describes by Landry in 1859, occurs throughout the world, affects children, adults of both sexes, but is more prevalent in men, and all age groups equally. More frequent in males between 16 and 25 years of age and between 45 and 60 years of age

 Commonly cause by viral agents: Campylobacter jejuni Cytomegalovirus Epstein-Barr virus Mycoplasma pneumoniae Haemophilus influenzae Human Immunodeficiency virus (HIV)

PATHOPHYSIOLOGY

Pathophysiology of GBS
Predisposing factors: Precipitating factors: Age- 16-25; 45-60 years Post-infection old Surgery Sex- more prevalent in Influenza men immunizations increased in pregnant Trauma and postpartum Stress/Lifestyle women. Food poisoning

Invasion of causative agents (e.g. Campylobacter jejuni) Enters the body by the use of multifenestrated cells or other mechanisms

Activation of innate immune response

Uptake of the pathogens by immature antigen presenting cells Pathogen and host have homologous or identical amino acid sequences, antigens in its capsules are shared with nerves

Migration to lymph nodes, a mature, differentiated APC can present in major histocompatibility complex molecules and activate CD4T cells that recognize antigens from the infectious pathogens

Antibodies will be produced, leading to activation of the complement system and phagocytosis of the bacteria

Molecular Mimicry

Failure of the immune system to distinguish between the two proteins

Autoimmunity activation

Immune responses directed against the capsular components produce antibodies that cross react with myelin
Lymphocytes and macrophages migrate into the areas adjacent to the nerve Lymphocytic infiltration of spinal roots & peripheral nerves Macrophage-mediated, multifocal stripping of myelin and axonal damage

Demyelination of nerve segments

Assessment: Positive for GBS if these signs are present: - Paresthesias - Paralysis - Hypotonia, areflexia EMG: detects tiny electrical signals on the muscles Dull and aching pains in the lower back, flank and proximal legs Sinus tachycardia, hyper/hypotensi on, loss of sweating

Increased disruption of the axons

Defects in the propagation of electrical nerve impulses, with eventual conduction block

Peripheral nerve denervation and atrophy

Lumbar tap: high CHON level w/o cellular abnormality (600mg/ml) Nerve conduction tests: (-) patellar reflex MRI: forms images of the bodys internal structures Nerve biopsy: removal of a tiny piece of nerve; examined for damage signs Management: - ECG monitoring - a-adrenergic blockers - Hypotension:

ANS dysfunction

Treatment: - Plasmapheresis - IVIG - PT and exercise

GBS

Cell body dies

Extensive axonal destruction

Collateral re-innervation from surviving axon Ascending weakness progresses

Drooling, fainting, facial droop, dysphagia, dysarthria

Weakening of diaphragm and respiratory muscles

Dyspnea

Respiratory distress syndrome

Management: - Mechanical Ventilator

Respiratory arrest

Shock

DEATH

Ineffective Breathing Pattern and Impaired gas exchange r/t rapidly progressive weakness and impending respiratory failure
Incentive Spirometry Chest Physiotherapy Monitoring changes in vital capacity and negative inspiratory force Mechanical ventilation Intubation

 Suctioning Assess the blood pressure and heart rate frequently Administer medications like bronchodilators

Impaired physical mobility r/t paralysis

Paralyzed extremities are supported in functional positions Passive range of motion exercises Prevent the development of Deep Venous Thrombosis Padding may be placed over bony prominences Evaluates laboratory test results that may indicate malnutrition or dehydration

 Collaboration with the physician and dietician will result in a plan to meet the patients nutritional and hydration needs

Imbalanced nutrition: less than body requirements r/t inability to swallow

Administers IV fluids as prescribed Administers parenteral nutrition as prescribed Monitors the return of bowel sounds Gastrostomy tube may be placed if unable to swallow Assess the return of gag reflex Assess bowel sounds before resuming oral nutrition

References:
Hockenberry, M. J. & Wilson, D. (2007). Wongs Nursing Care of Infants and Children. 8th ed.vol.2.pages.1819-1821.Phillippines: Elsevier Inc. Smeltzer, S., Bare, B., Hinkle, J. & Cheever, K. (2008). Brunner & Suddarths Textbook of Medical- Surgical Nursing. 11th ed. USA: Lippincott Williams & Wilkins. Lewis, S.M. et. al. (2004). Medical Surgical Nursing: Assessment and Management of Clinical Problems. 6th ed. United States of America: Mosby, Inc. Black, J., & Hawks, J.H. (2005). Medical- Surgical Nursing: Clinical management for positive outcomes. 7th ed. Louis, Missouri: Elsevier Saunders. Porth, C. (2011). Essentials of pathophysiology. Philadelphia:Lippincott Wiliams & Wilkins. McCance, K. (1994). Pathophysiology: the basic basis for disease in adults and children 2nd ed. St. Louis: Mosby.

 http://en.wikipedia.org/wiki/Guillain%E2%80 %93Barr%C3%A9_syndrome http://www.mayoclinic.com/health/guillainbarre-syndrome/DS00413