Name of Patient: Patient P.N.

                                            Age/Sex: 19 / Female__________  Room/Bed no.: Room 123 Bed no. 3

Chief Complaint: Hallucinations___________________  Attending Physician: Dr. Perez
Diagnosis: Guillain Barre Syndrome

Date Cues Nee Nursing Diagnosis Goal of Care Nursing Interventions IMPLIMEN
/Ti d TATION
me

S:  E Impaired urinary elimination r/t
O L neuromuscular impairment as
C O: I evidenced by urinary retention
T M and paralysis.
O I
B  Urinary N Rationale:
E retention A Guillain-Barré syndrome (GBS)
R  Paralysis T is a dangerous health condition
 Muscle I that develops when the body's
2 weakness O defense (immune) system attacks
 Oligoria N a section of the peripheral
0  Urine nervous system by accident. The
ouput of 24 P peripheral nervous system allows
2 A the brain and spinal cord to
cc/hr
T communicate with various parts
1 of the body. If the PNS fails or is
T R: Monitoring the I&o helps
E damaged, nerve inflammation
R occurs, resulting in numbness,
N muscle weakness, or the inability
to move a part or all of one side
of the body (paralysis), which
includes the loss of bladder
control.
(Martin, P., 2019)
 Within 8 hours of 1. Assess progressive degree 1
nursing care, the of paralysis and effect on
patient will be able urinary elimination.
to establish routine R: To establish data on the
urinary elimination effect of motor dysfunction
patterns. that travels upward from
extremities.
2
2. Monitor the intake and output
of the patient every 4 to 8
hours and assess for the
color(appearance) of urine if
its cloudy and check for foul
smelling urine.
to determine if there is any
changes in the I&O ratio of
the patient. Checking the
appearance and the smell of
urine helps to identify
presence of infection or 3
further type of elimination
problem.

Martin, P., (2019). 6th 3. Palpate the bladder every 2

Guillain-Barre Syndrome hours. 4
Nursing Care Plans. R: To determine presence of
Retrieved on September 29, urinary retention as paralysis
2021 from progresses.
https://nurseslabs.com/guilla
in-barre-syndrome-nursing- 5
care-plans/ 4. Monitor BUN, creatinine,
white blood cell (WBC)
count.
R: These reflect renal
function and identify
complications.

5. Catheterize patient for 6

residual urine, as indicated.
Insert an indwelling urinary
catheter.
R: To maintain elimination
and this helps to relieve
bladder distention and urinary
retention of the patient.
7
6. Assist client in urinary
elimination rehabilitation
program; perform Crede’s
maneuver in a gentle manner
if indicated.
R: Promotes urine elimination
and return to a normal pattern 8
as soon as possible.

7. Instruct the patient to increase

Fluid intake up to 1,500-2,000
ml daily.
R: Sufficient hydration 9
promotes urinary output and
aids in preventing infection. 

8. Encourage Client to limit

intake of coffee and alcohol.
R: Coffee and Alcohol are
chemicals known to be
bladder irritants.
 10
9. Instruct patient to avoid
constipation or fecal
impaction by eating well
balanced diet with plenty of
fiber (fruits, vegetables and
whole grains).
R: Impacted stool may place
pressure on the bladder
outlet, causing urinary
retention.

10. Instruct the patient to report Mitchie E.

any reduction or absence of Agcopra St. N
urinary elimination.
R: Avoids complication
of neuromuscular impairment
of disease and effect on
urinary bladder function.

References:
Doenges, M., Moorhouse, M.,
& Murr, A., (2016). Nurse’s
Pocket Guide.14th Edition.
F.A. Davis Company

Martin, P., (2019). 6th

Guillain-Barre Syndrome
Nursing Care Plans.
Retrieved on September 29,
2021 from
https://nurseslabs.com/guillai
n-barre-syndrome-nursing-
care-plans/