NURSING DIAGNOSIS

Impaired Physical Mobility related to neuromuscular impairment evidenced by

decreased muscle strength.

RATIONALE/EXPLANATION

Guillain-Barre syndrome (GBS) also known as infectious polyneuritis is an

autoimmune disease in which there is an acute inflammation of the spinal and cranial
nerves manifested by motor dysfunction that predominates over sensory dysfunction
(Martin, P., 2019).

INTERVENTION

1. Assess motor strength or functional level of mobility. Understanding the particular

level guides the design of best possible management plan (Martin, P., 2019).
2. Monitor nutritional needs as they associate with immobility. Good nutrition also
gives required energy for participating in an exercise or rehabilitative activities
(Martin, P., 2019).
3. Place the client in a position of comfort. Provide frequent position changes as
tolerated. Promotes relaxation and prevent the development of decubitus ulcers
(Martin, P., 2019).
4. Administer heparin as ordered. -weight heparin (LMWH) is
administered in the prophylaxis of deep vein thrombosis (Martin, P., 2019).
5. Provide padding to bony prominences such as elbow and heels. Maintain
extremity in a physiological position, reduces the risk of pressure ulcers (Martin,
P., 2019).
6. Perform active, passive and isotonic range of motion exercises as appropriate.
Improves joint mobility, stimulates circulation and enhance muscle tone (Martin,
P., 2019).
7. Evaluate the need for assistive devices and provide a safe environment e.g., bed
in low position and side rails up. Correct utilization of wheelchairs, canes, transfer
bars, and other assistance can promote mobility and reduces the risk of falls
(Martin, P., 2019).
8. Provide rest periods in between activities. Consider energy-saving techniques.
Rest periods are essential to conserve energy and avoid fatigue (Martin, P.,
2019).
9. Assist client and their families to establish goals in participation with activities,
exercise and position changes. Enhances a sense of anticipation of progress or
improvement and promotes independence (Martin, P., 2019).
10. Consider the need for home assistance (e.g., physical therapy and occupational
therapy). Formulates a course of treatment with specific interventions to improve
muscle function and to retrain in performing activities of daily living (ADLs)
(Martin, P., 2019).
REFERENCES

Martin, P., 2019. 6 Guillain-Barre Syndrome Nursing Care Plans. Retrieved from:
https://nurseslabs.com/guillain-barre-syndrome-nursing-care-plans/3/