Group 3

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Case Scenario: Hepatitis B, Guillain Barre Syndrome, Neurological and respiratory assessment

A 65-year-old admitted to the medical surgical unit with Hepatitis B is experiencing symptoms
of Guillain Barre. Identify symptoms and manifestations of the disease process. Using nursing
judgment, at what level would you call for orders to intubate this patient? What are nursing
considerations for this patient?

Guillain-Barre Syndrome
● Also known as acute idiopathic polyneuritis
● An autoimmune attack on the peripheral nerve myelination
● The result is acute, rapid segmental demyelination of peripheral nerves and some cranial
nerves, producing ascending weakness with dyskinesia (inability to execute voluntary
movements), hyporeflexia, and paresthesias (a sensation of numbness, tingling, or “pins
and needles”)
● An antecedent event (most often a viral infection) precipitates presentation

Pathophysiology
● Myelin is the substance that covers nerves and provides insulation and speeding in the
conduction of impulses from the cell body to the dendrites
● The cell that produces myelin is the Schwann cell
● In GBS, the Schwann cell can be spared, allowing for remyelination in the recovery
phase of the disease
● If damage has occurred to the axons, then regrowth is required and takes months or years
and is often incomplete
● GBS is the result of a cell mediated and humoral immune attack on peripheral nerve
myelin proteins that causes inflammatory demyelination
 ● It occurs when an infectious organism which contains an amino acid mimics the
peripheral nerve myelin protein. The immune system cannot distinguish between the two
proteins and attacks and destroys peripheral nerve myelin
● With the autoimmune attack, there is an influx of macrophages and other immune-
mediated agents that attack myelin and cause inflammation and destruction, interruption
of nerve conduction, and axonal loss

Clinical Manifestations
● Typically begins with muscle weakness and diminished reflexes in lower extremities
● Hyporeflexia and weakness may progress to tetraplegia
● Demyelination of the nerves that innervate the diaphragm and intercostal muscles results
in neuromuscular respiratory failure
● Sensory symptoms include paresthesias of the hands and feet and pain related to the
demyelination of sensory fibers
● The antecedent event usually occurs 1-3 weeks before symptoms begin
● Weakness usually begins in the legs and may progress upward
● Maximum weakness (the plateau) varies in length but usually includes neuromuscular
respiratory failure and bulbar weakness
● Peak severity typically occurs within 2 weeks and no longer than 4 weeks. If progression
is longer, the patient is classified as having chronic inflammatory demyelinating
polyneuropathy and any residual symptoms are permanent
● Cranial nerve demyelination can result in blindness, inability to swallow or clear
secretions, autonomic dysfunction manifested by instability of the cardiovascular system
(tachycardia, bradycardia, hypertension, orthostatic hypotension)
● GBS does not affect cognitive function or LOC

Assessment and Diagnostic Findings

The patient presents with symmetric weakness, diminished reflexes, and upward progression of
motor weakness. A history of viral illness (hepatitis), in the previous few weeks suggests the
diagnosis. Changes in vital capacity and negative inspiratory force are assessed to identify
impending neuromuscular respiratory failure. Serum lab tests are not useful in the diagnosis.
However, elevated protein levels are detected in CSF evaluation, without an increase in other
cells. Evoked potential studies demonstrate a progressive loss of nerve conduction velocity.
● GBS diagnosed with lumbar puncture (positive result would be elevated protein without
elevated WBC’s
○ Before lumbar picture, have patient empty bladder
○ During, position lateral recumbent with knees up to abdomen and bend chin to
chest
○ after, lie flat and consume fluids to help replace CSF loss

Medical Management
Due to possibility of rapid progression and neuromuscular respiratory failure, GBS is a medical
emergency that may require management in an ICU.
● Assess muscle strength and respiratory function - alert physician if changes occur
● Respiratory therapy or mechanical ventilation may be necessary to support pulmonary
function and adequate oxygenation
● Some clinicians recommend elective intubation before onset of extreme respiratory
fatigue
● Emergent intubation may result in autonomic dysfunction, and mechanical ventilation
may be required for an extended period
● The patient can be weaned from mechanical ventilation after respiratory muscles can
again support spontaneous respiration and maintain adequate tissue oxygenation
● Other interventions aim to prevent complications of immobility - these include
anticoagulant agents, PCDs, etc.
● TPE and IVIG are used to decrease antibody levels and reduce amount of time the patient
is immobilized and dependent on mechanical ventilation
● Cardiovascular risks require continuous ECG monitoring
● Tachycardia and hypertension are treated with medications like short acting alpha
adrenergic blocking agents
● Hypotension is managed by increasing IV fluid
References:

● Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 14th edition

● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821638/