Mr. Gianopoulos, after a URI, developed Guillain-Barré syndrome. Which nursing action is the priority?

Mr. Gianopoulos, after a URI, developed Guillain-Barré syndrome. Which nursing action is the priority?

• A. Treating the infection triggering onset
• B. Managing respiratory muscle dysfunction
• C. Strengthening and stretching targeted muscles
• D. Preventing major complications due to immobility

Answer: (D)

When Guillain-Barré syndrome causes significant weakness and immobilization, the most urgent nursing priority is preventing major complications from immobility. Prolonged bed rest and reduced mobility raise the risk of pressure ulcers, venous thromboembolism, pulmonary problems such as atelectasis and pneumonia, constipation, urinary retention, and joint contractures. The nurse should implement turning and skincare routines, passive range-of-motion exercises, and early mobility as tolerated; promote good pulmonary hygiene with deep breathing, coughing, and incentive spirometry as able; monitor for signs of DVT and autonomic instability; ensure adequate nutrition and hydration; and establish a plan for bowel and bladder management. While monitoring respiratory status and managing any respiratory muscle weakness is essential if it develops, preventing complications from immobility addresses the broad, immediate needs that can arise as weakness progresses, making it the priority in many acute-care scenarios.

When Guillain-Barré syndrome causes significant weakness and immobilization, the most urgent nursing priority is preventing major complications from immobility. Prolonged bed rest and reduced mobility raise the risk of pressure ulcers, venous thromboembolism, pulmonary problems such as atelectasis and pneumonia, constipation, urinary retention, and joint contractures. The nurse should implement turning and skincare routines, passive range-of-motion exercises, and early mobility as tolerated; promote good pulmonary hygiene with deep breathing, coughing, and incentive spirometry as able; monitor for signs of DVT and autonomic instability; ensure adequate nutrition and hydration; and establish a plan for bowel and bladder management. While monitoring respiratory status and managing any respiratory muscle weakness is essential if it develops, preventing complications from immobility addresses the broad, immediate needs that can arise as weakness progresses, making it the priority in many acute-care scenarios.