Patient P.V., a 74-year-old male, presented with progressive body weakness that began 15 days prior. He reported weakness starting in his lower extremities and progressing upwards. He was admitted to the hospital with a chief complaint of body weakness and a diagnosis of Guillain-Barré syndrome was considered. Guillain-Barré syndrome is an autoimmune disorder where the body's immune system attacks the peripheral nervous system, causing muscle weakness and possible paralysis. Nursing care involved assessing the patient, administering medications to treat the condition, providing respiratory support if needed, and patient/family education on Guillain-Barré syndrome and its management.

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LICEO DE CAGAYAN UNIVERSITY
R.N. Pelaez Boulevard, Cagayan de Oro City 9000
COLLEGE OF NURSING
NCM501106
In Partial Fulfillment of the Requirements
In
NCM501104 Related Learning Experience
A Case Presentation on

2. Submitted to:
Mr. Roberto Alli, RN, MN
Clinical Instructor
Submitted by:
GOLINDANG, Kyle
JALAGAT, Kristian Rey
LAMELA, April Joel
SABELLA, Winset Rose
SANCHEZ, Adyth
SHORETTE, Jun Mari Thel
Group B3 BSN 106-A
February 13, 2012
Liceo De Cagayan University
College of Nursing
NCM104
A Case Study
Mr. A. V.
Submitted to
Mr. Roberto Alli, RN,MN
As Partial Requirement for NCM104
Submitted by
Adyth P. Sanchez
Name of Student
Rating Scale
A. WRITTEN WEIGHT RATING
I. Introduction 5
a) Overview of the case
b) Objective of the study
c) Scope and Limitation of the study
II. Health History 5
a) Profile of patient
b) Family and personal health history
c) History of Present Illness

3. d) Chief Complaint
III. Developmental Data 5
IV. Medical Management 20
a) Medical Orders and rationale (10)
b) Drug Study (10)
V. Pathophysiology with Anatomy and Physiology 10
VI. Nursing Assessment (SystemReview & Nursing Assessment II) 10
VII. Nursing Management 30
a) Ideal Nursing Management (NCP) (10)
b) Actual Nursing Management (SOAPIE) (20)
VIII. Referrals and Follow-up 5
IX. Evaluation and Implications 5
X. Documentation 5
a) Documentation of evidence of care for 1 week rotation
b) Organization/ Grammar/ Bibliography
Total Score 100
Equivalent Grade
TABLE OF CONTENTS
I. Introduction
a.) Overview of the Case
b.) Objective of the Study
c.) Scope and Limitation of the Study
II. Health History
a.) Profile of Patient
b.) Family and Personal Health History
c.) History of Present Illness
d.) Chief Complaint
III. Developmental Data
IV. Medical Management

4. a.) Medical Orders Laboratory Results
b.) Drug Study
V. Pathophysiology with Anatomy and Physiology
VI. Nursing Assessment (System Review & Nursing Assessment II)
VII. Nursing Management
a.) Ideal Nursing Management (NCP)
b.) Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X. Documentation/ Bibliography
I. INTRODUCTION
A. Overview of the Case
The diverse group of neurologic disorders that make up infectious and autoimmune
disorders, cranial and peripheral neuropathies present unique challenges for nursing care.
Infectious processes of the nervous system sometimes cause death or permanent dysfunction.
Autoimmune disorders usually have a slow, progressive course, requiring the nurse to manage
symptoms and facilitate patients’ and families’ understanding of the disease process. Cranial
and peripheral nerve disorders may affect the patient’s comfort, functional independence, and
self-esteem. The nurse who cares for patients with these disorders must have a clear
understanding of the pathologic processes and the clinical outcomes. Some of the issues
nurses must help patients and families confront include adaptation to the effects of the disease,
potential changes in family dynamics, and, possibly, end-of-life issues.
Guillain-Barré syndrome is an autoimmune attack of the peripheral nerve myelin. 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 (numbness). In 66% of cases, there is a predisposing event,
most often a respiratory or gastrointestinal infection, although vaccination, pregnancy,and
surgery have also been identified as antecedent events (Bella & Chad, 1998). Infection with
Campylobacter jejuni (a relatively common gastrointestinal bacterial pathogen) precedes
Guillain-Barreé syndrome in a few cases (Ho& Griffin, 1999; Lindenbaum, Kissel& Mendel,
2001).
The antecedent event usually occurs 2 weeks before symptoms begin. Weakness
usually begins in the legs and progresses upward for about 1 month. Maximum weakness

5. varies but usually includes neuromuscular respiratory failure and bulbar weakness. The duration
of the symptoms is variable: complete functional recovery may take up to 2 years (Hickey,
2003). Any residual symptoms are permanent and reflect axonal damage from de-myelination.
The annual incidence of Guillain-Barré is 0.6 to 1.9 cases per 100,000. Eighty-five
percent of patients recover with minimal residual symptoms. Severe residual deficits occur in up
to 10% of patients. Residual deficits are most likely in patients with rapid disease progression,
those who require mechanical ventilation, or those 60 years of age or older. Death occurs in 3%
to 8% of cases, resulting from respiratory failure, autonomic dysfunction, sepsis, or pulmonary
emboli (Bella & Chad, 1998)
B. Objective of the study
At the end of 2 days of hospital exposure and continuous care at the Emergency room
ofPolymedic General Hospital, the completion of this case study enables the proponent to do
the following:
 Describe and explain what Guillain-Barré syndrome.
 Review the anatomy and physiology of the organs involved.
 Identify the risk factors contributing to the occurrence of the disease.
 Expound on the laboratory and diagnostic procedures done with the patient, their
purposes, and specific nursing responsibilities before, during and after the procedure.
 Enumerat the different medications administered for the disease, their
indications, contraindications, side effects, and specific nursing responsibilities.
 Formulate significant nursing diagnoses, with their significantly related nursing
care plans.
 Render series of nursing interventions for the client’s care
 Provide and disseminate important information as teachings to the client and the
significant others to boost the knowing and understanding of the nature of the said
health condition.
 Improve skills and knowledge as health care providers in the clinical area.
C. Scope and Limitation of the Study
This study includes the collection of information specifically to the patient’s health
condition. The study also includes the assessment of the physiological and psychological status,
adequacy of support systems and care given by the family as well as other health care
providers.
The scope of this study would include:

6. a. Data collected via assessment, interviews with the patient, family members and
clinical records.
b. Actual and ideal problems for 2 days including the initial assessment and its
appropriate nursing intervention that would be applied within her stay in the hospital at
PGH
c. Developing a plan of care that will reduce identified predicaments and
complications.
d. Coordinating and delegating interventions within the plan of care to assist the
client to reach maximum functional health.
e. Further evaluating the effectiveness of nursing interventions that have been
rendered to the client.
An array of factors influencing the limitations of this study includes:
a. Data collected is limited only to assessment and interview to the patient, patient’s
chart and nurse on duty.
b. The interaction, assessment and care were only limited to a total of 16 hours (2
days clinical duty, 1 day assessment) with actual nursing intervention done.
c. The lack of complete family history obtained was due to lack of laboratory
examinations or diagnostic examinations.
II. HEALTH HISTORY
A. Patient’s Profile
Client’s Name: Patient P. V.
Birthday: March 24, 1937
Age: 74 years old
Sex: Male
Civil Status: Married
Height: 156 cm
Weight: 49 kg
Nationality: Filipino
Religion: Roman Catholic
Address: Zone 8 Bulua, Cagayan de Oro City
Number of Children: 3
Allergy: No known food and drug allergies
Occupation: Retired
Informant: Patient
B. Family and Personal Health History
According to the patient, he acquired his high blood on the paternal side but on the
maternal side, no history of hypertension and diabetes.

7. During his secondary level, Patient P. V. started to smoke and can consume about 1
pack of cigarette a day and drink 5 bottles of beverages with his friends or occasionally. He was
influenced by his High School barkadas to drink and smoke. But he stopped smoking and
drinking in the year 2000. He has no known food and drug allergies. He received blood
transfusion but could not recall when but according to him there were no reaction at all.
C. History of Present Illness
This is a case of patient P. V. a 74 year old male, Married with 3 children, residing at
Zone 8 Bulua, Cagayan de Oro City with a chief complaint of body weakness.
15 days prior to admission, patient was admitted at Cagayan de Oro Polymedic Medical
Plaza due to affected wound sustained during Typhoon Sendong, Patient was admitted for 10
hospital days and was noted to have weakness at lower extremities later progressing to
the upper body until patient could not barely move.
2 days prior to admission, patient was discharged but without improvement.
D. Chief Complaint
- Body weakness
Date of Admission: January 30, 2012
Time of Admission: 1:41 P.M.
Admitting Diagnosis: To consider Gullain-Barre Syndrome
Attending Physician: Dr. Phillip Lazo
III. DEVELOPMENTAL DATA
A. Freud’s Psychoanalytic Theory
Freud offered dynamic and psychosocial explanations for human behavior. He
conceptualized what we call the psychosexual stages of development. Freud believed that there
are specific stages in which an individual has a specific need, and if needs are left unfulfilled or
over stimulated, according to Freud there are dramatic effects on an individual’s behavior.
Freud’s explanation of these developmental stages provided early psychosocial explanations for
an individual’s deviance or abnormal behavior. Freud outlined five stages of development: the
oral stage, the anal stage, the phallic stage, the latency stage, and the genital stage.
Stage Description Justification
Genital
Stage
(13 and Up)
During the final stage of
psychosexual development, the
individual develops a strong sexual
interest in the opposite sex. Where
in earlier stages the focus was
solely on individual’s needs, interest
in the welfare of others grows during
this stage. If the other stages have
been completed successfully, the
individual should now be well-
balanced, warm and caring. The
goal of this stage is to establish a
balance between the various life
areas.
Patient P. V. belongs in this stage. He
already had a family and he was able
to establish a good relationship with
them. He was able to develop a sense
of responsibility towards his family
and was able to establish balance
between the various areas of life.

8. B. Erikson’s Stages of Psychosocial Development
The Psychosocial Stages of Development developed by Erikson enumerates eight
stages though which healthily developing human should pass from infancy to late adulthood.
Erikson considers life as composed of sequence of levels of achievement and each stage
indicates a certain task to be achieved. An achievement would mean a healthier personality
while failure would also mean that the person will not be able to go to the next level and
probably will lead to regression.
C. Havighurst’s Developmental Task
According to Havighurst, learning is fundamental to life and in order to have a deeper
insight on growth and development, one must understand it and recognize the premise that
human being continues to learn throughout life. Happiness is being achieved when a particular
task of a certain age is achieved by the person successfully but if not, failure occurs which is a
feeling of unhappiness and disapproval from people surrounding the client.
Stage Description Justification
Later
Maturity
(60 years
old and
over)
Important tasks that needs to be
accomplished during this stage
includes the following:
1. Adjusting to decreasing
strength and health
2. Adjusting to retirement
and reduced income
3. Adjusting to death of
spouse
4. Establishing relations with
one's own age group
5. Meeting social and civic
obligations
6. Establishing satisfactory
living quarters
Patient was able to accomplish all
of these tasks. He was already
been able to adjust to his
decreasing strength and health.
He was able to adjust with his
retirement and the lesser salary
that he can get. He has his own
friends which also have the same
age with him.
Stage Description Justification
Ego
Integrity vs.
Despair
(Seniors,65
years
onwards)
This phase occurs during old age
and is focused on reflecting back on
life. Those who are unsuccessful
during this phase will feel that their
life has been wasted and will
experience many regrets. The
individual will be left with feelings of
bitterness and despair. Those who
feel proud of their accomplishments
will feel a sense of integrity.
Successfully completing this phase
means looking back with few regrets
and a general feeling of satisfaction.
These individuals will attain wisdom,
even when confronting death.
Patient P. V. belongs to this stage at
this point of his life. According to him
he doesn’t feel any regret of what his
life have been before and during the
present. He was able to accept things
that had happened over the years.

9. IV. MEDICAL MANAGEMENT
Date Doctor’s order Rationale
January 30, 2012
(1:35PM)
*Please admit patient under my service - Allows close monitoring of the patient and
immediate response during emergencies.
*Secure consent to care - To provide adequate care and to establish
legality.
* Soft diet with strict aspiration
precaution
- Soft diet contains foods that are soft and
easy for you to chew or swallow. Aspiration
precaution to prevent airway obstruction.
To meet the patient’s metabolic needs.
* Laboratory
CBC, Hgt
U/A
Na, K,SGPT,Crea
12 lead ECG
Chest X-ray PA
FBS,uric acid
Lipid profile
- To check for any abnormalities in the
blood and glucose level.
- To check if there’s a problem in the urine.
- To monitor if there’s a following
abnormalities in minerals and kidney.
- To know if there’s corresponding
arrhythmia or dsyrrhythmia in the heart.
- To view if there’s a cardiomegaly or lung
problem.
- To check for the blood sugar and uric acid
abnormalities.
- A test to check for risk of coronary heart
disease.
5:00PM * Medication:
Paracetamol 500mg 1tab every every
4 hours
Sitagliptin (Janvia) 50mg 1 tablet
Ceftriaxone initial dose 2gm ANST(-)
Glucerna OF 100cc every 3 hours
- Antipyretic drug help to treat fever.
- Drug reduces blood sugar levels in patients
with type 2 DM.
- Anti-infective use to kill bacteria.
- Products are specifically and scientifically
designed to meet the needs of people with
abnormal glucose metabolism.
*Monitor vital signs every 4 hours and
record
- Measures of various physiological
statistics and order to assess the most basic
body functions.
*Please inform AP
*Refer accordingly
- To refer any abnormalities noted in the
patient.
January 31, 2012 *OF 1200cal/day 1500cc every3 hours - To provide patients nutrition.
*PCM 500mg 1tab every4 hours - Antipyretic drug help to treat fever.
*Plain Normal Saline Solution 1 liter
40gtts/min
-Used togiveintravenous fluid tothepatientsfrom
salt and waterdeprivation.

10. Laboratory results
Nursing Implication:
Hyperuricemia can be caused by the over-production of uric acid in the
body or the inability of the kidneys to clear out enough uric acid. Possibly
there’s a problem in the bile pigment in the liver of the patient. A low HDL
cholesterol level is thought to accelerate the development of atherosclerosis
because of impaired reverse cholesterol transport and possibly because of
the absence of other protective effects of HDL, such as decreased oxidation
of other lipoproteins. And patient FBS is increase possibly patient has DM.
January 31, 2012
ABNORMALITIES:
Direct Bilirubin 0.87mgs/dl (0.05-0.30)
Uric acid 7.55mgs/dl (3.40-7.00)
Lipidprofile
HDL 29.25mgs/dl (30.00-85.00)
Total Bilirubin 1.43mgs/dl (0.20-1.00)
Fasting bloodsugar 116.76mgs/dl (70.00-90.00)
Hgt157mg/dl 157mg/dl (80-120)

11. Nursing Implication:
Turbidity or cloudiness may be caused by excessive cellular material or
protein in the urine. There’s a decreased filtration of protein in the nephrons.
The lower the pH, the greater the acidity of a solution and becomes
increasingly acidic as the amount of sodium and excess acid retained by the
body increases. WBC detected due to infection and presence of bacteria. And
RBC present if there’s damage in the kidney.
Drugstudy
PARACETAMOL 500mg 1 tablet
Classification– Antipyretic
Indication- for fever
Mechanism of Action - Inhibits the synthesis of prostaglandin that may serve as mediator for pain and
fever,primarilyinthe CNS
Contraindication- previoushypersensitivity,hepaticdisease
Side effects- hepaticfailure,renal failure,rashes
January 31, 2012
URINALYSIS RESULT
Color: Yellow
Appearance: Turbid
Glucose: negative
Protein: 2 positive
Reaction: 6.0pH
SpecificGravity: 1.010
WBC: 20
RBC: plenty
Bacteria: moderate

12. Nursing implication - Advise patient to consult health care professionals if discomfort noted or if fever
isnot relieved
CEFTRIAXONE (ROCEPHINE)
Classification– Anti-invectives
Indication- Skinto skinstructure infectionsandjointinfections
Mechanismof Action - bindtobacterial cell wall membrane causingcell death
Contraindication- hypersensitive,renalimpairment
Side effects- seizure,diarrhea,nausea,vomiting,jaundice,rashes,superinfection
Nursingimplication- instructpatienttotake drugs withmeals
SITAGLIPIN (JANVIA)
Classification– Antidiabeticdrug
Indication- treatmentforincreasedglucose levelinblood
Mechanism of Action - competitively inhibit the enzyme dipeptidyl peptidase 4 (DPP-4). This enzyme
breaks down the incretins GLP-1 and GIP, gastrointestinal hormones released in response to a meal.[11]
By preventing GLP-1 and GIP inactivation, they are able to increase the secretion of insulin and suppress
the release of glucagon by the pancreas. This drives blood glucose levels towards normal. As the blood
glucose level approaches normal, the amounts of insulin released and glucagon suppressed diminishes,
thus tending to prevent an "overshoot" and subsequent low blood sugar (hypoglycemia) which is seen
withsome otheroral hypoglycemicagents.
Contraindication - contraindicated in patients with a history of a serious hypersensitivity reaction to
sitagliptin,suchasanaphylaxisorangioedema.
Side effects - common side effects of sitagliptin are upper respiratory tract infection and headache.
Sitagliptin also is associated with abdominal pain, nausea and diarrhea. Sitagliptin did not increase the
occurrence of hypoglycemia.
Nursing implication - Sitagliptin may be taken with or without food. And check the blood glucose level
before administer.
V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY
Anatomy and Physiology of Autonomic Nervous System
The peripheral nervous system consists of the somatic nervous system (SNS) and the
autonomic nervous system (ANS). The SNS consists of motor neurons that stimulate skeletal
muscles. In contrast, the ANS consists of motor neurons that control smooth muscles, cardiac

13. muscles, and glands. In addition, the ANS monitors visceral organs and blood vessels with
sensory neurons, which provide input information for the CNS.
The ANS is further divided into the sympathetic nervous system and the parasympathetic
nervous system. Both of these systems can stimulate and inhibit effectors. However, the two
systems work in opposition—where one system stimulates an organ, the other inhibits. Working
in this fashion, each system prepares the body for a different kind of situation, as follows:
 The sympathetic nervous system prepares the body for situations requiring alertness or
strength, or situations that arouse fear, anger, excitement, or embarrassment (“fight-or-
flight” situations). In these kinds of situations, the sympathetic nervous system stimulates
cardiac muscles to increase the heart rate, causes dilation of the bronchioles of the lungs
(increasing oxygen intake), and causes dilation of blood vessels that supply the heart and
skeletal muscles (increasing blood supply). The adrenal medulla is stimulated to release
epinephrine (adrenalin) and norepinephrine (noradrenalin), which in turn increases the
metabolic rate of cells and stimulates the liver to release glucose into the blood. Sweat
glands are stimulated to produce sweat. In addition, the sympathetic nervous system
reduces the activity of various “tranquil” body functions, such as digestion and kidney
functioning.
 The parasympathetic nervous system is active during periods of digestion and rest. It
stimulates the production of digestive enzymes and stimulates the processes of digestion,
urination, and defecation. It reduces blood pressure and heart and respiratory rates and
conserves energy through relaxation and rest.
In the SNS, a single motor neuron connects the CNS to its target skeletal muscle. In the ANS,
the connection between the CNS and its effector consists of two neurons—the preganglionic
neuron and the postganglionic neuron. The synapse between these two neurons lies outside the
CNS, in an autonomic ganglion. The axon (preganglionic axon) of a preganglionic neuron enters
the ganglion and forms a synapse with the dendrites of the postganglionic neuron. The axon of
the postganglionic neuron emerges from the ganglion and travels to the target organ (see
Figure 1). There are three kinds of autonomic ganglia:
 The sympathetic trunk, or chain, contains sympathetic ganglia called paravertebral
ganglia. There are two trunks, one on either side of the vertebral column along its entire
length. Each trunk consists of ganglia connected by fibers, like a string of beads.
 The prevertebral (collateral) ganglia also consist of sympathetic ganglia. Preganglionic
sympathetic fibers that pass through the sympathetic trunk (without forming a synapse
with a postganglionic neuron) synapse here. Prevertebral ganglia lie near the large
abdominal arteries, which the preganglionic fibers target.
 Terminal (intramural) ganglia receive parasympathetic fibers. These ganglia occur near or
within the target organ of the respective postganglionic fiber.
Figure 1. The target organs of the different nervous systems.

14. A comparison of the sympathetic and parasympathetic pathways follows (see Figure 2):
 Sympathetic nervous system. Cell bodies of the preganglionic neurons occur in the lateral
horns of gray matter of the 12 thoracic and first 2 lumbar segments of the spinal cord. (For
this reason, the sympathetic system is also called the thoracolumbar division.)
Preganglionic fibers leave the spinal cord within spinal nerves through the ventral roots
(together with the PNS motor neurons). The preganglionic fibers then branch away from
the nerve through white rami (white rami communicantes) that connect with the
sympathetic trunk. White rami are white because they contain myelinated fibers. A
preganglionic fiber that enters the trunk may synapse in the first ganglion it enters, travel
up or down the trunk to synapse with another ganglion, or pass through the trunk and
synapse outside the trunk. Postganglionic fibers that originate in ganglia within the
sympathetic trunk leave the trunk through gray rami (gray rami communicantes) and
return to the spinal nerve, which is followed until it reaches its target organ. Gray rami are
gray because they contain unmyelinated fibers.
 Parasympathetic nervous system. Cell bodies of the preganglionic neurons occur in the
gray matter of sacral segments S2–S4 and in the brainstem (with motor neurons of their
associated cranial nerves III, VII, IX, and X). (For this reason, the parasympathetic system
is also called the craniosacral division, and the fibers arising from this division are called
the cranial outflow or the sacral outflow, depending on their origin.) Preganglionic fibers of
the cranial outflow accompany the PNS motor neurons of cranial nerves and have
terminal ganglia that lie near the target organ. Preganglionic fibers of the sacral outflow
accompany the PNS motor neurons of spinal nerves. These nerves emerge through the
ventral roots of the spinal cord and have terminal ganglia that lie near the target organ.
Figure 2. A comparison of the sympathetic and parasympathetic pathways.

16. PrecipitatingFactors:
•Age
•Sex
Predisposing Factors:
•Postinfection to
Campylobacter jejuni
•Poor Hygiene
•Stress
•Diet
•Lifestyle
Campylobacter jejuni
Enters the body by the use of multifenestrated
cells or other mechanisms
Innateimmune response results in the uptake of
thepathogens by immature antigen presenting
cells.
Migrationto the lymphnodes, a mature,
diffentiated antigen presenting cell can present in
major histocompatibility complex molecules and
activateCD4 T cells that recognize antigens from
theinfectious pathogens.
Pathogenand host have homologousor identical amino
acidssequences, antigens in its capsule shared with
nerves.
B cells can be activated as well by
newly activated Th2 cells. This
produces a cell mediated and humoral
response against the pathogens.
Antibodies will be produced, leading to
activationof the complement system
and phagocytosis of the bacteria.
Molecular mimicry
V. Pathophysiology of Guillain-Barré Syndrome
- is an autoimmune attack of the peripheral nerve myelin. 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
(numbness).

17. Immune responses directed against the
capsular components produce
antibodies that cross react with myelin.
Lymphocytes and macrophages circulate
in the blood and eventually find myelin.
Lymphocytic infiltration of spinal roots
and peripheral nerves, followed by
macrophages-mediated multifocal
stripping of myelin and axonal damage.
Defects on the propagation of electrical
nerve impulses, with eventual
conduction block.
Antibodies will be produced, leading to
activation of the complement system
and phagocytosis of the bacteria.
Molecular
mimicry
Guillain Barre Syndrome

18. Sensory
changes,
paresthesias or
numbness in
feet and hands.
Acute progressive
ascending
weakness
•Lower limbs
•Upper limbs
•hyporeflexia
Dull aching pains of
lower back , flank,
proximal legs.
Cranial nerve
involvement, facial
droop
•Dysarthria
•Dysphagia
•Difficulty with
protruding
•Plasma Exchange
•Intravenous immune
globulin (IVIG)
•Physical Therapy and
exercise
•medication
Guillain Barre Syndrome
If treated
GOOD
PROGNOSIS
•Extensive axonal
destruction
If not treated
BAD
PROGNOSIS
•Ascending weakness
progresses
•Weakening of the
diaphragm and
respiratory muscle.
•Respiratory distress
syndrome

19. VI. NURSING SYSTEM REVIEW CHART
Name: Patient P. V. Date: Jan. 31, 2012
Temp.: 36.5 C Heart Rate: 80bpm Respiration Rate: 20cpm Height: 156cm Weight: 49 kgs
An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location of the problem in
the figure using[X].
EENT:
[X] impaired vision [ ] blind
[ ] pain redden [ ] drainage
[ ] gums [ ] hard of hearing[ ] deaf
[ ] burning[ ] edema [ ] lesion teeth
[ ] assess eyes ears nose
[ ] throat for abnormality [ ] no problem
RESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest
[ ] apnea [ ] rales [ ] cough
[ ] bradypnea [ ] shallow [ ] bronchi
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic
[ ] assess resp.rate, rhythm, pulseblood
[ ] breath sounds,comfort [X] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia[ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia[ ] murmur
[ ] tingling[ ] absentpulses [ ] pain
Assess heartsounds,rate rhythm, pulse,blood
Pressure,circ.,fluid retention, comfort
[x] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
[ ] assess abdomen,bowel habits,swallowing
[ ] bowel sounds,comfort [X] no problem
GENITO – URINARY AND GYNE
[ ] pain [ ] urine [ ] color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
[ ] assess urinefrequency, control,color,odor, comfort
[ ] gyne bleeding [X] no problem
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure
[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors
[ ] confused [ ] vision [ ] grip
[ ] assess motor,function, sensation,LOC, strength
[ ] grip, gait,coordination,speech [X] no problem
MUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [X] poor turgor [ ] cool [X] wound [ ] flushed
[ ] atrophy [X]pain [ ]ecchymosis [ ]diaphoretic [ ]moist
[X] assessmobility,motion gait, alignment, jointfunction
[ ] skin color,texture, turgor, integrity [ ] no problem
*nearsightedness
*sunken eyes
*with Foley catheter
attached to urobag
*upper right bed
sores, 1-1 ½ in
diameter
*body weakness
*body pain 7/10
*poor hygiene;
body odor
*poor skin
turgor; dry skin
*weight loss
*limited
movement
*wound

20. SUBJECTIVE OBJECTIVE
Communication:
[ ] hearing loss Comments:
[X] visual changes “ hanap-hanap langgyud akong
[ ] denied panan-aw.” as verbalized by the patient.
[ ] glasses [ ] languages
[ ] contact lens [ ] hearingaide
R L
Pupil size:2-3mm [ ] speech difficulties
Reaction: pupil equally round and reactive to light and
accommodation
Oxygenation:
[ ] dyspnea Comments :
[X] smoking history “Ga sigarilyo ko pero sa una ra man to.”
Sincehigh school as verbalized by the patient
[ ] cough
[ ] denied
Resp. [X] regular [ ] irregular
Describe: regular breath sounds heard whileauscultated
R: symmetrical to the left lung.
L: symmetrical to the right lung.
Circulation:
[ ] chest pain Comments:
[ ] leg pain “wala man koy problema ana.”
[ ] numbness of As verbalized by the patient
extremities
[x]denied
Heart Rhythm [X] regular [ ] irregular
Ankle Edema: with bipedal edema
Pulse Car. Rad. DP. FEM*
R 72 68 72 not obtain
L 71 66 71 not obtain
Comments
Right and left pulses arestrongand palpable.
Nutrition:
Diet : Soft diet with strictaspiration precaution.
[ ] N [ ] V Comments:
Character “Nabantayan nko nga nagniwanga
[X] recent change in jud ko.” as verbalized by the Patient
weight, appetite
[ ] swallowing
difficulty
[ ] denied
[ ] dentures [X] none
Full Partial W/ Patient
Upper [ ] [ ] [ ]
Lower [ ] [ ] [ ]
Elimination:
Usual bowel pattern [ ] urinary frequency
once a day 5 times a day
[ ] constipation [ ] urgency
remedy [ ] dysuria
none [ ] hematuria
Date of Last BM [ ] incontinence
2/05/12- 7am [ ] polyuria
[ ] Diarrhea [ ] foley in place
character [x] denied
none
Comments: Bowel sounds:
Patient has an active Active
Bowel sounds.
Abdominal distention present
In defecating. yes [ ] no [X]
Urine* (color,consistency odor)
Urine color is yellowamber
transparentand slightly
aromatic.
MGT. of Health & Illness:
[X] alcohol [X] denied
Can consume 5 bottles with friends in work or drinks occasionally
[ ] SBE: N/A Last Pap Smear: N/A LMP: N/A
Briefly describe the patient’s ability to follow treatments (diet,
meds, etc.) for chronic health problems (if present).
The patient, as well as his significant others, participates and
cooperates with his treatment.

21. SUBJECTIVE OBJECTIVE
Skin Integrity:
[ ] dry Comments:
[ ] itching “ wala koy problema sa akongpamanit.”
[ ] other as verbalized by the patient
[x] denied
.
[X] dry [ ] cold [ ] pale
[ ] flushed [ ] warm
[ ] moist [ ] cyanotic
*rashes,ulcers,decubitus (describesize,location,drainage)
Bed sores noted on the upper right, about 1 to 1 ½ in
diameter
Activity/Safety:
[ ] convulsion Comments:
[ ] dizziness “Sakit kayo akonglawas tungod dili ko maka
[X] limited motion lihok-lihok.”As verbalized by the patient.
of joints
Limitation in ability to
[X] ambulate [X]bathe self
[X]other [ ] denied
[ ] LOC and orientation the patient is oriented to the place, date
and time.
Gait: [ ] walker [ ] cane [ ] other
[ ] steady [ ] unsteady
[ ] sensory and motor losses in faceor extremities:
No sensory and motor losses in faceor extremities.
[X] ROM limitations:thepatient has limited range of motion
Comfort/Sleep/Awake:
[X] pain Comment:
(whole body, 7/10) “Sakit gyud akong lawas.Pero maka tulog
[ ] nocturia man nuon ko pag gabie,” as verbalized by
[ ] sleep difficulties the patient.
[ ] denied
[X] facial grimaces
[ ] guarding
[ ]No other signs of pain
.
[ ] siderail releasefromsigned (60 + years)
N/A
Coping:
Occupation: Retired
Member of household: Wife and 3 Children
Most supportive person: Daughter
Observed non-verbal behavior: the patient was conscious and
coherent
Person(Phone number): kept confidential
SPECIAL PATIENT INFORMATION (Use lead pencil)
Not ordered Daily weight Not ordered PT/OT
110/60 BP q shift Not ordered Irradiation
Not ordered Neuro vs Not ordered Urine test
Not ordered CVP/SG. Reading Not ordered 24-hour Urine Collection
Date
Ordered
Diagnostic/Laboratory
exams
Date done Date
Ordered
IV Fluids/
Blood
Date done
1/30/12 CBC, Hgt,
U/A, Serum Electrolyte,
SGPT, Creatinine
Blood Electrolyte
Chet X-ray-PA
12 Lead ECG
FBS, Uric Acid
1/31/12
1/30/12 Plain Normal saline soution 1 liter
at 40 drops per minute
1/31/12

22. VII. NURSING MANAGEMENT
A. IDEAL NURSING MANAGEMENT
CUES NURSING DX OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective:
“wala koy
problema sa
akong pamanit”
As verbalized by
the patient
Objective:
>Dry skin
>Poor turgor
> Bed sores
noted
Impaired skin
integrity related to
complete bed rest
At the end of the
care patient
maintains intact
skin as evidence by
absence of skin
break down
>assess skin integrity, noting
color, moisture, texture, and
temperature
>maintain good skin care,
keeping skin clean and
lubricated with lotion as
needed
>turn q2h according to a an
established turning schedule
>keep bed clothes dry and
free of wrinkles, crumbs
>provide kinetic therapy or
alternating-pressure mattress
as indicated
>skin is prone to
breakdown especially
when the client is
complete bedrest
>to maintain good skin
integrity
>improves skin circulation
and reduces pressure
time on bony prominence
>reduces/prevents skin
irritation
>improves systemic and
peripheral circulation and
decreases pressure
Goal not met,
because patient
always denies his
problem with the
integrity of his skin.
And patient won’t
cooperate
regarding this
matter
>Bed sores still
noted

23. CUES NURSING DX OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective:
“Sakit kayo
akong lawas
tungod dili ko
maka lihok-
lihok.” As
verbalized by
the patient
Objectives:
>body
weakness
>limited
movement
>fatigue
>body odor
>poor hygiene
Self care deficit
related to
decreased
strength as
evidenced by
poor personal
hygiene
At the end of our
care client will be
able to perform
self care activities
within level of
own ability
>determine current activity
level/ physical condition.
>assist according to degree
of disability, allow as much
autonomy as possible
>anticipate hygienic needs
and calmly assist as
necessary with care o nails,
skin mouth care, shaving
>encourage scheduling
activities early in the day or
during the time when
energy level is best
>reposition frequently when
client is immobile
>to develop plan of
care for rehabilitation
>participation in own
care can ease
frustration over lose of
independences
> assisting client
reduces fatigue and
enhancing participation
>to decrease to risk of
fatigue
>reduces pressure on
susceptible areas,
prevents skin
breakdown.
Goal partially met,
with the help of
the significant
others patient
was able to
perform self care
activities

24. Cues Nursing
diagnosis
Objectives Interventions Rationale Evaluation
Subjective:
“Sakit kayo
akong lawas
tungod dili ko
maka lihok-
lihok.” As
verbalized by
the patient
Objectives:
>body
weakness
>limited
movement
>fatigue
Impaired physical
mobility related to
muscle weakness
as a result of
disease process
At the end of the
care patient
maintain optimal
physical mobility,
as evidenced by
good range of
motion
> assess motor strength
and reflexes
>Turn and position q2h as
needed
>maintain limbs slightly
extended and begin a
passive range of motion
>encourage diet high fiber
and adequate fluid intake.
>coordinate and work
physical therapist
>checking for level of
progression of
ascending paralysis
>to prevent bed sores
>to prevent
contractures, and
maintain function
>reduces risk of
constipation related to
decreased level of
activity.
>to assist in
maintaining muscle
tone
Goal was partially
met, Client was
able to maintain
optimal physical
mobility, good
range of motion
noted
 Good

25. B.ACTUAL NURSING MANAGEMENT
S
“Nabantayan nko nga nag niwanga jud ko.” as
verbalized by the Patient
O
>decrease appetite
>weight loss
>soft diet with AP
A
Imbalanced nutrition: less than body requirements
related to inadequate food intake as evidence of
weight loss
P
At the end of our care pt. will be able to verbalize
understanding of nutritional needs and demonstrate
stable weight toward individually expected range
I
>assessed clients ability to swallow
-impaired gag reflex affects to client to eat
>provided with small frequent feedings
-to improve nutritional food intake
>encouraged to increase oral fluid intake
-to improve hydration
>provided with the opportunity to choose food
preferences
-enhance participation and may promote nutritional
needs
>recommended with daily monitoring of weight
-provides information regarding the effectiveness of
dietary plan

26. E
Client was able to verbalize understanding of
nutritional needs.
S
“Sakit kayo akong lawas tungod dili ko maka lihok-
lihok.” As verbalized by the patient
O
>bodyweakness
>limited movement
>fatigue
A
Impaired physical mobility related to muscle
weakness as a result of disease process
P
At the end of our care patient maintain optimal
physical mobility, as evidenced by good range of
motion
I
> assessed motor strength and reflexes
-checking for level of progression of ascending
paralysis
>Turned and positioned q2h
-to prevent bed sores
>maintained limbs slightly extended and begin a
passive range of motion
- to prevent contractures, and maintain function
>encouraged diet high fiber and adequate fluid intake
-reduces risk of constipation related to decreased level
of activity.
E
Client was able to maintain optimal physical mobility

27. S
“Sakit kayo akong lawas tungod dili ko maka lihok-
lihok.” As verbalized by the patient
O
>pain scale of 7/10
> guarding sign
>limited movement
A
Acute pain related to alteration in muscle tone
P
At the end of 15 min the patient will be able to
verbalize relief of pain
I
>encouraged client to assume position for comfort
-to relieve muscle fatigue and discomfort
>encouraged to do the deep breathing exercise
-to reduce/ relieve pain
>provided with back rub
-reduces pain alteration of sensory neurons, muscle
relaxation.
>assisted with ROM exercises
-to reduce muscle joint stiffness
E
patient was able to verbalize pain.

28. VIII. REFERRALS AND FOLLOW-UP (DISCHARGE PLAN)
As referrals, parents should contact physician for immediate management of the
condition if any unusualities occurs. The patient was instructed to have follow-up check
up with her physician in the exact day at the exact time of schedule, usually one week
after discharge, even if he already feels better. Follow-up is needed to check the patient
as well as possible side effects of certain treatments and drugs. Continued care also is
needed to minimize problems related to immobility, neurogenic bowel and bladder, and
pain. Early involvement of allied health staff is recommended. Early recognition and
treatment of GBS also may be important in the long-term prognosis, especially in the
patient with poor clinical prognostic signs, such as older age, a rapidly progressing
course, and antecedent diarrhea. Patient was advised for compliance of medications
prescribed to him by the doctor.
IX. EVALUATION AND IMPLICATION
Our assessment for two successive days showed that my patient’s status
became stable and had improved the patient’s view towards promoting health. We had
established rapport and harmonious communication during the whole course of the
study, reviewed patient’s chart and had carried out doctor’s orders.
Moreover, I had understood the Anatomy, Physiology and Pathophysiology of the
disease condition of the patient which is Guillain-Barre Syndrome. We had identified
Patient’s Clinical Manifestations as basis for the Actual and Ideal Nursing Care Plans
and had intervened identified problems through patient-based nursing care.
As nursing student, the knowledge that we had gained during the 2 days
assessing and caring of the patient had enhanced our understanding about the patient’s
condition.
This exposure had helped us improved and developed our interpersonal
relationship to people whom we worked with.

29. X. BIBLIOGRAPHY
 Amy Karch(2009).Nursing Drug Guide.Philadelphia: Lippincott Williams &
Wilkins.
 Black, Joyce et. Al(2009). Medical-Surgical Nursing Clinical Management for
Positive Outcomes(8th edition). Volume 1. Singapore: Elsevier Pte Ltd.
 Kozier, Barbara et. Al(2004).Fundamentals of Nursing, Concepts, Process and
Practice (4th edition). Philippines: Pearson Education South Asia Pte Ltd.
 Kozier, Barbara et. Al(2008). Fundamentals of Nursing(8th edition).Volume 1.
Philadelphia: Pearson Education South Asia Pte Ltd.
 Smeltzer, Suzanne et. Al(2008).Textbook of Medical-Surgical Nursing(11th
edition). Volume 1. Philadelphia: Lippincott Williams & Wilkins.
Internet:
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 www.google.com
 www.wikipedia.com
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