What is the priority nursing intervention for the child with ascending paralysis as a result of Guillain-Barré syndrome (GBS)?
a. Immunosuppressive medications
b. Respiratory assessment
c. Passive range-of-motion exercises
d. Anticoagulant therapy
B
Special attention to respiratory status is needed because most deaths from GBS are attributed to respiratory failure. Respiratory support is necessary if the respiratory system becomes compromised and muscles weaken and become flaccid. Children with rapidly progressing paralysis are treated with intravenous immunoglobulins for several days. Administering this infusion is not the nursing priority. The child with GBS is at risk for complications of immobility. Performing passive range-of-motion exercises is an appropriate nursing intervention, but not the priority intervention. Anticoagulant therapy may be initiated because the risk of pulmonary embolus as a result of deep vein thrombosis is always a threat. This would not be the priority nursing intervention.
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