A patient was admitted for treatment of Guillain-Barré syndrome (GBS). Prioritize these nursing diagnoses:

1. Ineffective airway clearance

2. Risk for emotional distress

3. Fluid volume deficit

4. Potential for injury

1, 3, 4, 2

Explanation

• Remember your ABCs- Airway, Breathing, Circulation. Priority is given to the airway of a patient with GBS. The condition involves muscles weakness which can lead to respiratory muscle paralysis, making the patient unable to cough effectively.

• The patient with GBS is at high risk if he/she is unable to cough effectively to clear the airway or has difficulty swallowing. This can cause aspiration of saliva and precipitate acute respiratory failure.

• Fluid volume ("Circulation") may become a problem later on as muscle paralysis may lead to low blood pressure, but this is not the top priority.

• The patient may be at risk for injury due to the inability to use the muscles to protect oneself, but this is once again not the top priority.

• Emotional distress would be lowest priority, after the physiological and safety needs have been addressed.

Visit our website for other NCLEX topics now!