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
• 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