delirium and guillian barre Flashcards
What is delirium?
An acute state of confusion.
What are the common causes of delirium?
D.E.L.I.R.I.U.M. mnemonic: Dementia/dehydration, Electrolyte imbalances/emotional stress, Lung, liver, heart, kidney, brain conditions, Infection/ICU, Rx drugs, Injury/immobility, Untreated pain/unfamiliar environment, Metabolic disorders.
What are the signs and symptoms of delirium?
Impaired memory, judgment, and orientation; agitation; hallucinations; confusion; emotional lability; restlessness; hyperactive or hypoactive presentation.
What are the nursing interventions for delirium?
Address the cause, frequent monitoring, limit distractions, prevent falls using noninvasive precautions (e.g., bed alarm), anticipate patient needs, reorient and redirect, promote sleep, educate family.
What diagnostic tests are used for delirium?
Neurological assessments and the Confusion Assessment Method (CAM): Requires features 1 and 2, plus either 3 or 4: 1) Acute change in baseline mental status, 2) Difficulty focusing attention, 3) Disorganized thinking (rambling or irrelevant conversation), 4) Altered level of consciousness.
When are medications prescribed for delirium?
Only given to patients with severe agitation when necessary for safety.
What is Guillain-Barré Syndrome (GBS)?
An immune response following an infection that leads to injury of the myelin sheath (AIDP) or the nerve axon itself (AMAN), causing motor dysfunction.
What happens in Acute Inflammatory Demyelinating Polyneuropathy (AIDP)?
Nerve conduction is delayed or blocked due to demyelination.
What happens in Acute Motor Axonal Neuropathy (AMAN)?
Damage to nerve axons leads to severe motor dysfunction.
How does GBS affect nerve transmission?
The immune attack causes edema and segmental demyelination, exposing nerve membranes at the nodes of Ranvier, impairing impulse transmission, leading to flaccid paralysis, muscle denervation, and atrophy.
How does neurologic function recover in GBS?
Remyelination occurs slowly, with function returning in a proximal-to-distal pattern.
What causes GBS?
The exact cause is unknown, but both humoral and cellular immune responses are involved. Most cases follow a bacterial or viral infection of the upper respiratory or GI tract.
What are the hallmark signs and symptoms of GBS?
Acute, ascending, rapidly progressive, symmetric limb weakness; paresthesia (numbness and tingling); hypotonia (reduced muscle tone); weak or absent reflexes; pain.
What are the autonomic dysfunctions associated with GBS?
Orthostatic hypotension, hypertension, abnormal vagal responses (bradycardia, heart block, asystole), bowel/bladder dysfunction, facial flushing, diaphoresis.
How does GBS affect cranial nerves?
Facial weakness, paresthesia, extraocular movement problems, dysphagia (difficulty swallowing).
What assessments are necessary during the acute phase of GBS?
Evaluate motor and sensory function, report changes in motor function, reflexes, cranial nerve function, and LOC.
What respiratory and cardiac functions should be monitored in GBS?
Monitor ABGs, vital capacity, BP, heart rate, and rhythm for dysrhythmias or autonomic instability.
How is blood pressure managed in GBS?
Administer vasopressors and volume expanders for low BP.
What should be done if fever develops in GBS?
Obtain blood and sputum cultures, then start appropriate antibiotic therapy.
How should gag reflex and swallowing be assessed in GBS?
Test for gag reflex, note drooling and secretion problems, as these increase aspiration risk.
What emotional and educational support should be provided to a GBS patient?
Understanding the disease, side effects, treatment, recovery process, importance of physical, occupational, and speech therapy, reporting exacerbations, maintaining good hygiene to prevent infections.
Why is aspiration risk education important for GBS patients?
Due to cranial nerve involvement, patients may have dysphagia and impaired gag reflex, increasing their risk for aspiration.
Why is fatigue management important in GBS?
Fatigue is common, so patients should rest as needed during recovery.
