While caring for a client with Guillain-Barre syndrome, which finding should the practical nurse (PN) report to the charge nurse?
A.
Irregular heart rate.
B.
Profuse diaphoresis.
C.
Lower leg weakness.
D.
Full facial flushing.
The Correct Answer and Explanation is:
The correct answer is A. Irregular heart rate.
Explanation
Guillain-Barre Syndrome (GBS) is an acute, inflammatory demyelinating polyneuropathy that primarily affects the peripheral nervous system. It often begins with symptoms like muscle weakness and tingling sensations and can rapidly progress to more severe issues, including paralysis. One of the critical concerns with GBS is its potential impact on autonomic functions, including cardiac rhythm and blood pressure regulation.
Irregular Heart Rate (Option A) is a significant finding that should be promptly reported to the charge nurse. GBS can affect autonomic nervous system function, leading to arrhythmias, fluctuations in heart rate, and blood pressure instability. These cardiac manifestations are potentially life-threatening and require immediate attention to manage potential complications such as bradycardia, tachycardia, or other severe arrhythmias. Monitoring and managing these issues are crucial to prevent complications such as cardiac arrest.
Profuse Diaphoresis (Option B) is also a notable symptom and could be related to autonomic dysfunction. However, it is less urgent compared to cardiac irregularities, as profuse sweating does not immediately threaten the client’s life but should still be monitored and addressed as part of the overall care plan.
Lower Leg Weakness (Option C) is a common symptom in GBS, reflecting the progression of the syndrome. While important to monitor, it is not as urgent as irregular heart rate. Lower leg weakness is a hallmark of GBS, but the immediate threat is related to the autonomic complications, which can include cardiac issues.
Full Facial Flushing (Option D) is less specific and not typically associated with GBS in a way that would prompt immediate reporting compared to cardiac symptoms. It might be related to other factors or less severe autonomic disruptions.
In summary, due to the critical nature of potential cardiac complications associated with autonomic dysfunction in Guillain-Barre Syndrome, an irregular heart rate is the most pressing finding that warrants immediate attention from the charge nurse.