CHAPTER 5 Nervous System^231
- Labile blood pressure and cardiac dysrhythmias due to autonomic nervous
system response
INTERPRETING TEST RESULTS
- Lumbar puncture will show cerebrospinal fluid (CSF) with increased pro-
tein; may not be present initially. - Nerve conduction studies show slowed velocity.
- Pulmonary function tests show diminished tidal volume and vital capacity.
TREATMENT
- Monitor respirations and support ventilation if necessary.
- Plasmapheresis for plasma exchange to remove the antibodies in the circu-
lation. - Administer immunoglobulin intravenously after drawing labs for serum IgA.
- NG tube feeding if swallowing is a problem.
NURSING DIAGNOSES
- Ineffective breathing pattern
- Impaired gas exchange
- Impaired physical mobility
- Powerlessness
NURSING INTERVENTION
- Monitor for progression of change of sensation.
- Monitor respiratory status for change in effort or rate, use of accessory
muscles, cyanosis, change in breath sounds, breathlessness when talking,
irritability, and decreased cognitive awareness. - Call physician if there are respiratory changes or decrease in pulse oximeter
reading.