The nurse is planning care for a patient who sustained third degree burns over 42% of the body during an industrial accident the previous day. The patient is intubated, sedated, and chemically paralyzed. Which patient problem is most important for the nurse to address?

The 23-year-old patient is brought to the emergency department after contacting emergency services to report profound weakness that started in his feet and worsened and spread cranially over the past few days. He reports severe diarrhea after a camping trip a week ago. Upon assessment, strength, sensation, and deep tendon reflexes are significantly reduced, with the lower extremities more severely affected than his upper extremities. Vital signs are normal and the patient seems to be breathing well. There is increased protein in the cerebrospinal fluid found after a lumbar puncture. The patient is admitted to the intensive care unit for further management and observation. The ICU nurse includes which interventions in the plan of care? Select all that apply.  

The patient presents to the emergency department complaining of severe gastrointestinal distress after meals that has persisted for 36 hours. He reports that these symptoms have occurred off and on for a few years now, but he is seeking care now because they are interrupting his ability to sleep. Which additional assessment indicates the poorest prognosis for this patient?