Republic of the PhilippinesDIVINE WORD COLLEGE OF BANGUED

BANGUED, ABRA

NURSING DEPARTMENT

A Case Study on

BELL’S PALSY

In Partial Fulfillment of the Requirements in NCM 103(Related Learning Experience) Leading to the Degree of Bachelor of Science in Nursing

ABRA PROVINCIAL HOSPITAL

(APH)

Medical Ward

Presented To:

Ms. Noemi B. Mariano, RN, RM, MANMs. Ruby May Ramos, RN, RM, MAN

Presented by:

GROUP II

Alvarez, Dianne AprilBallena, Lorenz Christopher

Bonete, ManilynCamposagrado,Michael Jay

Gonzales, Krista MareeHernandez, Ronald Allan

Perez, Jimena MicielTaberdo, Mary Grendhelyne

Villamor, Ingrid Mae

August 20, 2010

TABLE OF CONTENTS

I. INTRODUCTIONA. Background of the Study ---------------------------------------------------------------------------------- 1B. Rationale of the Study ------------------------------------------------------------------------------------- 2C. Significance of the Study ---------------------------------------------------------------------------------- 2D. Scope and Delimitation ------------------------------------------------------------------------------------ 3E. Theoretical Framework ------------------------------------------------------------------------------------ 3

II. PATIENT’S PROFILE ----------------------------------------------------------------------------------------------- 4

III. MEDICAL HISTORYA. Present History of Illness -------------------------------------------------------------------------------- 5B. Past Medical History of Illness ------------------------------------------------------------------------- 5C. Family History of Illness --------------------------------------------------------------------------------- 5

* Genogram ------------------------------------------------------------------------------------------------- 6D. Socio-economic Profile ----------------------------------------------------------------------------------- 6E. Environmental History ----------------------------------------------------------------------------------- 6

IV. GENERAL SURVEY ------------------------------------------------------------------------------------------------ 6

V. PHYSICAL ASSESSMENTS ----------------------------------------------------------------------------------- 7-21

VI. FUNCTIONAL HEALTH PATTERNS ---------------------------------------------------------------------- 22-23

VII. CLINICAL PATHWAY -------------------------------------------------------------------------------------- 24-25

VIII. DIAGNOSTIC/ LABORATORY EXAMINATIONS ---------------------------------------------------- 26-27

IX. ANATOMY & PHYSIOLOGY ----------------------------------------------------------------------------------- 28

X. PATHOPHYSIOLOGY & SCHEMATIC DIAGRAM ----------------------------------------------------- 29-30

XI. DRUG STUDY ------------------------------------------------------------------------------------------------

XII. MEDICAL MANAGEMENT -----------------------------------------------------------------------------

XIII. LIST OF NURSING DIAGNOSES (NANDA) ----------------------------------------------------------

XIV. NURSING CARE PLAN/SOAPIE ------------------------------------------------------------------------

XV. BIBLIOGRAPHY ------------------------------------------------------------------------------------------

I. INTRODUCTION

A. Background of the Study

Bell's palsy or Idiopathic Facial Paralysis is a form of temporary facial paralysis resulting from damage or trauma to one of the facial nerves. It is the most common cause of facial paralysis. Generally, Bell's palsy affects only one of the paired facial nerves and one side of the face, however, in rare cases, it can affect both sides. When something is paralyzed, it can't move, so half of the person's face might look stiff or droopy. The paralysis does not last forever, but someone who has it will have trouble moving one side of his or her face muscles on one side of the face. Bell's palsy can develop over a matter of days. Because it can happen suddenly, someone might think the problem is a stroke — when a blood vessel in the brain gets clogged or bursts. Like Bell's palsy, a stroke can paralyze a person's face. But Bell's palsy is caused by nerve trouble and isn't as serious as a stroke. Bell's palsy can be scary, but it usually doesn't last long and goes away without treatment.

This condition was named after a Scottish doctor, Sir Charles Bell, who studied the two facial nerves that direct how the face moves. You have one facial nerve for each side of your face. These nerves send messages from the brain to the face. Through these messages, the facial nerves control the muscles of your face, forehead, and neck. Symptoms generally present over a 24-48 hour time period with 60% of patients experiencing a viral prodrome, characterized by stuffy nose, sore throat, and generalized achiness. Bell’s palsy often follows an upper respiratory infection, most often viral, and is believed to be due to postinfectious demyelination of the facial nerve. Fifty-percent of patients will also experience sensory loss of the face, neck or tongue, and 90% will experience hyperacusis which is painful sensitivity to sound. Drinking and eating may be affected secondary to paresis, and lacrimation may be decreased.

The annual incidence of Bell's palsy is about 20 per 100,000 population, and the incidence increases with age. Bell’s palsy affects about 30,000 people here in the Philippines every year and about 40,000 people in the United States. It affects approximately 1 person in 65 during a lifetime. Familial inheritance has been found in 4–14% of cases. Bell's Palsy is three times more likely to strike pregnant women than non-pregnant women. It is also considered to be four times more likely to occur in diabetics than the general population. Three in four patients improve without treatment. With or without treatment, most people begin to get better within 2 weeks and most recover completely within 3 to 6 months.

Recent studies have shown that steroids such as prednisone -- used to reduce inflammation and swelling -- are an effective treatment for Bell's palsy.

As of July 2010, according to the record section staff, this is just the second time that the Abra Provincial Hospital handled this kind of case, Bell’s palsy.

1B. Rationale

The group unanimously chose this case because they thought it is very interesting and extraordinary compared to the common cases they’ve encountered in the medical ward.

The main objective of the study is to determine the causes, precipitating and predisposing factors that constitute to the onset of the disease process. Moreover, the group wants to render series of nursing interventions for the progress of the client from his illness.

This study will greatly help the researchers and improve their skills and knowledge as health care providers.

C. Significance of the Study

For the patient

This study is significant to the patient because this will enable him to be knowledgeable about the condition he is going through and know the necessary nursing interventions that he can do independently, for him to recover from his illness.

For the Family Members

This study will spare the family members of the patient knowledge and understanding of the nature regarding the condition and illness that the patient has. Consequently, this will boost their concern and they will learn how to help the patient recover from his illness.

For the Group

This study will educate the group about the disease process. What certain factors contribute to its onset and the necessary measures on how to treat and prevent the disease in order for them to provide and disseminate information as teachings to the client as well as to his significant others.

For the Nursing Students

This study is of great importance for the nursing students because this will guide them on how to manage their patients if ever they get to encounter the same condition and case. This will make it easier for them to deal with their patients.

2D. Scope and Delimitation

This study focuses on the clinical and medical summary of the patient, the clinical interventions, diagnostic and laboratory exams performed to the patient from admission to discharge. It also includes nursing care plans, drug study and discharge planning. The biographical profile of the patient is also included, from general data, medical history, social, and environmental history of the patient. The data which are included in this study were gathered mainly through interview with the patient and his wife, we also acquired information basing from his chart.

However, the group was not able to assess the patient’s tongue, gums and teeth because he was unable to fully open his mouth during the physical assessment conducted by the group. The group was also unable to acquire the patient’s anthropometric measurements like height and weight because Mr. Qui Reight was weak and incapable of moving during the physical examination.

E. Theoretical Framework

DOROTHEA OREM

Developed the SELF CARE and SELF DEFICIT THEORY. Her theory is directed mainly on self care needs. It is defined as goal oriented activities that are set towards generating interest in the part of the client to maintain life and health development. The theory aimed towards making the clients perform self care activities in order to live independently. She defined self care as an activity that promotes a person’s well being.

She conceptualized three nursing systems as follows:1. WHOLLY COMPENSATORY: the nurse is expected to accomplish all the patient’s

therapeutic self care or to compensate for the patient’s inability to engage in self care or when the patient needs continues guidance and self care.

2. PARTIALLY COMPENSATORY: when both nurse and patient engage in meeting self care needs.

3. SUPPORTIVE EDUCATIVE: the system that requires assistance in the decision making behavior control and acquisition of knowledge and skills.

APPLICATION:Among the three classifications of nursing systems, the group classified the patient

under the wholly compensatory class. This is likely applicable to the client because he is required to perform necessary activities for self care but cannot do so without any assistance. This is due to the weakness of the lower extremities that he is experiencing. The patient is in need of assistance in performing self care measures like eating, drinking, ambulating and stretching.

The group did some necessary interventions like encouragement of verbalization of feelings and concerns, promotion of passive exercises like muscle flexion on the lower extremities to prevent atrophy, provided enough information about his condition to minimize knowledge deficit.

3II. PATIENT’S PROFILE

Name : MR. QUI REIGHT

Address : Taping, Lagangilang

Age : 45y/o

Sex : Male

Civil Status : Married

Religion : Roman Catholic

Birthdate : September 23, 1964

Place of Birth : Lagangilang, Abra

Date of Admission : July 28, 2010

Time Admitted : 2:08 PM

Hospital : Abra Provincial Hospital

Hospital Number : 908496

Room & Bed Number : Male Charity Ward # 01

Admitting Physician : Dr. Gilbert Contreras

Attending Physician : Dr. Gilbert Contreras

Admitting Diagnosis : Bell’s Palsy

Chief Complaint : Body weakness

Final Diagnosis : Bell’s Palsy

Date of Discharge : August 2, 2010

4III. MEDICAL HISTORY

A. Present History of Illness

It was July 07, 2010 when Mr. Qui Reight experienced influenza but he didn’t sought for any consultation because he thought this will subside after he take medicine. It did subside after 2 weeks.

On July 20, 2010, Mr. Qui Reight felt malaise on his lower extremities. He thought this is because of his tiredness from work so he just took a tablet of Alaxan and ignored it. To his curiosity, the malaise continued for 1 week, he barely felt anything. And when he woke up on July 28, 2010, he could not move the left side of his face, no matter how hard he tried. His eye would not close completely and he could not raise the corner of his mouth. This incident bothered him and his family that is why they went to Abra Provincial Hospital for consultation. He was admitted that very day with an admitting diagnosis of Bell’s Palsy and admitting vital signs of: BP>130/100mmHg, PR>72bpm, RR>22cpm and temp> 36.2.

B. Past Medical History

Mr. Qui Reight had experienced illnesses during his childhood years like mumps, measles and chicken pox. He said he had no allergies. He said that he could not recall if he has been fully immunized or not. When he was about 18years old, he encountered an incident wherein his legs were injured, because of this incident; he was not able to walk for 4 months. He undergone therapy to treat his condition and eventually recovered.

C. Family History of Illness

According to Mr. Qui Reight, most of the members of their family, both paternal and maternal sides had a medical history of Hypertension, Diabetes Mellitus, Liver Cirrhosis, and Cancer of the Stomach. His father died at the age of 85 due to old age. He reported that his mother is still alive and is suffering from Rheumatic Arthritis. Mr. Qui Reight also claimed that one of his cousins died due to stroke that is why they suspected that he had a stroke attack when he felt malaise over his lower extremities.

5D. Socio-economic History

Both Mr. Qui Reight and his wife work as farmers in a land which is owned by one of their neighbor. Their monthly estimated income is around 4,000-6,000php, this depends on the kind of harvest they had.

Two among their five children were able to finish college and both of them already have their own family and are no longer living with them.

Despite their financial problems, they still make sure that they are able to eat up to three full meals every day. Their family usually spends their free time by listening to a battery-operated radio since they don’t have energy supply in their place. Mr. Qui Reight drinks alcohol up to two times every week and smokes up to half pack per day.

E. Environmental History

Mr. Qui Reight lives in Taping, Lagangilang. Their house is made up of cement, with two rooms, their dining and living areas are rolled into one. Their house is located inside a compound-like are with four neighbors. They don’t have energy supply and their source of water is through an artesian well which is located at the front of their house. They are sharing their comfort room with his brother’s family that is why it is located around 8 meters outside their house.

IV. GENERAL SURVEY

The patient was conscious and coherent when the group conducted general survey regarding his holistic status. This includes physical appearance, body structure, mobility, gait and behavior.

The patient has an overall appearance is normal except that his face was distorted due to his illness. The group was not able to acquire the patient’s height and weight because he is unable to stand up and his lower extremities were very weak. His range of motion was very limited.

During the interview, Mr. Qui Reight had difficulty in expressing his true feelings and expressions due to the paralysis of his face. However, he gave full cooperation and assistance to the group, for them to acquire all the information that they need.

6VIII. DIAGNOSTICS AND LABORATORY EXAMINATIONS

Date Ordered: July 28, 2010Requesting Physician: Dr. Contreras

Lab test: HBSAg DeterminationDate Done: July 28, 2010

Specimen: PLASMAResult: REACTIVE

Date Ordered: July 28, 2010Requesting Physician: Dr. ContrerasPurpose/Rationale: BLOOD CHEMISTRY is ordered to rule out any presence of infection and in order to have a baseline data.Date Done: July 29, 2010

Parameters Normal Values Results Analysis/Interpretation

BUN 8-25mg/dL 16.9mg/dL NORMAL

CREATININE 0.5-1.7mg/dL 0.8mg/dL NORMAL

SGOT 5-34u/L 33.4u/L NORMAL

SGPT Up to 38u/L 32.3u/L NORMAL

Date Ordered: July 28, 2010Requesting Physician: Dr. ContrerasPurpose/Rationale: URINALYSIS is ordered to determine urine composition and possible abnormal components such as protein and glucose or infection.Date Done: July 29, 2010

Parameters Normal Values Results Analysis/Interpretation

COLOR Clear to dark yellow

Yellow NORMAL

TRANSPARENCY Clear Slightly turbid Indicates presence of infection

ALBUMIN Negative Trace

PH 4.6-8.0 6.5 NORMAL

SUGAR Negative Negative NORMAL

SPECIFIC GRAVITY

1.010-1.025 1.010 NORMAL

PUS CELLS Negative 3-6hpf Indicates presence of infection

RBC 3,800-5,800/mm 3,600/mm DECREASED

AMT. URATES/PO4

Negative Positive Presence of infection

BACTERIA Negative Positive Presence of infection

IX. ANATOMY AND PHYSIOLOGY

The nerve that is injured with Bell's Palsy is CN-VII (7th cranial nerve). It originates in an area of the brain stem known as the Pons. The 7th nerve passes through the stylomastoid foramen and enters the parotid gland. It divides into its main branches inside the parotid gland. These branches then further divide into 7000 smaller nerve fibers that reach into the face, neck, salivary glands and the outer ear. The nerve controls the muscles of the neck, the forehead and facial expressions, as well as perceived sound volume. It also stimulates secretions of the lower jaw, the tear glands and the salivary glands in the front of the mouth. Taste sensations at the front 2/3 of the tongue and sensations at the outer ear are transmitted by the 7th nerve.

Each facial nerve directs the muscles on one side of the face, including those that control eye blinking and closing, and facial expressions such as smiling and frowning. Additionally, the facial nerve carries nerve impulses to the lacrimal glands (tear glands), the salivary glands, and the muscles of a small bone in the middle of the ear called the stapes. The facial nerve also transmits tastesensations from the tongue. When Bell's palsy occurs, the function of the facial nerve is disrupted, causing an interruption in the messages the brain sends to the facial muscles. This interruption results in facial weakness or paralysis.

28X. PATHOPHYSIOLOGY AND SCHEMATIC DIAGRAM

Post infectious demyelination (loss of fatty covering of the nerve coveringscalled myelin sheath) of the facial nerve due to a prior upper respiratory infection

( INFLUENZA )

Inflammation within a small bony tube called the fallopian canal

Pressure is produced on the nerve resulting to its compression within its bony canal

Inability of the damaged nerve to exit the skull and divide into its several branches

Impairment of ALL functions controlled by the 7th cranial nerve

Interruption in the transmission of messages the brainsends to the facial muscles

Idiopathic Facial Paralysis orBELL’S PALSY

Facial weakness or Paralysis to one or both sides;drooping of the eyelid and corner of the mouth; drooling; dryness of the

eye or mouth; impairment of taste; excessive tearing in one eye; speech difficulties and inability to eat on the affected area due to the

relaxation of facial muscles29

Explanation:

Studies show that certain cases of Bell’s Palsy often occur after an upper respiratory tract infection. The onset of a bacterial or viral infection cause the facial nerve to swell and inflame in reaction to the infection, resulting then to the damage of the fatty covering of nerve cells called the myelin sheath, this is referred to as demyelination. Since Mr. Qui Reight had experienced influenza for 2weeks prior to the occurrence of his facial paralysis, it can be regarded as one of the precipitating factors which contributed to his present illness. Post infectious demyelination occurred due to

his influenza. The infection causes damage to the nerve cells, primarily the seventh cranial nerve, most commonly known as the facial nerve. In reaction to the infection, inflammation of the nerve within its small bony tube called the fallopian canal occurs. And since the canal is an extremely narrow area, an inflammation within it is likely to exert pressure on the nerve, compressing it. Likewise, if the nerve itself becomes inflamed within this small canal, it can encounter pressure, with the same result of compression. This will likely disable the nerve to exit the skull and divided into its several branches, resulting in impairment of all functions controlled by the 7th cranial nerve. Because of this, the function of the facial nerve is disrupted, causing an interruption in the transmission of messages the brain sends to the facial muscles. This interruption results in facial weakness or paralysis. Because the facial nerve has so many functions and is so complex, damage to the nerve or a disruption in its function can lead to many problems. Symptoms of Bell's palsy, which vary from person to person and range in severity from mild, it may include weakness, or paralysis on one or both sides of the face, drooping of the eyelid and corner of the mouth, drooling, dryness of the eye or mouth, impairment of taste, and excessive tearing in one eye, speech difficulties and inability to eat on the affected area due to the relaxation of facial muscles. Most often these symptoms, which usually begin suddenly and reach their peak within 48 hours, lead to significant facial distortion.

30XII. MEDICAL MANAGEMENT

The objectives of treatment are to maintain the muscle tone of the face and to prevent and minimize enervation. The patient should be reassured that no stroke has occurred and that spontaneous recovery occurs within three to five weeks in most patients. Steroid therapy ( Prednisone ) may be given to reduce inflammation or edema, which in turn reduces vascular compression and permits restoration of blood circulation to the nerve. Early administration of the drug appears to diminish the severity of the disease, relieve the pain, prevent or minimize denervation.

Facial pain is controlled with analgesics. Heat may be applied to the involved side of the face to promote comfort and the flow of blood through the muscle.

Nursing Management

Patients need reassurance that a stroke has not occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Teaching patients with Bell’s palsy to care for themselves at home is an important nursing priority.

XIII. LIST OF NURSING DIAGNOSES

Cues Nursing Diagnoses JustificationRisk for aspiration related to impaired swallowing secondary to paralysis.

Although it is a potential diagnosis, the group regards this as the highest priority because it has the possibility to result in airway obstruction which

may cause great danger to the patient.

S:“Haan nak unay makakaan ta marigatan nak nga aglukmon nakkong.” - as verbalized

O:- inability to chew food properly- long meals with little consumption- gagging before a swallow- repetitive swallowing- decrease in body weight- weak in appearance

Impaired swallowing related to relaxation of facial muscles as evidenced by inability to chew food properly, long meals with little consumption, gagging before an attempt to swallow, repetitive swallowing, decrease in body weight, weakness in appearance and by verbalization of, “Haan nak unay makakaan ta marigatan nak nga aglukmon nakkong.”

The group has chosen this as the second priority because it makes the patient really uncomfortable and he is incapable of eating properly that is why his health is affected by this problem.

S: “Marigatan nak nga magna nakkong, al’alalayan nak ni baket ko.”- as verbalized.

O:- weak in appearance- inability to move about- decreased activity- facial grimace- restless

Activity intolerance related to weakness of lower extremities as manifested by weakness in appearance, inability to move about, decreased activity, facial grimace, restlessness and by verbalization of, “Marigatan nak nga magna nakkong, al’alalayan nak ni baket ko.”

The group has chosen this as the third priority because the patient is in need of great help to improve activity tolerance in order for him to perform his ADL without the need of assistance of his SO’s.

Risk for injury related to altered mobility

The group regards this as the fourth priority because according to Maslow’s hierarchy of needs, safety and security comes next after physiologic needs.

S:“haan suna nga makapatang unay” -as verbalized by the SO.

O:- slurring speech- decreased ability to talk

Impaired verbal communication related to paralysis of the facial muscles as evidenced by slurring speech, decreased ability to talk properly, difficulty expressing thoughts verbally, weakness in appearance

The group regards this as the last priority because we have to make that the patient is in good condition in order for us to improve his ability to verbalize feelings and concerns.

properly - difficulty expressing thoughts verbally- weak in appearance- facial grimace

facial grimace and by verbalization of his SO, “haan suna nga makapatang unay.”

07-30-107-7PM

8:00am> Received lying on bed with an ongoing IVF of D5W iL + 1 amp Vit BC x 8 hours infusing well @ 30-31gtts/min at the latest level of 650 cc.

>conscious and coherent>NPI established>bedside care done>v/s checked and recordedS>

O>A>Risk for aspiration related to impaired swallowing secondary to paralysis.P>After 6 hrs of rendering nursing interventions, the patient will demonstrate techniques to prevent and/or correct aspiration.I>Assessed client’s ability to feed self, amount of daily intake of foods and fluids.>Assessed client’s ability to swallow, presence of gag reflex, cough and clear

airway.>Placed in sitting upright position for meals or drinking for 30 mins.afterwards

10:00 > S/E by Dr. Contreras with new orders made and carried out.Offered small bites and sips in unaffected side of mouth; place chin downward and stroke neck.>Provided soft foods that stick together or in a form of a bolus.>Administered oral medication in crash form as ordered.E>Goal met. After 6 hours of rendering nursing interventions, the patient demonstrated techniques to prevent and/or correct aspiration.>meds given at due time.>needs attended.>endorsed.

07-31-107-7PM

8:00am>Received sitting on bed with an ongoing IVF of D5W iL x 8 hours regulated at 30-31gtts/min infusing well

>NPI established.>morning care done.>v/s checked and recorded.S> O>body malaise

>inability to move lower extremetiesA> Risk for injury related to altered mobility.P> After 2 hours of rendering nursing interventions, the patient will verbalize understanding of individual factors that contribute to possibility of injury.I>Assess level of anxiety and alteration in thought processes.>Assess client’s muscle strength, gross and fine motor coordination.>Ascertain knowledge of safety needs/injury prevention and motivation.>Identify safety devices.E>Goal met. After 2 hours of rendering nursing interventions, the patient verbalized understanding of individual factors that contribute to possibility of injury.>meds given at due time.>needs attended.> ensured safety.>endorsed.

08-01-107-7PM

8:00am> Received lying on bed with an ongoing IVF of D5W iL + 1amp Vit BC at 150 cc level.

> NPI established>v/s checked and recordedS> “Marigatan nak nga magna nakkong, al’alalayan nak ni baket ko.” - as

verbalized.O> weak in appearance

> Inability to move about>decreased activity> Facial grimace>restlessA> Activity Intolerance r/t weakness of lower extremities as manifested by the cues above.P> after 6 hours of rendering nursing interventions, the patient will use identified techniques to enhance activity tolerance.Adjusted activities to prevent overexertion.> Planned care to carefully balanced rest periods and activities to reduce fatigue.> Assisted client with activities to prevent injury.> Encouraged client to maintain positive attitude to enhance sense of well being.

2:20 PM> IVF consumed and replaced with same solution at same rate.E> Goal met. After 6 hours of rendering nursing interventions, the client was able to use identified techniques to enhance activity tolerance.>due meds given.>kept rested.>ensured safety.>endorsed.

08-02-107-7PM

8:00am> Received lying on bed with ongoing IVF of D5LRS x 8hrs, infusing well at 30-31gtts/min.

> NPI established>on DAT>v/s checked and recorded>morning care done

S> “Haan nak unay makakaan ta marigatan nak nga aglukmon nakkong.” - as verbalized

O>inability to chew food properly>long meals with little consumption> gagging before a swallow>repetitive swallowing>decrease in body weight> weak in appearanceA> Impaired swallowing related to relaxation of facial muscles as evidenced by inability to chew food properly, long meals with little consumption, gagging before an attempt to swallow, repetitive swallowing, decrease in body weight and weakness in appearance.P> After 6 hours of rendering nursing interventions, patient will be able to swallow and pass foods and fluids from the mouth.I> Noted hyper extension of head/neck during/after meals or repetitive swallowing suggesting inability to complete swallowing process.>Encouraged rest periods before meals to chew foods on unaffected side as appropriate to prevent fatigue.>Encouraged facial exercise to improve muscle strength.>Observed oral cavity after each bite and have client check around cheeks with tongue for swallowing food is unable to swallow.

9:00am>S/E by Dr. Contreras with new orders made and carried out.> encouraged verbalization of feelings and concerns.>ensured safety>endorsed.

07-29-107-7PM

8:00am> Received lying on bed with ongoing IVF of D5W iL + 1amp Vit BC x 8 hours infusing well @ 30-31gtts/min at the latest level of 550cc.

>NPI established>on DAT>v/s monitored>bedside care done

S> “haan suna nga makapatang unay” -as verbalized by the SO.O>slurring speech> decreased ability to talk properly >difficulty expressing thoughts verbally> weak in appearance>facial grimaceA> Impaired verbal communication related to paralysis of the facial muscles as evidenced by slurring speech, decreased ability to talk properly, difficulty expressing thoughts verbally, weakness in appearance and facial grimace.P> After 3 hours of rendering nursing interventions, patient will be able to establish methods of communication on which needs can be express like sign language.I>facilitated hearing and vision of sound or obtaining necessary aides desired for improving communication.>determined meaning of words used by the client and congruency of communication to attend needs of the client.>validated meanings of non-verbal communication to prevent errors.>maintained eye contact at client’s level to ensure congruency of communication.>discussed individual methods of dealing with impairment to enhance self esteem.E>Goal met. After 3 hours of rendering nursing interventions, patient was able to establish methods of communication on which needs can be express like sign language.>needs attended.> ensured safety.>endorsed.

XV. DISCHARGE PLANNING

Medication

- Advise client to continue taking the medications prescribed by the physician.- Discuss the importance of taking in steroid therapy like PREDNISONE to help reduce vascular compression and permits restoration of blood circulation to the nerve.

Exercise

- Encourage the client execute passive exercises like mild stretching to promote muscle flexion and to prevent muscle atrophy. - Encourage adequate rest periods before and after every exercise to prevent fatigue.- Explain to the client that exercises should be done not exceeding beyond his capacity to prevent overexertion.

Treatment

- Continue in taking in medications to maintain the muscle tone of the face and to prevent or minimize denervation.

Health Teachings

1. While paralysis lasts, the involved eye must be protected.2. The eye should be covered with a protective shield to prevent further infection.3. Teach the patient to close the paralyzed eyelid manually before going to sleep.4. Encourage the patient to wear sunglasses or goggles to decrease normal evaporationfrom the eye.

*If the nerve is not too sensitive….1. Massage the face several times daily to maintain muscle tone.2. Promote facial exercises such as wrinkling the forehead, blowing out the cheeks and

whistling to prevent muscle atrophy.

Out Patient

- Stress the importance of complying with scheduled follow-up check-ups.

Diet

- Encourage ingestion of soft foods and liquids so as not to damage the paralyzed area further.

Spiritual

- Remind the patient to have faith in God for his faster recovery.

XIV. BIBLIOGRAPHY

***Adams R and Victor M. Principles of Neurology, 4th ed. New York, McGraw-Hill, 198***Adler CS. Psychiatric aspects of headache. Baltimore, Williams & Wilkins, 1987***NANDA***TFN**PPD 2000***Wikipedia.com***Google.com***Ask.com