Bells palsy Nursing Care Plan
How to Complete Bells palsy Nursing Care Plan
Bells palsy template
Adult and Elder II
Nursing Care Plan (NCP)
Comprehensive Nursing Care Plans Instructions
- All NCPs must be submitted to the TurnItIn DRAFT and FINAL tabs found in the Assignments tab
- Late submission will result in a grade of “0”
- TurnItIn rating must either be a “yellow”, “green” or a “blue”
- Any ratings in “red” will not be graded
- The care plan is to be written in a narrative “paper” format
- Type double-spaced using 12-font (use only one style for the entire document)
- Your work should be between 8 to 10 pages long, excluding title page and references
- Less than 8 pages will not be accepted
- Follow APA 7th edition writing style
- Use course textbook or articles from peer-reviewed journals published in the last five years in your citations
- Your work must have the essential key elements listed below
Essential Elements of Comprehensive Nursing Care Plan (NCP)
- Title Page – Your name, course name, semester, and name of instructor
The following headings must be included and clearly written as such. If you do not indicate these headings, your work will be returned and marked unsatisfactory:
- Introduction – Narrate general survey/overview of the patient including reason for Include all relevant medical-surgical and psychosocial histories. Integrate relevant events during hospitalizations (e.g., surgeries, procedures, incidents such as a fall etc.). Which day of admission/post-operative day did you care for this patient?
- Assessment – Discuss key head-to-toe assessment data in an organized, coherent and systematic manner. Synthesize key information into the general picture of the patient’s reason for admission and relevant medical-surgical and psychosocial
- Pathophysiology – Discuss the pathophysiology and etiology of your patient’s key diagnosis and co-morbidities. Note: Use your own words & cite sources. Synthesize relationship between admission illness and significant past medical history (PMH) Explain pathophysiology of main signs and symptoms your patient is Relate relevant labs/diagnostic tests done during this hospitalization in the discussion
- Diagnostic Procedures & Laboratory Results – List laboratory results, diagnostic test results (e.g., X-ray, ultrasound) using the table Type this section single-spaced
| Diagnostic Procedure/Laboratory Test Results | Rationale
Indicate specific reason(s) for doing or obtaining this test for your patient |
Analysis of Results Indicate if normal or abnormal (e.g., high or low values) and correlate results with patient’s health problems by providing explanation of abnormalities noted
|
- Medications – List current medications/intravenous solutions the patient is Type medications as written in the prescriber’s order. Indicate the specific reason why your patient is prescribed the medication. Type this section single-spaced using this example:
| Medication (as ordered by M.D./NP)
– Classification – How does the medication work (chemical action)? |
Specific Reason For Taking Them? (Example: To treat Hypertension and HF) | Side Effects, Contraindications and lab values to be monitored
(Only important ones) |
Patient and Family Teaching
(Only specific and relevant instruction for that drug) Never write: Take as directed? |
| Aspirin 81 mg P.O. Daily Classification: Antiplatelet Chemical Action:
Blocks Thromboxane A2 to prevent platelet aggregation. |
Prophylaxis to prevent MI/Angina
Note: If you write the meds is for pain, mention the location of pain. If you write the meds is for infection, write to site of infection.
|
Note: each item must be labeled as below
Adverse Reactions: Bleeding, Tinnitus
Contraindications: Allergy, PUD
Lab Values: no special monitoring but should monitor CBC, PT/INR and PTT for patients on anticoagulants |
Teach patient about compliance with meds, use soft bristle toothbrush and use electric shaver as appropriate.
Note: Do not write: advice patient not drink alcohol if the patient does not drink alcohol. Or do not write: tell patient to use an electric razor if the patient does not shave
|
- Intravenous Fluid – write here the exact order of the IV fluid as written in the electronic order. If the patient has no IV fluid order, write “N/A”
- Nursing Care Plan – Use table Do not copy a Care Plan from a book. Your Care Plan should be individualized and must include psychosocial as well as physical priorities. Typed this section single-spaced using the table below.
- Write three (3) priority actual or potential (e.g., Risk for…) nursing diagnoses, including one psychosocial
- Write at least three (3) nursing interventions for each Interventions should address quality, safe, culturally competent, and interprofessional care.
- Write a rationale for each intervention and cite sources
- Evaluation – discuss if outcomes were met or not met and Or, alternatively, you can discuss if interventions were implemented or not and why. Elaborate in this section, using both objective and subjective data, to make your points and final impression. How might you intervene in the future if your initial attempt did not work?
| Nursing Diagnoses (List 3 priority
Nursing Diagnoses in order of priority. Must include one psychosocial nursing diagnosis) |
Expected Outcomes (Must complete short- & long-term goals for EACH priority nursing diagnosis listed. Goals should be SMART: specific, measurable, attainable, realistic, & time-framed) | Nursing Interventions & Rationales
(Evidenced based rationale for each intervention for each priority nursing diagnosis. Describe in your own words with references cited here & in reference list in APA format) |
Evaluation (How did/will you evaluate the effectiveness of
planned interventions listed in previous column? HINT: Assess attainment of SMART goals) |
| Type single-space |
- References – List all sources cited in the text using APA 7th edition formatting.
SOLUTION: Bells palsy Nursing Care Plan
Bells’ Palsy Comprehensive Nursing Care Plan
Student’s Name
Institutional Affiliation
Date
Introduction
This care plan is for a 58-year-old Female who has been admitted to the healthcare facility with a diagnosis of Bell’s palsy. At the time of her admission, the patient notes that she woke up from bed and discovered that she had facial paralysis. Accordingly, the patient has suffered left-side face paralysis. The patient has a history of several past illnesses that include hypertension, Shingles, pneumonia, hyperlipidaemia, and grade 2 aneurysm, which was clipped 6-years ago.
Physical Assessment
Upon a physical assessment, the patient’s relevant clinical signs include;
Blood pressure of 164/83 (Systolic normal: 120, diastolic normal 80)
Heart rate of 78 (Normal range 60-100)
Respiratory rate of 18 (Normal range 12 to 16)
Temperature 101.6F (Normal range 97-99 F)
SPO2 of 97% RA (Normal 95% or greater like adults)
The patient H/H was 11.1%, which is considered low (Normal 12-16% for females)
From these vital signs, it is imperative to note that the patient has high blood pressure and elevated temperatures.
Allergies: No known allergies or reactions to medications.
Mental history: No known history
Surgical history: No known history
Immunization history: Up to date
General: The patient is alert and oriented to person, place, and time.
Head-to-toe Assessment
Auscultation of the patient’s cardiovascular system shows that she has no chest pains or peripheral edema. Her heart rhythm and sinus are normal. Her S1 and S2 are normal. No palpitations are heard. The patient’s lower extremity peripheral pulses are full and normal. Breath sounds are clear. However, auscultation of her lungs revealed crackles and bibasal rales at the base of the lungs. The patient has right lower lobe (RLL) pneumonia. The patient did not experience any cough. No shortness of breath was noted.
An assessment of her gastrointestinal (GI) and genitourinary system (GU) shows that it is normal except for acute kidney injury (AKI). She does not suffer from any urinary tract infections (UTIs) or HIV 1 and 2. Furthermore, an assessment of the patient’s mucosa skeletal system indicates independent muscle movement. Her skin is warm, dry, and intact.
Pathophysiology
Bell’s palsy is the most common diagnosis linked to facial nerve paralysis. It is a disease of the seventh cranial nerve (facial nerve) that produces facial weakness or paralysis. The definite cause of the disease is unknown, although viral infections by the varicella-zoster virus, herpes simplex virus, human herpes virus, and usutu virus have been implicated. These viruses enter the human body via mucosa and establish their latent presence in multiple ganglia of the neuroaxis (Zhang et al., 2020). Once in the ganglia, these viruses reactivate in the presence of circulating antibodies causing Bell’s palsy. Some of the complications of the condition include blindness, impaired nutrition, and corneal ulcers.
Laboratory/radiological studies and results
| Diagnostic Procedure/Laboratory Test Results | Rationale
Indicate specific reason(s) for doing or obtaining this test for your patient |
Analysis of Results Indicate if normal or abnormal (e.g., high or low values) and correlate results with patient’s health problems by providing explanation of abnormalities noted
|
| Complete blood count (CBC) | · To predict calcification of abdominal aortic aneurysm.
· To determine the amount of red and white blood cells in the blood, and the presence of infection. |
· The results of the complete blood count tests indicated that her H/H was low at 11.1% (Normal 12-16% for females).
· The patient’s haematocrit level was normal at 39.3% (Normal 37-48% for females). · Her white blood cell was very high at 24.1x10E3/uL (Normal range 4300-10800). A high WBC count indicates that the patient has an infection. · Her blood platelet count (PLT) was normal at 386 (Normal range 150000-450000/uL).
|
| Comprehensive metabolic panel (CMP) | · To check the patient’s body chemical balance and metabolism.
· To check how well the kidneys and liver are functioning.
|
· Results of this test indicated her sodium levels at 142 (Normal 135-145), chloride at 101 (normal 95-105), blood urea nitrogen (BUN) at 25 (Normal range 8-25), and glucose at 2.4 mmol/L(Normal range 3.9-5.6 mmol/l).
· The patient had elevated levels of potassium at 5.7 (Normal range 3.5-5) and creatine at 2.4 (Normal range 0.6-1.5). The excessive creatine was being excreted by the kidneys.
|
| Blood culture | To rule out meningitis or any infection in the brain | No meningitis or brain infection detected |
| Prothrombin time (PT) test | To evaluate the patient’s blood clotting process | The results of this test indicated that the patient’s PT was at 9.4 seconds (Normal range 11-13.5 seconds). |
| Partial thromboplastin (PTT) test | To measure the time taken for blood to clot. | Results showed her PTT as being 21(Normal range 25-35). |
| Electrocardiogram (EKG) | To record electrical signals in the heart. This procedure is critical in detecting heart problems and in monitoring aortic aneurysms before they burst | Heart is normal and works within its optimal range |
| CAT scan | To detect the he presence of an aneurysm, check whether a aneurysm has burst, and detect whether blood has leaked into the brain | Grade 2 aneurysm detected |
Medications
| Medication (as ordered by M.D./NP)
– Classification – How does the medication work (chemical action)? |
Specific Reason For Taking Them? (Example: To treat Hypertension and HF) | Side Effects, Contraindications and lab values to be monitored
(Only important ones) |
Patient and Family Teaching
(Only specific and relevant instruction for that drug) Never write: Take as directed? |
| Medication: Prednisone PO Classification: Corticosteroids
Mode of action: Works by decreasing inflammation via suppression of the movement of polymorphonuclear leukocytes and reversing increased capillary permeability. |
Used to reduce inflammation due to Bell’s palsy. | · Some of the side effect of this medication includes blurred vision, fainant, fast and irregular heartbeat, increased urination, and unusual weaknesses.
· The medication is contraindicated in patients with systemic fungal infections. |
The patient should be informed that this medication may cause a rise in blood sugar and hence the need to report any serious symptoms to a healthcare professional. |
| Medication: Atorvastatin
Classification: HMG-CoA reductase inhibitors Mode of action: works by blocking enzymes that allow the body to make cholesterol, thus reducing the amount of cholesterol in the body |
To treat hyperlipidemia
|
· Common side effects of atorvastatin include nausea, headache, nose bleeding, sore throat, and diarrhoea.
· The medication is contraindicated in patients taking alcohol. Furthermore the drug should not be used in pregnant mothers or individuals who are hypersensitive to any of its components. |
The patient should be advised never to take alcohol while taking atorvastatin. Furthermore, they should be educated on how to recognize serious side effects and report these effects to a healthcare professional. |
| Medication: Zosyn and Vancomycin IV
Classification: Zosyn belongs to a class of medications known as penicillin. It works by killing bacteria that cause infections in the body. Vancomycin IV belongs to a class of medications known as glycopeptide antibiotics. It works by inhibiting cell wall synthesis by binding to the D-Ala-D-Ala terminals thus inhibiting transpeptidase formation.
|
To treat pneumonia infection | · Common side effects of Zosyn include swelling, redness, and pain on the injection site, dizziness, insomnia, nausea, stomach pain, and diarrhoea.
· Patients who are allergic to piperacillin or tazobactam should not be prescribed Zosyn. · Vancomycin side effects include tarry stool, bleeding gums, blood in stool, dizziness, and feeling of fullness in the ears. · Vancomycin should not be used in patients who develop a ringing in the ears or hearing loss. It should also not be used in patients with renal impairment or in individuals who have developed bacterial resistance.
|
These medications do not cause serious side effects. However, patients are advised to immediately report any serious side effects to a healthcare professional. |
| Medication: Metoprolol
Classification: Beta-blockers Mode of action: work by relaxing blood vessels and slowing the heart rate to reduce blood pressure (Morris & Dunham, 2022). |
To treat hypertension | · Some of the most common side effects of Metoprolol include chest pain, dilated neck veins, fatigue, increased heartbeat, trouble breathing, and swelling of the face, fingers, and feet.
· The medication should not be prescribed in patients with a heart rate less than 45 beats per minutes and those with a second or third grade degree heart block. |
The patient should be educated on how to identify severe side effects and the need for blood tests to check for unwanted effects.
The patient should be advised to swallow the whole drug. They should not chew or crush them. |
| Medication: Acyclovir
Classification: Nucleoside analog Mode of action: Works by inhibiting viral DNA synthesis by acting as an analog to deoxyguanosine triphosphate |
To treat Shingles | · Common side effects of the medication include stomach upset, vomiting, dizziness, agitation, joint pains, and hair loss.
· The medication should not be prescribed in patients with renal failure and haemolytic uremic syndrome. |
· The patient in the case should be advised not to use this medication in case she has allergies to acyclovir.
· The patient should be advised not to exceed the prescribed dosage. |
Intravenous Fluid: N/A
Nursing Care Plan
| Nursing Diagnoses (List 3 priority
Nursing Diagnoses in order of priority. Must include one psychosocial nursing diagnosis) |
Expected Outcomes (Must complete short- & long-term goals for EACH priority nursing diagnosis listed. Goals should be SMART: specific, measurable, attainable, realistic, & time-framed) | Nursing Interventions & Rationales
(Evidenced based rationale for each intervention for each priority nursing diagnosis. Describe in your own words with references cited here & in reference list in APA format) |
Evaluation (How did/will you evaluate the effectiveness of
planned interventions listed in previous column? HINT: Assess attainment of SMART goals) |
| Acute pain related to physiologic alteration of the disease as evidenced by crying, increased blood pressure, respiratory rate. | Reduction in pain as reported by the patient 2 hours after the administration of nursing interventions. | · Monitor vital signs to obtain baseline data to support different nursing interventions
· Perform pain assessment frequently while documenting and changes from previous collected data. This is critical in assessing the effectiveness of nursing interventions and to identify any underlying worsening condition (Path, 2018). · Encourage verbalization of feeling and provide comfort measures. This is critical in evaluating coping skills and in identifying areas of concern. This will also help improve the healing process (Path, 2018). |
The patient should verbalize a reduction in pain after 2 hours of nursing intervention. |
| Disturbed body image related to alterations in structure and functions of the face as evidenced by unilateral facial paralysis, wrinkled forehead, and drooping of left eye. | The patient will be able to demonstrate increased self-esteem and body image after 2 hours of nursing intervention | · Assess patient’s knowledge of changes in structure or function of body parts. This is critical in determining the level of response and perceived value that the patient attaches to the affected part (Path, 2018).
· Assist the patient to identify the actual changes. This is due to the fact that the patient may be perceiving changes that may not be actually present (Path, 2018). · Encourage the patient to verbalize their concerns regarding the disease process and future expectations. This is critical in identifying the patient’s misconception so as to address them (Path, 2018). |
The patient should be able to demonstrate improved self-esteem. |
| Risk for injury of the eye from dust and foreign particles. | Within 3 hours of nursing intervention, the patient should be able to care for his eyes and protect them from injuries. | · Teach the patient to cover his eyes using protective shields reduce corneal irritation and ulceration (Vera, 2023).
· Teach the patient how to apply eye ointments to keep eyelids closes while sleeping. Distortion of the eyelids may alter proper drainage of tears (Vera, 2023). · The patient should use sunglasses to decrease normal evaporation from the eye. |
The patient should verbalize absence of injury to the eye and reduced irritation. |
References
Morris, J. & Dunham, A. (2022) Metoprolol. [Updated 2022 Oct 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532923/
Path, N. (2018). Bell’s Palsy management and nursing care plan. Retrieved on 10th august 2023 from https://www.nursingpath.in/2018/05/bells-palsy-management-and-nursing- care.html#:~:text=Teaching%20About%20Maintaining%20Muscle%20Tone&text=u pward%2 0motion%20several%20times%20daily,effort%20to%20prevent%20muscle%20atrop hy.
Vera, M. (2023). Bell’s Palsy. Retrieved on 10th August 2023 https://nurseslabs.com/bells- palsy- nursing-management/
Zhang, W., Xu, L., Luo, T., Wu, F., Zhao, B., Li, X. (2020). The etiology of Bell’s palsy: A review. Journal of Neurology, 267(7), 1896-1905.
