ACKNOWLEDGEMENT Teamwork divides the task and multiplies the success teamwork is one thing student nurses cannot

t succeed without. In completing this paper, the participation and contribution of each member has taken its place in the final product. Without which all this would have been impossible to achieve. That being said we would like to express our gratitude to all those who have helped make all this, a definite success. First of all, we would like to thank the Almighty Father, for guiding us throughout our whole nursing life. For giving us the patience, courage and perseverance to deal with all the mishaps and problems weve had to fight our way through to complete this paper. We thank Him endlessly for sharing his wisdom to every single person involved in this work our parents, clinical instructors, patients and our fellow nurses. Second, we would like to thank our patient, for welcoming us despite of her fragile condition. We would like to show our appreciation for the obvious participation of his family for answering all our questions, and giving us the necessary information about our patient, and the entire family. To our kind clinical instructor, Mrs. Rhoda N. Ocampo, R.N., who helped us in reading the files in the charts and gave us little bits of information about presenting cases. To our parents and families, we are forever grateful, for allowing us to have sleepless nights to finish our case presentation. We would like to thank all of them for supporting us in the challenges weve all had to undergo together. Without their support we would have not had the motivation to do all this and be happy in our choice of work. Lastly we would like to thank and congratulate ourselves for working together and achieving all this. This case presentation would not have been possible if not for the participation, patience and support from each member of the group. A wise man once said, In order to succeed, your desire for success should be greater than your fear of failure. For all the pep talks and memories we have made in the process of making this presentation a big success. INTRODUCTION
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Health is a dynamic condition that represents a range of physical and emotional states and our health is our most precious asset given by our creator. It is our major responsibility to protect our health from becoming ill and preventing it from danger, our knowledge would be the key, knowledge of how our body works, of what we should not do to keep it in its best possible functions, and perhaps most important of all, the knowledge that enables us to recognize any illness or disorder in its earliest stage, when medical treatment stands the greatest chance of success. In connection, our case study was made to reveal the nature of an illness called Facial Nerve Paralysis or Bells Palsy providing additional knowledge and eliminating vagueness regarding this disease, but not in any sense a substitute for the enormous range of service provided by the medical profession. Bells palsy or idiopathic facial paralysis is a disease caused by inflammation of unknown origin affecting the facial nerve resulting in acute paralysis of one side of the face. The condition may cause considerable emotional distress because of its characteristic appearance drooping appearance around the eye and mouth thus adversely effecting self-esteem and life experience. Bells palsy is seen in approximately 2 to 3 people per 10,000 and may resolve by itself within a few months with severe cases taking up to one year. Unfortunately, up to 10% of patients 12,682 will experience cases some degree here of in permanent the paralysis. Philippines. (http://www.gancao.net/acupuncture/bells-palsy-acupuncture-herbs-228) In 2003, there were estimated (http://www.cureresearch.com/b/bells_palsy/stats-country.htm)

Our group is scheduled to have our clinical duty at the ENT Ward of Southern Philippines Medical Center, where we have come across different patients. Among these patients is the woman who is 23 years old. The subject of our case study has differed among others. She was diagnosed having facial nerve palsy. We believed that it is something that we students need to understand fully.

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This case study will help us student nurses in more ways. It will not only re acquaint us with the concepts we have learned in our Primary Health Care and Nursing Care Management lectures but it also gives us the chance to master and gather much enough experiences to equip us for greater challenges ahead. By knowing more, we function more effectively, efficiently and safely. Presentation of the case in relation to the concept will serve as the groups final evaluation. The case study must be able to portray what the group learned. It should also be a manifestation of the groups hard work throughout the rotation. And, the experience of making this case study must leave a valuable lesson that the group will never forget. Moreover, we just have to remember that in learning all these things, we are now guided and oriented on what else we can do to augment the quality of human life.

OBJECTIVES

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After 1 day of data gathering, research and analysis, our group shall have devised objectives that will guide us for the proper understanding and fair interpretation of the case of our chosen patient. GENERAL OBJECTIVES Cognitive Within the 1 day span of duty, the student nurses will be able to: Gather significant data from the patients chart which includes the doctors order, laboratory exams and etc. to have complete information about the patients current condition. Research on the anatomy and physiology of the clients affected system. Research on the possible causes and also the symptoms the patient experienced that may suggest the current condition of the patient. Determine and interpret the medical management employed including laboratory and diagnostic procedures. Identify and study the drugs prescribed to the patient which affects the patients current situation. Psychomotor Within the 1 day span of duty, the student nurses will be able to: Conduct a thorough physical assessment and to interpret the assessment in order to give the care the patient need. Formulate nursing care plans and apply them to satisfy the patients needs and give appropriate nursing interventions. Make a discharge plan for the patient using M.E.T.H.O.D and validate the patients prognosis according to categories.

Affective Within the 1 day span of duty, the student nurses will be able to:

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 Establish rapport and therapeutic communication in order to gain information about the patient which includes the medical and family health history, expectations of her condition to gather significant data from the patients chart and to his family and etc.; and for the betterment of nursing care. Assume the role of being the patients advocate.

PATIENTS DATA Name : Bea A.

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Age Sex Weight Height Address Birthday Birthplace Civil Status Nationality Religion Educational Attainment Occupation

: : : : : : : : : : : :

27 years old Female 49kg 52 Riverside, Davao City May 18, 1987 Bukidnon Single Filipino Roman Catholic High School Graduate none/housewife

MEDICAL DATA

Hospital Ward / Bed Number Reason for Admission Admitting Date and Time Admitting Diagnosis Admitting Physician Final Diagnosis

: : : : : : :

SPMC ENT ward, Isolation Room Ear discharge June 29, 2010 at 10:44 am Facial Nerve Palsy Dr. Mark Wingleaf Yu

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GENOGRAM

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FAMILY HISTORY

Family Background Our patient, Bea A., is the third child of Shaina and John Lloyd. She has four siblings, three boys and one girl. Both of her parents dont have the same illness like the one she has. Her parents do not have any illness like hypertension, diabetes mellitus, or cancer. Her mother has six female siblings and is second of seven. Her father has one male sibling. They are all living with no present illness according to the patient. Her mother delivered all of them through normal spontaneous vaginal delivery without any complications during the said delivery. She was born and grew up in the province of Bukidnon. She was living in a bahay kubo with no water supply and electricity. At the age of three, she lived in her grandmothers house to have her education. It is because it is nearer and her grandmother pays for the fees of her schooling. She only lived in her parents house during her grade 3 4 of schooling. She had her primary and secondary education in the same province. She moved here in Davao City in the year 2007 with his boyfriend. It is because she wants to be with his boyfriend and she could also not pursue college education because of financial problems. She met her boyfriend, Sam, in Bukidnon. They met because Sam heard of a job opportunity in Bukidnon which is construction works. She is currently living in Riverside, Davao City together with his live-in partner while the rest of her family is in Bukidnon. She is now 23 years old, born on May 18, 1987. Her husband is a contractual worker and does not have a permanent job. He is only called whenever there are carpentry job available. In one job, he could have 1,000 pesos as an average wage. He could have at least one job per month. In times where there are no available resources left for the two of them, Sam would ask for financial help to his parents or to his brother.
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Diet and Lifestyle In her younger years, she already lived in her grandmothers house already. She had a habit that itching or cleaning her ears every now and then. She was playful and loves to play outside. During her high school years, she was active in sports. She participates in women softball games. She would still play in the outdoors and still have her habit of itching her ears. However, after moving here in Davao, she did not have any sports to play anymore and stays a lot in their house. She does the household chores everyday. Her hygiene was a part of her everyday activities. She was fond of cleaning her ears with a cotton bud inserting half of it inside the ear canal. She cleans it vigorously.

Her usual meals consist of vegetables and fish. She also eats meats such as chicken, pork and beef but only in minimal amount. They would eat cheaper viands because of financial constraints. Her leisure time is watching TV and talking to her neighbours. She does not have any vices such as drinking liquors and smoking.

History of Past Illnesses Bea A. has her complete immunization (BCG, DPT, Oral Polio Vaccine, Hepatitis B vaccine, measles vaccine) at the Bukidnon Health Center. Aside from common illness such as fever, cough, and colds, Bea A. did not experience other illnesses. If she has fever, she would only take over the counter drugs such as Neozep, Paracetamol and Bioflu. She also uses herbal medicine such as tawa-tawa and kalabog and for her; it has a therapeutic effect on her body.

History of Present Illness

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Because of her habit of cleaning and itching her ear every now and then even without proper handwashing, there was a complication arise. Six weeks prior admission, Bea A. experienced pus discharges in her left ear. She then used cotton buds and checked the ear and she noticed that there were pus and blood discharges. She had the same experience for one week. She felt that her ear is hot and swelling. After one week observing of the pus ear discharges, she eventually noticed that her left side of her face is already numb. In addition to that, she could already felt pain in her ears and still ear pus would come out of her ears. She then decided to consult to a doctor. She went to the clinic of Dr. Hernandez to have a check-up and she was prescribed Amoxicillin and Mefenamic Acid for her pain. Since the medications are not effective, she decided to have her second check-up at the Southern Philippines Medical Center where she was diagnosed to have Facial Nerve Palsy. She was admitted last June 29, 2010 at around 10:44 am under ENT service, isolation room.

PHYSICAL ASSESSMENT

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General Survey Physical assessment was taken on July 2, 2010 at 10am, 71 hours and 16 minutes after admission. Received sitting on bed, conscious, alert and responsive with an on-going IVF bottle PNSS 1 liter at 200cc level infusing well 20gtts/min rate to left metacarpal vein. Upon entering in the room of a 23 year old female whos conversing with her watcher with a height of 52with a weight of approximately 49 kg and is wearing a oranged colored tshirt and blue, flower-patterned pajamas, whos lower half is covered in a blanket. Appears clean and neat with hair combed. With noted foul body odor. Was relaxed, fully rested with no hesitancy in changing body position. No noted pallor or other noticeable signs of illness. Is cooperative and able to follow requests with promptness and is in a sociable mood and willing to interact. Speech is understandable, moderate pace. Voice is fully audible, speaks at moderate volume and has clear voice tone. Speaks clearly with coherent organization of thought, speaks in logical sequence, makes sense and has good sense of reality with minimal vagueness and is able to further respond to and clarify inquiries. Vital Signs are: Blood Pressure: 120/80 Respiratory Rate: 19 Pulse Rate: 68 Temperature: 35.8 C

Neurological System Has no noted difficulty in speaking: Is fully oriented upon interview and is able to state the current location, time of the day, day of the week, duration of current hospital stay, duration
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of illness and the names of the family members. With regards to memory client is able to recall various events of the day including time seen by the physician and is also able to recall and repeat information given early in the interview. Has good attention span with maintained eye contact. Good motor function upon verbal request and is able to converse normally with good grammar, sentence structure and showed ability to speak bilingually.

Skin Upon inspection, skin color varies from light to deep brown. Skin is generally uniform except in areas exposed to the sun including face and upper extremities which is of a darker tone. Areas of lighter pigmentation include the palms, lips and nail beds. No edema noted Noted mole on lobule of left ear. Has noted puncture mark on right mid forearm, encircled with a dark colored pen. Upon palpation, skin was moist. Skin felt generally warm on areas under the blanket but cool on the arms. With a Temperature of 35.8 C. Skin springs back to previous state upon light pinching of the left forearm indicating good skin turgor.

Head Upon inspection, the skull is normocephalic and symmetric, with frontal, parietal, and occipital prominences and has smooth skull contour. Palpation of the skull reveals absence of nodules and masses has symmetric facial features. Facial movements are assymmetrical and is particularly evident when showing emotions such as smiling. Head is full of hair, black in color with some noted brown strands, reaching below shoulder level. Bangs do not reach eyebrows. Hair is parted through the side and does not cover the face. Has thin hair strands and dry hair. No presence of infection or infestation was noted. The left mastoid part is bigger than the other side. There is weakness on left side of face muscle.

Eyes

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Eyebrows were symmetrically aligned with equal movement. Eye lashes was equally distributed and curled slightly outward. The skin of the eyelids were intact, no discharges and no discoloration. Noted unable to open eye lids fully. Lids close assymmetrically however with noted frequent blinking on right eye only with a rate of 36 blinks per minute. Upon inspection, anicteric sclera. No noted visible sclera above corneas Palpebral conjunctiva appeared smooth and pink. Lacrimal gland, lacrimal sac and nasal lacrimal duct had no noted edema or tearing. Has brown colored iris. Pupils are black in color, equal in size of about 3mm. Both pupils constrict when illuminate. Has noted sensitivity to light; pain observed after penlight test. Has noted exotropia. Both eyes move in unison but uncoordinated.

Ears During inspection, the color of auricles is same as the facial skin and is symmetrical. Auricles are aligned with the outer canthus of the eye. Upon palpation, found to be firm and not tender; noted pain on left ear. Pinnea recoils after it is folded. External ear has hair follicles and dry cerumen. Upon inspection with a penlight, noted continuous blood and pus discharges on left external ear canal. Upon assessment of hearing, normal voice tones are audible, however more acuity on right ear than left. During the watch tick test, unable to hear the ticking on left ear.

Nose Upon inspection, nose is wide, symmetric and straight. Upon palpation, no noted tenderness or lesions. Able to breath freely through nares. Upon inspection with a penlight, mucosa is pink; no noted swelling, redness, growth or lesions. No noted purulent discharge or bleeding. Olfactory sense is functional, able to smell without difficulty. Nasal septum is intact and in the midline between the nasal chambers.

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Mouth Upon inspection outer lips are dark pink in color; appeared soft and smooth; with symmetrical contour and has ability to purse lips. Noted slight dryness and roughness. Inner, lips are pinkish red and uniform in color soft, moist and smooth. Teeth appear smooth, generally white with slightly yellow crown; has complete set of 32 adult teeth. Gums are pink, moist and appear firm. No noted retraction of gums. Tongue is in central position of the mouth, light pink in color; moist; slightly rough with noted thin whitish coating in some areas. Reported loss of taste. Papillae are raised. Able to move side to side. Smooth tongue base with prominent veins. No noted lesions or dryness. Soft palate is pink and smooth. Hard palate is light pink and irregular in texture. Uvula is positioned in midline of palate.

Neck During inspection, neck muscles are equal in size and head is centered. Coordinated head movement with no observable difficulty. Neck has full range of motion. Upon palpation, no noted enlarged lymph nodes. Trachea is in central placement in the midline of the neck. Thyroid gland not visible upon inspection.

Chest and lungs Has symmetrical anterior chest expansion with a respiratory rate of 19 breaths per minute. Spine is vertically aligned. Noted productive coughing. Sputum appears with noted whitish color. Upon auscultation, faint crackles are audible. Breathing pattern rhythmic and with minimal effort during respirations. Right and left shoulders are of the same height. Anterior chest wall is intact, no noted tenderness or masses. Posterior chest has full and symmetric respiratory excursion. Upon palpation of the posterior chest there is bilateral symmetry of vocal fremitus although faint vibrations. Upon percussion of the posterior chest, sounds resonate; no noted dullness or flatness over lung tissue. Upon auscultation of the upper chest using a stethoscope, no noted adventitious breath sounds.
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Heart Upon auscultation, the two heart sounds are audible, the systole and diastole. Noted very audible, loud apical pulsations. Upon palpation of the carotid artery, pulse volumes are symmetric, with full pulsations and good thrusting quality. Thrusting quality remains the same when client breathes, turns head, and changes from sitting to from supine position. Radial pulse is also symmetric in volume along with full pulsations and good thrusting quality. Noted pulse rate of 68 beats per minute. Jugular veins not visible upon inspection.

Abdomen Abdomen round, flabby and is uniform, medium brown in color with unblemished skin. Abdomen has rounded, symmetrical countour. No noted enlargement of liver or spleen. Has symmetrical movements upon respiration. Upon auscultation, bowel sounds are audible, with irregular gurgling noises occurring approximately every 30 seconds. Upon palpation, no noted tenderness; relaxed abdomen with soft texture.

Genito-Urinary No noted change in urinary pattern. Urine is amber-colored. No noted pain while urinating. No observed hematuria.

Back and Extremities Upon inspection upper extremities and lower extremities are grossly proportional to body shape. Nails of upper extremities are trimmed and cleaned with capillary refill of less than 2 seconds. Toenails are trimmed and cleaned. No noted deformities or edema. Upon palpation,
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muscles are soft with minimal tone. Able to ambulate normally, unassisted with no noted difficulty. No observable difficulty changing position in bed. Muscles are at 100% of normal strength on each side of the body and able to fully move against gravity and resistance. Joints in upper and lower extremities have good range of motion. Noted deformity on radiocarpal joint in the form of a dislocation. Noted pain upon movement and palpation. Other than the aforementioned, joints move smoothly with no noted deformities, swelling, pain, tenderness or crepitation. Spinal column vertically aligned and is straight with no noted protrusions or deformities.

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DEVELOPMENTAL DATA Development is an increase in the complexity of function and skill progression. It is the capacity and the skill of a person to adapt to the environment and it implies a progressive and continuous process of change leading to a state of organized and specialized functional capacity. Development is the behavioral aspect of growth, such as a persons ability to walk, talk, and run. It proceeds from simple to complex or from single acts to integrated acts. Any interpretation of this process by a disease or a disorder is called developmental delay. These changes can be measured quantitatively but more distinctly measured in qualitative changes.

THEORIST Cognitive Development by Jean Piaget is defined as an orderly and sequential process in which the variety of new experiences must occur in order for intellectual abilities to develop. Piaget believed that human beings are all born with an innate drive toward knowledge which is our overall need for survival.

STAGE Formal-Operational Stage (11 years and above) -develop hypothetical-deductive reasoning -abstraction -make hypothesis and solve problems -LOGICO -MATHEMATICAL -INTELLIGENCE

JUSTIFICATION Achieved Bea A. achieved this stage of being a person. We can see that she had developed her intellect well because she sought for medical attention when she noticed unusualities in her body. It is evidenced that she is using her knowledge and critical thinking. When she noticed that there is something wrong with her, she pay attention on it instead of just letting the situation pass. We can conclude that Bea A. achieved this cognitive stage.

Developmental Task Theory

Early Adulthood (18-30 years old)

Partially Achieved
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Robert Havighurst was an educator who theorized that learning was a lifelong process. He believed that a person moves through 6 life stages, each associated with a number of tasks that must be learned. Havighurst characterizes developmental task as follows: A developmental task is midway between an individual need and societal demand. It assumes an active learner interacting with an active social environment. Failure to master a task leads to unhappiness of the individual, difficulty mastering future task, and interacting with others.

Selecting a Mate Marriage Partner

Bea A. lives with her live-in partner in Maa Davao City. They dont have a child yet because they want to have enough financial support before they will create a bigger family. Though Bea A. became a housewife most of her time and she keeps to a point that shell be able to relax and unwind with her partner and family.

Learning to live with a Starting a Family Rearing Children Managing a Home Occupation

Getting started with an Taking on Civic Responsibilities

Finding a Congenial Social Group As a wife, Bea A. is well supported by her partner, especially with her present problem about her health condition, as he stayed with his wife/partner in the hospital.

Bea A. , on this stage didnt passed, as her educational attainment was only up to high school level, thus, she never experienced working at an office.

Psychosocial Developmental Theory

Intimacy vs. Isolation (Young Adults, 20 to 34 years)

Partially Achieved Bea A. lives with her live-in partner in Maa. They are not yet
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Erik Erikson Focuses and gives emphasis on the belief that psychological development depends on the quality of social relations people establish at various points in life. In other words, the persons ego development.

Intimacy means the process of achieving relationships with family and marital or mating partner(s). Erikson explained this stage also in terms of sexual mutuality - the giving and receiving of physical and emotional connection, support, love, comfort, trust, and all the other elements that we would typically associate with healthy adult relationships conducive to mating and child-rearing. There is a strong reciprocal feature in the intimacy experienced during this stage - giving and receiving especially between sexual or marital partners. Isolation conversely means being and feeling excluded from the usual life experiences of dating and mating and mutually loving relationships. This logically is characterised by feelings of loneliness, alienation, social withdrawal or non-participation. married and has no children yet. Bea was able to find her mate which she has commited to. She was able to give and receive support, love, comfort and trust to her partner. She didn't withdrawn herself to the society or to other people. Bea A. also sought for help about her illness, this shows that she hadnt loss the trust for the society or other people.

DEFINITION OF COMPLETE DIAGNOSIS Facial Nerve Paralysis or Bell's Palsy

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Facial Nerve Paralysis/Palsy results from loss of function pf the facial nerve. It is characterized by paralysis of the muscles of facial expression which may be associated with loss of other facial nerve functions such as lacrimation, salivation, sound dampening and loss of taste in the two anterior thirds of the tongue.

(689. Albert L. Baert. Encyclopedia of Diagnostic Imaging Springer-Verlag Berlin Heidelberg New York, 2008)

Facial Nerve Paralysis is the dysfunction of the facial nerve (7th cranial nerve), causing paralysis or weakness of the muscles of the ears, eyelids, lips, and nostrils. Weakness or paralysis caused by impairment of the facial nerve or the neuromuscular junction peripherally or the facial nucleus in the brainstem.

(295. Paul W. Brazis, Joseph C. Masdeu, Jos Biller. Localization in clinical neurology 5th edition . Lippincott Williams & Wilkins, 2001 )

Facial nerve paralysis: Loss of voluntary movement of the muscles on one side of the face due to abnormal function of the facial nerve (also known as the 7th cranial nerve) which supplies those muscles. Facial nerve paralysis is also called Bell's palsy. s

(http://www.medterms.com/script/main/art.asp?articlekey=6482)

ANATOMY and PHYSIOLOGY

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The facial nerve is the seventh (VII) of twelve paired cranial nerves. It emerges from the brainstem between the pons and the medulla, and controls the muscles of facial expression, and functions in the conveyance of taste sensations from the anterior two-thirds of the tongue and oral cavity. It also supplies preganglionic parasympathetic fibers to several head and neck ganglia. Course The motor part of the facial nerve arises from the facial nerve nucleus in the pons while the sensory part of the facial nerve arises from the nervus intermedius. The motor part and sensory part of the facial nerve enters the petrous temporal bone into the internal auditory meatus (intimately close to the inner ear) then runs a tortuous course (including two tight turns) through the facial canal, emerges from the stylomastoid foramen and passes through the parotid gland, where it divides into five major branches. Though it passes through the parotid gland, it does not innervate the gland. This action is the responsibility of cranial nerve IX, the glossopharyngeal nerve. The facial nerve forms the geniculate ganglion prior to entering the facial canal. Branches

Greater petrosal nerve - provides parasympathetic innervation to lacrimal gland, sphenoid sinus, frontal sinus, maxillary sinus, ethmoid sinus, nasal cavity, as well as special sensory taste fibers to the palate via the Vidian nerve. Nerve to stapedius - provides motor innervation for stapedius muscle in middle ear Chorda tympani - provides parasympathetic innervation to submandibular gland and sublingual gland and special sensory taste fibers for the anterior 2/3 of the tongue.
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Outside skull

Posterior auricular nerve - controls movements of some of the scalp muscles around the ear Branch to Posterior belly of Digastric and Stylohyoid muscle Five major facial branches (in parotid gland) - from top to bottom: o Temporal (frontal) branch of the facial nerve o Zygomatic branch of the facial nerve o Buccal branch of the facial nerve o Marginal mandibular branch of the facial nerve o Cervical branch of the facial nerve

A traditional mnemonic device for the five major branches of the facial nerve is, "The Zebra Bummed My Cat." Other mnemonics for the divisions of the facial nerve include, "Today Zoe Bummed My Car", "To Zanzibar By Motor Car", "Tell Ziggy Bob Marley Called", "Ten Zebras Bit My Cock", "Two Zulus buggered my cat" and "The Zoo Bought Monkey Clothes." Embryology The facial nerve is developmentally derived from the hyoid arch (second pharyngeal branchial arch) Function Efferent Its main function is motor control of most of the muscles of facial expression. It also innervates the posterior belly of the digastric muscle, the stylohyoid muscle, and the stapedius muscle of the middle ear. All of these muscles are striated muscles of branchiomeric origin developing from the 2nd pharyngeal arch. The facial also supplies parasympathetic fibers to the submandibular gland and sublingual glands via chorda tympani. Parasympathetic innervation serves to increase the flow of saliva from these glands. It also supplies parasympathetic innervation to the nasal mucosa and the lacrimal gland via the pterygopalatine ganglion. The facial nerve also functions as the efferent limb of the corneal reflex and the blink reflex. Afferent In addition, it receives taste sensations from the anterior two-thirds of the tongue and sends them to the gustatory portion of the solitary nucleus. The facial nerve also supplies a small amount of afferent innervation to the oropharynx below the palatine tonsil. There is also a small amount of
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cutaneous sensation carried by the nervus intermedius from the skin in and around the auricle (earlobe). (http://en.wikipedia.org/wiki/Facial_nerve)

CN VII. Facial Nerve

The facial nerve is mixed nerve containing both sensory and motor components. The nerve emanates from the brain stem at the ventral part of the pontomedullary junction. The nerve enters the internal auditory meatus where the sensory part of the nerve forms the geniculate ganglion. In the internal auditory meatus is where the greater petrosal nerve branches from the facial nerve. The facial nerve continues in the facial canal where the chorda tympani branches from it the facial nerve leaves the skull via the styolomastoid foramen. The chorda tympani passes through the petrotympanic fissure before entering the infratemporal fossae. The main body of the facial nerve is somatomotor and supplies the muscles of facial expression. The somatomotor component originates from neurons in the facial motor nucleus located in the ventral pons. The visceral motor or autonomic (parasympathetic) part of the facial nerve is carried by the greater petrosal nerve. The greater petrosal nerve leaves the internal auditory meatus via the hiatus of the greater petrosal nerve which is found on the anterior surface of the petrous part of the temporal bone in the middle cranial fossa. The greater petrosal nerve passes forward across the foramen lacerum where it is joined by the deep petrosal nerve (sympathetic from superior cervical ganglion). Together these two nerves enter the pterygoid canal as the nerve of the pterygoid canal. The greater petrosal nerve exits the canal with the deep petrosal nerve and synapses in the pterygopalatine ganglion in the pterygopalatine fossa. The ganglion then gives of nerve branches which supply the lacrimal gland and the mucous secreting glands of the nasal and oral cavities. The other parasympathetic part of the facial nerve travel with the chorda tympani which joins the lingual nerve in the infratemporal fossa. They travel with lingual nerve prior to synapsing in the submandibular ganglion which is located in the lateral floor of the oral cavity. The submandibular ganglion originates nerve fibers that innervate the submandibular and sublingual glands. The visceral motor components of the facial nerve originate in the lacrimal or superior salivatory nucleus. The nerve fibers exit the brainstem via the nervus intermedius. (The nervus
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intermedius is so called because of its intermediate location between the eighth cranial nerve and the somatomotor part of the facial nerve just prior to entering the brain). There are two sensory (special and general) components of facial nerve both of which originate from cell bodies in the geniculate ganglion. The special sensory component carries information from the taste buds in the tongue and travel in the chorda tympani. The general sensory component conducts sensation from skin in the external auditory meatus, a small area behind the ear, and external surface of the tympanic membrane. These sensory components are connected with cells in the geniculate ganglion. Both the general and visceral sensory components travel into the brain with nervus intermedius part of the facial nerve. The general sensory component enters the brainstem and eventually synapses in the spinal part of trigeminal nucleus. The special sensory or taste fibers enter the brainstem and terminate in the gustatory nucleus which is a rostral part of the nucleus of the solitary tract. (http://www.meddean.luc.edu/lumen/MedEd/grossanatomy/h_n/cn/cn1/cn7.htm)

FACIAL NERVE

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The motor fibers of the facial nerve arise from a nucleus in the lower part of the pons, from which they extend by way of several branches to the superficial muscles of the face and scalp. Efferent autonomic fibers of the facial nerve extend to the submaxillary and sublingual salivary glands, as well as to the lacrimal glands. Sensory fibers from the taste buds of the anterior two thirds of the tongue run in the facial nerve to cell bodies in the geniculate ganglion, a small swelling on the facial nerve, where it passes through a canal in the temporal bone. From the ganglion, fiber extends to a nucleus in the medulla.

(ANATOMY and PHYSIOLOGY 5th Edition by: Gary A. Thibodeau and Kevin T. Patton)

ETIOLOGY PREDISPOSING FACTORS

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Etiologic factors

Patient Manifestation (PRESENT/A BSENT) Present

Rationalization

Justification

1. Age

Bell' Palsy can occur at any age. The age of our patient But the most common age that is 23 years old. Bell's Palsy occurs is the age of before 15 and after 60. Inheritance of this illness may be autosomal dominant with low penetration. No one of the family of our patient had a case of Bell's Palsy.

2.Hereditary

Absent

PRECIPITATING FACTORS
Patient Manifestati on (PRESENT /ABSENT)

Etiologic factors

Rationalization

Justification

1. Diabetes Mellitus

Absent

The diabetic patient is more Our patient is not prone than the non-diabetic diabetic. person to nerve degeneration, and this tendency to nerve degeneration is not age-related (http://diabetes.diabetesjournals.o rg/content/24/5/449.abstract). The 7th cranial nerve passes through the complex tortuous route in the skull before it gets to the muscle and other structures. Some of the openings that the nerve must pass through are extremely narrow. One of these openings in the skull is called "coincidently", the fallopian Our patient has never been pregnant.

2. Pregnancy

Absent

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canal is comparatively long relationship to the nerve it self and therefore any swelling of the cranial nerve can result to compression and impaired functioning of the nerve itself. 3. Trauma in the head part. Absent Head trauma can obstruct any Our patient never had nerve located in the head, one head trauma. will be affected is the facial nerve Bleeding and pus is present on our patient during assessment.

4. Ear Infection

Present Absent

5. compromised immune systems

6. Exposure to Viral infection

Absent

Bell's palsy is most often connected with a viral infection such as herpes (the virus that causes cold sores), Epstein-Barr (the virus that causes mono), or influenza (the flu). It's also associated with the infectious agent that causes disease. The immune system's response to a viral infection leads to inflammation of nerve. Because it's swollen, the nerve gets compressed as it passes through a small hole at the base of the skull.

SYMPTOMATOLOGY

27 | P a g e

Basic signs and symptoms

Present/ absent

Rationalization

1. Weakness and paralysis, usually on one side of the face

Present

2. Drooping of eyelid 3. Tearing in the eye on the affected side. 4. Drooping of one side of the mouth. 5. Loss of the sense of taste

Present Present

Present

Present

When the facial nerve is working properly, it carries a host of messages from the brain to the face. These messages may tell an eyelid to close, one side of the mouth to smile or frown, or salivary glands to make spit. Facial nerves also help our bodies make tears and taste favorite foods. But if the nerve swells and is compressed, as happens with Bell's palsy, these messages don't get sent correctly. The result is weakness or temporary paralysis of the muscles on one side of the face.

PATHOPYSIOLOGY

Ear infection 28 | P a g e

Bacteria enters the ear due to habit of inserting unclean pinky finger inside the ear whenever it is itching and deep insertion of cotton buds Bacteria produces enterotoxins Enterotoxins is a toxic substance that excreted by microorganism can cause damage to the host by destroying cells or disrupting normal cellular metabolism. Inflammatory reaction around the seventh cranial nerve, usually at the internal auditory meatus where the nerve leaves bony tissue. Produces a conduction block that inhibits appropriate stimulation to the muscle by the motor fibers of the facial nerve. Results to the characteristics of unilateral or bilateral facial weakness and paralysis.

Weakness and paralysis usually on one side of the face.

29 | P a g e

Drooping of the eyelid. Tearing on the eye on the affected side.

Results to the characteristics of unilateral or bilateral facial weakness and paralysis.

Drooping of one side of the mouth.

Bell's

Loss of the sense of taste.

If treated Nursing management * Teaching eye care. -cover the eye with protected shield at night -apply eye ointment to keep eyelids closed during sleep. -close the paralyzed eyelids manually before going to sleep. -wear wrap sunglasses to decrease normal evaporation from the eye. * Teaching about maintaining muscle tone -show patient how to perform facial massage which gentle upward motion several times daily when the patient can tolerate the massage.

Treatment *Systemic therapy -use of corticosteroids and antiviral agents * Surgery -Procedures to correct lower eye lid droop: Suborbicularis oculi fat lift and lateral tarsal strip -Procedures to correct lagopthalmus: pretersal goldweight implantation, tarsorrhaphy, transposition of the temporalis muscle, facial nerve grafting. -Brow ptosis is repaired with a Lead to permanent facial weakness and paralysis. If not treated

Bad Prognosis

Good Prognosis

Doctors Order Rationale Patients who have problems Remarks DONE

Date and Time 06/29/10 -

Doctors Order Please admit patient

Good Prognosis

30 | P a g e Bad Prognosis

10:10 am

under ENT service isolation ward

related to ears, nose and throat that need a close monitoring in the medical facility are admitted in the ENT ward. Isolation ward is intended to patients who had an underlying disease that is communicable.

Secure consent to care

A signed consent from an able client is needed before any procedure is done particularly invasive procedures, to ensure that the client approves of the invasive procedure to be done. This also serves as a legal basis in case of problems in the future

DONE

Vital signs every 4 hours

To monitor patients status and determine changes in the bodys condition.

DONE

On DAT

Diet as tolerated is only given when the client can tolerate any food she desires that is nutritious, if this will not lead to any complications and if the

DONE

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client needs further monitoring for lab test. Laboratory tests: Complete Blood Count, platelet - CBC and platelet test monitoring is done in order to evaluate the level of RBC, which can give information about the oxygen-carrying capacity of the blood and can be an important component of nutrition assessment and platelet are monitored or checked to evaluate blood coagulation. Blood Typing -Blood typing is done for a variety of reasons including when a person plans to donate blood or to be transfused blood or if pregnant. and to establish compatibility between the donor and the recipient to avoid transfusion reaction. Serum sodium, potassium Serum sodium and potassium tests are taken to test if the patients kidney is functioning well. DONE DONE DONE

Chest X-Ray

Chest X-ray is intended to

DONE
32 | P a g e

visualize any abnormalities of the lungs and heart that may contraindicate a surgical operation to be performed on the patient. This is needed for a cardiopulmonary clearance prior to a surgery. An X-Ray Procedure is used to study and diagnose disease of the skeletal system as well as for detecting some disease processes in soft tissue. Xrays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. X-rays are made by using external radiation to produce images of the body, its organs and other internal structures for diagnostic purposes. X-rays pass through body tissues onto specially treated plates (similar to camera film) and a negative type picture is made (the more solid a structure is, the whiter it
33 | P a g e

appears on the film). Mastoid series Mastoid series is done to view three or four times of the mastoid bone all somewhat are angled. It is commonly indicated to those who have trauma, mastoiditis and tumor Temporal CT-Scan The temporal bone houses and is surrounded by many vital structures. The temporal bone is actually comprised of 4 bones consisting of the squamous, petrous, tympanic, and mastoid segments, CT scan is used to define normal and abnormal structures in the body and/or assist in procedures by helping to accurately guide the placement of instruments or treatments. Please start venoclysis with 1 liter PNSS at 20gtts/min To promote fluid balance in the body, to maintain hydration status and for IV medication administration purposes. PNSS is an isotonic solution, it has the same
34 | P a g e

DONE

DONE

osmolality as the body fluids Medications: Please start Pen G 5 M units IVTT every 6 hours ANST via soluset - Pen G is an antibacterial type of drug it is given to our client because her condition might be caused by bacterial type of microorganism. given after negative sensitivity test to ensure that the client is not hypersensitive to drug - ketorolac, A Non-steroidal Anti-inflammatory drug for ketorolac 30mg IVTT every 8 hours Short term management of moderately severe acute pain. It May inhibit prostaglandin synthesis, to produce anti-inflammatory, analgesic, and antipyretic effects -Ranitidine It is a histamine H2 receptor antagonist and anti-ulcerative for Active duodenal and gastric ulcer. It Competitively inhibits ranitidine 50mg IVTT every 8 hours action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretions.
35 | P a g e

DONE

-Support and increase the rate of metabolism, Maintain healthy skin and muscle tone, Enhance immune and nervous system function, Promote cell growth and division, including that of the red blood cells that help prevent Vitamin B complex 1cap Bid Monitor Intake and Output every shift anemia Monitoring the intake and output of patients are necessary to determine the fluid balance of their body. A large volume difference between the patients intake and output may indicate excessive fluid excretion (more output than intake) or fluid retention in the body (less output than intake). Patients are at risk for fluid imbalances since one of the major organs affected is the kidney, which is also responsible for retaining fluid in the body. DONE

Monitor Vital signs and record to chart

For close monitoring of the DONE client and if there is any

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every 4 hours May give dexamethasone 8mg ODx3 doses ones with normal chest X-Ray Refer accordingly

unusualities. If chest X-ray is normal with DONE no unusualities then may give dexamethasone, a glucocorticoid. Appropriate referral provides continuous treatment and proper interventions DONE

06/09/10 8:00 am

give paracetamol 500mg 1 tab every 4 hours PRN if temperature is greater than 38c TSB for fever

Paracetamol is given with 4 hours interval if fever still persists.

DONE

Tepid sponge bath is done if there is an elevation in the clients temperature, it is done if client is experiencing slight fever.

DONE

refer accordingly

Appropriate referral provides continuous treatment and proper interventions

DONE

06/30/10

follow up lab results

Laboratory results must be followed up so that results will be evaluated and to see if there is irregularities with the result and proper intervention must be made

DONE

Continue

Continue medications as

DONE
37 | P a g e

medications

prescribed by the physician to treat the condition of the client.

refer accordingly

Appropriate referral provides continuous treatment and proper interventions

DONE

06/30/10 4:30

follow up CBC results

CBC results must be followed up to see if there are any irregularities with the blood components

DONE

may give chloramphenicol 500mg cap QID

Chloramphenicol is an antibacterial primarily bacteriostatic thereby inhibiting bacterial protein synthesis

DONE

may give metronidazole 500mg cap TID

It is Anti-infective; Antiprotozoal. Use as preoperative, intraoperative, postoperative prophylaxis for patients undergoing surgery. It acts by disturbing DNA synthesis in susceptible bacterial organisms

DONE

refer Thank you

Appropriate referral provides continuous treatment and proper interventions

DONE

07/01/10

follow up mastoid

Mastoid and chest x-ray

DONE
38 | P a g e

8:00am

results and chest xray

must be followed up to evaluate the results and proper intervention must made, the physician must see the results to view what is the source of the problem or to see how is it.

continue meds

Continue medications as prescribed by the physician to treat the condition of the client.

DONE

07/02/10 8:45 am

still for mastoid xray and pure tone audiometry

Mastoid x-ray and pure tone audiometry is to be done it must be followed by the client so that condition will be evaluated, maybe the client does not able to comply with the first order of the physician.

Please send patient to OPD for suctioning this 9:00 am today July 02, 2010

Secretions may block the pathways. Pathways should be cleared to prevent complications and to aid the clients comfort. Pure tone audiometry is the key hearing test used to identify hearing threshold levels of an individual, enabling determination of the degree, type and

DONE

After OPD let patient out on pass for pure tone audiometry outside SPMC

DONE

39 | P a g e

configuration of a hearing loss. Thus, providing the basis for diagnosis and management. PTA is a subjective, behavioural measurement of hearing threshold, as it relies on patient response to pure tone stimuli. Therefore, PTA is used on adults and children old enough to cooperate with the test procedure. Refer Thank you Appropriate referral provides continuous treatment and proper interventions 07/02/10 1:30 pm Wet reading: chest x-ray no significant chest findings mastoid series: poorly aerated left mastoid There are no irregularities with the chest x-ray, results of the chest x-ray shows no significant findings that will help them in solving the problem. mastoid series shows that the left mastoid of the client is poorly aerated. 07/03/10 6:05 am please schedule patient for stat MRM for decompression modified radical mastoidectomy, ENT An operation to eradicate disease of the middle ear
40 | P a g e

DONE

DONE

DONE

cavity and mastoid process, in which the mastoid and epitympanic spaces are converted into an easily accessible common cavity by removing the posterior and superior external canal walls. inform OR/ANOD Informing the operating room that an operation is scheduled to be performed allows the operating room staff to prepare the operating area and the needed staff and materials for the operation. secure consent Consent is needed for legal DONE purposes and for giving approval to the medical team and the institution to perform the invasive procedure to the patient. This also ensures that the client is aware of the reasons for the operation and that he permits the invasive surgery to be performed refer Referral is needed so that there is order in any procedure also so that the
41 | P a g e

DONE

DONE

physician will know if client agrees with the procedure to be done. It is also needed to notify the physician.

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DIAGNOSTIC TESTS Date Reported: June 30, 2010

Blood Chemistry

Blood chemistry testing identifies many chemical blood constituents. It is often necessary to measure several blood chemicals to establish a pattern of abnormalities. A wide range of tests can be grouped under the headings of enzymes, electrolytes, blood sugar, lipids, hormones, vitamins, minerals and drug investigation. Other tests have no common denominator. Selected tests serve as screening devices to identify target-organ damage.

TEST sodium

RESULT 137.10 mmol/L

REFERENCE 136.00-155.00 mmol/L

REMARK Normal

RATIONALE Sodium is the major cation in the extracellular fluid, and it has a water retaining effect. When there is a excess sodium in the ECF, more kidneys. cortex, water will from be the reabsorbed

INTERPRETATION The result is within normal range.

Aldosterone, promotes sodium

secreted from the adrenal reabsorption from the distal

43 | P a g e

tubules deficit, and

of

the

kidneys.

When there is a sodium more water aldosterone reabsorption secreted and more sodium occurs. With an increased serum sodium level, there is a decrease in aldosterone secretion and excess sodium is excreted through the kidneys. Potassium 4.20 mmol/L 3.5-5.5 mmol/L Normal Potassium is the electrolyte found most abundantly in the (cells), intracellular with a level of fluids cellular 150 The result is within normal range.

potassium

mEq/L. Serum potassium level is the measurable body potassium, and death could occur if serum levels less than 2.5 mEq/L or greater than 7.0 mEq/L persist
44 | P a g e

Nursing Responsibilities Explain to the patient that the test is to measure the sodium (electrolyte) level in the blood. Explain the procedure involving use of tourniquet. Instruct the patient that he/ she may eat and drink before the test Recognize clinical problems and drugs related to Hypernatremia /Hyponatremia. Assess/ observe for signs of Hypernatremia /Hyponatremia. For hyponatremia: encourage to avoid drinking only plain water. Suggest fluids with solutes. For hypernatremia: encourage to drink plenty of water, unless it is contraindicated. Monitor the medical regimen in correcting hyponatremia/ hypernatremia. Encourage not to eat food high in sodium. For hypernatremia. Check for serum sodium and other laboratory results and report serum electrolyte changes. Check specific gravity of urine Take vital signs to determine cardiac status during hyponatremia/ hypernatremia. Recognize clinical problems and drugs related to Hyperkalemia /Hypokalemia. Assess/ observe for signs of Hyperkalemia /Hypokalemia. Record intake/ output. Report any alterations in the potassium levels. Determine the hydration status. For hypokalemia: eat high potassium food, for hyperkalemia: eat low potassium foods.
45 | P a g e

For Sodium:

For Potassium:

Monitor ECG results. Monitor the medical regimen in correcting hypokalemia/ hyperkalemia.

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Date Reported: June 30, 2010 COMPLETE BLOOD COUNT A Complete blood count (CBC), otherwise known as a Full blood count, is a hematological diagnostic test that is requested by a doctor or other another medical professional for the purpose of evaluating the composition and concentration of cellular blood components. The CBC is a basic screening test and is one of the most frequently ordered laboratory procedures. The findings in the CBC give valuable diagnostic information about the hematologic and other body systems, prognosis, response to treatment, and recovery. The CBC consists of a series of tests that determine number, variety, percentage, concentrations, and quality of blood cells. A CBC may be used as a preoperative to ensure adequate carrying capacity of oxygen and hemostatis and to identify the presence of infection. TEST Hemoglobin RESULT 102 g/ L REFERENCE 115-155 g/ L REMARK Low RATIONALE INTERPRETATION

Hemoglobin determination is Result is below normal part of a complete blood count. range indicates anemia It screens for disease associated with anemia, determines the severity of anemia, follows the response anemia to treatment for and evaluates
47 | P a g e

polycythemia. Hemoglobin, component of the main

erythrocytes,

serves as the vehicle for the transportation of oxygen and carbon dioxide. Hemoglobin also serves as an important buffer in the extracellular fluid. In tissue, oxygen concentration is lower and the carbon dioxide level and hydrogen are ion concentration Unoxygenated higher.

hemoglobin

binds to hydrogen ions thus raising the pH. The efficiency of this buffer system depends on the ability of the CO2 or bicarbonate to be eliminated in the lungs and kidneys, respectively.

48 | P a g e

Hematocrit

0.37

0.36-0.38

Normal

Hematocrit

is

part

of

the

Result is within normal range.

complete blood count. This test determines red blood cell mass. The results are expressed as the percentage of packed red cells in a volume of whole blood. It is an important measurement in the determination of anemia or polycythemia.

RBC Count

4.58 x10^6/uL

4.20-6.10 x10^6/uL

Normal

RBCs

contain

haemoglobin,

Result is within normal range.

which is needed to carry oxygen to body cells. the values for the total number and of RBCs, haemoglobin hematocrit

have to be known to calculate the RBC incides, and to identify the types of anemias. WBC Count 6.27 x10^3/uL 5.0-10.0 x10^3/uL Normal White blood cells, or leukocytes are cells of
49 | P a g e

Result is within

the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a hematopoietic stem cell. Leukocytes are found throughout the body, including the blood and lymphatic system. The number of WBCs in the blood is often an indicator of disease. An increase in the number of leukocytes over the upper limits is called leukocytosis, and a decrease below the lower limit is called leukopenia. The physical properties of leukocytes, such

normal range.

50 | P a g e

as volume, conductivity, and granularity, may change due to activation, the presence of immature cells, or the presence of malignant leukocytes in leukemia. DIFFERENTIAL COUNT Neutrophil 84 % 55-75% High Neutrophils numerous are the most Result is above normal blood elevated Neutrophils indicates the presence of acute infections, inflammatory disease, tissue damage and cancer.

circulating

cells and they respond more rapidly in large numbers to the inflammatory and tissue injury sites than leukocytes. during acute infection, the bodys first line of defence is the neutrophils. Lymphocyte 14% 20-35% Low They comprise the

second Result is below normal Decreased level may

51 | P a g e

largest group of leukocytes. Lymphocytes are responsible

for immune responses. are cells. two The main B lymphocytes: B

There of

indicate as a result of cancer and neurologic disorders.

types cells

cells and T make

antibodies that attack bacteria and toxins while the T cells attack body cells themselves when they have been taken over by viruses or have become cancerous. Lymphocytes secrete products modulate (lymphokines) the that functional

activities of many other types of cells and are often present at sites of chronic inflammation Monocyte 2% 2-10% Normal Monocytes and macrophages play important roles in the immune defence, inflammation and tissue remodelling and they do so by phagocytosis, antigen processing and presentation and
52 | P a g e

Result is within normal range.

by

cytokine

production.

Analysis of these processes can be done with primary cells or with model cell lines. Here the cell line Mono Mac 6 is a useful tool, which represents the only mature human monocytic cell line available to date. Eosinophil 0 1-6% Low Eosinophils become active when you have certain allergic diseases, infections, and other medical conditions. Result is below normal Decreased level may indicate as a result of stress and adrenal cortical hyperfunction. Platelet 250 x10^3/uL 150-400 x10^3/uL Normal The platelet count is the number Platelet count is within of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated
53 | P a g e

normal range.

measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow. MCH (Mean corpuscular hemoglobin) 28.4 pg 25.60-32.20 pg Normal Mean corpuscular hemoglobin Platelet count is within (MCH) is a calculation of the average amount of oxygencarrying hemoglobin inside a red a blood higher cell. Macrocytic while RBCs are large so tend to have MCH, microcytic red cells would have a lower value. (MCH) is a calculation amount of of the average oxygen-carrying normal range.

hemoglobin inside a red blood

54 | P a g e

cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value. MCHC (Mean corpuscular hemoglobin concentration) 35.3 g/dl 32.20-35.50 g/dl Normal Mean corpuscular hemoglobin Platelet count is within concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin concentrated is abnormally inside the red normal range.

cells, such as in burn patients and hereditary spherocytosis, a

55 | P a g e

relatively disorder. MCV (Mean corpuscular volume) 80 fl 79.40-94.80 fl Normal Mean

rare

congenital

corpuscular

volume Platelet count is within normal range.

(MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, smaller deficiency thalassemias. Nursing Responsibilities your than anemia RBCs are normal or

(microcytic) as is seen in iron

Explain test procedure. Explain that slight discomfort may be felt when skin is punctured. Avoid stress if possible because altered psychological states influence and damage normal CBC values
56 | P a g e

Select hemogram components ordered at regular intervals, should be consistently drawn at the same time of day for accurate comparison. Natural body rhythms cause fluctuations in lab values at certain times of the day.

Dehydration or overhydration can dramatically alter values. Both of these states should be communicated to the lab. Fasting is not necessary. However, fat-laden meals may alter some test results.

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Date Reported: June 30, 2010 TEST Clotting time RESULT 3:00 mins REFERENCE 2:00-5:00 mins REMARK Normal RATIONALE The tests frequently used to monitor clotting time are prothrombin time, partial thromboplastin activated time, partial INTERPRETATION The result is within normal range.

thromboplastin time, and coagulation time or LeeWhite clotting time. Bleeding time 1:15 mins 1:00-3:00 mins Normal The tests frequently The result is within normal range.

performed when there is a history of bleeding, familial bleeding screening. or preoperative

Nursing Responsibilities Explain the purpose of the laboratory and diagnostic test.
58 | P a g e

Give a detailed explanation concerning the laboratory and diagnostic procedures and the need for the compliance with procedure.

Explanation of the tests and procedures to the family members could be helpful with test compliance. Inform of any food, beverages and drug restrictions. Listen to the expressed anxiety and promote test compliance. Assess the chest discomfort by eliciting the intensity, duration, and location of the pain from the patient. Provide care as prescribed by the physician.

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DRUG STUDY Generic Name: Penicillin G

Brand Name: Classification: Suggested Dose: Mode of Action:

Pen G Antibiotic 5 million units IVTT evey 6 hours All penicillin derivatives produce their bacteriocidal effects by inhibition of bacterial cell wall synthesis. Specifically, the cross linking of peptides on the mucosaccharide chains is prevented. If cell walls are improperly made cell walls allow water to flow into the cell causing it to burst. is indicated in the therapy of severe infections caused by penicillin G-susceptible microorganisms when rapid and high penicillin levels are required in the conditions listed below. Therapy should be guided by bacteriological studies (including susceptibility tests) and by clinical response.

Indication:

Pneumococcal infections. Staphylococcal infections-penicillin G sensitive. Other infections

Contraindications: Interactions:

A history of a previous hypersensitivity reaction to any penicillin Concurrent administration of bacteriostatic antibiotics (e.g., erythromycin,tetracycline) may diminish the bactericidal effects of penicillins by slowing the rate of bacterial growth. Bactericidal agents work most effectively against the immature cell wall of rapidly proliferating microorganisms. Penicillin blood levels may be prolonged by concurrent administration of probenecid which blocks the renal tubular secretion of penicillins.
60 | P a g e

Displacement of penicillin from plasma protein binding sites will elevate Side Effects: the level of free penicillin in the serum. The following hypersensitivity reactions: skin rashes ranging from maculopapular eruptions to exfoliative dermatitis; urticaria; and reactions resembling serum sickness, including chills, fever, edema,arthralgia and prostration.

Severe and occasionally fatal anaphylaxis Hemolytic anemia, leucopenia, thrombocytopenia, nephropathy, and neuropathyare rarely observed adverse reactions and are usually associated with highintravenous dosage. Cardiac arrhythmias and cardiac arrest may also occur. (High dosage of penicillin G sodium may result in congestive heart failure due to high sodium intake.)

Adverse Effects:

Patients given continuous intravenous therapy with penicillin G potassium in high dosage (10 million to 100 million units daily) may suffer severe or even fatal potassium poisoning, particularly if renal insufficiency is present. Hyperreflexia, convulsions,

Nursing Responsibilities:

and coma may be indicative of thissyndrome. 1. Give the right drug to the right patient at the right time with the right dose at the right route. 2. Inform the patient about the drug she is receiving including the risks and benefits. 3. Note any allergy to drug and to other drugs related.
4. Inform that the drug should only be used to treat bacterial infections

5. Instruct patient to take as directed

6. Remind that skipping doses or not completing the full course of

therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood thatbacteria will develop resistance and will not be treatable
7. remind that stopping the medication too early may result in a return

Bibliography:

of the infection. http://www.rxlist.com/pfizerpen-drug.htm

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Generic Name:

Ranitidine Hydrochloride

Brand Name: Classification: Suggested Dose:

Zantac, Zantac-C, Zantac EFFERdose, Zantac Geldose, Zantac 75 Pharmacologic class: Histamine H2 receptor antagonist Therapeutic class: Antiulcerative Adults: 150mg PO bid or 300mg once daily hs. Dosage up to 6g/day may be prescribed in patients with Zollinger-Ellison syndrome

Parenteral: 50mg IV or IM q6 to q8h. When administering IV push, dilute to a total volume of 20 ml and inject over a period of 5 minutes. Dilute 50mg ranitidine in 100ml of D5W and infuse over 15 to 20 minutes.

Mode of Action:

Maintenance therapy of duodenal ulcer: 150mg PO hs. Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food and pentagastrin-stimulated gastric acid are inhibited. Active duodenal and gastric ulcer Maintenance therapy for duodenal or gastric ulcer Pathologic hypersecretory conditions, such as Zollinger-Ellison syndrome(ZES) Gastroesophageal reflux disease Erosive esophagitis Heartburn Contraindicated in patients hypersensitive to drug and those with acute porphyria.
62 | P a g e

Indication:

Contraindications:

Interactions:

Antacids: may interfere with ranitidine absorption Diazepam: may decrease absorption of diazepam Glipizide: may increase hypoglycemia effect Procainamide: may decrease a renal clearance procainamdie Warfarin: may interfere with warfarin clearance CNS: vertigo, malaise, headache EENT: blurred vision Hepatic: jaundice Other: burning and itching at injection site Pancytopenia Reversible leucopenia Thrompocytopenia Anaphylaxis

Side Effects:

Adverse Effects:

Nursing Responsibilities:

Angioedema 1. Give the right drug to the right patient at the right time with the right dose at the right route. 2. Inform the patient about the drug she is receiving including the risks and benefits. 3. Note any allergy to drug and to other drugs related. 4. Instruct patient to take as directed with or immediately following meals. 5. Remind patient to take once-daily prescription drug at bedtime for best results. 6. Advise patient to report abdominal pain, blood in stool or emesis and other signs and symptoms. 7. Use cautiously in patients with hepatic dysfunction. Adjust dosage with impaired kidney function 8. Instruct patient to avoid things that may aggravate symptoms (i.e., alcohol, aspirin, NSAIDS, caffeine, chocolate, and black pepper) 9. Symptoms of breast tenderness will usually disappear after several weeks; report if persistent and evaluate need to stop drug.
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Bibliography:

10. Maintain adequate hydration. Spratto, G. and Woods, A. (2008). 2008 Edition PDR Nurses Drug Handbook. NY, USA. Pages 1356-1358 Lippincott Williams and Wilkins. Nursing 2007 Drug Handbook. Pages 722-723

Generic Name:

Ketorolac Tromethamine

Brand Name: Classification: Suggested Dose:

Toradol Nonsteroidal anti-inflammatory drug 10 mg PO every 4-6 hours, or 30-60 mg IM, switching to oral form as soon as possible, or 30 mg IV as single dose Opthalmic: 1 gtt to affected eye q.i.d; reduce dosage with renal impairment and in patients>65 years old

Mode of Action:

Possesses anti-inflammatory, analgesic, and antipyretic effects

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Indication:

Short term management of pain Ocular itchingcaused by seasonal allergic rhinitis Postoperative inflammation following cataract surgery Pain and burning or stinging following corneal refractive surgery Contraindicated in patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and those at risk for renal impairment from volume depletion or at risk of bleeding.

Contraindications:

Contraindicated in patients with history of peptic ulcer disease or GI bleeding, past allergic reactions to aspirin or other NSAIDs, and during labor and delivery or breas-feeding.

Contraindicated as prophylactic analgesic before major surgery or intraoperatively when hemostasis is critical; and in patients currently receiving aspirin or probenecid. ACE inhibitors: may cause renal impairment, particularly in volume depleted patients. Anticoagulants, salicylates: may increase salicylate or anticoagulant levels in the blood Antihypertensives, diuretics: may decrease effectiveness Lithium: may increase lithium level Methotrexate: may decrease methotrexate clearance and increased toxicity CNS: dizziness, dizziness, headache, sedation CV: edema, hypertension, palpitations GI: nausea, dyspepsia, GI pain, diarrhea, peptic ulceration, vomiting, constipation, flatulence, stomatitis Hema: decreased platelet adhesion, purpura, prolonged bleeding time. Skin: pruritus, rash, diaphoresis Other: pain at injection site
65 | P a g e

Interactions:

Side Effects:

Adverse Effects:

Arythmias Perforation Bronchospasm

Nursing Responsibilities:

Anaphylaxis 1. Identify reasons for therapy, onset, location, pain intensity/level, characteristics of symptoms 2. Correct hypervolemia prior to administering 3. Warn patient receiving drug IM that pain may occur at injection site. Put pressure on site for 15-30 seconds after injection to minimize local effects 4. Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine, or stool; coffee-ground vomit; and black, tarry stool. Tell him to notify immediately if any of these occurs. 5. Alert the patient using NSAIDS for serious GI toxicity, including peptic ulcers and bleeding can occur despite lack of symptoms. 6. Instruct to take only as directed; do not exceed prescribed dosage. May take with food/milk if GI upset occurs. 7. Inform the patient that drug causes drowsiness and dizziness; avoid activities that require mental alertness 8. Instruct to avoid alcohol, aspirin, and all OTC agents without approval 9. With eye drops, transient stinging or burning may occur. Instruct not to wear soft contact lens. Report eye reactions that do not subside with therapy 10. Drug is for short term use only, review adverse effects related to prolonged therapy and with other conditions. Spratto, G. and Woods, A. (2008). 2008 Edition PDR Nurses Drug Handbook. NY, USA. Pages 858-860 Wolters Kluwer, Lippincott Williams and Wilkins. Nursing 2007 Drug Handbook. Pages 385-387

Bibliography:

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Generic Name:

Dexamethasone

Brand Name: Classification: Suggested Dose: Mode of Action:

Decadron Glucocorticoid 8 mg once a day Dexamethasone is a glucocorticoid agonist. Unbound dexamethasone crosses cell membranes and binds with high affinity to specific cytoplasmic receptors. This results in a modification of transcription and, hence, protein synthesis in order to achieve inhibition of leukocyte infiltration at the site of inflammation, interference in the function of mediators of inflammatory response, suppression of humoral immune responses, and reduction in edema or scar tissue. The antiinflammatory actions of dexamethasone are thought to involve phospholipase A2 inhibitory proteins, lipocortins, which control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes. Arthritis
Lupus Psoriasis, or Breathing disorders Allergic disorders Skin conditions

Indication:

Contraindications: Interactions:

Ulcerative colitis Fungal infection anywhere in the body. Hypersensitive to any components of this product.

Aminoglutethimide Amphotericin B injection and potassium-depleting agentsantibiotics

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 Anticholinesterases Anticoagulants, oral Antidiabetics Antitubercular drugs Cholestyramine. Cyclosporine Dexamethasone suppression test (DST) Digitalis glycosides Estrogens, including oral Hepatic Enzyme Inducers, Inhibitors and Substrates Ketoconazole Nonsteroidal anti-inflammatory agents (NSAIDS) Phenytoin Skin tests. Thalidomide Side Effects: Vaccines Sleep problems (crash), mood changes; Acne, dry skin, thinning skin, bruising or discoloration; Slow wound healing; Increased sweating; Headache, dizziness, spinning sensation Vomiting, stomach pain, bloating; Muscle weakness, or Changes in the shape or location of body fat (especially in your Adverse Effects: arms, legs, face, neck, breasts, and waist). Problems with vision Swelling, rapid weight gain, feeling short of breath; Severe depression, unusual thoughts or behavior, seizure (convulsions);
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 Bloody or tarry stools, coughing up blood; Pancreatitis Low potassium Nursing Responsibilities: Dangerously high blood pressure 1. Give the right drug to the right patient at the right time with the right dose at the right route. 2. Inform the patient about the drug she is receiving including the risks and benefits. 3. Note any allergy to drug and to other drugs related.
4. they should be warned not to discontinue the use of corticosteroids

abruptly or without medical supervision

5. remind them that a prolonged use may cause adrenal insufficiency

and make patients dependent on corticosteroids, they should advise any medical attendants that they are taking corticosteroids and they should seek medical advice at once should they develop an acute illnessincluding fever or other signs of infection
6. Warned to avoid exposure tochickenpox or measles, Patients should

also be advised that if they are exposed, medical advice should be sought without delay.
7. Patients should be carefully observed with frequent measurements of

blood pressure, weight, height, intraocular pressure, and clinical evaluation for the presence of infection
8. Instruct to Take this medication by mouth as directed by your doctor 9. Take with food or milk to prevent stomach upset 10. Inform that the dosage and length of treatment are based on your

medical condition and response to therapy. Your doctor may attempt to reduce your dose slowly from time to time to minimize side Bibliography: effects. http://www.drugs.com/mtm/dexamethasone.html http://www.drugbank.ca/drugs/DB01234 http://www.rxlist.com/decadron-drug.htm
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Generic name

Chloramphenicol

Brand name

Chloromycetin

Classification Suggested dose Mode of action

Antibiotic, Chloramphenicol 500 mg capsule Chloramphenicol is primarily bacteriostatic. It binds to the 50S subunit of the ribosome, thereby inhibiting bacterial protein synthesis.

Indication

Used in treatment of cholera, as it destroys the vibrios and decreases the diarrhea. It is effective against tetracycline-resistant vibrios. It is also used in eye drops or ointment to treat bacterial conjunctivitis. hypersensitive to the drug; pregnancy, especially near term opthalmically in the presence of dedritic keratitis, vaccinia,

and during labor; lactation. Contraindication vericalla, mycobacterial or fungal eye infections, or following removal or a corneal foreign body. bone marrow depressant drugs Drug interactions Acenocoumarol Acetohexamide Anisindione Chlorpropamide Cyclosporine Dicumarol Ethotoin Fosphenytoin Glibenclamide Gliclazide Glipizide Glisoxepide
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Generic name Brand name

Vitamin B Complex

Surbex

Classification Suggested dose

Water soluble vitamins The solution for injection is applied parenterally - intramuscularly or (rarely) intravenously in dose 1-2 ml daily or each second day, within 5-10 days. The film-coated tablets are used orally in following doses: adults - 26 tablets daily; children 1-2 tablets daily.

Mode of action

The water-soluble vitamins act largely as coenzymes, with small molecules combing with a larger protein compound (apoenzyme) to form an active enzyme that accelerates the interconversion of chemical compounds. Coenzymes participate directly in chemical reactions; when the reaction runs its course, coenzymes remain intact and participate in additional reactions. Water-soluble vitamins, similar to their fat-soluble counterparts, consist of carbon, hydrogen, and oxygen atoms. They also contain nitrogen and metal ions including iron, molybdenum, copper, sulfur, and cobalt. Because of their solubility in water, water-soluble vitamins disperse in the body fluids without being stored to any appreciable extent. If the diet regularly contains less than 50% of the recommended values for watersoluble vitamins, marginal deficiencies may develop within 4 weeks Support and increase the rate of metabolism

Indication

Maintain healthy skin and muscle tone Enhance immune and nervous system function Promote cell growth and division, including that of the red blood cells that help prevent anemia Reduce the risk of pancreatic cancer, one of the most lethal forms of cancer, when consumed in food, but not when ingested in vitamin tablet form]
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Contraindication

Vitamin B complex should not be used in hypersensitivity to any of the

Generic name Brand name

Metronidazole Apo-Metronidazole (CAN), Flagyl, Flagyl 375, Flagyl ER, Flagyl IV, MetroGel, MetroGel-Vaginal, NidaGel (CAN), Noritate, Protostat

Classification Suggested dose Mode of action

Anti-infective; Antiprotozoal 500mg IVTT 2 hrs Disturbs DNA synthesis in susceptible bacterial organisms

Indication

Preoperative, intraoperative, undergoing surgery

postoperative

prophylaxis

for

patients

Contraindicated with hypersensitivity to metronidazole; Use cautiously with CNS diseases, hepatic

pregnancy (do not use for trichomoniasis in first trimester). Contraindication disease, candidiasis (moniliasis), blood dyscrasias, lactation. Drug interactions Drug-drug Decreased effectiveness with barbiturates Disulfiram-like reaction (flushing, tachycardia, nausea, Psychosis if taken with disulfiram Increased bleeding tendencies with oral anticoagulants Falsely low (or zero) values in AST, ALT, LDH,

vomiting) with alcohol Drug-lab test triglycerides, hexokinase glucose tests

Side effects

CNS: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, 74 | P a g e fatigue EENT: Rhinitis, sinusitis, pharyngitis, GI: Nausea, vomiting, diarrhea, abdominal pain, furry tongue,

NURSING THEORIES APPLICABLE TO THE CASE PRESENTED 1. Florence Nightingales Environment Theory

Being well is using ones power to the full extent. Health is maintained to the prevention of disease via environmental health factors. She linked health with five environmental factors: (1) pure or fresh air, (2) pure water (3) efficient drainage, (4) cleanliness, and (5) light especially direct sunlight. Deficiencies in these 5 factors produced lack of health or illness. An individual with vital reparative processes needs to deal with disease and desirous of health. It is therefore important to keep the patient warm, maintaining a noise-free environment, and attending to the patients diet on terms of assessing intake, timeliness of the food, and its effect of the person. To our patient: The patients condition being admitted in the ENT ward SPMC is considerably inappropriate for her wellness. The ward surrounded by other patients who were emotionally and financially as well may affect her well being too. The ward is inevitably noisy and crowded due to the other patients conditions with their watchers and visitors health around. Environment at the scenario is obviously detrimental to our clients status; she is unable to rest fully and was even disturbed the more. However, her stay in this institution is relevant to the determination of her cases definite diagnosis and possible treatment available. Theres no other option for her available considering her financial condition but the institutions environment.

2. Lydia Halls Core, Care, Cure theory 75 | P a g e

The care, cure, core model provides an opportunity for Patients to develop trust and communicate their fears and concerns in relation to disease management. Patients who have their care, cure, and core needs met have improved self-esteem and awareness of the importance of disease management and improved quality of life. Care Model Hands on care for patients produce an environment of comfort and trust and promotes open communication between nurses and patients. Cure Model The cure model dominates when nurses perform physical assessments and care management plans .During this phase, nurses assess patients ability to perform activities of daily living based on physical changes that occur during walking, talking or bathing. Core Model The core model dominates when nurses and patients are able to discuss emotional concerns and distress to physical and mental changes due to patients disease process.

To our patient: As student nurses, it is our duty to give comfort to our patient and this involves communication / conversation and the patients should develop feelings of security and verbalize concerns of disease management, emotional, and/or social issues in relation to the lifestyle changes they are experiencing. Bea A., with her live-in partner, was open in expressing of his thoughts and fears, this would decrease her anxiety. She was interested in addressing her concerns and distress due to her perceived ability or inability to manage his disease, and general fear of their disease process. As student nurses of Bea, we perform physical assessment and make a plan of care for her needs and condition.

3. Jean Watsons Human Caring Theory

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According to Watson nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health. She believes that despite the difficult and stressful situations, nurses must learn how to deal with the complexities arising in every patient situation and must find ways in preserving their caring practice. Jean Watson view caring as the most valuable attribute nursing has to offer to humanity. Her key assumptions about caring include ten Carative Factors. She describes caring in both philosophical and scientific terms Caring is more healthogenic than is curing. A science of caring is complementary to the science of curing. The ten primary carative factors The structure for the science of caring is built upon ten carative factors. These are: 1. The formation of a humanistic- altruistic system of values. 2. The installation of faith-hope. 3. The cultivation of sensitivity to ones self and to others. 4. The development of a helping-trust relationship 5. The promotion and acceptance of the expression of positive and negative feelings. 6. The systematic use of the scientific problem-solving method for decision making 7. The promotion of interpersonal teaching-learning. 8. The provision for a supportive, protective and /or corrective mental, physical, sociocultural and spiritual environment. 9. Assistance with the gratification of human needs. 10. The allowance for existential-phenomenological forces.

To our patient During our duty in Southern Philippines Medical Center, the main duty of the nurse for patient is observed. We really gave time to take care of our patient. We established trust the first time we met our patient Bea A. with the significant others and respected her as a human person. We, as student nurses, also lend our ears in listening to client and the significant others verbalization of negative and positive feeling regarding the onset of the disease. After
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establishing trust, we rendered health teachings that could aid in the recovery of the client such as complying with the medications as ordered by the doctor.

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NURSING CARE PLAN Ineffective Tissue Perfusion Date/ Time J U L Y 2, 2010 @ 10:00 am Subjective: A Cues Need Nursing Diagnosis w/ Ineffective Tissue Perfusion related to decrease hemoglobin count Objective of Care Nursing Interventions w/ Evaluation

luspad gud ko as C verbalized by the T patient. I Objective: V - Weak pulse I - Hgb of T 102.0 g/dl - BP: 120/80 Y - Pulse rate: 68 - Capillary E refill of 2. X - Palmar pallor E noted. R C I S E

Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased in oxygen resulting in the failure to nourish the tissues at the capillary level. ( Pathophysiology concepts and applications for health care professionals)

At the end of 5 1. 1. Assess for possible hours span of causative factors related to care, patient: temporarily impair arterial blood flow. - Patient Early detection of cause maintains facilitates prompt, effective optimal tissue treatment. perfusion to vital organs, as evidenced by 2. Monitor quality of all strong pulses. peripheral pulses, warm Assessment is needed for skin and ongoing comparisons; loss of absence of peripheral pulses must be reported or treated respiratory distress and immediately. absence of vomiting. 3. Elevate the head of the patient. To prevent vomiting. 4. Encourage quiet, restful environment atmosphere. Conserves energy or lower tissue oxygen demands

Goal Met.

At the end of 5 hours span of care, patient: Patient was free from further complications as evidenced by normal pulses, with no respiratory distress, skin was warm to touch, and patient does not vomits.

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P A T T E R N 7. Discuss individual risk factor such as smoking, drinking alcohol, and taking of NSAIDs. information necessary for client to make informed choices about remedial risk factors and committed to lifestyle changes, as appropriate, to prevent onset of complications/manage symptoms when condition is present. 6. Encourage rest after meal. To maximize blood flow to stomach, enhancing digestion.

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Alteration in Nutrition Date/ Time J U L Y 2, 2010 @ 10:00 am Objective: dili ko kakaon ug daghan kay nabudlayan ko mukaon as verbalized by the patient Subjective: N U T R I T I O N Paralysis A of one side of the L face Flaccid Facial muscle Loss of taste M E T A Traumatized tissue can alter the intake of nutrients to meet metabolic needs of an individual. Cues Need Nursing Diagnosis w/ Alteration in Nutrition related to trauma as evidenced by muscle weakness. At the end of 5 hours span of care, patient: Experience adequate nutrition through oral intake. Experience an increase in the amount or type of nutrients ingested. 1. Document actual weight; do not estimate. Patients may be unaware of their actual weight or weight loss due to estimating weight. Goal Met. Objective of Care Nursing Interventions w/ Evaluation

At the end of 5 hours span of care, patient:

(Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationale by Marilynn E. Doenges Mary Moorhouse Alice Murr )

2. Suggest ways to assist Nutritional status patient with meals as is adequate needed. Ensure a pleasant environment, Intake of 980cc facilitate proper position, and provide Output of 390cc good oral hygiene and dentition. Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration. 3. Provide companionship during mealtime. Attention to the social aspects of eating
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B Inability O to puff out L cheek. I C

is important in both the hospital and home settings. 4. Discourage beverages that are caffeinated or carbonated. These may decrease appetite and lead to early satiety.
5. Use

P A T T E R N

flavoring or seasoning in foods. To enhance food satisfaction and stimulate appetite.

6. Provide

oral care before/after meals 7. Promote adequate fluid intake Limiting fluids 1 hour prior to meal decreases possibility of early satiety

Disturbed Body Image

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Date / Time J U L Y 2, 2010 @ 10:00 am

Cues

Need

Nursing Diagnosis w/

Objective of Care

Nursing Interventions w/

Evaluation

Objectives:

S E

Disturbed Body Image related to traumatized tissue

Assymetrica L l facial F movement Weakness on left side of facial muscle Inability to close left eye Pus discharges in left ear Exotropia

P E R C E P

T I O N

At the end of 5 1. Establish therapeutic nursehours span of client relationship care, patient: to convey an attitude of - Verbalize caring and developing of trust. acceptanc e of self in Biophysical illness 2. Provide information at situation can lead to clients level of acceptance. - Verbalize confusion in mental relief of to allow easier assimilation picture of ones anxiety physical self. and adaptatio n to 3. Discuss reasons for isolation and procedures when used and (Nurses Pocket actual make time to talk/listen to Guide Diagnoses, body client Prioritized image Interventions, and - Verbalize to decrease sense of Rationale by understan isolation. Marilynn E. ding of Doenges body changes Mary Moorhouse Alice Murr ) 4. Visit client frequently and acknowledge the individual as someone who is worthwhile. Provides opportunities for listening to concerns and

Goal Met.

At the end of 5 hours span of care, patient: Begin to cope with the changes caused by disability. Verbalizes adjustment or adaptation to disability.

Unable to open S eyelids fully

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E L F

questions.

5. Observe interaction of client with significant others. Distortions in body image may be unconsciously reinforced by family members.

C O N C E P T

6. Encourage significant others to treat client normally and not as invalid. to convey acceptance and not revulsion when the clients appearance is affected.

P A T T E R N

7. Provide assistance with self care needs as necessary to promote individual independence.

8. Encourage client to look at/touch affected body part to begin to incorporate changes into body image.
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9. Help client to select and use clothing. to minimize body changes and enhance appearance.

Risk for Infection Date / Time J U L Y 2, 2010 @ 10:00 am Moist skin Punctured marks of injections. Diagnosed as facial nerve palsy. Cues Need Nursing Diagnosis w/ Objectives: H E A L T H Inadequate acquired immunity is at increased risk for being invaded by pathogenic Risk for Infection related to tissue destruction secondary to facial muscle paralysis At the end of 5 hours span of care, patient: Free of skin breakdow n. Demonstr ate technique s, lifestyle changes to promote 1. Provide for isolation as indicated. Reduce risk of cross contamination. Goal Met. Objective of Care Nursing Interventions w/ Evaluation

At the end of 5 hours span of care, patient: Remains free from infection Demonstra ted techniques , lifestyle
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2. Maintain sterile technique for invasive procedure like inserting IVF. Prevent contamination.

E Insertion site R of Intravenous. C E P T I O N

organisms. -

(Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationale by Marilynn E. Doenges Mary Moorhouse Alice Murr )

safe environm ent. Verbalize understan ding of individual causative/ risk factors.

3. Monitor visitors/caregivers To prevent exposure of client. 4. Maintain adequate hydration and perineal care. Reduce risk of ascending UTI.

changes to promote safe environme nt. Verbalizes understand ing of individual causative/r isk factors.

H E A L T H

5. Instruct client in techniques to protect the integrity of skin. To prevent spread of infection.

M A

6. Emphasize necessity of taking antibiotics as indicated. Premature discontinuation of treatment when client begins to feel well may result in return of infection.

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N A G E M E N T

P A T T E R N

Risk for Injury Date / Time Cues Need Nursing Diagnosis Objective of Nursing Interventions w/ Evaluation
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w/ J U L Y 2, 2010 @ 10:00 am Exotropia High bed Temperatur e:35.8; afebrile P E R C E P T I O N Uncoordina ted eye Loss of hearing on left ear Objectives: H E A L T H Risk for injury related to decrease in sensory perceptual functioning of visual and auditory fields. Auditory and visual field impairment, the component that increases the risk of injury. This finding highlights the importance of auditory and visual field deficits in the risk of injury and falls and supports other findings on decrements in mobility and increased risk of bumping with worsening auditory and visual field function. (Source: Physical

Care At the end of 5 hours span of care, patient: - Be free from injury - Identify potential risk factors in the environment - Recognize need for assistance to prevent injuries - Identify resources to assist in promoting a safe environment . 1. Orient patient to Goal Met. environment. Orientation reduces fear related to At the end of 5 unfamiliar hours span of environment. care, patient: 2. Provide adequate lighting during night time. The use of natural or halogen lighting is preferred to improve vision for patients with vision problems. 3. Asses mood, coping abilities, personality styles Result in carelessness/ increased risk-taking without consideration of consequences Remains free from injury Identifies potential risk factors in the environme nt Recognize s need for assistance to prevent injuries Identifies resources to assist in promoting
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4. Recommend use of visual aids when appropriate. The use of

H E A L T H

Therapy Clinical Handbook for Pta's By Olga Dreeben page 448)

appropriate visual aid may prevent from injury.

a safe environme nt

5. Remove environmental barriers To ensure safety.

M A N A G E M E N T

6. Maintain bed in low position with side rails up, if appropriate. Side rails help remind patient not to get up without help when needed. 7. Keep bed in locked position. This prevent falls.

P
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A T T E R N

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PROGNOSIS

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CRITERIA TO RATE ONSET OF ILLNESS

GOO D

FAIR

POO R

JUSTIFICATION

RATIONALE

This was rated as good People should seek or visit because the patient, Bea medical A. sought attention. She prescribed detect easy recovery or institution observe for any medical check-ups as soon as they

proper medication for her deviations from their usual normal physiologic pattern. This may prevent the exacerbation of a specific disease which may later on complicate if not given appropriate medical attention. We rated this criterion as . The duration of illness DURATION OF ILLNESS poor for her condition depends ultimately on the because a week before the severity and intensity of a admission she noticed pus certain disease and the on her left ear but she patients A week after the pus she status eagerness which may by to be her didnt pay attention on it. improve her current health noticed that the pus has evidenced

blood already and she compliance to the doctors went to the clinic of Dr. order and avoidance to Hernandez for check-up. aggravating factors and etc. Then a week after that she felt numbness on her left face and went to SPMC PRECIPITATIN G FACTORS for admission. We gave good because she Precipitating only one precipitating those factors and factor present from all modifiable the case. factors that can are are be

other factors presented in reversible with the proper treatment and management. Another definition is that it is usually the culprit for a
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FAMILY SUPPORT

Our clients parents are very supportive towards

specific disease. Our family is our foundation; our source of

Calculations Poor Fair Good = 1x1 = 1 = 2x1 = 2 = 3x6 = 18 Poor Fair Good

Scoring 1 2 3

Range 1.0-1.6 1.7-2.3 2.4-3.0

Total 21/8 = 2.625

After evaluating, we have rated the clients prognosis as GOOD. This means that the patient has a very good chance of complete recovery because his condition has been acted upon at an early stage, thereby the loss of chance of recurrence of the condition, and his gender, age, attitude towards health and supportive family will help him cope with the surgery physiologically and psychologically.

Discharge Planning Medication Take corticosteroid drug as ordered by the physician to lessen swelling.
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 Strictly follow amount of dosage that was ordered by the physician to prevent adverse effects. Once paralysis is slowly healing, taper drug as ordered by the physician, do not stop abruptly to avoid complications such as adrenal crisis. Take NSAIDs as ordered by the physician. Do not increase dose. Consult the doctor if pain or swelling not treated. Do not overdose Ranitidine. May cause harmful complications. Consult the physician if adverse effects occur. Monitor blood pressure upon taking Corticosteroids, may cause increase in BP. Anti-bacterial drug could be given to lessen signs and symptoms of the disease. It must be taken as ordered by the physician. Do not take unless it is prescribed. Exercise Exercise daily if tolerated. Use headband during exercises to prevent sweat to go inside the affected eye. Clear area of exercise of potential hazards that would cause complications to the present status. Massage affected part area to promote proper blood flow and to prevent hardening of muscles that would cause deformation. Treatment Do necessary precautions to prevent complications due to the dryness of the eyes. Close eyes manually by using the back of the fingers or lubricate eyes using eye drops. Use goggles or any device that could be used to protect affected eyes from dusts. Pharmacological treatment must be followed strictly.

Hygiene Clean affected eye thoroughly to prevent infection. Make sure that hand is always clean to prevent infection in the affected eye.
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 Do oral care properly. Assist mouth in moving to allow access in cleaning the mouth. Take a bath at least twice a day to lessen risk of infection. Use mild soap to lessen irritation in the affected eye. Out Patient Order Diet Encourage to eat three times a day. Must not skip nor miss a meal. Lessen salt and water intake during taking corticosteroids drug. May cause water Encourage eating rich in protein foods to promote wound healing. Encourage taking in foods rich in calcium to prevent osteoporosis during taking Encourage eating of nutritious foods such as fruits and vegetables to strengthen Take multivitamins which is not contraindicated to protect against illness. Follow-up check up regularly if indicated by physician or if unusualities occur. Report new or persistent signs of symptoms which are unfamiliar; it may be due to Check auditory status. To know if complications is worsening or not. Check for any signs of pus coming out from the ears.

some other causes.

and salt retention.

corticosteroids in long term. immune system.

RECOMMENDATION

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For the FAMILY: We recommend that the family will still continue to give the patient love and support especially in assisting her in doing the activities of daily living. It could help the patient in a faster recovery. The family must learn to understand the patients situation. They must also be aware of some medications that are really needed for the patient and the right knowledge to implement it properly. For the PATIENT: The patient should be aware with her condition. She must be well oriented of the facts about the things that she should be alarmed of. We recommend that the patient will comply with all the medications given to her by the physician. And as a patient she must follow all the doctors guidelines to her. She must discipline herself to all the things that must be avoided. Also, patient must learn the importance of proper hygiene in order to lessen other possible infections. For the HOSPITAL: The environment of the client must be well organized and clean to .promote relaxation and sanitation that would extremely help the patient to achieve good health. More importantly, the institution where the patient stays must also observed and practiced organized and clean environment to elevate clients comfort and promote wellness to all patients.

REFERENCES

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M. D. Boada and C. J. Woodbury. Journal of Neurophysiology, Vol 62, Issue 6 689. Albert L. Baert. Encyclopedia of Diagnostic Imaging Springer-Verlag Berlin 295. Paul W. Brazis, Joseph C. Masdeu, Jos Biller. Localization in clinical E. Theriault and J. Diamond. The Journal of experimental Biology.205, 1-12 http://www.medterms.com/script/main/art.asp?articlekey=6482 http://en.wikipedia.org/wiki/Robert_J._Havighurst http://en.wikipedia.org/wiki/Erikson

1260-1269, Copyright 1989 by APS

Heidelberg New York, 2008

neurology 5th edition. Lippincott Williams & Wilkins, 2001

(2002). 2002 The Company of Biologists Limited

%27s_stages_of_psychosocial_development#Love:_Intimacy_vs._Isolation_.28Young_ Adults.2C_20_to_34_years.29

http://www.businessballs.com/erik_erikson_psychosocial_theory.htm http://jn.physiology.org/cgi/content/abstract/62/6/1260 http://www.answers.com/topic/cutaneous-muscle http://www.gancao.net/acupuncture/bells-palsy-acupuncture-herbs-228 http://www.cureresearch.com/b/bells_palsy/stats-country.htm http://en.wikipedia.org/wiki/Facial_nerve http://www.meddean.luc.edu/lu ANATOMY and

men/MedEd/grossanatomy/h_n/cn/cn1/cn7.htm

PHYSIOLOGY 5th Edition by: Gary A. Thibodeau and Kevin T. Patton

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