Question

what is the Care Plan as well as a Nurse's Progress Note on the patient with Characteristics below Ms. Z, a 30-year-old pregnant female, recreational badminton player, who spontaneously woke up with the inability to voluntarily move the right side of her face, including the inability to close her right eye, and slight drooping at the corner of her mouth. She tried to explain to her husband what was happening, but lacked the motor control to enunciate words. In a panic, he noticed she had facial drooping and mistook the lack of motor control for slurring of her words-- he thought she was having a stroke. Remembering the acronym, F.A.S.T., he called the ambulance. However, given her presentation and exceptional health history, the attending physician ended up excluding a stroke as a possible diagnosis. He thought Ms. Z's signs and symptoms better matched with Bell's Palsy because everything aligned perfectly with a Grade 5 on the House-Brackmann facial nerve scale (Links to an external site.) . She was prescribed corticosteroids and referred on to a neurologist who confirmed the diagnosis of Bell's Palsy with electroneuronography. The neurologist referred her to an ophthalmologist who prescribed her lubricating eye drops and suggested that she wore a pair of sunglasses or safety glasses to prevent any corneal drying and scratches. The opthamologist recommended that Ms. Z partook in physiotherapy for treatment so that she can safely return to badminton and everyday functioning without long-term implications. Clinical Impression Following the full examination of Ms. Z, there were a number of aspects regarding her case noted in the subjective and objective that make her a candidate for physiotherapy. Patient-centered care involves working towards pre-determined goals; which involve returning to sport and functional activities in the case of Ms. Z. Though the literature supporting physiotherapy is not strong for treating facial nerve paralysis and consequent lack of muscle innervation, Ms. Z is motivated to return to the badminton court. Currently, the positive tests described above pose a challenge in her visual and spatial awareness. Thus, sports-specific interventions can be used safely in a clinical setting to improve Ms. Z's condition that can be transferred onto the court and in everyday life. In addition, the problem list seen below can help guide and track the treatment: Problem list Lack proprioceptive awareness Decreased motor control of the facial muscles Cannot raise eyebrows Unable to produce different facial expressions Smile Difficulty with pronunciation Visual attention/input to right side The prognosis for Bell's palsy is described in the literature; stating that "most patients with Bell's palsy recover normally within 3 weeks, with or without medical intervention. However, full restoration may take up to 9 months in some cases and up to 30% of patients are left with complications, such as potentially disfiguring facial weakness or persistent lacrimation, needing further medical therapy". With this information, Ms. Z will be encouraged to seek physiotherapy treatment twice a week for six weeks. The first three weeks will be focusing on pain management and functional movement; followed by the last three weeks primarily focusing on return to sport and daily functional activities. Intervention Before being referred to physiotherapy, Ms. Z was prescribed corticosteroid treatment by the attending physician in the emergency room, as she is older than 16 and was treated within 72 hours of onset. Her diagnosis was confirmed using electroneuronography (ENoG) testing by her neurologist. Ms. Z's treatment also included eye care and protection from an opthamologist. At physiotherapy, Ms. Z was treated using acupuncture and exercise in hopes of speeding up her return to badminton and everyday function. Treatment Goals: Ms Z.'s treatment goals included returning to badminton through improving muscular control of the right side of the face, improving proprioceptive awareness while vision is impaired due to decreased lacrimation and eye protection, and decreasing pain surrounding her jaw. Overall, Ms. Z improved greatly on her balance over the course of her physiotherapy interventions. These improvements will transfer onto the court as she continues to work towards return to sport. Bell's palsy requires a multidisciplinary approach. Ms. Z should continue to see her ophthalmologist to treat symptoms related to the eye. Derived from the facial nerve, the greater pretrosal nerve is responsible for control and production of lacrimation in the eyes and the zygomatic branch, which supplies the Orbicularis Oculi, is responsible for eye closure so that the tear film can be spread equally over the eye. For Ms. Z, her facial nerve has undergone some type of damage and, therefore, must take the necessary steps toward managing her dry eye and mitigating the likelihood of suffering from vision loss in the future. In addition, there is evidence that supports the correlation between facial paralysis, specifically Bell's palsy and emotional distress, psychological care and support is recommended. The research suggests that psychological distress can start as early as the first week of onset, and patients with House-Brackmann grade 3 and higher have a greater risk for depression, lower quality of life and lower self-reported attractiveness. Thus, given that in our assessment findings in the House-Brackmann Facial outcome being 5, we decided to ensure that we monitor and screen Ms. Z's psychological well-being by using The Patient Health Questionnaire (PHQ-9). Ms. Z scored 8 on the PHQ-9 which puts her at a moderate risk for depression. As a result, we would refer Ms. Z to a clinical psychiatrist. Discussion Bell's Palsy presents as insidious unilateral facial paralysis which results from compression of cranial nerve VII. It is still poorly understood, however, etiology is believed to be associated with infection, nerve compression and autoimmune dysregulation. The diagnosis is made by ruling out more common issues such as stroke, Lyme disease, & tumor. With these ruled out, electroneuronography can be used to make the definitive diagnosis of Bell's Palsy. This case study involves a pregnant 30-year-old female, named Ms. Z. She is a recreational badminton player, who was diagnosed with right unilateral facial paralysis (Bell's Palsy) via electroneurography. After receiving corticosteroid injections in the ER, Ms. Z attended physiotherapy. Her main goal was to return to badminton by improving her right facial function, proprioceptive awareness and to decrease pain in her jaw. She received acupuncture and an exercise treatment plan to improve facial function and whole-body proprioception. Current evidence does not support the use of physiotherapy to rehabilitate facial muscle function in patients with Bell's Palsy. However, since she is a higher functioning badminton athlete, she was very concerned about how the visual symptoms of her condition would impact her hasty return to sport. For her safety, proprioception exercises were prescribed to compensate for loss of vision. Additionally, Ms. Z had a very strong patient preference for facial function exercises and acupuncture, therefore these were included in her treatment plan. Pain and balance were assessed throughout her rehabilitation plan. Her pain dropped by 45 mm over the course of three weeks in the VAS outcome measure where the minimum clinically important difference is 13.7 mm. Additionally, Ms. Z improved notably on her balance over the 6-week treatment block. She went from being unable to complete a tandem stance with eyes closed to completing a tandem balance on a bosu ball with eyes closed for 30 seconds. This marked improvement in balance will undoubtedly translate into a safer return to badminton. Although physiotherapy is not indicated for facial muscle function in patients with Bell's palsy, patient preference and functional goals play a large role in treatment. Symptoms can impede other activities of daily living and compensation strategies can be taught to aide the patient in coping with their condition. It is important to note that patients with Bell's palsy have been linked to greater risk of emotional distress due to, in part, the inability to participate in ADLs and enjoyable activities. Ms. Z was determined by the House-Brackmann Facial outcome measure and the PHQ-9 to be at risk for a greater risk for depression, lower quality of life and lower self-reported attractiveness. Because of this, Ms. Z will be referred to a psychologist

Answer 1

Bells palsy is a condition affecting the the facial nerve, which is the 7th cranial nerve. Here the cause may be rigorous practice, wind exposure etc that can cause weakness to the nerves.

Nursing care plan includes the following:

In this particular case, the patient experiences lack of proprioception, ocular disturbances, loss of muscle tone etc. Hence the nursing interventions are to be planned in such a way that apart from medication, these should aid the patient for recovery.

1. Eye care:

Use of protective wears during night

Topical application over eyes to keep the eyes closed during sleep

Using goggles to prevent dryness of eyes

2. Muscle tone care:

Gentle facial massage

Upward massage

Making facial expressions like frowning, wrinkling etc

Blowing out the cheeks

Hot massage over face

3.Psychosupportive care:

Psycho educating the patient that this condition has a good prognosis.

It can bring her back to her sports life.

It will not keep her off from playing badminton.

Sports Therapy and relaxation techniques

4. Diet care:

Practice chewing food with the side which is healthy

Regular intake of hot food which is nutritious

5. Oral care:

Keep your mouth and teeth clean

Maintaining healthy germ free gums