PATIENT CARE PLAN
STUDENT
PATIENT INITIALS
ADMITTING DX
Wendel Veres
VZ
AGE
55
Left Facial Numbness
SEX
DATE
F
07/25/2018
DATE
OTHER MEDICAL DX
07/25/18
CAD, Diabetes Mellitus, Hypertension
Bell’s Palsy
NURSING DIAGNOSIS
(in priority order)
PATIENT-CENTERED
GOALS
NURSING
INTERVENTION
RATIONALE
EVALUATION
Risk for Infection related
to Bell’s Palsy as
evidenced by Left Eye
Droop
STG:
Patient will remain
infection free during shift
Assessment:
- Monitor vital signs every 4 hours
- Monitor for visual changes
- Monitor CBC and absolute neutrophil
count
Intervention:
- Administer artificial tears
- Administer glucocorticoid medications
- Collaborate with physician & health care
team regarding screening specimens for
culture and sensitivity
Teaching:
- Teach patient how to properly administer
artificial eye drops
- Teach the patient and family about
environmental and infectious host factors,
and aspects of prevention
- Educate the patient on the value of
frequent handwashing
Assessment:
- Provides a baseline that allows
quick recognition of deviations
(Cox; 54)
- Dryness of eye can lead to
irritation of cornea (Cox; 54)
- Provides essential basis for
diagnosis and treatment (Cox;
55)
Intervention:
- Lubricates cornea, relieves
dry, irritated eyes (WebMD)
- Reduces inflammation of the
facial nerve (WebMD)
- Allows accurate determination
of the causative organism &
identification of the antibiotic
that will be most effective
against the organism (Cox; 55)
Teaching:
- Allows patient to safely
administer medicated eye drops
at home (WebMD)
- Provides basic knowledge for
self-help and self-protection
(Cox; 55)
- Prevents cross-contamination
and nosocomial infections (Cox;
55)
STG:
Patient left eye remained infection free
during shift. Cornea lubricated, moist,
no signs of dryness or irritation
Subjective:
“The left side of my face is
numb, and it’s hard to
close my left eye, it’s
irritating.”
Objective:
- Facial droop left side of
face
- Left eye resists closing
- Smile one sided
- Slight drooling around
mouth
LTG:
Patient will return
demonstrate measures to
decrease the risk of
infection by discharge
LTG:
Pending discharge
PATIENT CARE PLAN