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