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ACKNOWLEDGEMENT

Teamwork divides the task and multiplies the success teamwork is one thing student

nurses cannot 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 will experience some degree of permanent paralysis.

(http://www.gancao.net/acupuncture/bells-palsy-acupuncture-herbs-228) In 2003, there were

12,682 estimated cases here in the Philippines.

(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


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


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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 : 27 years old

Sex : Female

Weight : 49kg

Height : 52

Address : Riverside, Davao City

Birthday : May 18, 1987

Birthplace : Bukidnon

Civil Status : Single

Nationality : Filipino

Religion : Roman Catholic

Educational Attainment : High School Graduate

Occupation : none/housewife

MEDICAL DATA

Hospital : SPMC

Ward / Bed Number : ENT ward, Isolation Room

Reason for Admission : Ear discharge

Admitting Date and Time : June 29, 2010 at 10:44 am

Admitting Diagnosis : Facial Nerve Palsy

Admitting Physician : Dr. Mark Wingleaf Yu

Final Diagnosis :

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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 t-

shirt 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 STAGE JUSTIFICATION

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 forsurvival.

Formal-Operational Stage (11

years and above)

-develop hypothetical-deductive

reasoning

-abstraction

-make hypothesis and solve

problems

-LOGICO

-MATHEMATICAL

-INTELLIGENCE

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 futuretask, and interacting with

others.

Selecting a Mate

Learning to live with a

Marriage Partner

Starting a Family

Rearing Children

Managing a Home

Getting started with an

Occupation

Taking on Civic

Responsibilities

Finding a Congenial SocialGroup

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.

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

TheoryIntimacy 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

achievingrelationships with family

and marital or mating partner(s).

Erikson explained this stage also in

terms of sexualmutuality - 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 beingand 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

withdrawalor 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 (7 th 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 5 th

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 thepons and themedulla, and controls the muscles of facial expression, and

functions in the conveyance oftastesensations from the anterior two-thirds of the tongue and

oral cavity. It also supplies preganglionicparasympathetic fibers to several head and neck

ganglia.

Course

The motor part of the facial nerve arises from the facial nerve nucleusin thepons while the

sensory part of the facial nerve arises from thenervus intermedius.

The motor part and sensory part of the facial nerve enters thepetrous temporal boneinto 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 foramenand passes

through theparotid 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 thegeniculate 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 specialsensory taste fibers to the palate via the Vidian nerve.

Nerve to stapedius - provides motor innervation forstapedius muscle in middle ear

Chorda tympani - provides parasympathetic innervation tosubmandibular gland andsublingual gland and special sensory taste fibers for the anterior 2/3 of the tongue.

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http://en.wikipedia.org/wiki/Cranial_nerveshttp://en.wikipedia.org/wiki/Cranial_nerveshttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Medulla_oblongatahttp://en.wikipedia.org/wiki/Medulla_oblongatahttp://en.wikipedia.org/wiki/Medulla_oblongatahttp://en.wikipedia.org/wiki/Tastehttp://en.wikipedia.org/wiki/Tastehttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Parasympathetichttp://en.wikipedia.org/wiki/Gangliahttp://en.wikipedia.org/wiki/Gangliahttp://en.wikipedia.org/wiki/Facial_nerve_nucleushttp://en.wikipedia.org/wiki/Facial_nerve_nucleushttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Nervus_intermediushttp://en.wikipedia.org/wiki/Nervus_intermediushttp://en.wikipedia.org/wiki/Nervus_intermediushttp://en.wikipedia.org/wiki/Petrous_temporal_bonehttp://en.wikipedia.org/wiki/Petrous_temporal_bonehttp://en.wikipedia.org/wiki/Internal_auditory_meatushttp://en.wikipedia.org/wiki/Inner_earhttp://en.wikipedia.org/wiki/Facial_canalhttp://en.wikipedia.org/wiki/Stylomastoid_foramenhttp://en.wikipedia.org/wiki/Stylomastoid_foramenhttp://en.wikipedia.org/wiki/Parotid_glandhttp://en.wikipedia.org/wiki/Glossopharyngeal_nervehttp://en.wikipedia.org/wiki/Geniculate_ganglionhttp://en.wikipedia.org/wiki/Geniculate_ganglionhttp://en.wikipedia.org/wiki/Greater_petrosal_nervehttp://en.wikipedia.org/wiki/Sphenoid_sinushttp://en.wikipedia.org/wiki/Sphenoid_sinushttp://en.wikipedia.org/wiki/Sphenoid_sinushttp://en.wikipedia.org/wiki/Frontal_sinushttp://en.wikipedia.org/wiki/Frontal_sinushttp://en.wikipedia.org/wiki/Maxillary_sinushttp://en.wikipedia.org/wiki/Ethmoid_sinushttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Vidian_nervehttp://en.wikipedia.org/wiki/Vidian_nervehttp://en.wikipedia.org/wiki/Nerve_to_stapediushttp://en.wikipedia.org/wiki/Stapediushttp://en.wikipedia.org/wiki/Chorda_tympanihttp://en.wikipedia.org/wiki/Submandibular_glandhttp://en.wikipedia.org/wiki/Submandibular_glandhttp://en.wikipedia.org/wiki/Sublingual_glandhttp://en.wikipedia.org/wiki/Cranial_nerveshttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Medulla_oblongatahttp://en.wikipedia.org/wiki/Tastehttp://en.wikipedia.org/wiki/Tonguehttp://en.wikipedia.org/wiki/Parasympathetichttp://en.wikipedia.org/wiki/Gangliahttp://en.wikipedia.org/wiki/Facial_nerve_nucleushttp://en.wikipedia.org/wiki/Ponshttp://en.wikipedia.org/wiki/Nervus_intermediushttp://en.wikipedia.org/wiki/Petrous_temporal_bonehttp://en.wikipedia.org/wiki/Internal_auditory_meatushttp://en.wikipedia.org/wiki/Inner_earhttp://en.wikipedia.org/wiki/Facial_canalhttp://en.wikipedia.org/wiki/Stylomastoid_foramenhttp://en.wikipedia.org/wiki/Parotid_glandhttp://en.wikipedia.org/wiki/Glossopharyngeal_nervehttp://en.wikipedia.org/wiki/Geniculate_ganglionhttp://en.wikipedia.org/wiki/Greater_petrosal_nervehttp://en.wikipedia.org/wiki/Sphenoid_sinushttp://en.wikipedia.org/wiki/Sphenoid_sinushttp://en.wikipedia.org/wiki/Frontal_sinushttp://en.wikipedia.org/wiki/Maxillary_sinushttp://en.wikipedia.org/wiki/Ethmoid_sinushttp://en.wikipedia.org/wiki/Nasal_cavityhttp://en.wikipedia.org/wiki/Vidian_nervehttp://en.wikipedia.org/wiki/Nerve_to_stapediushttp://en.wikipedia.org/wiki/Stapediushttp://en.wikipedia.org/wiki/Chorda_tympanihttp://en.wikipedia.org/wiki/Submandibular_glandhttp://en.wikipedia.org/wiki/Sublingual_gland


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Outside skull

Posterior auricular nerve - controls movements of some of the scalp muscles around theear

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 pharyngealbranchial

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 digastricmuscle, the stylohyoid muscle, and thestapedius muscle of the

middle ear. All of these muscles are striated muscles ofbranchiomeric origin developing from

the 2nd pharyngeal arch.

The facial also suppliesparasympathetic 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 thepterygopalatine ganglion.

The facial nerve also functions as the efferent limb of thecorneal reflex and the blink reflex.

Afferent

In addition, it receives tastesensations 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 oropharynxbelow thepalatine tonsil. There is also a small amount of

22 | P a g e
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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)

Rationalization Justification

1. Age Present Bell' Palsy can occur at any age.But the most common age that

Bell's Palsy occurs is the age of

before 15 and after 60.

The age of our patientis 23 years old.

2.Hereditary Absent 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.

PRECIPITATING FACTORS

Etiologic factors

Patient

Manifestati

on

(PRESENT

/ABSENT)

Rationalization Justification

1. Diabetes

MellitusAbsent

The diabetic patient is more

prone than the non-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).

Our patient is not

diabetic.

2. Pregnancy Absent 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.

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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

nerve located in the head, one

will be affected is the facial nerve

Our patient never had

head trauma.

4. Ear Infection Present

Bleeding and pus is

present on our patient

during assessment.

5. compromisedimmune systems

Absent

6. Exposure to

Viral infection

Absent

Bell's palsy is most often

connected with a viral infectionsuch as herpes (the virus that

causes cold sores), Epstein-Barr

(the virus that causes mono), orinfluenza (the flu). It's also

associated with the infectious

agent that causes disease. The

immune system's response to aviral infection leads to

inflammation of nerve. Because

it's swollen, the nerve getscompressed as it passes through a

small hole at the base of the

skull.

SYMPTOMATOLOGY

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Basic signs and symptoms Present/ absent Rationalization

When the facial nerve is

working properly, it carries ahost 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 happenswith 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.

1. Weakness and paralysis,

usually on one side of the face

Present

2. Drooping of eyelid Present

3. Tearing in the eye on the

affected side.

Present

4. Drooping of one side of the

mouth.

Present

5. Loss of the sense of taste Present

PATHOPYSIOLOGY

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Ear infection


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Bacteria enters the ear due to habit of inserting unclean

pinky finger inside the ear whenever it is itching and

Bacteria produces

Enterotoxins is a toxic substance that excreted by microorganism

can cause damage to the host by destroying cells or disrupting

Inflammatory reaction around the seventh cranial nerve, usually

at the internal auditory meatus where the nerve leaves bony

Produces a conduction block that inhibits appropriate

stimulation to the muscle by the motor fibers of the

Results to the characteristics of

unilateral or bilateral facial

weakness and paralysis.

Weakness and

paralysis usually on

one side of the face.


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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 beforeany procedure is done

particularly invasive

procedures, to ensure that

the client approves of the

invasive procedure to be

done.

This also serves as a legalbasis 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 cantolerate 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 BloodCount, platelet

- CBC and platelet testmonitoring 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.

DONE

- 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.

DONE

- Serum sodium,

potassium

Serum sodium and

potassium tests are taken to

test if the patients kidney is

functioning well.

DONE

- Chest X-Ray Chest X-ray is intended to DONE

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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. X-

rays 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

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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

DONE

- 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.

DONE

- Please start

venoclysis with 1

liter PNSS at20gtts/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

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osmolality as the body fluids

Medications:

- Please start Pen G 5

M units IVTT every6 hours ANST via

soluset

- ketorolac 30mg

IVTT every 8 hours

- ranitidine 50mg

IVTT every 8 hours

- Pen G is an antibacterial

type of drug it is given toour 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

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

action of histamine on the

H2 at receptor sites of

parietal cells, decreasing

gastric acid secretions.

DONE

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- Vitamin B complex

1cap Bid

-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

anemia

- Monitor Intake andOutput every shift

Monitoring the intake andoutput 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

client and if there is any

DONE

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every 4 hours unusualities.

- May give

dexamethasone 8mg

ODx3 doses ones

with normal chest

X-Ray

If chest X-ray is normal with

no unusualities then may

give dexamethasone, a

glucocorticoid.

DONE

- Refer accordingly 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

Paracetamol is given with 4

hours interval if fever still

persists.

DONE

- TSB for fever 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

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8:00am results and chest x-

ray

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 x-

ray 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.

DONE

- After OPD let

patient out on pass

for pure tone

audiometry outside

SPMC

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

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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.

DONE

- secure consent Consent is needed for legal

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

DONE

- refer Referral is needed so that

there is order in any

procedure also so that the

DONE

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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 theheadings 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 RESULT REFERENCE REMARK RATIONALE INTERPRETATION

sodium 137.10

mmol/L

136.00-155.00 mmol/L Normal 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 water will be

reabsorbed from the

kidneys. Aldosterone,

secreted from the adrenal

cortex, promotes sodium

reabsorption from the distal

The result is within

normal range.

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tubules of the kidneys.

When there is a sodium

deficit, more aldosterone

secreted and more sodium

and water reabsorption

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 intracellular fluids

(cells), with a cellular

potassium level of 150

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


normal range.

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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

For Sodium:

- 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.

For Potassium:

- 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.

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- Monitor ECG results.

- Monitor the medical regimen in correcting hypokalemia/ hyperkalemia.

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COMPLETE

BLOOD COUNTA 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 RESULT REFERENCE REMARK RATIONALE INTERPRETATION

Hemoglobin 102 g/ L 115-155 g/ L Low Hemoglobin determination is

part of a complete blood count.

It screens for disease associated

with anemia, determines the

severity of anemia, follows the

response to treatment for

anemia and evaluates

Result is below normal

range indicates anemia

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polycythemia.

Hemoglobin, the main

component of 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 ion

concentration are higher.

Unoxygenated 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.

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Hematocrit 0.37 0.36-0.38 Normal Hematocrit is part of the

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.

Result is within

normal range.

RBC Count 4.58

x10^6/uL

4.20-6.10 x10^6/uL Normal RBCs contain haemoglobin,

which is needed to carry oxygen

to body cells. the values for the

total number of RBCs,haemoglobin and hematocrit

have to be known to calculate

the RBC incides, and to identify

the types of anemias.

Result is within

normal range.

WBC Count 6.27

x10^3/uL

5.0-10.0 x10^3/uL Normal White blood cells,

or leukocytes are cells of

Result is within

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the immune system involved in

defending the body against

both infectious disease and

foreign materials. Fivedifferent

and diverse types of leukocytes

exist, but they are all produced

and derived from

a multipotent cell in thebone

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

ofdisease. 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.

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as volume, conductivity,

and granularity, may change

due to activation, the presence

of immature cells, or the

presence

ofmalignant leukocytes

in leukemia.

DIFFERENTIAL COUNT

Neutrophil 84 % 55-75% High Neutrophils are the most

numerous circulating blood

cells and they respond more

rapidly in large numbers to the

inflammatory and tissue injury

sites than leukocytes. duringacute infection, the bodys first

line of defence is the

neutrophils.

Result is above normal

elevated Neutrophils

indicates the presence

of acute infections,

inflammatory disease,

tissue damage andcancer.

Lymphocyte 14% 20-35% Low They comprise the second

largest group of leukocytes.

Lymphocytes are responsible

Result is below normal

Decreased level may

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forimmune responses. There

are two main types of

lymphocytes: B cells and T

cells. The B cells 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 (lymphokines) that

modulate the functional

activities of many other types of

cells and are often present at

sites ofchronic inflammation

indicate as a result of

cancer and neurologic

disorders.

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

Result is within

normal range.

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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

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 is abnormally

concentrated inside the red

cells, such as in burn patients

and hereditary spherocytosis, a

Platelet count is within

normal range.

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relatively rare congenital

disorder.

MCV

(Mean corpuscular

volume)

80 fl 79.40-94.80 fl Normal Mean corpuscular volume

(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, your RBCs are

smaller than normal

(microcytic) as is seen in iron

deficiency anemia or

thalassemias.

Platelet count is within

normal range.


- 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

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- 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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TESTRESULT REFERENCE REMARK RATIONALE INTERPRETATION

Clotting time 3:00 mins 2:00-5:00 mins Normal The tests frequently used to

monitor clotting time are

prothrombin time, partial

thromboplastin time,

activated partial

thromboplastin time, and

coagulation time or Lee-

White clotting time.


normal range.

Bleeding time 1:15 mins 1:00-3:00 mins NormalThe tests frequently

performed when there is a

history of bleeding, familial

bleeding or preoperative

screening.


normal range.


- Explain the purpose of the laboratory and diagnostic test.

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DRUG STUDY

Generic Name: Penicillin G

Brand Name: Pen G

Classification: Antibiotic

Suggested Dose: 5 million units IVTT evey 6 hours

Mode of Action: 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.

Indication: 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.

Pneumococcal infections.

Staphylococcal infections-penicillin G sensitive.

Other infections

Contraindications: A history of a previous hypersensitivity reaction to any penicillin

Interactions: Concurrent administration ofbacteriostatic antibiotics

(e.g., erythromycin,tetracycline) may diminish the bactericidal effects ofpenicillins by slowing the rate ofbacterial 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.

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Displacement of penicillin from plasma protein binding sites will elevate

the level of free penicillin in the serum.

Side Effects: 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.

Adverse Effects: 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.)

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 potassiumpoisoning, particularly

ifrenal insufficiency is present. Hyperreflexia, convulsions,

and coma may be indicative of thissyndrome.

Nursing

Responsibilities:

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 treatbacterial 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

of the infection.

Bibliography: http://www.rxlist.com/pfizerpen-drug.htm

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Generic Name: Ranitidine Hydrochloride

Brand Name: Zantac, Zantac-C, Zantac EFFERdose, Zantac Geldose, Zantac 75

Classification: Pharmacologic class: Histamine H2 receptor antagonist

Therapeutic class: Antiulcerative

Suggested Dose: 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.

Maintenance therapy of duodenal ulcer: 150mg PO hs.

Mode of Action: 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.

Indication: 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

Contraindications: Contraindicated in patients hypersensitive to drug and those with

acute porphyria.

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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

Side Effects: CNS: vertigo, malaise, headache

EENT: blurred vision

Hepatic: jaundice

Other: burning and itching at injection site

Adverse Effects: Pancytopenia

Reversible leucopenia

Thrompocytopenia

Anaphylaxis

Angioedema

Nursing

Responsibilities:

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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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 surgeryContraindications: 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.

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.

Interactions: 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

Side Effects: 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

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Adverse Effects: Arythmias

Perforation

Bronchospasm

AnaphylaxisNursing

Responsibilities:

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 alertness8. Instruct to avoid alcohol, aspirin, and all OTC agents without

approval

9. With eye

compilation editted

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