Nursing Care Plan (Bell’s Palsy)

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective data: Anxiety related to After 5 hours of Monitor vital signs To identify physical After 2 hours of
“My mother died change in health nursing intervention (e.g., rapid or responses nursing intervention
of a stroke, I am status as evidenced the client will irregular pulse, associated with the client was
sure that is what is by increased facial  Appear relaxed rapid both medical and  Appear relaxed
going on. Am I weakness and and report that breathing/hyperve emotional and report that
going to die?” as unable to taste anxiety is ntilation, changes conditions. anxiety is reduced
verbalized by the food. reduced to a in blood pressure, to a manageable
patient. manageable diaphoresis, To avoid the level.
level. tremors, or contagious effect
restlessness) or transmission of
Objective Data: anxiety.
Fearful Establish a
Crying therapeutic Helps client identify
Increased blood relationship, what is reality
pressure conveying empathy based.
Increase and unconditional
respiratory rate positive regard. To promote
Vital signs are relaxation and may
taken as follows: Provide accurate enhance patient’s
BP:148/60 mmHg information about coping abilities by
T:98.2’f the situation refocusing
RR:26 cpm attention.
PR:83 bpm Provide comfort
measures.(e.g., To focus on or
calm/quiet correct faulty
environment, soft catastrophic
music, a warm interpretations of
bath, or a back rub) physical symptoms.

Use cognitive
therapy

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
 Nursing Care Plan (Bell’s Palsy)
Subjective data: Acute pain related After 5 hours of Establish rapport  To have baseline After 2 hours of
“Masakit yung to physiologic nursing and monitor vital data and a nursing
kalaiwang tenga alteration of the intervention the signs of the patient therapeutic intervention the
ko” as verbalized disease as client will: communication client was able to :
by the patient. evidenced by pain  Report pain is Perform pain with the patient. • Verbalize pain is
behind and in front relieved or assessment each relieved and
Objective Data: of left ear. controlled time pain occurs.  To demonstrate controlled as
Restlessness Document and improvement in evidenced by
Crying investigate status and to “nabawasan na ang
Increased blood changes from identify worsening sakit ng kaliwang
pressure previous reports of underlying tenga ko” as
Increase and evaluate condition. verbalized by the
respiratory rate results of pain patient.
Vital signs are interventions.  To evaluate coping
taken as follows: abilities and to
BP:148/60 mmHg Encourage identify areas of
T:98.2’f verbalization of additional concern
RR:26 cpm feelings about the
PR:83 bpm pain such us  To promote no
concern about pharmacological
tolerating pain, pain management
anxiety, pessimistic
thoughts  To maintains
“acceptable” level
Provide comfort of pain. Notify
measures (e.g., physician if
touch, regimen is
repositioning, use inadequate to
of heat or cold meet pain control
packs, nurse’s goal.
presence), quiet
environment, and
calm activities.

Administer
analgesics, as
indicated, to
maximum dosage,
as needed.

NURSING NURSING
ASSESSMENT PLANNING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Disturbed body After 2 hours of  Assess patient’s  The level of Goal met, after 1 day
Patient complaints related to bell’s nursing knowledge of change response is related of nursing
of weakness of the palsy as intervention, the in structure or to the perceived intervention, the
left side of her face evidenced by patient will be able function of the body value or patient was able to
unilateral  facial to demonstrate part. importance that demonstrate
 Nursing Care Plan (Bell’s Palsy)
paralysis, increased self- the patient places increased self-
drooping of left esteem.  Assist patient to on the affected esteem.
eye, inability to identify actual body part.
raise eyebrow, changes.
Objective: puff  out cheeks,  Patients may
Temperature- frown, and smile  Encourage perceive changes
98.2°F or wrinkle verbalization about that are not
forehead concerns of the actually present.
Blood Pressure- disease process and
148/60 mmHg future expectations.  This provides an
opportunity to
Pulse-83 bpm identify
fears/misconcepti
Respiratory rate- ons and deal with
26. cpm them directly.