ASSESSMENT NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE INTERVENTION

BP is a peripheral INDEPENDENT INDEPENDENT

SUBJECTIVE Risk of disturbed facial paralysis, After 1 hour of
visual sensory there’s have no After 1 hour of 1.Establish rapport 1.To gain the level of nursing
Mother’s reports that substantial nursing trust with the patient. interventions the
perception related to
she has difficulty with researches have interventions patient patient was able
neuromuscular
left eye closure. proven the etiology 2.monitor patient’s 2.allow the evaluation to remain free
impairment as will remain free
of it. vital sign of any neurological harm resulting
manifested by loss of from harm resulting complication such as from visual
protective eye closure. Ineffective agent from visual abnormal. disturbances.
OBJECTIVE disturbances.

Left Facial Asymmetry Inflammation and

subsequent 3.assess patient’s 3.the level of response
swelling of one knowledge of change is related to the
BP - 90/50
facial nerve. in structure of perceived value or
function of the body importance that the
PR -100 bpm part. patient’s places on the
Blockage of normal affected body part.
neural activity

4.assist patient to 4.patient may

Loss of innervation identify actual perceive changes that
to one side of the changes. are not actually
face present.

5.encourage the 5.allow to examine if

Difficulty with left patient to report theirs have present of
eye closure.. immediately any infection.
pain experienced
around the eye.
6.place an eye patch 6.to protect the eye
on the affected eye. from scratch. And
keep the eye closed
and moist during
night.

DEPENDENT

1. administer 1.artificial tear or

artificial tears or ophthalmic ointment
ophthalmic is used to prevent the
ointment as eye from dryness.
ordered.

2. Administer 2. anti-inflammatory
prednisone initiated to reduce
(corticosteroid). inflammation in
vascular compression
and permits
restoration of blood
circulation to the
nerve.

3. Administer 3.analgesic is an agent

analgesic to moist heat in
involved side of the
face.