Response 1:
Sample case: Mrs. C, a 30-year-old female, woke up from a nap and noticed her inability to voluntary move the right side of her face. Along with that, she also could not close the right side of her eye and had a noticeable slight droop at the corner of the mouth. Her husband, who was aware of the signs of a stroke, noticed the signs that matched some of the signs of a stroke, so he called 911 to rush her to the hospital. She presented to the hospital where stroke was ruled out based on her imaging and insignificant health history. She was, however, diagnosed with Bell’s palsy.
SUBJECTIVE – 30 y/o female presented to the hospital with complaints of rapid and progressive weakness of the eyebrows, forehead, and angle of the mouth. She also reports inability to close the eyelid and lip on one side of the mouth. Additionally, she reports a difference in taste, sensitivity to sound, dry eye that worsens after a full day’s work looking at a computer screen. The symptoms have been progressing throughout the past week.
OBJECTIVE – Noted partial to complete weakness of the forehead. Facial droop on right, as well as drooping at the right side of the mouth are present. Speech slightly slurred and some drooling noted. The House-Brackman Facial Nerve Grading System is at 4/6.
ASSESSMENT – Bell’s palsy is a non-progressive neurological disorder of the 7th cranial nerve. It is characterized by the sudden onset of facial paralysis which may also be preceded by a mild fever, pain behind the ear, a stiff neck, or stiffness of on side of the face. Paralysis results from decreased blood supply to or compression of the 7th cranial nerve. The exact cause of bell’s palsy is unknown, but viral and immune disorders are frequently implicated as the cause (National Organization for Rare Disorders, 2021).
PLAN – Cranial nerve assessment; electromyography for confirm diagnosis and measure extent of never damage; lubricating eyedrops, glasses, or temporary patching to help protect exposed eye from corneal abrasion or any other damage if unable to close it; corticosteroid regimen consisting of 60 to 80mg a day for a week, which is the mainstay pharmacologic treatment for bell’s palsy (Warner, et. al, 2021).
The topic of bell’s palsy as demonstrated by the short case study, can mimic some of the signs and symptoms of stroke, and therefore, it is a very appropriate condition for graduate nursing students to be familiar with as misdiagnosis is not uncommon. Treatment does not always result in immediate resolution, and therefore, such condition is primarily managed in the outpatient setting where FNPs can manage the patient, so it is important to know the clinical guidelines on treatment, in addition to knowing its clinical manifestations and careful assessment to differentiate it from other more or less serious conditions. As mentioned previously, it can mimic stroke like symptoms, and so I would say that I can certainly expect to see this in the inpatient setting initially where patient may receive their initial bell’s palsy diagnosis. However, for those who have established diagnosis of such condition, I expect to see it managed primarily in the outpatient setting.
Response 2:
Acute Otitis Media in Children
Acute otitis media is one of the most common diseases in childhood. According to Mousseau et al. (2018), about 75 percent of children have at least one episode of acute otitis media before their first birthday. Acute otitis media is an infection of the middle ear space. It can be viral, bacterial, or a coinfection. The most common causing bacteria are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. The most common causing viral pathogens are respiratory syncytial virus (RSV), coronavirus, influenza viruses, adenoviruses, human metapneumovirus, and picornaviruses (Danishyar & Ashurst, 2021). When I think about acute otitis media, I think about my 8-year-old son, Elijah. He endured ear infections from age 2 months to 14 months old. The symptoms that he had included crying, irritability, poor feeding, and fever. Elijah had about 10 ear infections in a year. At 16 months of age, he had ear tubes placed. He had a speech delay, acid reflux, and recurrent ear infections. The doctor recommended that Elijah have ear tubes placed because of his speech delay and the recurrent ear infections. Placing ear tubes reduces the risk of future ear infections, restores hearing loss caused by middle ear fluid, improves speech and balance problems, and improves behavior and sleep problems (ENT Health, 2019).
I chose acute otitis media in children because graduate nursing students should learn about how to treat acute otitis media and how to diagnose a patient with ear problems. According to Deniz et al. (2017), there is emerging antimicrobial resistance for acute otitis media and should have selective antibiotic prescribing. Not all ear problems are related to otitis media, and it is up to the provider to differentiate between prescribing antibiotics or not. For children with acute otitis media, about 50 percent of children are prescribed antibiotics. In the U.S., about 80 percent of children have prescribed antibiotics (Deniz et al., 2017). Acute otitis media is typically seen in the outpatient setting.
When diagnosing a patient with acute otitis media, I would take into consideration that the patient may have had an upper respiratory tract infection. The eardrum may be red and bulging. The patient may also have a fever, decreased light reflex on the eardrum, an opaque tympanic membrane, and decreased tympanic membrane mobility. Recommendations of analgesics are used for ear pain, fever, and irritability. It is important to use analgesics at bedtime because disrupted sleep is one of the most common symptoms that motivate parents to seek care. Both ibuprofen and acetaminophen are effective, and ibuprofen is preferred for a longer duration of action. The concern that comes up is antibiotic-resistant bacteria, and to improve acute otitis media the management involves deferring antibiotic therapy in patients least likely to benefit from antibiotics. Antibiotics should be prescribed for children who are 6 months or older with severe signs and symptoms such as moderate or severe otalgia, otalgia for 48 hours, or a temperature of 102.2 degrees Fahrenheit or higher. According to Harmes, et al. (2013), one study found that two out of three children will recover without antibiotics. If a child needs antibiotics, the choice is to use amoxicillin. If there is no improvement with analgesics, then antibiotics should be used to help treat acute otitis media.