Bell's palsy

Bell's palsy is a form of facial paralysis resulting from a dysfunction of the cranial nerve VII (the facial nerve) that results in the inability to control facial muscles on the affected side. Damage to the facial nerve that controls muscles on one side of the face causes that side of your face to droop . The nerve damage may also affect your sense of taste and how you make tears and saliva. This condition comes on suddenly, often overnight, and usually gets better on its own within a few weeks.

 Named after Scottish anatomist Charles Bell, who first described it. Bells palsy is a non-specific diagnosis given to facial paralysis when all of the specific causes such as a brain tumor, Lyme Disease, or stroke have been ruled out.
Symptoms of Bell's palsy usually begin suddenly and reach their peak within 48 hours.

 It is thought that an inflammatory condition leads to swelling of the facial nerve. The nerve travels through the skull in a narrow bone canal beneath the ear. Nerve swelling and compression in the narrow bone canal are thought to lead to nerve inhibition, damage or death. No readily identifiable cause for Bell's palsy has been found.

Facial Nerve Anatomy

 The facial nerve controls the muscles that move the eyebrows, close the eyes, and move the mouth and lips. It also controls the tear glands, one of the salivary glands, and the taste buds in the front of the tongue. Electrochemical signals are relayed between the brain and many facial muscles by 7000 nerve fibers that comprise the facial nerve. When the facial nerve is damaged, as in Bell's palsy, the action of each nerve fiber is disrupted. Because the facial nerve controls several functions, several symptoms occur.

Pathophysiology

 The risk factors for Bells palsy are not completely understood, but the chances of obtaining or having Bells palsy in ones life may be one in 64 individuals. It is more commonly seen in patients who are pregnant have a family member with Bells palsy, have had previous Bells palsy as well as patients of Japanese ancestry. Other risk factors for patients with facial paralysis not necessarily related to Bells palsy include Lyme disease, typhoid fever, Guillain-Barr syndrome, trauma, temporal bone fracture, tumors including acoustic neuroma and other types of viruses. Again, it is extremely important to differentiate Bells palsy and facial paralysis. Facial paralysis is a general term given to all patients who have weakness of their face including patients with Bells palsy. Bells palsy is a subset of patients who have facial paralysis that is a resultant of a virus reactivation from herpes simplex virus.

 The pathophysiology of Bell's Palsy is not entirely clear, but is most likely related to compression of the facial nerve due to demyelination, inflammation, or ischemia (inadequate blood supply). The facial nerve is responsible for contraction of the muscles of the face in expression, lacrimation, and the senses of taste and hearing. As a result of its convoluted path through the temporal bone which is only slightly larger in diameter than itself, the 10,000 neurons that exist in the facial nerve are prone to impairment due to vascular congestion with secondary ischemia.

Clinical manifestation:
Sometimes you may have a cold shortly before the symptoms of Bell's palsy begin. Symptoms most often start suddenly, but may take 2 - 3 days to show up. They do not become more severe after that. Symptoms are almost always on one side only. They may range from mild to severe. The face will feel stiff or pulled to one side, and may look different. Other symptoms can include:

Difficulty eating and drinking; food falls out of one side of the mouth Drooling due to lack of control over the muscles of the face Drooping of the face, such as the eyelid or corner of the mouth Hard to close one eye Problems smiling, grimacing, or making facial expressions Twitching or weakness of the muscles in the face

Other symptoms that may occur:

Dry eye or mouth Headache Loss of sense of taste Sound that is louder in one ear (hyperacusis) Twitching in face Dizziness Hypersensitivity to sound

Nursing Care Plan

Nursing Objectives Diagnosis Acute Pain related to inflammati on of the facial nerve Within 8 hours of nursing intervention client will be able to reduce inflammation and a pain rate within acceptable range

Nursing Intervention 1. Assess severity of pain. 2. Accept clients description of pain 3. Observe nonverbal cues or behaviors to pain 4. Note acceptable level of pain 5. Note when pain occurs 6. Promote comfort measures 7. Administer medication 8. Encourage adequate rest period

Rationale

1. To evaluate degree and provide appropriate care measures 2. Pain is a subjective experience. 3. Obs. May or may not congruent to verbal reports. 4. Varies individual and situation 5. To med prophilactically ,as necessary. 6. To promote non pharmacologic pain management 7. To maintain acceptable level of pain 8. To promote wellness and prevent fatigue

Nursing Diagnosis Anxiety (moderate) related to situational crises

Objective Within 4 hours of nursing intervention and health teaching client will be able to reduce anxiety by demonstrating proper care management and verbalize yes I already understand what Bells palsy is.

Nursing Intervention 1. Assess level of anxiety. 2. Review current medication therapy. 3. Encourage client to express and acknowledge feelings of anxiety or uneasiness. 4. Provide accurate information abut the situation(Bells Palsy) 5. Assist client to use anxiety for coping with the situation, if helpful

Rationale 1. To provide appropriate care measures. 2. Some meds can heighten feelings/sense of anxiety. 3. To assist client identify feelings and begin to deal with problems. 4. To reassure and reduce anxiety. 5. Moderate anxiety heightens awareness and permits client to focus on dealing with problems

Goal Nursing Diagnosis

Nursing intervention

Rationale

Disturbed Body Image r/t situational changes (facial paralysis)

After 8 hours or nursing intervention the patient will demonstrates enhanced body image and self-esteem as evidenced by ability to look at, touch, talk about, and care for actual or perceived altered body part or function.

1. Assess perception of change in structure or function of body part (also proposed change).

The extent of the response is more related to the value or importance the patient places on the part or function than the actual value or importance. Stages of grief over loss of a body part or function are normal, and typically involves a period of denial, the length of which varies from individual to individual. It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth.

2. Acknowledge normalcy of emotional response to actual or perceived change in body structure or function 3. Encourage verbalization of positive or negative feelings about actual or perceived change. /

Goal Nursing Diagnosis

Nursing intervention

Rationale

4. Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities. 5. Demonstrate positive caring in routine activities.

Opportunities for positive feedback and success in social situations may hasten adaptation Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities.

Goal Nursing Diagnosis

Nursing intervention

Rationale

Risk for aspiration related to impaired swallowing secondary to paralysis

Within 8 hours of nursing intervention the client will demonstrate techniques to prevent and/or correct aspiration.

1- Identify at-risk client according to condition or disease process, as listed in Risk Factors. 2- Note clients level of consciousness, awareness of surroundings, and cognitive function. 3- Assess clients ability to swallow and strength of gag/cough reflex and evaluate amount/consistency of secretions. 4-Avoid keeping client supine/flat when on mechanical ventilation (especially when also receiving enteral feedings).

Rationale: to determine when observation and/or interventions may be required. Rationale: as impairments in these areas increase clients risk of aspiration. Rationale: Helps to determine presence/effectiveness of protective mechanisms. Rationale: Supine positioning and enteral feedings have been shown to be independent risk factors for the development of aspiration pneumonia.

Goal Nursing Diagnosis

Nursing intervention

Rationale

5-Auscultate lung sounds frequently, especially in client who is coughing frequently or not coughing at all, or in client on ventilator being tube-fed 6-Elevate client to highest or best possible position (e.g., sitting upright in chair) for eating and drinking and during tube feedings. 7-Determine liquid viscosity best tolerated by client. Add thickening agent to liquids, as appropriate.

Rationale: to determine presence of secretions/ silent aspiration. Rationale: The rested client may have less difficulty with swallowing. Rationale: Some individuals may swallow thickened liquids better than thin liquids.

Nursing Management

Nursing Management
Provide support and reassurance. Provide soft diet with supplementary feedings as indicated. Instruct to chew on unaffected side, avoid hot fluids/foods, and perform mouth care after each meal. Assess facial nerve function regularly Administer medications as ordered Corticosteroids: to decrease edema and pain -Mild analgesics as necessary Provide special eye care to protect the cornea. -Dark glasses (cosmetic and protective reasons) or eye shield -Artificial tears to prevent drying of the cornea -Ointment and eye patch at night to keep eyelid closed Patients need reassurance that a stroke has not occurred and that spontaneous recovery occurs within 3 to 5 weeks in most patients. Teaching patients with Bells palsy to care for themselves at home is an important nursing priority.

Medical Management

The objectives of the management are to maintain facial muscle tone and to prevent or minimize denervation. Steroidal therapy may be initiated to reduce inflammation and edema, which reduces vascular compression and permits restoration of blood circulation to the nerve. Early administration of corticosteroids appears to diminish severity , relieve pain, and minimize denervation. Facial pain is controlled with analgesic agents or heat applied to the affected side of the face. Additional modalities may include electrical stimulation applied to the face to prevent muscle atrophy.

Surgical Management

Surgery may be needed for exploration of the facial nerve or tumor is suspected, for surgical decompression of the facial nerve, and for surgical rehabilitation of a paralyzed face. Smile Surgery ~ American Academy of Neurology did not recommend any surgical intervention because of its adverse effects.Hearing loss which occurs to 3-15 % ..

Research Abstract

Recent applications of induced pluripotent stem cells (iPSCs) in the treatment of neurological disease and injury Koichi Ayukawa
Stem cells of the central nervous system (CNS) generate neural cells. Attempts have been made to transplant such cells to treat neurodegenerative diseases in animals. However, these techniques are of limited utility because of cell rejection and tumorigenicity. Recently, induced pluripotent stem cells (iPSCs) have been generated by stimulating the activities of genes encoding OCT4, Sox2, Klf4, and c-Myc. The results show that somatic cells can give rise to all types of body cells, including neurons required for transplantation, in the absence of any rejection response. In addition, some novel technologies employed to create iPSCs have resulted in a reduction in tumorigenicity. iPSCs are also useful in diagnosing neural diseases, because such cells are generated from skin fibroblast, making them easier to use in various tests including those assessing differentiation and transplantation. In the present work, we show that iPSCs can be generated from cells of patients with neurological diseases (Parkinsons disease, ALS, and Huntingtons disease), and that it is possible to direct differentiation of these cells into neurons and glial cells. Experimental and clinical efforts to repair neural disease or injury using iPSCs, conducted in both academic institutes and private facilities, are also described. http://www.researchtrends.net/tia/abstract.asp?in=0&vn=5&tid=47 &aid=3261&pub=2011&type=

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ABONALES, Napoleon Dwight ESTORQUE, Ma. Roslyn