Academic Discharge Summary Paper

Academic Discharge Summary Paper

Reason for Admission:

1. Bell’s palsy: (G51. 0). Administered Prednisone 60 mg once daily

List of All Procedures:

1. Head CT Scan- Normal
2. Topical ocular lubrication with artificial tears.

Consults during Hospitalization: The neurologist was consulted to review the patient for neurological deficits. The neurologist made the diagnosis of Bell’s palsy.

Condition of Patient at Discharge:

Vital Signs: BP- 128/78 (sitting); HR- 78; RR- 20; Temp- 98.24F; SPO2-99%

HEENT: Facial asymmetry, Mask-like, and sagging face. The patient cannot wrinkle the forehead, grimace, or smile on the right side. Eye: The right eye cannot completely close, and the lower lid sags; Low eyebrow position; Excessive tearing in the left eye.

Neurological: The patient has unilateral paralysis of facial muscles and impaired taste sensation on neurological exam. He cannot chew, sip fluids through a straw, or control drooling on the affected right side.

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Discharge Medications:

1. Prednisone 60 mg once daily for 6 days. The dose will be tapered after 10 days.

Prednisone is the standard medication used to manage Bell’s palsy (Heckmann et al., 2019). It is a glucocorticoid that is readily absorbed from the GI tract. It is the preferred drug because of its anti-inflammatory, immune-modulating, and metabolic effects.

Pending Test Results for Follow-Up: Nerve conduction testing and EMG.

Discharge Instructions:

The patient was taught to manually close the right eyelid at intervals and to instill artificial tears during the day. He was recommended to use a moisturizing ointment at night and patch or tape close the right eye at bedtime (Heckmann et al., 2019).

The patient was instructed to eat and drink using the unaffected left side of the mouth. He was advised to take frequent, small meals and a soft diet since they are better tolerated.

The primary caregiver was instructed on performing warm, moist heat; and facial exercises on the affected side of the face.

Discharge Follow-Ups:

Therapy: Taper Prednisone to 30 mg after 10 days (Heckmann et al., 2019).

As the patient’s muscle tone improves, he will be trained to grimace, force the eyes closed, wrinkle the brow, whistle, and blow air out of the cheeks 3-4 times daily for 5 minutes in front of a mirror.

Referrals & Consults: Consultation with a neurologist and otolaryngologist if the facial paralysis persists for several months.

Referral to an ophthalmologist if the patient has a persistent dry eye or painful eye (Heckmann et al., 2019).

Referral for counseling if the patient develops severe residual paralysis.

Follow-up: The patient will be monitored every two weeks if the EMG results show that the function of the involved facial muscles is below 25% of the normal side’s facial muscle function.

Summary:

During hospitalization, the patient asked if he is a potential candidate for a facial nerve block or surgery. He was informed that surgery is reserved for patients with complete, severe Bell’s palsy to decompress the facial nerve. However, cosmetic surgery is performed in some cases. The patient also inquired about when he should anticipate a full recovery. I informed him that most patients with Bell’s palsy recover fully within a few weeks or months (Zhang et al., 2020). However, some experience residual weakness and a few develop permanent neurologic deficits.

The body image and self-esteem of patients with Bell’s palsy are significantly affected. Thus, there is a need to research interventions for psychosocial support for these patients and organizations that provide these services in the community.

Geriatric Considerations:

The mean age peak for Bell’s palsy is between the second and the fourth decade. Diabetes and hypertension are common generic risk factors for Bell’s palsy and occur more frequently in the elderly (Monini et al., 2018). Thus, their concomitant presence in the elderly increases the incidence of Bell’s palsy in geriatrics. A combination of physical rehabilitation and steroid treatment is established to lead to betters outcomes, especially in geriatric patients with Bell’s palsy. The recovery from a severe grade of Bell’s palsy depends on various factors that include medical treatment, rehabilitative therapy, and the natural history of the disease (Monini et al., 2018). Therefore, rehabilitation therapy will be crucial for this patient based on his age.

Ethical considerations surround principles of beneficence and nonmaleficence. The practitioner should prescribe therapeutic interventions that will benefit the patients without causing physical or psychological harm to the patient. The benefits of the interventions should outweigh the risks.

Health education for this patient should focus on eye care to prevent corneal abrasions. In addition, facial muscle exercises using passive range of motion should be recommended, and actively closing the eyes and smiling (Heckmann et al., 2019). Facial exercises increase muscle strength and coordination in the face.

References:

Heckmann, J. G., Urban, P. P., Pitz, S., Guntinas-Lichius, O., & Gágyor, I. (2019). The Diagnosis and Treatment of Idiopathic Facial Paresis (Bell’s Palsy). Deutsches Arzteblatt international, 116(41), 692–702. https://doi.org/10.3238/arztebl.2019.0692

Monini, S., Buffoni, A., Romeo, M., Di Traglia, M., Filippi, C., Atturo, F., & Barbara, M. (2018). Kabat rehabilitation for Bell’s palsy in the elderly. Acta Oto-Laryngologica, 137(6), 646-650. https://doi.org/10.1080/00016489.2016.1262553

Zhang, W., Xu, L., Luo, T., Wu, F., Zhao, B., & Li, X. (2020). The etiology of Bell’s palsy: a review. Journal of Neurology, 267(7), 1896–1905. https://doi.org/10.1007/s00415-019-09282-4

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please follow the instructions to write the academic discharge summary note:

Please write this discharge summary note on a patient who came to the ER for Bell’s palsy and neurology was consulted. The note is from the neurologist’s standpoint and signed off with a discharge summary note

Below are the directions :

Academic clinical discharge summary notes provide a unique opportunity to practice and demonstrate advanced practice documentation skills, develop and demonstrate critical thinking and clinical reasoning skills, and practice identifying acute and chronic problems and formulating an evidence-based plan of care.

This assignment uses a template. Refer to the “AGACNP Discharge Summary Template,” located on the college page of the Student Success Center under the AGACNP tab.

Develop an academic clinical discharge summary note based on a hospital patient seen during clinical/practicum. The discharge summary note should include the following:

1. Reason for admission: Include the reason for admission, a list of diagnoses in order of acuity, and an ICD-10 diagnosis.
2. List of all procedures: Include all dates, significant findings, and any anesthetics and contrast used during procedures.
3. Complete list of consults during hospitalization: Include any providers or services consulted during the stay.
4. Patient’s condition at discharge: Include a physical exam before discharge that documents that the patient is stable at discharge and has safe disposition and transportation. What diagnostic criteria confirmed the discharge diagnosis?
5. Complete list of discharge medications: Full list with all dosages, frequencies, and quantity of medications prescribed or dispensed.
6. Pending test results for follow-up: Complete list of any pathology, cultures, radiology, or other diagnostic tests still pending, and who is responsible for follow-up on the final results.
7. Complete list of discharge instructions: Full list of directions regarding infection prevention, new medications, and returning to daily activities.
8. Complete list of discharge follow-ups: Full list of any therapies, treatments, referrals, consults, and follow-up appointments. What diagnostic criteria were needed after discharge?
9. Summary: What questions were raised during the hospital stay? Include all explanations and answers to these questions. What questions were raised that required further exploration? What kind of discharge planning did you need? Characterize your patient interaction activities.
10. Overall assessment: Identify health promotions, health education, ethical considerations, geriatric considerations, and expected outcomes.

Incorporate three peer-reviewed articles in the assessment or plan.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite Technical Support Articles is located in Class Resources if you need assistance.