CHAPTER 15 Facial Emergencies

Joni Hentzen Daniels, MSN, RN, CEN, CCRN, CNS

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Facial Emergencies

Bell’s Palsy (Idiopathic Facial Paralysis)

Herpes Zoster Oticus (Ramsay Hunt Syndrome)

Sinusitis

Trigeminal Neuralgia (Tic Douloureux)

Parotitis

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapter 1)

2. Focused assessment

a. Subjective data collection

1) History of present illness/chief complaint

a) Pain: PQRST (see Chapter 9)

b) Respiratory distress/shortness of breath

c) Sensory deficits/changes

(1) Auditory

(a) Ear pain

(b) Hearing loss

(c) Ringing in ears or hyperacusis (abnormally acute hearing)

(2) Visual

(a) Decreased tearing

(b) Partial or complete blindness

(c) Visual field defects and decreased light perception

(3) Tactile/kinesthetic

(a) Decreased sensation

(b) Facial pain and/or sensation of heaviness, numbness, tingling, and paresthesias

(4) Gustatory

(a) Impairment of taste

(b) Loss of taste or metallic taste

(5) Olfactory: unilateral or bilateral loss of smell

d) Malocclusion or trismus (inability to open mouth)

e) Facial asymmetry, swelling

f) Recent viral illness

g) Rash

h) Fever/chills

i) Nausea/vomiting

j) Dizziness/vertigo

k) Speech difficulties

l) Excessive salivation

m) Foreign body sensation

n) Exposure to and/or ingestion of noxious agents

(1) Contact substances

(2) Inhalants

o) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

(1) Neurologic disorders or diseases

(2) Hypertension: may be secondary cause of epistaxis

(3) Blood dyscrasias

b) Previous dental or ear, nose, and throat surgery

c) Smoking history

d) Substance and/or alcohol use/abuse

e) Last normal menstrual period: female patients of childbearing age

f) Current medications

(1) Prescription

(a) Analgesics: may affect neurologic assessment, e.g., slurred speech and altered level of consciousness

(b) Antibiotics

(c) Anticoagulants

(d) Psychotropic drugs: phenothiazine reaction may cause inability to close mouth

(2) Over-the-counter/herbal

g) Allergies

3) Psychological, social, and environmental factors

a) Age: some presentations more prone in specific age groups

b) Infection: viral, bacterial or fungal

c) Stressors: surgery, trauma, illness and psychosocial factors

d) Possible/actual assault, abuse, or intimate partner violence situations (see Chapter 3)

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Hygiene

e) Level of distress/discomfort

2) Inspection

a) Possible drooling

b) Symmetry of structures: size, position, and movement including palpebral fissures and nasolabial folds

c) Herpetiform vesicular eruption

d) Pupil reaction

3) Palpation

a) Sensory deficits or changes

b) Areas of tenderness

c) Frontal/maxillary sinuses

4) Percussion

a) Soft tissues over frontal sinuses

b) Soft tissues over maxillary sinuses

3. Diagnostic procedures

a. Laboratory studies

1) Anaerobic or aerobic cultures of wounds

2) Complete blood count (CBC) with differential

3) Coagulation profile

4) Arterial blood gas (ABG)

b. Imaging studies

1) Facial bones radiograph: maxilla, mandible, zygoma, orbits, and nasal bone

2) Waters’ view of facial bones and sinuses

3) Panoramic oral radiograph (Panorex)

4) Chest radiograph

5) Computed tomography (CT) scan: head, sinuses, and larynx

6) Sonography

c. Other

1) 12- to 15-lead electrocardiogram (ECG)

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Risk for aspiration

3. Acute/chronic pain

4. Impaired skin integrity

5. Risk for infection

6. Anxiety/fear

7. Deficient knowledge

8. Ineffective coping

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (seeChapter 1)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient’s responses and outcome, and modify nursing care plan as indicated

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatric

a. Growth or development related

1) During the sixth and seventh years, maximal enlargement of the face occurs. Primarily the eruption of teeth and the development of the midface influence facial proportions at that time

b. “Pearls”

1) Always explain to children what is going to be done to them and be honest

2) Limitation in verbal expressions presents a disadvantage in evaluation of children and complicates assessment

2. Geriatric

a. Aging related

1) Changes associated with aging

a) Perception

(1) Visual acuity loss

(2) Diminished hearing

(3) Decreased sense of taste

(4) Decreased sensitivity to touch

b) Consciousness

(1) Loss of short-term memory

(2) Slower thought processing

(3) Increased pain threshold

c) Musculoskeletal

(1) Muscle atrophy

(2) Decreased flexibility

2) Elderly patients tend to have deterioration in special senses

3) Chronic diseases add further limitations to aged patients

II. SPECIFIC FACIAL EMERGENCIES

A. Bell’s Palsy (Idiopathic Facial Paralysis)

Bell’s palsy is one of the most common presentations of all the facial nerve paralysis syndromes. Others include herpes zoster oticus (Ramsay Hunt syndrome), Lyme disease, and paralysis resulting from trauma, bacterial infections, cephalic tetanus, or neoplasms. Bell’s palsy is the paralysis of all facial muscles on one side of the face, including the forehead. It has long been thought to have a viral cause, and it occurs without evidence of cerebral pathologic changes. A prodromal illness, such as an upper respiratory infection, is described by 60% of patients. Symptoms associated with the facial paresis frequently include postauricular ear pain or headache, abnormally acute hearing (hyperacusis), decreased tearing, and impairment of taste.

Bell’s palsy is a diagnosis of exclusion. Other reasons for its cause have been associated with emotional stress, herpes simplex virus infection, and prolonged exposure to drafts or cold. Lyme disease is a differential diagnosis for facial paralysis, although it is almost always associated with bilateral facial nerve paralysis.

The symptoms are presumed to be caused by swelling of the facial nerve. In the narrow course through the temporal bone, the nerve becomes compressed and ischemic. Bell’s palsy is usually unilateral, but in rare instances may be bilateral. It can occur in children but is more common in adults. The majority of cases occurs in people older than 40 years of age, distributed equally between the sexes. The symptoms of Bell’s palsy are usually self-limiting, and complete resolution occurs within several weeks in 80% to 90% of cases. Treatment commonly includes protecting the affected eye. Medications often include antiviral agents and a short course of oral steroids. Assessment and treatment for Bell’s palsy are listed in Section B (Herpes Zoster Oticus).

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