A nurse is caring for a client diagnosed with Bell's palsy. Which nursing intervention should the nurse prioritize to prevent complications?
1Encourage the client to chew on the affected side to maintain muscle tone
2Instruct the client to protect the affected eye with artificial tears and eye patches✓ 정답
3Apply heat therapy to the affected side of the face for 30 minutes every 2 hours
4Massage the paralyzed facial muscles vigorously to prevent muscle atrophy
해설
Eye protection (artificial tears and eye patches) is the priority to prevent corneal damage and vision loss in Bell's palsy due to inability to blink or close the eyelid. Other interventions (chewing, heat, massage) are supportive but not immediate safety concerns.
Bell's palsy is an acute, unilateral peripheral facial nerve (CN VII) paralysis. While the exact etiology is often idiopathic, it leads to motor dysfunction on the affected side of the face. The primary clinical concern for nursing care is not the facial droop itself, but the inability to close the eyelid, a condition known as lagophthalmos. This prevents the normal distribution of tears and the protective blink reflex, leaving the cornea vulnerable.
Why Eye Protection is the Priority Intervention
The priority nursing intervention is to protect the affected eye. Without the ability to close the eyelid, the cornea is continuously exposed to the environment, leading to tear film instability, dryness, and inflammation. This condition, termed exposure keratopathy, can rapidly progress to serious complications, including corneal ulceration, infection, and potentially permanent vision impairment [4]. The goal of care is to replicate the protective and lubricating functions of the eyelid. This is achieved through a combination of moisture and physical barrier. Instructing the client to use preservative-free artificial tears provides continuous lubrication to the ocular surface, while an eye patch or moisture chamber creates a physical barrier, holding moisture in and protecting the cornea from debris and injury during sleep or throughout the day. This approach directly mitigates the risk of vision loss, which is the most serious and preventable complication of Bell's palsy [1, 3].
Analysis of Incorrect Options
- Option 1: Encourage the client to chew on the affected side to maintain muscle tone. This is incorrect and potentially harmful. The facial nerve innervates the muscles of facial expression, not the primary muscles of mastication (which are innervated by the trigeminal nerve, CN V). Chewing on the affected side will not rehabilitate the paralyzed facial muscles and increases the risk of biting the buccal mucosa due to loss of muscle tone and sensation on that side.
- Option 3: Apply heat therapy to the affected side of the face for 30 minutes every 2 hours. This is a non-priority and potentially dangerous intervention. While gentle, moist heat can sometimes be applied for comfort, the prolonged duration of 30 minutes every 2 hours is excessive and carries a high risk of burning the skin. The client has altered or absent sensation on the affected side and cannot perceive if the temperature is too hot, making thermal injury a significant risk.
- Option 4: Massage the paralyzed facial muscles vigorously to prevent muscle atrophy. This is contraindicated. Vigorous massage will not prevent atrophy, which is a result of nerve damage, not disuse. Aggressive manipulation can overstretch the already weakened and flaccid muscles, potentially leading to contractures and synkinesis (involuntary muscle movements) once nerve regeneration begins. Gentle, light massage, if prescribed, is performed with caution, but it is never a priority intervention over preventing vision loss.
References (research sources)
[4]
Eyelid Malpositions and Ocular Surface Disease: Clinical Correlations and Management Strategies.Research articleQuaranta Leoni FM, Marabottini N, Iuliano A, Strianese D, Savino G. (2025) · DOI: 10.3390/jcm14238523
Clinical Management for Bell's Palsy Eye Protection
The primary nursing priority for a client with Bell's palsy is preventing corneal injury due to lagophthalmos. Immediate and consistent eye care is essential to avoid exposure keratopathy, ulceration, and permanent vision loss.
Key Interventions
Lubrication: Administer preservative-free artificial tears frequently during waking hours. Apply a lubricating ophthalmic ointment at bedtime for prolonged moisture retention.
Physical Barrier: Instruct the client to wear an eye patch or moisture chamber goggles, especially during sleep. Taping the eyelid closed can be performed with caution using hypoallergenic tape, ensuring the cornea is not scratched.
Environmental Control: Advise wearing wraparound sunglasses outdoors to protect against wind, dust, and bright light.
Monitoring: Assess the affected eye every shift for signs of redness, discharge, foreign body sensation, or visual changes. Report any findings of corneal cloudiness or pain immediately.
Interventions to Avoid
Do not encourage vigorous massage of paralyzed muscles, as this can cause synkinesis or muscle contracture.
Avoid prolonged heat application without a protective barrier due to risk of thermal injury from impaired sensation.
Chewing exercises are not a priority and should only be performed with guidance from a physical therapist if indicated.
Patient Education Focus
Teach the client to manually close the eyelid by using the back of a finger to gently press the lid down throughout the day. Emphasize strict adherence to the eye care regimen and the importance of follow-up with an ophthalmologist if symptoms of irritation develop.
Lagophthalmos — Inability to close the eyelid completely, commonly seen in Bell's palsy, leading to corneal exposure and risk of ulceration.
Exposure Keratopathy — Corneal damage resulting from prolonged exposure of the ocular surface due to incomplete eyelid closure, causing dryness, inflammation, and potential ulceration.
Bell's Palsy — Acute, unilateral peripheral facial nerve paralysis of unknown cause, affecting motor function on one side of the face.
Artificial Tears — Preservative-free lubricating eye drops used to maintain moisture on the corneal surface when natural tear distribution is impaired.
CN VII (Facial Nerve) — The seventh cranial nerve responsible for motor innervation of facial muscles, including eyelid closure, and sensory functions such as taste.