Patient and problem
Tom Hiddleston, a white 40-year-old man, had recent complaints about flue-like symptoms and ear pain. He suffers from nasal inflammation, thick colorless discharge from the nose, and nasal congestion that causes difficulty breathing through his nose. Moreover, he feels pain around the nose and eyes, accomplished by headache. He reports having a virus infection for more than two weeks and a high fever for the last 3 days. As Mr. Hiddleston states, he caught the infection on his trip to London three weeks ago. The possible diagnosis based on his narrative is sinusitis in acute or chronic form. To precisely identify the diagnosis, Mr. Hiddleston should take a CT scan that provides a 3-D picture or an MRI to see the internal structures (Higuera, 2019). Moreover, additional investigations including a fiberoptic scope through the nose and blood test should be conducted (Higuera, 2019). After the confirmation of sinusitis, patient should receive ambulatory or stationary treatment according to the doctor’s recommendations. In case of refutation of diagnosis, the patient should take an additional urine test.
Chronic or acute sinusitis appears when the sinuses (the spaces inside the nose and head) are inflamed and swollen for the long period (Mayo Foundation, 2019a). Usually, sinusitis interrupts the way mucus normally drains, so, makes the nose stuffy (Mayo Foundation, 2019a). Bad tonus of muscles could difficult breathing, and the area around the eyes, nose, and forehead feel swollen or tender (Mayo Foundation, 2019a). Sinusitis could be triggered by infections, growth in nasal polyps, and other conditions related to the respiratory system.
Mr. Hiddleston, who is previously not diagnosed with sinusitis, reports having a seasonal dust allergy. Moreover, he claims to have had signs of coronavirus in the light form during the last winter. He has been smoking for 20 years and lost the sense of smell after the COVID-19. The PCR test is negative, moreover, he rejects having tuberculosis or hepatitis previously. Mr. Hiddleston had a rhinoplasty due to a broken nose bone.
Nursing Physical Assessment
Mr. Hiddleston has difficulties in breathing and a constant dry cough. The main symptomatic based on his conditions are the following: runny nose with thick colorless mucus coming from the nose, fever, headache accomplished with pain in nose and eyes, fatigue, and the absence of the sense of smell (Higuera, 2019). In addition, he is observed an increased body temperature is about 37.3 degrees Celsius. The patient’s blood pressure is normal about 110 mm Hg. The surface of the skin is clear and normally toned. Mr. Hiddleston states reduced appetite and weakness in the body and he has a sore throat and red tonsils (Higuera, 2019). His heart sounds are at the normal S1 level (Mayo Foundation, 2019b). He has hard breath and no wheezing in the lungs (Mayo Foundation, 2019a). The blood test revealed an extensive number of leukocytes that could refer to the inflammatory process.
As the diagnosis was confirmed, the stationary treatment includes several stages. Mr. Hiddleston has acute sinusitis, therefore, should be treated with antibiotics (Mayo Foundation, 2019b). As Mr. Hiddleston appeared allergic to amoxicillin, azithromycin should be taken two times daily for 7 days (Higuera, 2019). Moreover, to reduce pain around the eyes, and nose pain relievers like acetaminophen or ibuprofen should be taken (Mayo Foundation, 2019b). Mr. Hiddleston should irrigate nasal passages with the saline solution to reduce inflammation. The saline nasal spray should be used at least three times a day for two weeks (Mayo Foundation, 2019b). Additionally, nasal corticosteroids that prevent and treat inflammation such as fluticasone, mometasone, and beclomethasone should be implemented (Higuera, 2019). As the patient’s conditions will be improved, immunotherapy that reduced the body’s reaction to specific allergens is needed.
The main problem associated with the patient’s treatment is his prerequisites for sinusitis. Acute sinusitis could easily transform into chronic sinusitis that requires more complex measures in treatment. As he suffers from seasonal dust allergy and lost sense of smell after coronavirus infection, he increases his chances to experience sinusitis repeatedly (Mayo Foundation,2019b). Mr. Hiddleston should go through a complex investigation to understand and prevent possible negative outcomes of his conditions. My goal in this situation is to control and help a patient to conduct all treatment measures. The main consideration is to provide comfortable and complex treatment measures. Moreover, teaching and instructing the patient about the prevention methods are also important.
Evaluation and Recommendations
My nursing goals were to create a nursing care plan, identify the risk and initiatives related to the patient, conduct all investigations needed to assign the diagnosis, and facilitate comfortable and effective treatment. In writing a nursing care plan, I followed instructions provided by Usman et al. (2021) that included data collection and analysis. I formulated my nursing diagnosis and set short-term and long-term goals. Possible risks and outcomes were also evaluated by analyzing the patient’s Anamnesis Morbi. Moreover, detailed treatment methods and measures to avoid complications were introduced. We could recognize nursing intervention plan effective, as it covers all international standards in health care. Moreover, the plan includes various measures used to eliminate the issue in the long term. To avoid further complications patient should follow recommendations provided earlier.
Higuera, V. (2019). What you need to know about sinusitis. Healthline.
Mayo Foundation for Medical Education and Research. (2019a). Chronic sinusitis. Mayo Clinic.
Mayo Foundation for medical education and research. (2019b) Acute sinusitis. Mayo Clinic.
Usman, M., Vera, M., Sanders, D., Sohail, Mwanzah, J., Stefanie, Dorcas, Omondi, W., Bianca, sanga, H., Kulhanek, T., Palmer, D., Abdulmumeen, H., Petersen, O., Modupe, Irene, M., Amela, Zipporah, Watanake, … Solomon. (2021). Nursing care plans: The ultimate guide and database . Nurseslabs.