Allergic Rhinitis Assignment Discussion Paper

Patient Initials: _P.K___                    Age: _28______                                 Gender: __F_____

 SUBJECTIVE DATA:

 Chief Complaint (CC): “I’ve been sneezing a lot and my nose is stuffed, and I’ve been having trouble sleeping at night.”

 History of Present Illness (HPI): P.K. presents with complaints  of increased nasal congestion, sneezing, and nasal itch that has persisted for two weeks. Other symptoms reported by the patient include irritation, itchiness, and tearing in the eyes, as well as palate and throat discomfort. Symptoms are present all year round, but are most pronounced in the springtime. The client said that he had eczema when he was younger. A prescription Zyrtec 5mg pill is taken every night by the client, but it does not seem to be of help Allergic Rhinitis Assignment Discussion Paper.

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Medications: Zyrtec 5mg 1 tab once daily.

 Allergies: penicillin- rash. Seasonal.

 Past Medical History (PMH): Ear infection at age 10

Past Surgical History (PSH): None

Personal/Social History: Single with no children. Works as a high school teacher. Drinks alcohol occasionally. Denies tobacco and illicit drug use Allergic Rhinitis Assignment Discussion Paper.

Health Maintenance/immunizations: last eye exam 5 months ago. Immunizations up-to-date. No travel history.

Significant Family History:

Mother: 58 years old, diabetes

Father: died of kidney failure at 56

Brother: 30 years old, asthma

Review of Systems:

General: Denies changes in weight, no sweating at night, no fever and chills. Reports fatigue for the last two days due to lack of sleep.

HEENT: Reports watery eyes with itching and redness. Denies changes in vision. Reports itchy ear. Denies ear pain, discharge, hearing loss and ringing. Reports nasal congestion and itching with clear discharge and sneezing. Reports throat and palatal itching.

Respiratory: Denies wheezes, breathing difficulties and cough.

Cardiovascular/Peripheral Vascular: denies palpitations, chest pains and edema.

Gastrointestinal: Denies abdominal pains, nausea, vomit and constipation.

Genitourinary: Patient currently has no sexual partner actually. Denies any burning, frequency or changes in urinary pattern.

Musculoskeletal: Denies back pain, muscle pain, joint pain and swelling.

Neurological: Denies dizziness, light-headedness, seizures, or sense of disequilibrium.

Psychiatric: Denies anxiety, depression, sleep problems, or suicidal thoughts

Skin: Denies rashes, lesions and moles Allergic Rhinitis Assignment Discussion Paper

 OBJECTIVE DATA:

Physical Exam:

Vital signs: W 136lbs; H 5’6”; Temp 98F; RR 16; HR 83 BP 110/72.

General: Alert and oriented female in no acute distress. Appears well-developed, well-nourished, and well-dressed.

HEENT: normocephalic, atraumatic head with normal distribution of hair. Patent ear canals. TMs bilaterally pearly gray. Positive light reflexes and easily visualized landmarks. Slight inflammation of eyes noted, with watery discharge and injected blood vessels. Nasal crease noted, external nose is tender and erythematous. Pale and edematous nasal mucosa and turbinate. Slightly inflamed adenoids. Moist and pink oral mucosa. Breathes through mouth. Erythematous pharynx noted. Supple neck with trachea at the midline, no cervical lymphadenopathy.

Respiratory: symmetrical chest wall, regular respiration, no adventitious sounds.

Cardiovascular: S1, S2 with regular rate and rhythm, no murmurs, rubs or gallops. Capillary refill less than 3 seconds. No edema.

Gastrointestinal: Flat, soft and non-distended abdomen free from guarding. Bowel sounds are normoactive in all quadrants.

Musculoskeletal: Full ROM in all extremities.

Neurological: Steady gait, erect posture, stable balance.

 Diagnostic results:

CBC: awaiting results

Skin prick test.

ASSESSMENT:

Diagnosis

Primary Diagnosis

Allergic rhinitis– It is indicated by sneezing fits, runny nose, nasal blockage, and irritation in the palate and eyes. This condition is mostly caused by an IgE-related reaction to common outdoor and indoor environmental irritants (Akhouri & House, 2019)Allergic Rhinitis Assignment Discussion Paper.

Differential Diagnosis

Chronic rhinosinusitis– This is an irritation of the paranasal sinuses that lasts for longer than twelve weeks. Runny nose, postnasal discharge, congestion, Facial pressure, and overall lethargy are common symptoms (Sedaghat, 2018).

Viral rhinosinusitis-This is an episodic rhinitis episode that lasts shorter than two weeks and is characterized by sinus problems, runny nose, sneezing, and distinct levels of nasal itchiness. A sore throat, muscle aches, headaches, discoloration of mucus, and fever are some of the symptoms that may appear. It is more prevalent in the springtime and fall (Dunphy et al., (2017)

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PLAN:

  • Order allergen skin tests.
  • Prescribe Montelukast 10 mg 1 tab PO daily for 30 days, Ipratropium bromide 0.03% two sprays in each nostril 2 to 4 times a day as required, Sudafed 60 mg 1 tab PO twice a day for 7 days, and Prednisone 20 mg 1 tab PO twice a day for 5 days.
  • Recommend nasal irrigation with warm saline solution one to two times per day to wash way the mucus and lessen inflammation.
  • Educate on how to prevent being exposed to irritating substances.
  • To follow up in one week Allergic Rhinitis Assignment Discussion Paper.

 

Include a rationale as to why you think this is a good topic for graduate nursing students to learn.

My choice of this case study was based on the fact that so many people will present to the hospital with the symptoms described above, believing they have the flu. Allergic rhinitis is among the most prevalent conditions seen by primary care providers (Dains, 2015).

Indicate if the case represents something you would expect to see in an outpatient or inpatient setting.

Allergic rhinitis may manifest itself in both inpatient and outpatient settings, with outpatient settings being the more common environment.

Which guidelines would you use to develop a treatment plan? Allergic Rhinitis Assignment Discussion Paper

I would use Clinical Practice Guideline: Allergic Rhinitis by the American Academy of Otolaryngology–Head and Neck Surgery.

References

Akhouri, S., & House, S. A. (2019). Allergic Rhinitis. https://www.ncbi.nlm.nih.gov/books/NBK538186/

Dains, J., Bauman, L., Scheibel, P. (2015). Advanced health assessment & clinical diagnosis in primary care (5th ed.). Elsevier Health Sciences. https://online.vitalsource.com/#/books/9780323277280/

Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. (2017). Primary care: Art and science of advanced practice nursing. FA Davis.

Sedaghat, A. R. (2018). Chronic rhinosinusitis. Infections of the Ears, Nose, Throat, and Sinuses, 155-168. https://doi.org/10.1007/978-3-319-74835-1_13

Allergic Rhinitis Assignment Discussion Paper

Topic: Allergic Rhinitis – SOAP format (subjective, objective, assessment, plant) The case may be a real patient you have actually cared for or one that you heard about, read about, or made up. – Include a rationale as to why you think this is a good topic for graduate nursing students to learn. – Indicate if the case represents something you would expect to see in an outpatient or inpatient setting. – Which guidelines would you use to develop a treatment plan?