Introduction to the case or situation
Patient name: Tom Hiddleston.
Age: 40.
Initial Diagnosis: acute sinusitis.
Required investigations:
- CT scan that provides a 3-D picture or an MRI to see the internal structures;
- fiberoptic scope through the nose;
- blood test;
- urine test.
Complaints:
The patient has:
- flue-like symptoms: headache, stuffy nose;
- nasal inflammation, and congestion;
- difficulties in breathing;
- dry cough;
- pain in ears;
- pain around the nose and eyes.
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. 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)
Background details
- Mr. Hiddleston previously not diagnosed with sinusitis.
- Has a seasonal dust allergy.
- has had coronavirus in the light form during the last winter.
- has been smoking for 20 years.
- lost the sense of smell after the COVID-19.
- the PCR test is negative.
- Patient rejects having tuberculosis or hepatitis.
- Has a rhinoplasty due to a broken nose bone.
- Reports having a virus infection for more than two weeks and high fever for the last 3 days.
- Presumably got sick at the trip to London.
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 possible diagnosis based on his narrative is sinusitis in acute or chronic form.
Clinical assessment
- Risks:
- Acute sinusitis could turn inro chronic sinusitis;
- The patient has all prerequisites to receive sinusitis in chronic form.
- General conditions:
- Body temperature: 37.3 degrees Celsius;
- Blood pressure: 110 mm Hg;
- The surface of the skin is clear and normally toned;
- Reduced appetite and weakness in the body, and he has a sore throat and red tonsils (Higuera, 2019);
- Heart sounds are at the normal S1 level (Mayo Foundation, 2019b);
- Has hard breath and no wheezing in the lungs (Mayo Foundation, 2019a);
- Has an extensive number of leukocytes that could refer to the inflammatory process.
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.
Recommendations
- Treatment:
- Acute sinusitis requires antibiotics;
- As the patient is allergic to amoxicillin, azithromycin should be taken two times daily for 7 days (Higuera, 2019);
- Take pain relievers like acetaminophen or ibuprofen;
- Saline solution and saline nasal sprayto reduce inflammation;
- Fluticasone, or mometasone, or beclomethasone (prevent and treat inflammation).
- Recommendations:
- Immunotherapy;
- avoid virus infections;
- The patient should be under the constant control of the ENT doctors.
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). 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.
Application to future practice
- A good example of:
- creating a nursing care plan;
- Identifying the risk and initiatives related to the patient;
- conducting all investigations needed to assign the diagnosis;
- facilitating comfortable and effective treatment.
- Self-reflection, I:
- applied instructions provided by Usman et al. (2021) that included data collection and analysis;
- evaluated possible risks and outcomes;
- introduced detailed treatment methods and measures to avoid complications.
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, the plan includes various measures used to eliminate the issue in the long term.
References
Higuera, V. (2019). What you need to know about sinusitis. Healthline. Web.
Mayo Foundation for Medical Education and Research. (2019a). Chronic sinusitis. Mayo Clinic. Web.
Mayo Foundation for medical education and research. (2019b) Acute sinusitis. Mayo Clinic. Web.
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. Web.