Case Study ON respiratory symptoms

Case Study ON respiratory symptoms

1. Introduction
2. Patient

The patient is a woman called Signature. She is thirty-six years of age. She has had a myriad of complications for a long time. She has had a case of prolonged allergic rhinitis, atopic dermatitis, asthma, and recurrent sinusitis. In this particular instance, in the case study, she had gone to see her primary care physician following some respiratory symptoms. Some of which included a cough that had persisted for over three months, in which time it got only worse. Signature also reports that in the last one month, she has registered chest pains that only get worse with the slightest work.  At the same time, the patient said that her chronic rhinorrhea was only getting worse and bothersome. In this time, she also reports issues with her hearing, which has deteriorated in the last six months.

1. What is the problem is.

The patient has a series of conditions, such as; prolonged rhinitis, recurrent sinusitis, asthma, and dermatitis. All these conditions have been long term. Also, she has struggled with eczema since childhood.

During her visit, Signature has complained about a series of underlying conditions. She has had a persistent cough for three months. Her cough is productive, and she coughs blood. Also, she has been having a significant production of mucus. She attributes this to chronic rhinorrhea.  In the same context, she complains of chest pains for over a month. These pains get worse any time she does any work, no matter how minimal. The patient has also reported deteriorating hearing in the past six months. The reason for her referral by the primary care physician was because of the respiratory symptoms mentioned above.

1. What to do as a nurse

My area of focus will be tackling the supporting conditions and allergies that leading to the worsening of the patient’s asthma. To do this, I will undertake the following

• Conduct a detailed physical examination of the patient
• Interview the patient to get the symptoms they exhibit and the patient’s medical history
• Conduct a neurological, and radiological examinations
• Conduct and report on the cardiovascular examination of the patient.

2. Pathophysiology

Asthma, on the other and is a condition in which a person’s airway narrows because of swelling and produces a lot more mucus than usual (Patadia et al., 2014). It’s characterized by shortness of breath, chest pains, and wheezing cough attacks. Some other symptoms include increased heart rate, trouble sleeping due to frequent coughs.

3. History
4. Health problems of the patient

The primary condition that Signature suffers from is asthma and a severe case of allergies. However, she has other underlying conditions like allergic rhinitis, recurrent sinusitis, and atopic dermatitis (Jarvis et al., 2012). Rhinitis is caused by inflammation of the mucous membrane in the nose. It affects the ear, nose, and throat (Dykewicz & Hamilos, 2010). It’s characterized mostly by rhinorrhea, which in some cases can be chronic like in the case of Signature.  Sinusitis is caused by germs that grow and cause infection when a healthy sinus is filled with fluid. Some of its symptoms include congestion of the nasal cavity and rhinorrhea. Atopic dermatitis can simple be called chronic eczema. It’s also characterized by inflammation, itchy patches on elbow like in the case of this patient.

1. Previous treatment and medication

The patient is on daily antihistamines, intranasal fluticasone, and a combination of long-acting beta-agonist and glucocorticoid mometasone-formoterol. She has, however, not had any surgical procedures at all. She has a rescue inhaler and is on antibiotics for her sinuses.

4. Nursing Physical Assessment

Upon assessment the patient’s stats looked as follows;

• The patient is non- feverish ( afebrile)
• She has a heart rate of 105 beats per minute
• She exhibits a respiratory rate of eighteen breathes per minute.
• She has chronic eczema around her elbows
• She has bilateral otitis media
• She has clear nasal discharge and visible nasal polyposis.
• She also exhibits bilateral expiratory wheezing

5. Treatment because of the disease

By treating the cough, the patient will get relief from the chest pains. By medicating the sinusitis, the chronic rhinorrhea will dial down and offer comfort for breathing and curb the running nose. Medication for the bilateral otitis media will bring back the hearing that has been deteriorating for the past six months (Edmiston & Mitchell, 2013). With a combined medication and relief from the subsequent respiratory problems as a result of allergies and germ infection, the patient will experience relief from the increasing asthma attack that requires her to use the rescue-inhaler for more than four times in a week.

6. Nursing diagnosis and Patient Goal

The first thing that needs to be addressed is the allergies that are causing the asthma of the patient to flare up. The main problem, in my view, is not asthma but the cough and allergies. My main goal for helping the patient is to first and foremost offer quick and lasting relief for the patient. In turn, this will give the patient a chance at a more comfortable life. Coupled with my evaluation and recommendation, I believe with proper care, the patient will have ease of undertaking her activities in spite of her condition.

7. Nursing interventions

I will achieve my recommendations and goals by slating frequent observations and check-ups on the patient. Also, with the cooperation of the patient, we will be able to control patient allergies that worsen the sinuses.

8. Evaluation

By treating the cough and the allergies, the patient will get relief from the menace caused by asthma, like chest pain. By treating the sinus congestion, it inadvertently relieved the rhinorrhea.

9. Recommendations

I will recommend more frequent check-ups to assess patient progress. Also, upon future assessment, ones the patient experiences more relief from chest pain. I will recommend minimal exertion and undertaking very light to no duties at all. I will also suggest that the patient takes a keen interest in knowing avoiding allergens that lead to flaring of her sinusitis. Such, in the long run, leads to worsening of her asthma condition.

Reference

Dykewicz, M. S., & Hamilos, D. L. (2010). Rhinitis and sinusitis. Journal of Allergy and Clinical Immunology, 125(2), S103-S115.

Edmiston, R., & Mitchell, C. (2013). Hearing loss in adults. Bmj, 346, f2496.

Jarvis, D., Newson, R., Lotvall, J., Hastan, D., Tomassen, P. E. T. E., Keil, T., … & Brozek, G. (2012). Asthma in adults and its association with chronic rhinosinusitis: the GA2LEN survey in Europe. Allergy, 67(1), 91-98.

Patadia, M. O., Murrill, L. L., & Corey, J. (2014). Asthma: symptoms and presentation. Otolaryngologic Clinics of North America, 47(1), 23-32.