Case Study: Sinus Infection
Patient Initials: J.S.
Age: 34
Gender: Female
Current Medications: None
Medical History – Medical Problems:
– Seasonal allergies
– Previous sinus infections
– No known chronic medical conditions
Objective findings from physical examination:
– Vital signs: Blood pressure: 120/80 mmHg | Heart rate: 80 bpm | Respiratory rate: 16 breaths per minute | Temperature: 98.6°F
– Weight: 150 lbs
– Height: 5’6″
– BMI: 24.2 (within normal range)
Focused examination findings based on diagnoses being addressed:
– Nasal congestion
– Facial tenderness
– Tenderness over the sinuses
– Postnasal drip
– Difficulty breathing through the nose
ICD-10 Diagnosis (include ICD-10 code):
– Sinusitis, acute (J01.0)
Nursing Diagnoses or Care Plan based on the diagnosis:
1. Impaired airway clearance related to nasal congestion and thick mucus secondary to acute sinusitis.
2. Acute pain related to inflammation and pressure in the sinuses.
3. Deficient knowledge related to sinusitis management and self-care measures.
Nursing Care Planning for patient to include:
1. Encourage increased fluid intake to thin mucus and promote drainage.
2. Administer prescribed nasal decongestants or saline nasal sprays to relieve congestion.
3. Apply warm compresses over the sinuses to reduce discomfort and promote sinus drainage.
4. Educate the patient on the importance of completing the full course of prescribed antibiotics to effectively treat the infection.
5. Teach the patient proper hand hygiene techniques to prevent the spread of infection.
6. Provide instructions on self-care measures, such as steam inhalation and saline nasal irrigation.
7. Collaborate with the healthcare team to ensure appropriate pain management strategies are implemented.
8. Monitor the patient’s vital signs, symptoms, and response to treatment.
9. Document and communicate any changes in the patient’s condition to the healthcare provider.
Potential issues with achieving quality, comprehensive care:
1. Non-compliance with prescribed treatment regimen.
2. Inadequate understanding of self-care measures.
3. Inadequate pain management.
4. Lack of follow-up care.
Information on best practice care considerations:
1. Prescribe antibiotics for the treatment of acute bacterial sinusitis if symptoms persist for more than 10 days or worsen after initial improvement.
2. Encourage the use of nasal saline irrigation as an adjunctive therapy to relieve symptoms and promote sinus drainage.
3. Advise patients to avoid allergens or triggers that may worsen sinus symptoms.
4. Provide education on proper hand hygiene and respiratory etiquette to prevent the spread of infection.
5. Promote adherence to the full course of prescribed antibiotics to ensure complete eradication of the infection and prevent antibiotic resistance.
Care outcomes from current treatment:
– Resolution of nasal congestion and sinus pressure
– Reduction in facial tenderness
– Improvement in breathing through the nose
– Relief of pain
Possible side effects of medications or treatments:
– Nasal decongestants may cause rebound congestion or dryness of the nasal mucosa.
– Antibiotics may cause gastrointestinal disturbances, allergic reactions, or opportunistic infections.
Patient education planning/instructions:
1. Instruct the patient to complete the full course of prescribed antibiotics and to report any adverse reactions or persistent symptoms.
2. Teach the patient proper hand hygiene techniques and encourage respiratory etiquette, such as covering the mouth and nose with a tissue or elbow when coughing or sneezing.
3. Provide written instructions on how to perform nasal saline irrigation at home.
4. Emphasize the importance of avoiding allergens or triggers that may exacerbate sinus symptoms.
Care outcomes:
– Evaluate the patient’s response to treatment at the next follow-up appointment.
– Assess the effectiveness of interventions in relieving symptoms and improving quality of life.
References:
1. American Academy of Otolaryngology—Head and Neck Surgery. (2015). Clinical practice guideline: Adult sinusitis. Otolaryngology–Head and Neck Surgery, 152(2_suppl), S1-S39.
2. Chow, A. W., & Benninger, M. S. (2012). Care of the patients with acute bacterial rhinosinusitis: Update from the infectious disease society of America. Clinical Infectious Diseases, 54(12), 1452-1453.
3. Habib, A. R., & Singh, D. D. (2020). Acute sinusitis. In StatPearls [Internet]. StatPearls Publishing.
