Nursing Diagnosis: Ineffective airway clearance related to retained bronchial secretions secondary to chronic maxillary sinusitis, as manifested by respiratory

rate of 30breaths/minute, productive cough with whitish phlegm, clear nasal discharge, and feeling of anterior chest heaviness. Cues Objective: y Respiratory rate 30breaths/minute y Whitish phlegm approximately 10cc per expectoration y Clear nasal discharge y Anterior chest heaviness rated as 4/10. Subjective: a ubo-ubo ako y gamay kag daw okay naman akon sip-on . Ang dughan ko daw bug-at lang akon pamatyagan .

Goals of care Within 8 hours of clinical duty, patient will be able to: y y Maintain patent airway. Verbalize causative factors that lead to chronic maxillary sinusitis Appropriately cough out secretions using coughing exercises Lessened bronchial and nasal discharges Able to practice appropriate deep breathing exercises Decreased feeling of anterior chest heaviness

Nursing Interventions

Rationale

Evaluation

Patient s response

Independent: y Establish baseline vital signs, specifically respiratory rate

To identify alterations in respiratory status

DONE

y y y

Auscultate lung sounds on anterior and posterior thorax Elevate client s head; semifowler s position ive chest physiotherapy

y y y

To assess area of consolidation To facilitate breathing To mobilize secretions

DONE DONE DONE

y y y

Baseline vital signs: T- 36.8; RR25breaths/min; CR76beats/minute;CR-76beats/minute; BP 100/70mmHg. No adventitious sounds noted on anterior and posterior thorax Able to tolerate 45o position Able to cough out secretions

y y

Health teachings: y Health teachings about environmental factors such as allergens that could contribute to sinusitis y Teach patient to perform proper coughing techniques y Teach how to do appropriate deep breathing exercises Therapeutic y Encourage adequate rest y Provide a clean and allergen free environment y Increase fluid intake Collaborative y Administer medications as prescribed; expectorants, bronchodilators.

To prevent reoccurrence of infections

DONE

y y

To appropriately cough out secretions To encourage lung expansion

DONE DONE

y y

Able to enumerate environmental factors that could contribute to chronic maxillary sinusitis such as dusts, pollens,bacteria, strong odors. Able to perform half cough Able to do deep breathing exercises

y y y

To promote wellness Avoid allergic reactions Help loosens phlegm, prevent dehydration Aids in preventing bronchospasm and liquefy secretions

DONE DONE DONE

y y y

Verbalized to have adequate rest Does not manifest signs and symptoms of allergic reactions Verbalized to regularly drink 8-10 glasses of water a day Does not manifest signs and symptoms of bronchial spasm. Expectorate to clear whitish sputum

DONE

y y

y y y

approximately 5cc. (better prior to admission) Patent bilateral nares, verbalized to have lessened nasal discharge Respiratory rate of 24 breaths per minute, unlabored. Verbalized decreased feeling of anterior chest heaviness rated as 3/10 No sign of oxygen deprivation. Maintains patent nares and good nasal hygiene.

Provide recommended treatments: oxygen support, nasal sprays.

To supply oxygen demand, and to maintain good nasal hygiene.

DONE

General Evaluation: After giving nursing interventions, goals were met. Client does not manifest any sign of pulmonary distress, has patent bilateral nares, able to perform deep breathing exercises, cough out decreased bronchial secretions appropriately using half cough, verbalized lessened nasal discharge and feeling of anterior chest heaviness rated as 3/10.

Nursing Diagnosis: Infection related to accumulation of fluid in maxillary sinus secondary to bacterial invasion as manifested by elevated WBC and fever. Cues Goals of care Nursing Interventions Rationale Evaluation Within 8 hours of clinical Independent: Objective: duty, patient will be able to: DONE y Temperature: 37.7C y Decreased body y Establish baseline vital signs, y To identify alterations, y temperature by .3 C specifically body increased in body via axilla via axilla temperature suggests temperature y WBC results of 16.3 infection X10^9/L y Decreased WBC DONE y To recognize progression y between 4.5-11.0 y Monitor body temperature y Skin is warm to touch of fever X10^9/L DONE Subjective: y y Verbalized feeling of y Check laboratories that may y To verify existence of infection, elevated WBC wellness support presence of y Batyagan ko man suggests contamination infection such as CBC. nga daw init akon DONE lawas pero daw wala y y Perform therapeutic sponge y Cold water absorbs heat, thus helps in decreasing man gid sya ga bath. body temperature usbong sa akon mata Health teachings: DONE y To avoid further y y Stress the importance of infection, inhibit fluid hygiene specifically nasal accumulation hygiene.

Patient s response

Baseline vital signs: T- 36.8; RR25breaths/min; CR-76beats/minute;CR76beats/minute; BP 100/70mmHg. Temperature: 37.7C via axilla WBC results of 16.3 X10^9/L

Temperature via axilla decreased to 37.1C, skin is not warm to touch and verbalized feeling of betterment. Verbalized to practice appropriate blowing of nose ( allowing bilateral nares open during blowing to prevent increase in ear pressure ); follow therapeutic regimen of treatments. Verbalized to follow therapeutic medical management regarding taking antibiotic; that not to stop abruptly after feeling well. Verbalized to have enough rest and sleep Verbalized to include in diet vegetable and fruits like oranges.

Explain the importance of antibiotic therapy

To prevent drug resistant bacterias

DONE

Therapeutic y Encourage adequate rest and sleep y Include in the diet fruits and vegetables Collaborative ollow up ordered y laboratories; culture sensitivity, CBC, etc.

y y

To promote wellness To boost immune system

DONE DONE

y y

y y

To identify causative agent. Monitor effectiveness of

NOT DONE

NOT APPLICABLE

treatments y Administer anti-infectives as ordered y To treat causative agent NOT DONE y NOT APPLICABLE

General Evaluation: After giving nursing interventions, goals were not met. Client has decreased body temperature by .6 C, skin is not warm to touch and has verbalized feeling of betterment but WBC result is not available to determine effectiveness of treatment.

Nursing Diagnosis: Risk for acute pain related to localized accumulation of fluid in maxillary sinus secondary to sinusitis Cues Goals of care Nursing Interventions Rationale Within 8 hours of clinical Independent: Objective: duty, patient will be able to: y Assess respiratory status y To check for nasal congestion and nasal y Medical impression y Verbalized no pain in of chronic maxillary maxillary sinus patency. sinusitis. y Identify presence of pain y To give appropriate analgesics, and Subjective: determine progression of pain y Wala man sakit pero daw bug-at lang bala y Transilluminate maxillary y To determine severity of ang pamatyagan sa sinus accumulation of fluid dalum sang mga mata ko Health teachings: y To give prompt y Ask client to report pain. medication treatment y To promote lung y Teach how to do appropriate expansion deep breathing exercises Therapeutic y Provide an allergen free environment y Teach about proper blowing of nose

Evaluation DONE y

Patient s response Patent bilateral nares.

DONE

No pain.

DONE

Negative. Red glow shines on maxillary area.

DONE DONE

y y

No pain. Able to perform proper deep breathing exercises

To prevent allergic responses that could trigger sinusitis To equalize ear pressure

DONE

Does not manifest nasal stuffiness, and other allergic responses. Verbalized to practice blowing of nose with bilateral nares open.

DONE

Collaborative: y Give analgesics as ordered.

To prevent pain

NOT DONE

Not applicable

General evaluation: After nursing interventions, goal is met. Client does not manifest pain in maxillary sinus.

NURSING CARE PLAN

Submitted by: Beverly May Ambut ( BSN 3A-R)

NURSING CARE PLAN

( Sacred Heart Unit)
Submitted by: ASC 13 first shift

Submitted to: Mr. Mavin Reyes, RN

November 2011