Division of Nursing and Health Management - Essay Example

Case Study Assignment - Nurse Practitioner Paper Felician College Division of Nursing and Health Management Department of Graduate Nursing MSN Program NU540MSDL Pharmacology and Prescriptive Practice Case Study Assignment Problem List As apparent from the case, the problems of Mr. M. may be listed as follows. They are Fever and sinus headache due to acute maxillary rhinosinusitis, mild tonsillopharyngitis, bronchial asthma on albuterol MDI, hypertension on DASH diet and hydrochlorothiazide, risk of pneumonia, and self-medication. Top Issues for Care The top issues of nursing care are maxillary sinusitis, bronchial asthma, and hypertension Rationale Maxillary Sinusitis It is important to carefully assess the condition of the patient. Mr. M. has upper airway infection which occurred acutely. The symptoms have lasted for five days. These conditions would seldom require hospitalization. This kind of presentation is common in a community level nurse practitioner practice. It is important for the nurse practitioner to recognize the signs and symptoms so appropriate care may be provided. The patient had fever for five days with moderate fever up to 101 degrees with symptoms of sinus pain and pressure with greenish nasal discharge. A 5-day Fever has led to fatigue and fever and its remission led to sensations of hot and cold. On examination his tympanic membranes are injected bilaterally suggesting mild inflammation without any evidence of acute otitis. The bilateral inflammation of nasal turbinates indicates inflammation of nasal mucosa which is a part of this syndrome of upper respiratory infection. As indicated by Rosenfeld et al. (2007), almost all cases of sinusitis are associated with inflammation of nasal turbinate that overlies the meatus of the affected sinus. Bilateral involvement is suggested by bilaterally demonstrable inflammation of nasal turbinates and bilateral maxillary tenderness, although left was more than the right. The secretions from the sinuses and nasal mucosa were dripping along the posterior pharyngeal wall with inflammation of the throat. In many such cases inflammatory process begins along all the anatomical sites included in the upper respiratory tract, and the throat with the tonsils are the frequent sites of beginning of such infections. Thus tonsillar inflammation and pharyngeal inflammation are normal to encounter (Rosenfeld et al., 2007). The tonsillar involvement is limited to inflammation, and the absence of exudates indicates absence of infection. The patient is suffering from an associated nonallergic rhinitis where infection and underlying sinusitis are important causes. The rhinitis may also be associated with his use of antihypertensive agents as prescribed medications. Sinusitis or inflammation of the mucus lined cavities of the nose occurs in high proportion of cases of upper respiratory infections. The congested turbinates have most probably blocked the openings of the sinuses, so the initial infection has changed into an acute suppurative process causing purulent discharge. Chronic inflammation of the nasal passages due to environmental exposure is an important cause, and in the management and patient education, this must be adequately attended to. The other issue to be included in the management is counteraction of the pathophysiologic process. Running et al. (2006) indicated that acute sinusitis occurs with infection of the paranasal sinuses. It is known that the most frequent initiating event is upper respiratory infection. Inflammatory nasal congestion, edema, and transudation of fluid would lead to obstruction of the sinus cavities. These serve as excellent media for bacterial growth, and several common bacteria have been identified to cause such infections. The important issue in care management would be teaching patient self care. The instructions would involve methods which may promote drainage of the sinuses with the use of steam bath, increasing intake of fluid, and applying hot wet packs over the areas of involved sinuses. The patient uses over the counter Sudafed which must be discouraged. The importance of following antibiotic regimen is important since resistance of the organism may precipitate chronic infection or even aggravate acute infection leading to life-threatening infections. The patient must be taught about early signs of infection in the sinuses, and highlight the preventive measures. Healthy practices and avoiding contact with people with upper respiratory infections are important. Although sinusitis is a seemingly mild type of infection in the upper respiratory tract area, the care plan must include educating the patient about the warning signs of complications which include persistence of fever despite adequate antibiotic treatment, headache, and nuchal rigidity. In this particular case, the patient has a high chance of developing severe acute asthma and pneumonia, and the patient must be advised when to contact the physician. Antibiotics The commonest organisms involved in sinusitis are Streptococcus pneumonae, Haemophilus influenzae, and Moraxella catarrhalis. Therefore, treatment of infection with antibiotics remains the mainstay of management. The choice of antibiotics varies according to practice. As a consensus statement Mariano (2006) indicates that the first line of therapy usually includes amoxicillin, trimethoprim/sulfamethoxazole, and erythromycin. The second line antibiotics include cephalosporins and amoxicillin and clavulanic acid combinations. Newer agents such as macrolides, quinolones are also in use. All antibiotics should be used for 10 to 14 days for complete resolution of the infection. Research has shown little difference in clinical outcomes with either first or second line antibiotics. Given the greater cost, the antibiotic agent of choice will be beta-lactam antibiotic of the amoxicillin group (Mariano, 2006). Asthma Guidelines and Rationale of Treatment Since this illness, Mr. M. is suffering from asthma with symptoms 3 to 4 times per week, occasionally at night since this illness. The patient does not have COPD, and since it is associated with this illness it is a variant of intrinsic asthma. According to guidelines, this has been classified as moderate persistent asthma. As per guideline again, as indicated in Davies et al. (2008), the treatment would be low-to-medium dose inhaled corticosteroids and long-acting inhaled beta-2 agonists. The patient is currently on Albuterol MDI which is a short-acting beta adrenergic agonist. Although this is the medication of choice for relief of acute symptoms due to their rapid onset of actions, these are not appropriate in his case. Given the frequency of his symptoms, there is a considerable inflammatory process in his lungs. Therefore anti-inflammatory inhaled corticosteroids in a medium dose or low-medium dose corticosteroids and added long-acting bronchodilator would be most appropriate. Since he has night-time symptoms these would be most suitable. It is evident that the guideline chooses the medicines in order to control the underlying pathology of inflammation. Corticosteroids are recognized as the most effective and most potent anti-inflammatory medications. They alleviate symptoms, and they are effective in improving airway functions. Specifically for night-time symptoms, long-acting beta-2 adrenergic agonists are in use, although they are not effective in relieving immediate symptoms (Davies et al., 2008). Drug Therapy for Hypertension Although Mr. M. denies blurred vision, on examination, he was found to have bilateral slight AV nicking. This may be beginning of retinopathy. Hydrochlorothiazide is used widely for treatment of hypertension. They are inexpensive and well tolerated. They do not need dose titration, as in case of Mr. M. can be taken once daily, and have few contraindications. According to Sawicki and McGauran (2006) these agents are generally safe and in the hypertensive patients, they reduce mortality and morbidity. Only low dose should be prescribed for hypertension, and a common dose is 25 mg per day. Research provides string evidence that these are best initial treatment for uncomplicated hypertension. There is a concern regarding precipitation of diabetes in the nondiabetic hypertensive treated with this agent, but that cannot be a reason for not prescribing it. Since this patient is showing early signs of retinopathy, there may be two possible reasons. One the hypertensive disease is getting complicated with retinopathy. The other may be the patient has been developing diabetes due to prolonged use of hydrochlorothiazide. In any case, this agent must be withdrawn and treatment with a new agent must be contemplated after appropriate physician referral (Sawicki and McGauran, 2006). Recommendations Indicated in Carlfjord and Lindberg, (2008) 1. Use of oral and topical decongestants to decrease mucosal swelling and facilitate discharge. 2. Heated mist and saline irrigation. 3. Teaching patient self-care. 4. Advice and awareness regarding nasal decongestant agents. 5. Avoid environmental exposure of irritant agents (Carlfjord and Lindberg, 2008). Reference List Carlfjord, S. and Lindberg, M., (2008). Asthma and COPD in primary health care, quality according to national guidelines: a cross-sectional and a retrospective study. BMC Fam Pract; 9: 36. Davies, B., Edwards, N., Ploeg, J., and Virani, J., (2008). Insights about the process and impact of implementing nursing guidelines on delivery of care in hospitals and community settings. BMC Health Serv Res; 8: 29. Mariano, C., (2006). Review: antibiotics are more effective than placebo for acute bacterial rhinosinusitis Evid. Based Nurs.; 9: 43. Rosenfeld, RM., Andes, D., Bhattacharyya, N., Cheung, D., Eisenberg, E., Ganiats, TG., Gelzer, A., Hamilos, D., Haydon, RC., 3rd, Hudgins, PA., Jones, S., Krouse, HJ., Lee, LH., Mahoney, MC., Marple, BF., Mitchell, CJ., Nathan, R., Shiffman, RN., Smith, TL., and Witsell, DL., (2007). Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg; 137(3 Suppl): S1-31. Running, A., Kipp, C., and Mercer, V., (2006). Prescriptive patterns of nurse practitioners and physicians. J Am Acad Nurse Pract; 18(5): 228-33. Sawicki, PT. and McGauran, N., (2006). Have ALLHAT, ANBP2, ASCOT-BPLA, and So Forth Improved Our Knowledge About Better Hypertension Care Hypertension; 48: 1 - 7. Read More