Martin Musonda, a 19 years grade 12 pupil at AnoyaZuluHigh School is admitted to your Medical Ward with a diagnosis of severe smusitis.
(a) (i) Define Sinusitis 5%
(ii) Mention the four (4) main sinusis 8%
(b) State six (6) signs and symptoms of sinusitis 12%
(c) Discuss the management of Musonda till discharge 50%
(d) Explain five (5) complications which Musonda may develop if
Management is not effective 25%
(a) (i) Definition:
It is the inflammatory condition of the paranosal sinuses.
The main sinusies:
Six (6) signs and symptoms
Pain over the affected sinusie
Panilent Nasal drainage
Nasal obstruction and congestion
Low grade fever
Nasal stuffiness and headache
Management till discharge
X-ray of the sinusies or
Computed tomography, to confirm the diagnosis. It may show fluid in the sinusies or thickened mucous membrane.
Nasal endorscopy, used to examine the sinuses and obtain drainage for culture.
Medical treatment (Drugs)
Effective treatment depends on the type of sinusitis.
Amoxycillin, 250 mg, every 8 hours for 5 days. Orally.
Action: Bacteriastatic and bacteriodel.
Side effects: Nausea, diarrhea, rashes, leucopenia and thrombocytopanice in prolonged use.
Nursing Intervention: Avoid it in a patient with history of allergy, renal impairement and leucarmia. Observe for side effects or
Ampicillin 250 mg, orally, 6 hourly for 5-7 days.
Analgesics: Panadol, 1000mg, 3 times daily for 3 days.
Indication: To relieve mild to moderate pain and pynexia.
Side effects: Liver damage on prolonged use.
Nursing Action: Do not give it to a patient with inpaired kidney or liver function.
Ibuprofen: Dose 400mg, orally, 8 hourly, for 3 days.
Indication: Fever and in moderate pain
Side effects: GIT irritation and brouchosposis.
Antihistamines: These may be given if allergy is suspected.
Chlorpheniramine, 2 mg, orally, 6 hours,
Indication: Symptomatic relief of allergy.
Side effects: Exfoliation dematits and tinnitus may develop.
Bomethazine Hydrochloride 20 mg orally/IM
These may be given to relieve inflammation and as anti-allergic drugs.
Prednisolone 20 mg, once per day, for 7 days orally.
Side effects: In prolonged use may sappress immunity.
Nursing consideration: Should be given after breakfast.
Dexamethasone 20 mg initial dose IM.
Pain related to signs obstruction, inflammation or infection.
Altered nutrition, less than body requirements related to decreased appetite and inadequate food intake.
Knowledge deficiency on the condition and self care as manifested by anxiety.
Risk for infection related by impaired mucosal integrity.
Some throat as manifested by difficulties with swallowing.
Need for Health Education.
PAIN, RELATED TO OBSTRUCTION AND INFLAMMATION OF SINUSIS:
– The objective is to relieve pain and promote drainage of secretions.
– Encourage the patient to be taking a lot of fluids to liquefy secretions.
– Steam inhalation and Nasal sprays or humidifier can be used to promote secretion drainage.
– The patient should be encouraged to maintain semi fowler’s position to promote sinus drainage.
– Administer prescribed analgestics such as paracetamol 1g orally, 3 times per day
for 3 days, to relieve pain.
– Administer prescribed antibiotics to get ride of infection ieAmoxyccillin 500 mg, 6 hourly for 5 days.
Encourage frequent oral hygiene to enhance taste of food and remove foul edour.
Provide nutritious, attractive foods to stimulate appetite
Keep the environmental free of bad odour
Give chance to the patient to choose the type of foods he wants.
KNOWLEDGE DEFICITY ON THE CONDITION AND SELF CARE:
Explain to the patient the condition that is inflammation of sinusies characterized by pain and mucous discharge. It can be treated used appropriate drugs depending on the course. This is done to increase patient’s knowledge of self care.
Answer questions completely about self care responsibilities
Instruct the patient to follow interventions
If allergy is the course, follow instructions regarding environmental control, drug therapy and prevention of sinus infection.
Instruct the patient to take prescribed drugs
Observe side effects of drugs such as nausea and vomiting. If they are severe you may change the drug.
Report signs of infection to the physician so that appropriate intervention is instituded
NEED TO PROVIDE BASIC NURSING INTERVENTIONS:
Offer a bath to the patient on daily basis or when ever necessary
Provide psychological care to the patient to relieve anxiety. This can be done by explain all the procedures and by maintaining good patient and nurse relationship.
Observe the elimination pattern to detect abnormalities related to urinary out put and GIT.
Allow friends from school to see him and provide books for reading.
NEED FOR HEALTH EDUCATION FOR CONTINUED SELF CARE AT HOME:
The patient should avoid smoking or other irritants which can irritant nasal passages.
Should avoid factors which can predispose to exacerbations, such as swimming and diving.
Should take prescribed drugs. Instructions should be written.
Should maintain good hygiene especial of the nasal cavity and proper handling of discharges to avoid re-infection.
MutumwaMulena, a 9 years boy, known sickle cell sickler is admitted to your children’s ward in a sickle cell crisis.
(a) Define sickle cell disease 5%
(b) (i) State any five (5) precipitating factors of sickle cell 15%
(ii) Explain the four (4) types of sickle cell crisis 20%
(c) Discuss the management of Mutemwa till discharge 45%
(d) The parents to Mutemwa require counseling. Outline 15%
Five (5) principles of counseling you would consider
During the counseling session.
Sicckle cell disease is agenetic disorder characterized by
production of abnormal haemoglobin, anaemia and acute or
chronic tissue damage from vascular blockage by trapped
(b) (i) State precipitating factors:
– Dehydration. This increases blood visiosity
– Infection: Infection is associated with intravascular
haemolysis with marked spherocytosis due to
bacterial production of alecithineso which destroys
The red cell’s membrane.
(b) (ii) Four types of sickle cell crisis
Vaso-occlusive crisis or inforctive crisis.
It is also referred to as painful crisis which is the hallmark of this disease. The crisis occurs when red blood cells release oxygen to the tissue. In response abnormal Hb S associates to form fibres that cause RBG to take on a sickle shape. The sickle cells dump together and reduce or block blood flow to the area fed by the vessel. This cause obstruction of the blood vessel and produce widespread ischeamia. Meanwhile increased oxygen demand causes further sickling.
This is also called megaloblastic crisis. It results from bone marrow depression and is associated with infection. This crisis causes pallor bethargy, sleepiness, dyspnoea, and decreased bone marrow activity and RBC haemolysis.
Acute sequestration Crisis:
It usually cause sudden, massive entrapment of RBCs in the spleen and liver. Thrombosis of the venous outflow from an organ causes loss of function and acute painful enlargement. Massive splemic enlargement may result in severe anaemia and circulatory collapse with death.
Haemolytic Crisis usually occurs in patients who have glucose – 6 – phosphate dehydrogenase deficiency. This results to sickle cell anaemia rather than the disorder itself. Heemolytic crisis causes liver congestion and hepatomegally and worsens chronic jaundice.
Management of Mutemwa till discharge:
The following investigations may be carried out:-
Stained blood smear will reveal partially or completely sickled cells.
Sickle cell preparation sickledex. Blood specimen reaction is observed in hypoxic setting. Blood is mixed with a solution that deoxygenates Hbs. It becomes insoluble and causes turbidity. Development of cloudiness is positive for presence of Hbs.
Haemoglobinelectrophonesis. Blood specimen is exposed to electric field and types of haemoglobin are separated. Hbs may be positive in sickle cell anaemia.
There is no specific drugs which can be used to treat the disease. Supportive therapy is given and is directed towards alleviating the symptoms and prevention of complication. The following drugs smay be given:-
Dose: 2 – 6 l/Min by face mask
It is given to alter hypoxia and control sickling.
These are given to relieve pain
Pethedine: Intrausculary, whenever necessary or 8 hourly.
This drug is given in severe pain
Side effects: Addiction
Nursing consideration: Give the drug when there is great need. Doses should be limited to prevent addiction.
Mild analgnesics like panadol should be given in moderate pain.
These are given to combat opportunistic infections.
Penicillin V . Dose 250mg, orally, every 6 hours for 5 days.
Side effects: Urticaria, fever, joint pains etc.
Cousion: Don’t give to a patient who is allergic and with renal impairement.
Amoxillin, 250 mg, orally, every 8 hours, for 5 days.
Side effects: Nausea, diarrhea and some rashes
Caution: Don’t give in allergy, observe for side effects.
Intravenous fluids such as Normal Saline and dextrose 5%. Fluids are administered to reduce blood viscosity and maintain renal function.
Blood transfusion may be done. It should be done with caution to avoid worsening the condition. Regular transfusion may be done to suppress Hbs production and maintain the Hbs level below 30%. This minimizes complications like cerebrovascular accidents.
Folic acid is also given to the patient.
To relieve pain and promote rest.
To prevent complications
Need for close observations
Loss of appetite
Joint pains/swollen hands and feet
Fever due to disease process
Inability to maintain own good hygiene status
Need for Psychological support to the patient and parents
Risk of infection
Knowledge deficient on the disease
Deficient fluid volume
Promoting comfort and pain reduction
Handle the patient gently to avoid inducing pain
Relieve or avoid pressure on the swollen points by using bedcraddle to lift the heavy linen.
Encourage gentle flexion and extension of affected limbs to promote fluid circulation
Warm or cold compresses may be applied on pain area to relieve the inflammation.
Administer prescribed analgesics or nacortics. In severe pain administer pethedine 25-50mg every 8 hours. In mild pain paracetamol is given 500 mg, 3 times daily, orally for 3 days.
All the procedures should be well timed to avoid constant disturbance of the patient. The patient should be given time to rest.
The ward should be free from noise which can irritate the patient.
Promo tion of Hydration and good nutrition.
The vaso-occlusive nature of painful episodes requires adequate hydration to decrease blood viscosity.
Encourage the patient to take as much oral fluids as possible.
In severe cases the intravenous infusion should be commenced. Normal saline or dextrose can be given. Drop rate should be calculated and maintained to ensure that adequate fluids are given the patient.
Monitor fluid intake and output using the fluid balance chart.
Provide adequate food to the patient. The food should be well balanced to provide all the nutrients needed.
Involve the patient in making the menu
Provide a lot of fluids for vitamin C.
Feed the patient as often as possible.
Food should be appetizing
Oral care should be done before and after the meal to remove any dirty and promote salivation.
Prevention of Infection:
Patients with this condition have a high risk for infection.
As a nurse, monitor the patient for early signs of infection such as hyperpyrexia.
Monitor the patient’s temperature, blood pressure, respiration rate and pulse. Deviation from normal reading suggest infection. In this case temperature is very important.
Nurse the patient away from infection condition
Report any sudden of patient’s condition or institute prompt intervation, for example, fever, cover the patient on antibiotics or change the antibiotic. The physician should be consulted.
Patient usually is not active due to painful joints and weaknesses as a result of anaemia.
Encourage the patient to be changing position in bed.
Do passive exercise and encourage active exercise by sitting up in bed, movements within the room and by doing what ever procedure the patient can manage such as feeding himself.
All these are carried out to promote good muscle tone and body fluid circulation.
Knowledge deficity on the condition:
Discuss the disease process with the patient, for example it is an inherited condition which has no specific treatment.
The patient should know the precipitating factors such as coldness and infection.
Encourage the patient to avoid these precipitating factor.
Explain all treatment option to the patient such as coldness and infection.
Encourage the patient to avoid these precipitating factor
Explain all treatment option to the patient such as use of antibiotics, intravenous infusion.
Information provided to the patient will promote self care and coorperation during hospitalization.
Promotion of good hygienic status
Give daily big bath
Oral care every after a meal
Environmental should be clean all the time
Linen the patient is using should be clean
In acute state provide a bed pan
Encourage the patient to avoid
Give a diet rich in fibre to prevent constipation
Observe fluid intake and elimination and record on the fluid balance chart.
I E C:
Encourage the parents to come to the hospital for follow up care. The should seek promote medical care when the child is sick to prevent complications such as severe anaemia
The child should be taking a lot of fluids to prevent dehydration which can predispose to a crisis.
Keep the patient warm most of the times and avoid other precipitating factors.
Give adequate information on the condition to prevent anxiety.
(d) Five (5) Principles of counseling:
– Compassion. Compassion towards the client is absolutely essential for counseling to be effective. This is a prerequisite for effective communication.
– Communication style should be equal. This principle status that counseling is not effective if it is top to down. The care provider should not dominate, communication style should be equal between the client and care provider.
– Social influence or cultural background. The care provider should understand the cultural and social influence to understand the client’s behaviour.
– Positive emotional response.
The counselor should create conducive environment for the patient to open up and to be at easy.
– Assure and maintain privancy. The information given to the counselor should be confidential.