Write a care plan for patient
Your patient is a 35 year-old African American female patient that has allergic rhinitis. Her prescriptions include loratadine 5mg/day and fluticasone two nasal inhalations per day. Previously she had taken OTC drugs and asked if she could continue to take the OTC drugs with her prescription. She has never used a nasal inhaler before. She is admitted to your unit with a fever of 103? And you are supposed to take care of her. Write a care plan for this patient, providing six goals each with a non-pharmacological interventions and scientific rationales that you would use.
Medical Diagnoses: Allergic Rhinitis
Nursing Diagnoses:
- Risk for Impaired Airway Clearance
- Risk for Ineffective Health Maintenance
Assessment:
Subjective Data: Patient reports having experienced sneezing, nasal congestion, and nasal drainage for one month before admission. Patient also reports that over-the-counter (OTC) medications have been used to treat symptoms and expressed interest in using them in combination with her prescription medications.
Objective Data: Patient is diagnosed with allergic rhinitis, fever of 103. Patient has difficulty breathing, coughing, and sneezing.
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Short Term Goals:
- Patient will maintain patent airway and reduce fever within 24 hours
- Patient will use prescribed and/or over the counter medications as directed within 24 hours
- Patient will demonstrate proper use of inhaler within 24 hours
Long Term Goals:
- Patient will demonstrate improved health maintenance within 4 weeks
- Patient will demonstrate improved breathing within 4 weeks
- Patient will be free of symptoms of allergic rhinitis within 4 weeks
Intervention Scientific Rationale Evaluation Goal Achieved
- Risk for Impaired Airway Clearance
- Monitor and assess patient’s respiratory pattern and oxygen saturation levels.
- Maintain patent airway and reduce fever by administering antipyretic medications as ordered.
Monitoring and assessment of patient’s respiratory pattern and oxygen saturation levels will allow for early detection and management of potential complications caused by allergic rhinitis. Administering antipyretic medications as ordered helps to reduce fever, which can help to improve airway clearance. Yes, patient-maintained patent airway and reduced fever within 24 hours.
- Risk for Ineffective Health Maintenance
- Educate patient on the importance of taking medications as prescribed by health care provider.
- Demonstrate proper use of inhaler.
Educating the patient on the importance of taking medications as prescribed helps to ensure that the patient is engaging in effective health maintenance practices. Demonstrating proper use of the inhaler will help the patient to gain the most benefit from the medication when administering. Yes, patient used prescribed and/or over the counter medications as directed and demonstrated proper use of inhaler within 24 hours.
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- Improved Health Maintenance
- Encourage patient to take medications as prescribed.
- Educate patient on lifestyle changes that can help to reduce symptoms of allergic rhinitis.
Encouraging the patient to take medications as prescribed will help to ensure that the patient is engaging in effective health maintenance practices. Educating the patient on lifestyle changes that can help to reduce symptoms of allergic rhinitis will help the patient to better understand how to self-manage their condition. Yes, patient demonstrated improved health maintenance within 4 weeks.
- Improved Breathing
- Monitor and assess patient’s respiratory pattern and oxygen saturation levels.
- Administer bronchodilators as ordered.
Monitoring and assessment of patient’s respiratory pattern and oxygen saturation levels will allow for early detection and management of potential complications caused by allergic rhinitis. Administering bronchodilators as ordered helps to reduce airway obstruction and improve breathing. Yes, patient demonstrated improved breathing within 4 weeks.
- Free of Symptoms of Allergic Rhinitis
- Educate patient on the importance of taking medications as prescribed by health care provider.
- Educate patient on lifestyle changes that can help to reduce symptoms of allergic rhinitis.
Educating the patient on the importance of taking medications as prescribed helps to ensure that the patient is engaging in effective health maintenance practices. Educating the patient on lifestyle changes that can help to reduce symptoms of allergic rhinitis will help the patient to better understand how to self-manage their condition. Yes, patient was free of symptoms of allergic rhinitis within 4 weeks.
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