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Nursing Documentation For Rhinitis Allergy

Rhinitis Allergy

Definition

Members of Group 6B

Is inflammation of the nasal mukosa characterized by nasal congestion, rhinorrhea, sneezing, pruritis and postnasal drainage

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Annida Nur Shalihah

Dessy Permatasari

Dwi Junianto

Fatimah Q.F.

Hanifa Iqomatulhaq

Lanni Sulastri

Nida Luthfiyani

Nurhardini Rahmatika

Oselia Esa Muslimawati

Retno Hardiyanti

Etiology

Causes by an immediate or delayed reaction to airborne allergens.

Symptom

  • Sneezing
  • Itching
  • Nasal obstruction
  • Nasal discharge (Runny nose)
  • Watery eyes
  • Fatigue
  • Pruritis of the nose, ears, eyes and pallate

Case

Thank You

Intervention

Ms. M, 19 years, complained of her nose is blocked so it find hard to breathe, thin and clear fluid is discharged from the nose, red eyes and itchy. She knows that she is allergic to cold, dust and some kinds of food e.g. nut, chocolate. She was sneezing almost all the time when the allergic come. When the allergy recurrence, she find herself felt difficult to do the activity because she felt really exhausted. The doctor gave the medicine, cetirizine, that she rarely drink because it made her heartbeat palpitate and she didn’t like it. 4 years ago she diagnosed for bronchitis. Vital sign: BP 110/ 70 mmHg, HR 100x/mnt, RR 18/mnt, T 36,7oC, Compos Mentis

Antropometri: Height 158 cm, Weight 58 kg

2. Activity intolerance r.w imbalance of supply and oxygen demand

Purpose : assist patients in activity

Criteria : Clients are able to perform usual activities

Intervention :

  • review of patient activity
  • instruct the patient to rest
  • help the patientif they can not perform the activity

1. Ineffective airway r.w inflammation of the mucous membranes of the nose

Purpose : The airway is effective after the secret was issued

Criteria :

a. Airway back to normal, especially the nose

b. Clients do not breathe through the mouth again

Intervention :

  • Assess the existing secret buildup
  • Observation of vital signs
  • Collaboration with the medical team

Diagnosis

1. Ineffective airway r.w inflammation of the mucous membranes of the nose

2. activity intolerance r.w imbalance of supply and oxygen demand

3. Anxiety r.w deficient knowledge about the disease and medical treatment

3. Anxiety r.w deficient knowledge about the disease and medical treatment

Goal: Anxious clients reduced / lost

Criteria:

a. Clients will describe the anxiety level

b. Clients know and understand about the disease and its treatment.

Intervention :

  • Assess client's level of anxiety
  • Provide comfort and ketentaman on the client : Accompany client, empathy (comes with touching clients)
  • Give an explanation to the client about her illness slowly, calm seta use the phrase clear, concise easy to understand
  • Observation vital signs
  • If necessary,the collaboration with the medical team

Assesment

Physical Examination

Reference

  • Vital sign : Consciousness, Blood preassure, Heart rate, Respiratory rate, Temperature
  • Antropometri : Weight, Height, BMI
  • Review of system

2. Chief complaint

3. Medical history

4. Past medical history

5. Family history

6. Current medication

1. Herdman, Heather & Kamitsuru, Shigemi.2014.NURSING DIAGNOSIS: Definition & Classification 2015-2017.NANDA International, Inc.

2. www.nhs.uk/condition/rhinitis-allergic/pages/introduction.aspx

(Accessed on wednesday, 27-05-2015 at 02.36 pm)

1. Identity

Name : Ms. M

Age : 19 years old

Gender : Female

Status : n.a

Ethnic : n.a

Adress : n.a

Occupaation : n.a

Diagnosa medis : Allergy

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