DAVAO DOCTORS COLLEGE

Gen. Malvar St., Davao City

BACHELOR OF SCIENCE IN NURSING

Individual Case Presentation of

ALLERGIC RHINITIS
Presented to the Nursing Clinical Instructor of
Davao Doctors College
In partial Fulfillment of the Requirements in
Nursing Care Management 103
Related Learning Experience

Christine Joy Catacata, SN

July 2015

TABLE OF CONTENTS

I.

Patients Profile
Comprehensive Assessment

II.

Anatomy and Physiology

III.

Brief Pathophysiology

IV.

Medical Management / Course in the Ward

V.

Nursing Management (Nursing Care Plan )

VI.

Pharmacology

PATIENTS PROFILE

Name: Jumamil, Nenita Dimalaluan

Hospital Number: 00261058

Address: B7, L25, P2, Aguila St.,

Patient Number: IP15-008715

Awang Subd, Bacaca, DVO

Age: 61Y3M3D

Attending Physician: Dr. Batalla

Sex: Female
Nationality: Filipino
Civil Status: Married
Religion: Christian
Occupation: Govt. Employee

Chief Complain: Cough and Fever

Admission Diagnosis: Urticaria, SVI, allergic rhinitis; ess hpn

Past Health History:

Patient was known having thyroid disorder, essential hypertension that started 11
years ago. She is taking Losartan 50mg, once per day as her maintenance. She
had undergone TAHBSO in the early 1990s as well as Laparoscopic
Cholecystectomy last 2013. She had bronchial asthma that started last year and
taking Avamyst as her emergency drug but effect has poor compliance. She has
allergy in Levofloxacin.
3 days prior to admission, patient had onset of fever with a temperature of 38.
4*C associated with productive cough with yellow phlegm seen. Patient self

medicated Paracetamol 500 mg/tab and Sinecod(Ambroxol) which only provided

temporary relief. Patient also noticed muscle pain on the same day, medicated
with Norgesic Forte, still temporary relief was provided. On the night prior to
admission, patient still have persisted condition, hence the admission.
Present Medical History: During rounds, Patient was received lying on bed in
moderate high back rest. With ongoing #1 PNSS @ 80cc/hr at her left
metacarpal vein. Patient was alert, conscious and coherent during interaction
and can clearly verbalize her thoughts and concerns. Non productive cough was
observed. Patient still complained about chest pain during coughing.
Family History: On the paternal side,
Current Lifestyle:

ANATOMY

BRIEF PATHOPHYSIOLOGY
In allergic rhinitis, your body overreacts to some stimulus in the environment that
stimulus is called an allergen. The most common culprit is pollen. Pollen can
come from trees or grass. Pollen also tends to be seasonal. In other words, some
types of pollen are out in the type of environment with different temperature and
that gives rise to yet another term thats synonymous with allergic rhinitis or
seasonal allergies. Basically anything that can get into the air that you can inhale
can act as an allergen to somebody who suffers from allergic rhinitis. When
allergen goes into the nose and that allergen is going to come into contact with
this mast cell over here. Being a mast cell or basophil, on its surface it has a
particular protein thats shaped like a Y and that protein is called an Immune
Globulin which is shorten to Ig and this particular type of immune globulin is
called IgE. This pollen is going to get bound by this IgE molecule, and that IgE
molecule, just a protein sitting on the surface of this basophil is going to alert that
cell to its presence. In a person with allergic rhinitis this cell over reacts and it
overreacts big time. And when it sees that pollen grain it starts letting out little
molecules into its environment that tell all the celld around it to get excited as
well. So this whole group of nasal mucosa gets overreacted. The most common
type of molecule that gets excited is called histamine. Histamine is going to
cause all sorts of problems with inflammation and it can be really severe that the
mucosa can thicken up big time and get really engorged and edematous, swollen
that happens all through out the nose because these basophils or mast cells
arent just sitting in one particular area but they are scattered everywhere. In
adittion on being swollen, this mucosa is going to start to produce mucus, the
mucus is going to drip down along the turbinates that is going to drip down the
sides of the nose. Its going to pull on the base of your nasal cavity, as this mucus
pulls down in your nasal cavity its going to head down towards your throat so
you can cough up as well. Also as the mucosa swells up, it can swell the
nasolacrimal duct and shut, leading to watery eyes. Also when the eustachian
tube gets swollen bad enough, it can block the tube and cause fluid to back up
and thats going to lead to symptoms that are stiffness and decreased ability to

hear. Ofcourse theres also nerves in your nose that ultimately end in your brain
and as they get inflamed with all the process thats happening in your nose, they
become irritated and send signals to your body particularly the signal to sneeze
and then swelling continues to get bigger and more pronounce and more
pronounced and it can actually completely block off this entire nose. When that
happens air cant get by and when that happens breathing will become a
problem.

COURSE IN THE WARD

LABORATORY TESTS

URINALYSIS
EXAMINATION
RBC
RBC

RESULT RANG
229^/uL
41^HPF

E
0-11
0-2

REMARKS/ JUSTIFICATION
High. Some crenated
High

Conventional

CBC,PLT
EXAMINATION

RESULT RANGE

REMARKS/ JUSTIFICATION

Heemoglobin

142^g/L

120-140

High

Neutrophils

0.50

0.55-

Low.

0.65
Lymphocyte

0.32

0.35-

Low.

0.45
Monocyte

0.14

0.6-0.12

High.

Absolute

0.9

0.0-0.8

High.

Monocyte

CHEST XRAY
INTERPRETATION:

A comparison with the radiograph dated Feb 19,2015 discloses the same pleural
thickening in the left lateral hemithorax. Both lungs are clear lungs. The lateral
costrophenic sinuses are sharp. Heartsize is within normal limits. The
configuration is unremarkable. Pulmonary vascularity is normal. Hili are not
enlarged. Degenerative joint changes are again appreciated.

DATE
July 27, 15

MEDICATION
Losartan 50mg, 1tab, OD
Xanor 250mcg, OD
Montelukast+Levocitirizine10/5mg

1tab,OD, HS
Levopront 10mL, TID, PO
MEDICATIONS
DATE
July 27, 15

MEDICATION
Paracetamol 1tab (for fever)
Norgesic Forte 1tab (for body pain)

TIME
8AM
9PM
9PM
8AM, 2PM,8PM

TIME
PRN
PRN
PRN

MEDICATIONS