Help with a nursing diagnosis...

  1. This is the case study, dealing with the eyes and ears:
    some late 20's woman complains of tooth pain, headache on the front of their head with pressure, and malaise. There is yellow rhinorrhea pus-like discharge coming out of the nose.

    This is what I have so far, it might be allergies that got through her eyes, or she has an airborne droplet infection from someone she shook hands with and she rubbed her hands on her eyes afterwards.

    i'm trying to make a nursing diagnosis, and what i have so far is "ineffective airway clearance r/t narrowed airway aeb by tht puslike discharge

    but i believe the diagnosis has to relate to the ears and eyes, because thats what the case study is. i dont even know a nursing diagnosis related to the eyes and ears that has something to do with the case study above.

    anyone?
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  2. 11 Comments

  3. by   Nursetob2005
    it doesn't state exactly where the tooth pain is does it?
  4. by   RNsweetie
    given the tooth pain I think I would go to nutrition, less than body requirements, but also must include
    pain acute....


    just wondering if it is sinusitis the headache and the tooth pain and pus may be related to inflamation of the sinises?


    because you said it should relate to eyes and ears, I am wondering if it is related to an ear infection in which case you could bring in risk for falls r/t disruption with inner ear and loss of balance??

    what do you think?
    Erin
  5. by   Wheaties
    no it doesnt explain where the tooth pain is. this is a weekly case study scenario that we need to do every week. and its very very vague. i guess one can just assume where the tooth pain is, make something up i suppose.

    my assumption is that the yellow pus-like rhinorrhea probably drained to the tooth area and infected it, i dont know.

    and sinusitis is a good explanation, the symptoms are very similar. But i'm leaning towards rhinitis, because the symptoms between sinusitis and rhinitis are similar and the person already is experiencing rhinorrhea. its yellow so i think its infected.
    Last edit by Wheaties on Mar 11, '04
  6. by   Squirrlyman
    Quote from Wheaties
    This is the case study, dealing with the eyes and ears:
    some late 20's woman complains of tooth pain, headache on the front of their head with pressure, and malaise. There is yellow rhinorrhea pus-like discharge coming out of the nose.

    This is what I have so far, it might be allergies that got through her eyes, or she has an airborne droplet infection from someone she shook hands with and she rubbed her hands on her eyes afterwards.

    i'm trying to make a nursing diagnosis, and what i have so far is "ineffective airway clearance r/t narrowed airway aeb by tht puslike discharge

    but i believe the diagnosis has to relate to the ears and eyes, because thats what the case study is. i dont even know a nursing diagnosis related to the eyes and ears that has something to do with the case study above.

    anyone?
    Wheaties I am a second semester student so I certainly won't have any idea if this is accurate, but I have had an RDA liscense for about four years. Give some consideration to the fact that your patient may have an oral infection. The pressure, tooth pain, discharge, and maliaise are all somewhat indicative of dental caries that are severe in nature. You might want to try doing a thorough inspection of the pt's oral cavity. Hope it helps.
  7. by   michw2
    Acute pain R/t malaise and respiratory distress AEB stuffy nose with pus like drainage
  8. by   Wheaties
    ineffective airway clearance r/t possible exposure of allergens or infectious disease to the eye aeb yellow purulent rhinorrhea

    that's what i have, i just made it up. i just assumed that the rhinorrhea is making the client have difficulty breathing. and one of the ways allergies can get inside the person is through the eyes, or if it is an infectious disease such as a common cold, it can be transmitted by droplet nuclei and get in people's mouth, nose, or eyes when they shake someones hands and rub their own eyes.

    i just made it up, i'm not sure if its right, but it does have something to do with the eye, not the ears though.
  9. by   studentdeb
    Quote from Wheaties
    This is the case study, dealing with the eyes and ears:
    some late 20's woman complains of tooth pain, headache on the front of their head with pressure, and malaise. There is yellow rhinorrhea pus-like discharge coming out of the nose.

    This is what I have so far, it might be allergies that got through her eyes, or she has an airborne droplet infection from someone she shook hands with and she rubbed her hands on her eyes afterwards.

    i'm trying to make a nursing diagnosis, and what i have so far is "ineffective airway clearance r/t narrowed airway aeb by tht puslike discharge

    but i believe the diagnosis has to relate to the ears and eyes, because thats what the case study is. i dont even know a nursing diagnosis related to the eyes and ears that has something to do with the case study above.

    anyone?

    I am not a nursing student yet, but wanted to share with you that I have severe sinus problems which cause me to have alot of pain around my teeth and I was told it was because my sinus' put pressure on my upper teeth which sinus trouble could also cause problems with the ears and eyes. (I currently have been blocked in my right ear for about a month now). Maybe they could all be tied together somehow. Sorry if this doesn't help, I don't how to do diagnosis' yet.
  10. by   meownsmile
    Nutrional deficit r/t dental heath m/b tooth pain
    Infection r/t purulent nasal drainage m/b facial pressure, malaise
    Pain r/t HA, dental pain m/b (insert any symptoms of HA patient complains of, light sensitivity, cranial splinting, squinting), inadequate oral intake

    Just some thoughts
  11. by   sagelola
    I'd go with the sinusitis, too. Think maxillary sinus for the tooth pain, and frontal for the head pain. Plus the sinuses drain into the nose which is why she could be having the drainage through her nose. I like the pain and infection diagnoses. Ineffective airway clearance might be okay since that is when the person is unable to clear secretions from the respiratory tract, but I think I might come up with some other r/t symptoms...with the yellow pus-like discharge you would be thinking infections, not so much exposure to allergens, which would be clear/white (however you want to describe that!)

    Good luck, I am working on a case study right now dealing with tinnitus!
  12. by   wonderbee
    Acute pain r/t unknown etiology AEB complaint of headache and tooth pain, number ____ on pain scale. The way I understand a nursing diagnosis, we are supposed to diagnose the response to the illness. Since we don't have a medical diagnosis to start with, it's not for us to create one. If we don't know what is causing the headache, we really can't go filling in that r/t blank until that's established. It certainly does look like an infection but until "infection" has been medically established, we can't say for certain. I'm new at this and certainly could be way off track but so far, I haven't gotten any of my careplans back that have been using this process. Now ineffective airway clearance r/t nasal blockage AEB purulent yellow discharge is what I might go with on the airway.
  13. by   Carolanne
    I agree with a sinusitis condition... could be:

    Comfort, altered related to acute pain
    Airway clearance, ineffective related to retained secretions
    Infection, potential for

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