Sinusitis Care Plan

This therapeutic care plan will utilized the “I can treat and prescribe framework” to ensure that appropriate patient treatments are selected using a step by step approach, including assessment integration, drug and/or disease related problems, therapeutic goals, therapeutic alternatives and indications, plan of care and evaluation (OPHCNPP, 2012). By going through each step of this framework, and including or excluding treatment options based on individual patient factors and strong clinical evidence, this clinician will arrive at the most suitable treatment plan for the patient. H.K (32 year old male) presented with persistent facial pain for 7 days. He reported having a headache (6/10 on a pain scale) upon bending forward and awakening, occasional tooth pain, no nasal drainage, and no cough. H.K denied fever or chills but admitted to feeling “run-down”. His past medical history included varicella zoster at age 5 years, seasonal allergic rhinitis (pollen), viral respiratory tract symptoms 2 weeks ago (now resolved), and no recent antibiotic use over the past 3 months. He is married with two children who are not in daycare (ages 8 and 9). H.K is a supermarket manager, non-smoker, and denied substance abuse. The patient reported having private prescription drug coverage but was only taking Advil cold and sinus (2 tablets orally every 6 hours as required) with good effect. H.K’s vitals were taken (temp. 37.5°C tympanic, HR 74 reg., R 12 reg. and equal). His head and neck examination revealed that his sclera were clear and his pupils were round, reactive to light with accommodation. There was tenderness to palpation of the frontal and maxillary sinuses. Transillumination of the right and left maxillary sinuses revealed an opaque surface. His nares were erythematous and edematous with no obvious discharge. There was cobblestoning of the pharynx with slight erythema. His tonsils were two plus in size with no exudates. His neck examination revealed the absence of