NURS 6512: Superior Well being Evaluation and Diagnostic Reasoning
Week 5: Evaluation of Head, Neck, Eyes, Ears, Nostril, and Throat
Emily, age 15, is dropped at your clinic complaining of chills, aches, and a sore throat. With none testing, take into account the entire doable diagnoses. It might be a chilly, the flu, bronchitis, and even one thing extra critical, comparable to meningitis or mononucleosis. Assessing the precise trigger will contain far more than easy visible inspection. Some circumstances are so refined that they require using particular devices and exams along with a skilled eye and ear.
This week, you’ll discover how one can assess the pinnacle, neck, eyes, ears, nostril, and throat. Whether or not coping with a indifferent retina, sinusitis, meningitis, and even cough, superior apply nurses have to know the correct evaluation methods as a way to type correct diagnoses.
Studying Targets
College students will:
Apply evaluation expertise to diagnose eye, ear, and throat circumstances
Apply ideas, theories, and rules referring to well being evaluation methods and diagnoses for the pinnacle, neck, eyes, ears, nostril, and throat
Studying Sources
Required Readings (click on to broaden/scale back)
Required Media (click on to broaden/scale back)
Project 1: Case Research Project: Assessing the Head, Eyes, Ears, Nostril, and Throat
Photograph Credit score: Getty Pictures/Mix Pictures
Most ear, nostril, and throat circumstances that come up in non-critical care settings are minor in nature. Nevertheless, refined signs can typically escalate into life-threatening circumstances that require immediate evaluation and remedy.
Nurses conducting assessments of the ears, nostril, and throat should be capable of determine the small variations between life-threatening circumstances and benign ones. As an illustration, if a affected person with a sore throat and a runny nostril additionally has infected lymph nodes, the irritation might be because of the pathogen inflicting the sore throat slightly than a case of throat most cancers. With this data and a adequate affected person well being historical past, a nurse wouldn’t have to escalate the evaluation to a biopsy or an MRI of the lymph nodes however would in all probability carry out a easy strep check.
On this Case Research Project, you take into account case research of irregular findings from sufferers in a medical setting. You establish what historical past ought to be collected from the sufferers, what bodily exams and diagnostic exams ought to be performed, and formulate a differential prognosis with a number of doable circumstances.
To Put together
By Day 1 of this week, you’ll be assigned to a particular case research for this Case Research Project. Please see the “Course Bulletins” part of the classroom in your project out of your Teacher.
Additionally, your Case Research Project ought to be within the Episodic/Centered SOAP Observe format slightly than the standard narrative type format. Consult with Chapter 2 of the Sullivan textual content and the Episodic/Centered SOAP Template within the Week 5 Studying Sources for steerage. Keep in mind that all Episodic/Centered SOAP Notes have particular information included in each affected person case.
With regard to the case research you had been assigned:
Evaluation this week’s Studying Sources and take into account the insights they supply.
Think about what historical past can be needed to gather from the affected person.
Think about what bodily exams and diagnostic exams can be acceptable to collect extra details about the affected person’s situation. How would the outcomes be used to make a prognosis?
Determine a minimum of 5 doable circumstances that could be thought-about in a differential prognosis for the affected person.
The Assignment Essay
Use the Episodic/Centered SOAP Template and create an episodic/targeted notice concerning the affected person within the case research to which you had been assigned utilizing the episodic/targeted notice template offered within the Week 5 sources. Present proof from the literature to assist diagnostic exams that will be acceptable for every case. Checklist 5 completely different doable circumstances for the affected person’s differential prognosis and justify why you chose every.
By Day 6 of Week 5
Submit your Project
Studying Sources
Required Readings (click on to broaden/scale back)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Chapter 11, “Head and Neck”
This chapter evaluations the anatomy and physiology of the pinnacle and neck. The authors additionally describe the procedures for conducting a bodily examination of the pinnacle and neck.
Chapter 12, “Eyes”
On this chapter, the authors describe the anatomy and performance of the eyes. As well as, the authors clarify the steps concerned in conducting a bodily examination of the eyes.
Chapter 13, “Ears, Nostril, and Throat”
The authors of this chapter element the correct procedures for conducting a bodily examination of the ears, nostril, and throat. The chapter additionally offers footage and descriptions of widespread abnormalities within the ears, nostril, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior well being evaluation and medical prognosis in main care (sixth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Superior Well being Evaluation and Medical Prognosis in Main Care, sixth Version by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby through the Copyright Clearance Heart.
Chapter 15, “Earache”
This chapter covers the primary questions that should be requested concerning the affected person’s situation previous to the bodily examination in addition to how these questions result in a targeted bodily examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most typical causes of hoarseness. It offers methods for evaluating the affected person, each by questions and thru bodily exams.
Chapter 25, “Nasal Signs and Sinus Congestion”
On this chapter, the authors spotlight the important thing inquiries to ask concerning the sufferers signs, the important thing elements of the bodily examination, and potential laboratory work that is likely to be wanted to offer an correct prognosis of nasal and sinus circumstances.
Chapter 30, “Pink Eye”
The main focus of this chapter is on how one can decide the reason for crimson eyes in a affected person, together with key signs to contemplate and doable diagnoses.
Chapter 32, “Sore Throat”
A sore throat is one commonest considerations sufferers describe. This chapter contains inquiries to ask when taking the affected person’s historical past, issues to search for whereas conducting the bodily examination, and doable causes for the sore throat.
Chapter 38, “Imaginative and prescient Loss”
This chapter highlights the causes of imaginative and prescient loss and the way the causes of the situation will be identified.
Observe: Obtain the six paperwork (Pupil Checklists and Key Factors) under, and use them as you apply conducting assessments of the pinnacle, neck, eyes, ears, nostril, and throat.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Pupil guidelines. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Key factors. In Seidel’s information to bodily examination: An interprofessional strategy (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score Line: Seidel’s Information to Bodily Examination, ninth Version by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Well being Sciences. Reprinted by permission of Elsevier Well being Sciences through the Copyright Clearance Heart.
Colyar, M. R. (2015). Superior apply nursing procedures. Philadelphia, PA: F. A. Davis.
Credit score Line: Superior apply nursing procedures, 1st Version by Colyar, M. R. Copyright 2015 by F. A. Davis Firm. Reprinted by permission of F. A. Davis Firm through the Copyright Clearance Heart.
Chapter 71, “Visible Operate Analysis: Snellen, Illiterate E, Pictorial
This part explains the procedural data wanted to carry out eyes, ears, nostril, and mouth procedures.
Sullivan, D. D. (2019). Information to medical documentation (third ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Complete Historical past and Bodily Examination” (Beforehand learn in Weeks 1, three, four, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye motion testing in medical examination. Imaginative and prescient Analysis 90, 32–37. doi:10.1016/j.visres.2013.02.001. Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217
Rubin, G. S. (2013). Measuring studying efficiency. Imaginative and prescient Analysis, 90, 43–51. doi:10.1016/j.visres.2013.02.zero15. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436
Harmes, Okay. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Prognosis and remedy. American Household Physicians, 88(7), 435–440.
Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html
This web site offers medical pictures of sinusitis, together with X-rays, CT scans, and MRIs (magnetic resonance imaging).
Doc: Episodic/Centered SOAP Observe Exemplar (Phrase doc)
Doc: Episodic/Centered SOAP Observe Template (Phrase doc)
NURS 6512: Superior Well being Evaluation and Diagnostic Reasoning
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— free essay pattern
Episodic/Centered SOAP Observe
Identify
Educational Establishment
Episodic/Centered SOAP Observe
Affected person Data:
Initials – E. (Emily) Age – 15 Intercourse – Feminine
S.
CC: “I’ve been experiencing chills, aches, and sore throat for the final three days.”
HPI: The affected person is a 15-year outdated feminine who developed chills, aches, and sore throat three days in the past. The affected person describes the ache and chills as extreme. Shares them eight out of 10 in depth. The ache is usually situated across the chest space. The affected person studies the aches have intensified the sore throat. Emily studies the signs have been growing in severity. She solely feels relieved after within the morning hours. She began experiencing the signs after happening a visit throughout chilly climate. The affected person denies issue in respiratory. The affected person is alert and oriented. She denies headache. Emily seems pale and unwell.
Present Medicines: Acetaminophen 650mg OTC BID for 3 days.
Allergy symptoms: Penicillin causes pores and skin rashes.
PMHx: Pneumonia and flu vaccine are present. Tetanus vaccine administered at 7 years of age. Eczema pores and skin situation reported at 5 years. Pores and skin allergy properly managed. No surgical procedures reported.
Soc Hx: Emily is a grade 10 pupil. She lives together with her mom and two brothers. Emily, who’s the last-born within the household loves visiting new locations. Her two brothers and mom are wholesome with no continual medical situation. She has no historical past of alcohol, tobacco or ETOH abuse. She goes to high school within the neighborhood together with her mates. She is heterosexual and never sexually energetic.
Fam Hx: No household or genetic well being situation reported. She has one grandmother who’s alive however battling a coronary heart downside. Her mom and two brothers don’t have any historical past of continual well being circumstances. Her father died of bronchial asthma four years in the past.
ROS:
GENERAL: Emily studies no surprising weight reduction or achieve. She studies delicate fever and chills. She has been experiencing basic weak spot for the final 2 days.
HEENT:
Eyes: The affected person denies any eye issues or blurred imaginative and prescient. No itchy eyes, extreme tearing.
Ears: No listening to downside or itchy ears.
Throat: The affected person complains of a sore throat for the final three days. No working nostril, nasal congestion or sneezing.
SKIN: No pores and skin situation, itchiness or soreness reported.
CARDIOVASCULAR: Emily denies any chest ache or coronary heart downside. She denies any edema. ‘My coronary heart is an efficient well being situation even once I train in class.’
RESPIRATORY: The affected person denies shortness of breath, coughing or sputum. No nasal congestion. The lungs are clear.
GASTROINTESTINAL: The affected person studies regular bowel motion and no blood within the stool. The affected person denies nausea, vomiting, diarrhea or lack of urge for food.
GENITOURINARY: The affected person studies no ache in passing urine. The final menstrual interval was 24/11/2019.
NEUROLOGICAL: Emily denies headache, seizures, or dizziness. Regular bladder and bowel management. She denies of headache.
MUSCULOSKELETAL: The affected person studies no historical past of again ache, surgical procedure, or muscle damage.
HEMATOLOGIC: Emily denies bleeding, bruising or anemic situation.
LYMPHATICS: No historical past of splenectomy. She complains of swollen lymph nodes.
PSYCHIATRIC: The affected person denies any nervousness or melancholy. She is alert and oriented.
ENDOCRINOLOGIC: The affected person denies sweating at night time, no polyuria or polydipsia.
ALLERGIES: Penicillin causes pores and skin rashes. Emily complains of sore throat throughout climate modifications.
O.
VS: BP 120/76; R 20; 98.eight° F; 02 96% Wt 100lbs; Ht 61.7”
Common – The affected person seems pale and unwell.
Cardiovascular – Regular coronary heart fee and regular coronary heart sounds.
Gastrointestinal – Stomach is symmetrical, bowel sounds are regular.
Pulmonary – The lungs are clear to auscultation and percussion bilaterally.
Bodily examination: The outcomes of the bodily examination signifies that the affected person is feeling unwell. The outcomes point out the chills, aches and sore throat may deteriorate. The assorted programs together with respiratory are in good situation. The affected person reveals no historical past of respiratory issues. The well being situation reveals no historical past of allergy symptoms besides penicillin which causes pores and skin rashes. Emily studies that ‘it seems like having a light chilly.’
Diagnostic outcomes: Diagnostic outcomes don’t have any price/profit impact whereas diagnosing a chilly (Hayward et al., 2015). The signs are evident and thus it’s only below extreme circumstances that the diagnostic evaluation will be carried out.
SAO2 – 98%, lungs are clear to auscultation and percussion bilaterally.
Blood check: RF destructive.
A.
Differential Diagnoses:
Chilly: It’s a viral an infection that impacts the nostril and throat. The viral an infection triggers an irritation of the throat. It causes irritation of the throat (Singh, Singh, Jaiswal & Chauhan, 2017). The signs embody runny nostril, chills, aches, and headache. The chills happen on account of the physique attempting to reply to a bacterial or viral an infection. The situation will be triggered by publicity to chilly climate (Hayward et al., 2015).
Bronchitis – The situation causes irritation of the bronchial tubes. The signs embody coughing accompanied by mucus, wheezing, shortness of breath, and tightness of the chest (Tapiainen et al., 2016). Though the primary symptom is coughing it will probably additionally trigger a sore throat. In case of extreme bronchitis, a affected person could expertise a fever with a excessive temperature of 100 to 101°F (Schumacher et al., 2015).
Mononucleosis – The situation is attributable to the Epstein-Barr virus (EBV). It causes signs comparable to physique aches, chills, fever, and fatigue (De Paor, O’Brien, Fahey & Smith, 2016). Others embody nausea, sore throat, swollen tonsils, headache, and pores and skin rash (Womack & Jimenez, 2015).
Main Prognosis/Presumptive Prognosis: Chilly.
References
De Paor, M., O’Brien, Okay., Fahey, T., & Smith, S. M. (2016). Antiviral brokers for infectious mononucleosis (glandular fever). Cochrane Database of Systematic Critiques, (12).
Hayward, G., Thompson, M. J., Perera, R., Del Mar, C. B., Glasziou, P. P., & Heneghan, C. J. (2015). Corticosteroids for the widespread chilly. Cochrane Database of Systematic Critiques, (10).
Schumacher, Okay. R., Stringer, Okay. A., Donohue, J. E., Yu, S., Shaver, A., Caruthers, R. L., … & Russell, M. W. (2015). Fontan-associated protein-losing enteropathy and plastic bronchitis. The Journal of Pediatrics, 166(four), 970-977.
Singh, M., Singh, M., Jaiswal, N., & Chauhan, A. (2017). Heated, humidified air for the widespread chilly. Cochrane Database of Systematic Critiques, (eight).
Tapiainen, T., Aittoniemi, J., Immonen, J., Jylkkä, H., Meinander, T., Nuolivirta, Okay., … & Korppi, M. (2016). Finnish tips for the remedy of laryngitis, wheezing bronchitis and bronchiolitis in youngsters. Acta Paediatrica, 105(1), 44-49.
Womack, J., & Jimenez, M. (2015). Frequent questions on infectious mononucleosis. American Household Doctor, 91(6).
