NURS 6512: Superior Nicely being Analysis and Diagnostic Reasoning
Week 5: Analysis 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 note of your entire doable diagnoses. It is perhaps a cold, the flu, bronchitis, and even one factor further vital, akin to meningitis or mononucleosis. Assessing the exact set off will comprise excess of simple seen inspection. Some circumstances are so refined that they require utilizing explicit units and exams together with a talented eye and ear.
This week, you will uncover how one can assess the head, neck, eyes, ears, nostril, and throat. Whether or not or not dealing with a detached retina, sinusitis, meningitis, and even cough, superior apply nurses need to know the right analysis strategies as a strategy to sort appropriate diagnoses.
Learning Targets
School college students will:
Apply analysis experience to diagnose eye, ear, and throat circumstances
Apply concepts, theories, and guidelines referring to effectively being analysis strategies and diagnoses for the head, neck, eyes, ears, nostril, and throat
Learning Sources
Required Readings (click on on to broaden/reduce)
Required Media (click on on to broaden/reduce)
Challenge 1: Case Analysis Challenge: Assessing the Head, Eyes, Ears, Nostril, and Throat
Credit score rating: Getty Photos/Combine Photos
Most ear, nostril, and throat circumstances that come up in non-critical care settings are minor in nature. However, refined indicators can sometimes escalate into life-threatening circumstances that require fast analysis and treatment.
Nurses conducting assessments of the ears, nostril, and throat ought to be able to decide the small variations between life-threatening circumstances and benign ones. As an illustration, if a affected particular person with a sore throat and a runny nostril moreover has contaminated lymph nodes, the irritation is perhaps due to the pathogen inflicting the sore throat barely than a case of throat most cancers. With this knowledge and a ample affected particular person effectively being historic previous, a nurse would not need to escalate the analysis to a biopsy or an MRI of the lymph nodes nevertheless would most likely perform a simple strep verify.
On this Case Analysis Challenge, you take note of case analysis of irregular findings from victims in a medical setting. You identify what historic previous should be collected from the victims, what bodily exams and diagnostic exams should be carried out, and formulate a differential prognosis with a lot of doable circumstances.
To Put collectively
By Day 1 of this week, you will be assigned to a selected case analysis for this Case Analysis Challenge. Please see the “Course Bulletins” a part of the classroom in your challenge out of your Instructor.
Moreover, your Case Analysis Challenge should be inside the Episodic/Centered SOAP Observe format barely than the usual narrative sort format. Seek the advice of with Chapter 2 of the Sullivan textual content material and the Episodic/Centered SOAP Template inside the Week 5 Learning Sources for guidance. Take into account that all Episodic/Centered SOAP Notes have explicit info included in every affected particular person case.
With regard to the case analysis you had been assigned:
Analysis this week’s Learning Sources and take note of the insights they provide.
Take into consideration what historic previous might be wanted to assemble from the affected particular person.
Take into consideration what bodily exams and diagnostic exams might be acceptable to gather further particulars in regards to the affected particular person’s scenario. How would the outcomes be used to make a prognosis?
Decide a minimal of 5 doable circumstances that could possibly be thought-about in a differential prognosis for the affected particular person.
The Assignment Essay
Use the Episodic/Centered SOAP Template and create an episodic/focused discover regarding the affected particular person inside the case analysis to which you had been assigned using the episodic/focused discover template supplied inside the Week 5 sources. Current proof from the literature to help diagnostic exams that might be acceptable for each case. Guidelines 5 fully completely different doable circumstances for the affected particular person’s differential prognosis and justify why you selected each.
By Day 6 of Week 5
Submit your Challenge
Learning Sources
Required Readings (click on on to broaden/reduce)
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Chapter 11, “Head and Neck”
This chapter Assessments the anatomy and physiology of the head and neck. The authors moreover describe the procedures for conducting a bodily examination of the head and neck.
Chapter 12, “Eyes”
On this chapter, the authors describe the anatomy and efficiency of the eyes. In addition to, the authors make clear the steps involved in conducting a bodily examination of the eyes.
Chapter 13, “Ears, Nostril, and Throat”
The authors of this chapter component the right procedures for conducting a bodily examination of the ears, nostril, and throat. The chapter moreover affords footage and descriptions of widespread abnormalities inside the ears, nostril, and throat.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior effectively being analysis and medical prognosis in predominant care (sixth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Superior Nicely being Analysis and Medical Prognosis in Primary Care, sixth Model by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby by means of the Copyright Clearance Coronary heart.
Chapter 15, “Earache”
This chapter covers the first questions that ought to be requested regarding the affected particular person’s scenario earlier to the bodily examination along with how these questions lead to a focused bodily examination.
Chapter 21, “Hoarseness”
This chapter focuses on the most common causes of hoarseness. It affords strategies for evaluating the affected particular person, every by questions and via bodily exams.
Chapter 25, “Nasal Indicators and Sinus Congestion”
On this chapter, the authors highlight the essential factor inquiries to ask regarding the victims indicators, the essential factor components of the bodily examination, and potential laboratory work that’s prone to be needed to supply an appropriate prognosis of nasal and sinus circumstances.
Chapter 30, “Pink Eye”
The principle focus of this chapter is on how one can determine the explanation for crimson eyes in a affected particular person, along with key indicators to ponder and doable diagnoses.
Chapter 32, “Sore Throat”
A sore throat is one commonest concerns victims describe. This chapter comprises inquiries to ask when taking the affected particular person’s historic previous, points to seek 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 in which the causes of the scenario might be recognized.
Observe: Receive the six paperwork (Pupil Checklists and Key Elements) below, and use them as you apply conducting assessments of the head, 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 pointers. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key elements. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Pupil pointers. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key elements. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Pupil pointers. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Key elements. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.
Credit score rating Line: Seidel’s Info to Bodily Examination, ninth Model by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Nicely being Sciences. Reprinted by permission of Elsevier Nicely being Sciences by means of the Copyright Clearance Coronary heart.
Colyar, M. R. (2015). Superior apply nursing procedures. Philadelphia, PA: F. A. Davis.
Credit score rating Line: Superior apply nursing procedures, 1st Model by Colyar, M. R. Copyright 2015 by F. A. Davis Agency. Reprinted by permission of F. A. Davis Agency by means of the Copyright Clearance Coronary heart.
Chapter 71, “Seen Function Assessment: Snellen, Illiterate E, Pictorial
This half explains the procedural knowledge needed to hold out eyes, ears, nostril, and mouth procedures.
Sullivan, D. D. (2019). Info to medical documentation (third ed.). Philadelphia, PA: F. A. Davis.
Chapter 2, “The Full Historic previous and Bodily Examination” (Beforehand study in Weeks 1, three, 4, and 5)
Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in medical examination. Imaginative and prescient Assessment 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 finding out effectivity. Imaginative and prescient Assessment, 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 treatment. American Family 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 website online affords medical footage of sinusitis, along 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 Nicely being Analysis and Diagnostic Reasoning
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— free essay sample
Episodic/Centered SOAP Observe
Determine
Instructional Institution
Episodic/Centered SOAP Observe
Affected particular person Information:
Initials – E. (Emily) Age – 15 Intercourse – Female
S.
CC: “I have been experiencing chills, aches, and sore throat for the ultimate three days.”
HPI: The affected particular person is a 15-year outdated female who developed chills, aches, and sore throat three days prior to now. The affected particular person describes the ache and chills as excessive. Shares them eight out of 10 in depth. The ache is often located throughout the chest area. The affected particular person research the aches have intensified the sore throat. Emily research the indicators have been rising in severity. She solely feels relieved after inside the morning hours. She started experiencing the indicators after taking place a go to all through chilly local weather. The affected particular person denies subject in respiratory. The affected particular person is alert and oriented. She denies headache. Emily appears pale and unwell.
Current Medicines: Acetaminophen 650mg OTC BID for three days.
Allergy signs: Penicillin causes pores and pores and skin rashes.
PMHx: Pneumonia and flu vaccine are current. Tetanus vaccine administered at 7 years of age. Eczema pores and pores and skin scenario reported at 5 years. Pores and pores and skin allergy correctly managed. No surgical procedures reported.
Soc Hx: Emily is a grade 10 pupil. She lives collectively together with her mother and two brothers. Emily, who’s the last-born inside the family loves visiting new areas. Her two brothers and mother are healthful with no continuous medical scenario. She has no historic previous of alcohol, tobacco or ETOH abuse. She goes to highschool inside the neighborhood collectively together with her mates. She is heterosexual and by no means sexually energetic.
Fam Hx: No family or genetic effectively being scenario reported. She has one grandmother who’s alive nevertheless battling a coronary coronary heart draw back. Her mother and two brothers haven’t any historic previous of continuous effectively being circumstances. Her father died of bronchial bronchial asthma 4 years prior to now.
ROS:
GENERAL: Emily research no shocking weight discount or obtain. She research delicate fever and chills. She has been experiencing fundamental weak spot for the ultimate 2 days.
HEENT:
Eyes: The affected particular person denies any eye points or blurred imaginative and prescient. No itchy eyes, excessive tearing.
Ears: No listening to draw back or itchy ears.
Throat: The affected particular person complains of a sore throat for the ultimate three days. No working nostril, nasal congestion or sneezing.
SKIN: No pores and pores and skin scenario, itchiness or soreness reported.
CARDIOVASCULAR: Emily denies any chest ache or coronary coronary heart draw back. She denies any edema. ‘My coronary coronary heart is an environment friendly effectively being scenario even as soon as I prepare at school.’
RESPIRATORY: The affected particular person denies shortness of breath, coughing or sputum. No nasal congestion. The lungs are clear.
GASTROINTESTINAL: The affected particular person research common bowel movement and no blood inside the stool. The affected particular person denies nausea, vomiting, diarrhea or lack of urge for meals.
GENITOURINARY: The affected particular person research no ache in passing urine. The ultimate menstrual interval was 24/11/2019.
NEUROLOGICAL: Emily denies headache, seizures, or dizziness. Common bladder and bowel administration. She denies of headache.
MUSCULOSKELETAL: The affected particular person research no historic previous of once more ache, surgical process, or muscle harm.
HEMATOLOGIC: Emily denies bleeding, bruising or anemic scenario.
LYMPHATICS: No historic previous of splenectomy. She complains of swollen lymph nodes.
PSYCHIATRIC: The affected particular person denies any nervousness or melancholy. She is alert and oriented.
ENDOCRINOLOGIC: The affected particular person denies sweating at night time time, no polyuria or polydipsia.
ALLERGIES: Penicillin causes pores and pores and skin rashes. Emily complains of sore throat all through local weather modifications.
O.
VS: BP 120/76; R 20; 98.eight° F; 02 96% Wt 100lbs; Ht 61.7”
Frequent – The affected particular person appears pale and unwell.
Cardiovascular – Common coronary coronary heart charge and common coronary coronary heart sounds.
Gastrointestinal – Abdomen is symmetrical, bowel sounds are common.
Pulmonary – The lungs are clear to auscultation and percussion bilaterally.
Bodily examination: The outcomes of the bodily examination signifies that the affected particular person is feeling unwell. The outcomes level out the chills, aches and sore throat could deteriorate. The numerous packages along with respiratory are in good scenario. The affected particular person reveals no historic previous of respiratory points. The effectively being scenario reveals no historic previous of allergy signs moreover penicillin which causes pores and pores and skin rashes. Emily research that ‘it looks like having a light-weight chilly.’
Diagnostic outcomes: Diagnostic outcomes haven’t any worth/revenue influence whereas diagnosing a cold (Hayward et al., 2015). The indicators are evident and thus it is solely under excessive circumstances that the diagnostic analysis might be carried out.
SAO2 – 98%, lungs are clear to auscultation and percussion bilaterally.
Blood verify: RF damaging.
A.
Differential Diagnoses:
Chilly: It is a viral an an infection that impacts the nostril and throat. The viral an an infection triggers an irritation of the throat. It causes irritation of the throat (Singh, Singh, Jaiswal & Chauhan, 2017). The indicators embody runny nostril, chills, aches, and headache. The chills occur on account of the physique trying to answer to a bacterial or viral an an infection. The scenario might be triggered by publicity to chilly local weather (Hayward et al., 2015).
Bronchitis – The scenario causes irritation of the bronchial tubes. The indicators embody coughing accompanied by mucus, wheezing, shortness of breath, and tightness of the chest (Tapiainen et al., 2016). Although the first symptom is coughing it’s going to in all probability moreover set off a sore throat. In case of maximum bronchitis, a affected particular person may experience a fever with a extreme temperature of 100 to 101°F (Schumacher et al., 2015).
Mononucleosis – The scenario is attributable to the Epstein-Barr virus (EBV). It causes indicators akin 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 pores and skin rash (Womack & Jimenez, 2015).
Primary 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(4), 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 ideas for the treatment of laryngitis, wheezing bronchitis and bronchiolitis in children. Acta Paediatrica, 105(1), 44-49.
Womack, J., & Jimenez, M. (2015). Frequent questions on infectious mononucleosis. American Family Physician, 91(6).
