Posted: December 30th, 2021

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

NURS 6512: Superior Well being Evaluation and Diagnostic Reasoning
Week 5: Evaluation of Head, Neck, Eyes, Ears, Nostril, and Throat

Emily, age 15, is delivered to your clinic complaining of chills, aches, and a sore throat. With none testing, take into account the entire potential diagnoses. It might be a chilly, the flu, bronchitis, and even one thing extra severe, resembling meningitis or mononucleosis. Assessing the precise trigger will contain way more than easy visible inspection. Some circumstances are so delicate that they require the usage of particular devices and exams along with a educated eye and ear.

This week, you’ll discover the right way to 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 must know the correct evaluation strategies with a purpose to kind correct diagnoses.
Studying Targets

College students will:

Apply evaluation expertise to diagnose eye, ear, and throat circumstances
Apply ideas, theories, and rules regarding well being evaluation strategies and diagnoses for the pinnacle, neck, eyes, ears, nostril, and throat

Studying Assets

Required Readings (click on to increase/scale back)

Required Media (click on to increase/scale back)

Project 1: Case Examine Project: Assessing the Head, Eyes, Ears, Nostril, and Throat

Picture Credit score: Getty Photos/Mix Photos

Most ear, nostril, and throat circumstances that come up in non-critical care settings are minor in nature. Nevertheless, delicate signs can generally escalate into life-threatening circumstances that require immediate evaluation and remedy.

Nurses conducting assessments of the ears, nostril, and throat should be capable of establish 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 reasonably than a case of throat most cancers. With this data and a ample affected person well being historical past, a nurse wouldn’t must escalate the evaluation to a biopsy or an MRI of the lymph nodes however would most likely carry out a easy strep take a look at.

On this Case Examine Project, you take into account case research of irregular findings from sufferers in a medical setting. You establish what historical past needs to be collected from the sufferers, what bodily exams and diagnostic exams needs to be carried out, and formulate a differential analysis with a number of potential circumstances.

To Put together

By Day 1 of this week, you’ll be assigned to a selected case research for this Case Examine Project. Please see the “Course Bulletins” part of the classroom on your project out of your Teacher.
Additionally, your Case Examine Project needs to be within the Episodic/Centered SOAP Be aware format reasonably than the normal narrative type format. Consult with Chapter 2 of the Sullivan textual content and the Episodic/Centered SOAP Template within the Week 5 Studying Assets for steering. 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:

Overview this week’s Studying Assets and take into account the insights they supply.
Take into account what historical past can be needed to gather from the affected person.
Take into account what bodily exams and diagnostic exams can be applicable to collect extra details about the affected person’s situation. How would the outcomes be used to make a analysis?
Determine at the least 5 potential circumstances that could be thought of in a differential analysis for the affected person.

The Assignment Essay

Use the Episodic/Centered SOAP Template and create an episodic/targeted word in regards to the affected person within the case research to which you had been assigned utilizing the episodic/targeted word template supplied within the Week 5 sources. Present proof from the literature to assist diagnostic exams that might be applicable for every case. Checklist 5 totally different potential circumstances for the affected person’s differential analysis and justify why you chose every.
By Day 6 of Week 5

Submit your Project

Studying Assets

Required Readings (click on to increase/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 method (ninth ed.). St. Louis, MO: Elsevier Mosby.

Chapter 11, “Head and Neck”

This chapter critiques 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 supplies photos and descriptions of frequent abnormalities within the ears, nostril, and throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior well being evaluation and medical analysis 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 Middle.

Chapter 15, “Earache”

This chapter covers the principle questions that should be requested in regards to 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 commonest causes of hoarseness. It supplies methods for evaluating the affected person, each by means of questions and thru bodily exams.

Chapter 25, “Nasal Signs and Sinus Congestion”

On this chapter, the authors spotlight the important thing inquiries to ask in regards to the sufferers signs, the important thing components of the bodily examination, and potential laboratory work that is likely to be wanted to offer an correct analysis of nasal and sinus circumstances.

Chapter 30, “Purple Eye”

The main focus of this chapter is on the right way to decide the reason for crimson eyes in a affected person, together with key signs to think about and potential diagnoses.

Chapter 32, “Sore Throat”

A sore throat is one commonest considerations sufferers describe. This chapter consists of inquiries to ask when taking the affected person’s historical past, issues to search for whereas conducting the bodily examination, and potential 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 recognized.

Be aware: Obtain the six paperwork (Scholar Checklists and Key Factors) beneath, 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: Scholar guidelines. In Seidel’s information to bodily examination: An interprofessional method (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 Middle.

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 method (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 Middle.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Scholar guidelines. In Seidel’s information to bodily examination: An interprofessional method (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 Middle.

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 method (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 Middle.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Scholar guidelines. In Seidel’s information to bodily examination: An interprofessional method (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 Middle.

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 method (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 Middle.

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 Middle.

Chapter 71, “Visible Operate Analysis: Snellen, Illiterate E, Pictorial

This part explains the procedural information 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, Ok. 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 supplies medical pictures of sinusitis, together with X-rays, CT scans, and MRIs (magnetic resonance imaging).

Doc: Episodic/Centered SOAP Be aware Exemplar (Phrase doc)

Doc: Episodic/Centered SOAP Be aware Template (Phrase doc)

NURS 6512: Superior Well being Evaluation and Diagnostic Reasoning

————
— free essay pattern

Episodic/Centered SOAP Be aware
Identify
Educational Establishment

Episodic/Centered SOAP Be aware
Affected person Info:
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 generally situated across the chest space. The affected person studies the aches have intensified the sore throat. Emily studies the signs have been rising 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 appears to be like pale and unwell.
Present Medicines: Acetaminophen 650mg OTC BID for 3 days.
Allergic reactions: 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 nicely managed. No surgical procedures reported.

Soc Hx: Emily is a grade 10 pupil. She lives along 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 persistent medical situation. She has no historical past of alcohol, tobacco or ETOH abuse. She goes to high school within the neighborhood along with her buddies. She is heterosexual and never sexually lively.
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 persistent well being circumstances. Her father died of bronchial asthma four years in the past.
ROS:
GENERAL: Emily studies no sudden weight reduction or achieve. She studies gentle fever and chills. She has been experiencing normal weak point 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 operating 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 after 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 harm.
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 evening, no polyuria or polydipsia.
ALLERGIES: Penicillin causes pores and skin rashes. Emily complains of sore throat throughout climate adjustments.
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 charge 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 exhibits no historical past of respiratory issues. The well being situation exhibits no historical past of allergic reactions besides penicillin which causes pores and skin rashes. Emily studies that ‘it looks like having a gentle chilly.’
Diagnostic outcomes: Diagnostic outcomes don’t have any value/profit impact whereas diagnosing a chilly (Hayward et al., 2015). The signs are evident and thus it is just below extreme circumstances that the diagnostic evaluation will be carried out.
SAO2 – 98%, lungs are clear to auscultation and percussion bilaterally.
Blood take a look at: RF detrimental.
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 embrace 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 embrace coughing accompanied by mucus, wheezing, shortness of breath, and tightness of the chest (Tapiainen et al., 2016). Though the principle symptom is coughing it could actually 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 brought on by the Epstein-Barr virus (EBV). It causes signs resembling physique aches, chills, fever, and fatigue (De Paor, O’Brien, Fahey & Smith, 2016). Others embrace 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, Ok., 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 frequent chilly. Cochrane Database of Systematic Critiques, (10).
Schumacher, Ok. R., Stringer, Ok. 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 frequent chilly. Cochrane Database of Systematic Critiques, (eight).
Tapiainen, T., Aittoniemi, J., Immonen, J., Jylkkä, H., Meinander, T., Nuolivirta, Ok., … & Korppi, M. (2016). Finnish pointers for the remedy of laryngitis, wheezing bronchitis and bronchiolitis in kids. Acta Paediatrica, 105(1), 44-49.
Womack, J., & Jimenez, M. (2015). Frequent questions on infectious mononucleosis. American Household Doctor, 91(6).

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