Posted: May 1st, 2022

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

NURS 6512: Superior Effectively being Analysis and Diagnostic Reasoning
Week 5: Analysis 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 consideration your complete potential diagnoses. It is perhaps a cold, the flu, bronchitis, and even one factor further extreme, resembling meningitis or mononucleosis. Assessing the exact set off will comprise far more than straightforward seen inspection. Some circumstances are so delicate that they require the utilization of specific units and exams together with a well informed eye and ear.

This week, you will uncover the suitable option to assess the top, neck, eyes, ears, nostril, and throat. Whether or not or not dealing with a detached retina, sinusitis, meningitis, and even cough, superior apply nurses should know the right analysis methods with a goal to sort right diagnoses.
Learning Targets

Faculty college students will:

Apply analysis experience to diagnose eye, ear, and throat circumstances
Apply concepts, theories, and guidelines relating to nicely being analysis methods and diagnoses for the top, neck, eyes, ears, nostril, and throat

Learning Property

Required Readings (click on on to extend/reduce)

Required Media (click on on to extend/reduce)

Venture 1: Case Study Venture: Assessing the Head, Eyes, Ears, Nostril, and Throat

Image Credit score rating: Getty Images/Combine Images

Most ear, nostril, and throat circumstances that come up in non-critical care settings are minor in nature. However, delicate indicators can typically escalate into life-threatening circumstances that require quick analysis and treatment.

Nurses conducting assessments of the ears, nostril, and throat must be able to set up the small variations between life-threatening circumstances and benign ones. As an illustration, if a affected individual 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 fairly than a case of throat most cancers. With this knowledge and a ample affected individual nicely being historic previous, a nurse would not should escalate the analysis to a biopsy or an MRI of the lymph nodes nonetheless would most definitely perform a straightforward strep check out.

On this Case Study Venture, you take into consideration case analysis of irregular findings from victims in a medical setting. You determine what historic previous must be collected from the victims, what bodily exams and diagnostic exams must be carried out, and formulate a differential Assessment with various potential circumstances.

To Put collectively

By Day 1 of this week, you will be assigned to a particular case analysis for this Case Study Venture. Please see the “Course Bulletins” a part of the classroom in your challenge out of your Instructor.
Moreover, your Case Study Venture must be inside the Episodic/Centered SOAP Bear in mind format fairly than the traditional narrative kind 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 Property for steering. Remember that all Episodic/Centered SOAP Notes have specific info included in every affected individual case.

With regard to the case analysis you had been assigned:

Overview this week’s Learning Property and take into consideration the insights they provide.
Have in mind what historic previous may be wanted to collect from the affected individual.
Have in mind what bodily exams and diagnostic exams may be relevant to gather further particulars concerning the affected individual’s state of affairs. How would the outcomes be used to make a Assessment?
Decide at least 5 potential circumstances that may very well be considered in a differential Assessment for the affected individual.

The Assignment Essay

Use the Episodic/Centered SOAP Template and create an episodic/focused phrase regarding the affected individual inside the case analysis to which you had been assigned using the episodic/focused phrase template equipped inside the Week 5 sources. Current proof from the literature to help diagnostic exams that is perhaps relevant for each case. Guidelines 5 completely totally different potential circumstances for the affected individual’s differential Assessment and justify why you selected each.
By Day 6 of Week 5

Submit your Venture

Learning Property

Required Readings (click on on to extend/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 critiques the anatomy and physiology of the top and neck. The authors moreover describe the procedures for conducting a bodily examination of the top 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 ingredient the right procedures for conducting a bodily examination of the ears, nostril, and throat. The chapter moreover provides photographs and descriptions of frequent abnormalities inside the ears, nostril, and throat.

Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Superior nicely being analysis and medical Assessment in predominant care (sixth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Superior Effectively being Analysis and Medical Prognosis in Most important Care, sixth Model by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby by way of the Copyright Clearance Center.

Chapter 15, “Earache”

This chapter covers the precept questions that must be requested regarding the affected individual’s state of affairs earlier to the bodily examination along with how these questions end in a focused bodily examination.

Chapter 21, “Hoarseness”

This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the affected individual, every by way of questions and through bodily exams.

Chapter 25, “Nasal Indicators and Sinus Congestion”

On this chapter, the authors highlight the necessary factor inquiries to ask regarding the victims indicators, the necessary factor elements of the bodily examination, and potential laboratory work that’s prone to be needed to supply an right Assessment of nasal and sinus circumstances.

Chapter 30, “Purple Eye”

The principle focus of this chapter is on the suitable option to determine the rationale for crimson eyes in a affected individual, along with key indicators to consider and potential diagnoses.

Chapter 32, “Sore Throat”

A sore throat is one commonest concerns victims describe. This chapter consists of inquiries to ask when taking the affected individual’s historic previous, points to seek 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 best way the causes of the state of affairs can be acknowledged.

Bear in mind: Get hold of the six paperwork (Scholar Checklists and Key Elements) beneath, and use them as you apply conducting assessments of the top, 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 tips. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key components. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Scholar tips. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key components. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Scholar tips. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nostril, and throat: Key components. In Seidel’s info to bodily examination: An interprofessional technique (ninth ed.). St. Louis, MO: Elsevier Mosby.

Credit score rating Line: Seidel’s Data 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 Effectively being Sciences. Reprinted by permission of Elsevier Effectively being Sciences by way of the Copyright Clearance Center.

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 way of the Copyright Clearance Center.

Chapter 71, “Seen Function Assessment: Snellen, Illiterate E, Pictorial

This half explains the procedural info needed to hold out eyes, ears, nostril, and mouth procedures.

Sullivan, D. D. (2019). Data to medical documentation (third ed.). Philadelphia, PA: F. A. Davis.

Chapter 2, “The Full Historic previous and Bodily Examination” (Beforehand be taught 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 learning 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 provides medical footage of sinusitis, along with X-rays, CT scans, and MRIs (magnetic resonance imaging).

Doc: Episodic/Centered SOAP Bear in mind Exemplar (Phrase doc)

Doc: Episodic/Centered SOAP Bear in mind Template (Phrase doc)

NURS 6512: Superior Effectively being Analysis and Diagnostic Reasoning

————
— free essay sample

Episodic/Centered SOAP Bear in mind
Determine
Instructional Institution

Episodic/Centered SOAP Bear in mind
Affected individual 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 individual is a 15-year outdated female who developed chills, aches, and sore throat three days up to now. The affected individual describes the ache and chills as excessive. Shares them eight out of 10 in depth. The ache is mostly located throughout the chest area. The affected individual 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 individual denies situation in respiratory. The affected individual is alert and oriented. She denies headache. Emily seems to be like pale and unwell.
Current Medicines: Acetaminophen 650mg OTC BID for three days.
Allergic reactions: 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 state of affairs reported at 5 years. Pores and pores and skin allergy properly managed. No surgical procedures reported.

Soc Hx: Emily is a grade 10 pupil. She lives alongside along with her mother and two brothers. Emily, who’s the last-born inside the family loves visiting new places. Her two brothers and mother are healthful with no persistent medical state of affairs. She has no historic previous of alcohol, tobacco or ETOH abuse. She goes to highschool inside the neighborhood alongside along with her buddies. She is heterosexual and by no means sexually vigorous.
Fam Hx: No family or genetic nicely being state of affairs reported. She has one grandmother who’s alive nonetheless battling a coronary coronary heart draw back. Her mother and two brothers haven’t any historic previous of persistent nicely being circumstances. Her father died of bronchial bronchial asthma 4 years up to now.
ROS:
GENERAL: Emily research no sudden weight discount or obtain. She research light fever and chills. She has been experiencing regular weak level for the ultimate 2 days.
HEENT:
Eyes: The affected individual 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 individual complains of a sore throat for the ultimate three days. No working nostril, nasal congestion or sneezing.
SKIN: No pores and pores and skin state of affairs, 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 nicely being state of affairs even after I prepare at school.’
RESPIRATORY: The affected individual denies shortness of breath, coughing or sputum. No nasal congestion. The lungs are clear.
GASTROINTESTINAL: The affected individual research common bowel movement and no blood inside the stool. The affected individual denies nausea, vomiting, diarrhea or lack of urge for meals.
GENITOURINARY: The affected individual 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 individual research no historic previous of once more ache, surgical process, or muscle hurt.
HEMATOLOGIC: Emily denies bleeding, bruising or anemic state of affairs.
LYMPHATICS: No historic previous of splenectomy. She complains of swollen lymph nodes.
PSYCHIATRIC: The affected individual denies any nervousness or melancholy. She is alert and oriented.
ENDOCRINOLOGIC: The affected individual denies sweating at night, no polyuria or polydipsia.
ALLERGIES: Penicillin causes pores and pores and skin rashes. Emily complains of sore throat all through local weather changes.
O.
VS: BP 120/76; R 20; 98.eight° F; 02 96% Wt 100lbs; Ht 61.7”
Frequent – The affected individual appears pale and unwell.
Cardiovascular – Common coronary coronary heart cost 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 individual is feeling unwell. The outcomes level out the chills, aches and sore throat could deteriorate. The various packages along with respiratory are in good state of affairs. The affected individual reveals no historic previous of respiratory points. The nicely being state of affairs reveals no historic previous of allergic reactions in addition to penicillin which causes pores and pores and skin rashes. Emily research that ‘it seems like having a delicate chilly.’
Diagnostic outcomes: Diagnostic outcomes haven’t any worth/revenue impression whereas diagnosing a cold (Hayward et al., 2015). The indicators are evident and thus it’s just under excessive circumstances that the diagnostic analysis can be carried out.
SAO2 – 98%, lungs are clear to auscultation and percussion bilaterally.
Blood check out: RF detrimental.
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 embrace runny nostril, chills, aches, and headache. The chills occur on account of the physique making an attempt to answer to a bacterial or viral an an infection. The state of affairs can be triggered by publicity to chilly local weather (Hayward et al., 2015).
Bronchitis – The state of affairs causes irritation of the bronchial tubes. The indicators embrace coughing accompanied by mucus, wheezing, shortness of breath, and tightness of the chest (Tapiainen et al., 2016). Although the precept symptom is coughing it might really moreover set off a sore throat. In case of utmost bronchitis, a affected individual might experience a fever with a extreme temperature of 100 to 101°F (Schumacher et al., 2015).
Mononucleosis – The state of affairs is introduced on by the Epstein-Barr virus (EBV). It causes indicators 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 pores and skin rash (Womack & Jimenez, 2015).
Most important 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 frequent 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 frequent chilly. Cochrane Database of Systematic Critiques, (eight).
Tapiainen, T., Aittoniemi, J., Immonen, J., Jylkkä, H., Meinander, T., Nuolivirta, Okay., … & Korppi, M. (2016). Finnish pointers for the treatment 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 Family Physician, 91(6).

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