Walden University – NURS 6531 Week 3: Head, Eyes, Ears, Nose and Throat Disorders SOAP Note

Walden University – NURS 6531 Week 3: Head, Eyes, Ears, Nose and Throat Disorders SOAP Note Assignment

Walden University – NURS 6531 Week 3: Head, Eyes, Ears, Nose and Throat Disorders SOAP Note Assignment

Walden University – NURS 6531: Primary Care of Adults Across the Lifespan | Week 3 Essay Assignment Paper

As introduced last week, the physical examination of a patient is usually initiated by the observation of external characteristics. Not surprisingly, abnormal or disease manifestations may cause changes to the head, eyes, ears, nose, or throat (HEENT). Understanding the manifestations which may occur when examining the HEENT system is critical for the advanced practice nurse. Fast and reliable nursing essays help online. Order a unique, plagiarism-free paper now! Get soap notes writing help.

This week, we will discuss the examination of the head, eyes, ears, nose and throat, analyze the differential diagnoses, the role of the patient information, and potential treatment options for patients with any disorder affecting this system.

Learning Objectives

By the end of this week, students will: Prepare NURS 6531 Week 3: Head eyes ears nose and throat disorders soap note Assignment

• Assess differential diagnoses for patients with HEENT disorders
• Analyze the role of patient information in differential diagnosis for HEENT
• Evaluate patient treatment options for HEENT
• Understand and apply key terms, concepts, and principles related to head, eyes, ears, nose and throat disorders
• Analyze pattern recognition in patient diagnoses

Find out more on how to write a good soap note

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Buttaro, T. M., Trybulski, J., Polgar Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice (5th ed.). St. Louis, MO: Elsevier.

• • Part 6, “Evaluation and Management of Eye Disorders” (pp.326-358)

This part covers eye examinations and explores the pathophysiology, clinical presentation, physical examination, diagnostics, and management of eye disorders, including cataracts, conjunctivitis, and dry eye syndrome.

• • Part 7, “Evaluation and Management of Ear Disorders” (pp. 359-377)

This part reviews factors contributing to the diagnosis and treatment of ear disorders, such as symptoms, patient history, physical exams, and indications for referral or hospitalization. It also covers lifespan considerations, complications, and methods for educating patients and families about ear disorders.

• • Part 8, “Evaluation and Management of Nose Disorders” (pp.378-397)

This part explores the development of differential diagnoses for nose disorders. Nose disorders such as chronic nasal congestion and discharge, nasal trauma, rhinitis, and sinusitis are examined, as well as related complications, indications for referral or hospitalization, and health promotion strategies.

Required Media

Laureate Education, Inc. (Executive Producer). (2013a). Case studies: Ear disorder. Baltimore, MD: Author.

NURS 6531 Week 3: Head, Eyes, Ears, Nose and Throat Disorders SOAP Note Assignment

NURS 6531 Discussion: Diagnosing HEENT Disorders Essay Assignment Paper

In clinical settings, advanced practice nurses may initiate a physical examination of a patient by examining the components of the HEENT system. Assessing primary diagnoses and differential diagnoses as they concern the HEENT system are important in informing your practice in providing optimal care.

For this Discussion, consider the following three case studies of patients presenting with head, eyes, ears, nose, and throat disorders.

Case Study 1

An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes. Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation.

Case Study 2

A middle-aged male presents to the office complaining of a two-day history of a left earache. The onset was gradual, but has steadily been increasing. It has been constantly aching since last night, and his hearing seems diminished to him. Today he thinks the left side of his face may even be swollen. He denies upper respiratory infection, known fever, or chills. His patient medical history is positive for Type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has a known allergy to Amoxicillin that results in pruritus. Medications currently prescribed include Metformin 1,000 milligrams po twice a day, lisinopril 20 milligrams po daily, Aspirin 81 milligrams po daily, and simvastatin 40 milligrams po daily. The physical exam reveals a middle aged male at a weight of 160 pounds, height of 5’8”, temperature of 98.8 degrees Fahrenheit, heart rate of 88, respiratory rate of 18, and blood pressure of 138/76. Further examination reveals the following:

• Face: Faint asymmetry with left periauricular area slightly edematous
• Eyes: sclera clear, conj wnl
• L ear: + tenderness L pinna, + edema, erythema, exudates left external auditory canal, TM not visible
• R ear: no tenderness, R external auditory canal clear without edema, erythema, exudates
• + tenderness L preauricular node, otherwise no lymphadenopathy
• Cardiac: S1 S2 regular. No S3 S4 or murmur.
• Lungs: CTA w/o rales, wheezes, or rhonchi.

Case Study 3

A middle-aged female presents to the office complaining of strep throat. She states she suddenly developed a sore throat yesterday afternoon, and it has gotten worse since then. During the night she felt like she was chilled and feverish. She denies known recent contact with anyone else who had strep throat, but states she has had strep before and it feels like she has strep now. She takes no medications, but is allergic to penicillin. The physical examination reveals a slender female lying on the examination table. She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat evaluation is positive for bilateral tonsillar swelling without exudates. Her neck is supple with bilateral, tender, enlarged anterior cervical nodes.

To prepare:

• Review the case studies provided in this week’s Resources.
• You will either select or be assigned one of the three case studies provided.
• Reflect on the provided patient information including history and physical exams.
• Think about a differential diagnosis. Consider the role the patient history and physical exam played in your diagnosis.
• Reflect on potential treatment options based on your diagnosis.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

By Day 3

Post an explanation of the primary diagnosis, as well as 3 differential diagnoses, for the patient in the case study you selected. Describe the role of the patient history and physical exam played in the diagnosis. Then, suggest potential treatment options based on your patient diagnosis.

Read a selection of your colleagues’ responses.

By Day 6

NURS 6531 Assignment 1: Practicum Experience – Episodic SOAP Note #1 Essay Assignment Paper

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

To Prepare: NURS 6531 Week 3: Head, Eyes, Ears, Nose and Throat Disorders SOAP Note Assignment

• Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment. See also SOAP Note Example
• Use the Episodic SOAP Note Template to complete this Assignment.

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

• Subjective: What details did the patient provide regarding his or her personal and medical history?
• Objective: What observations did you make during the physical assessment?
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?
• Reflection notes: What would you do differently in a similar patient evaluation?
• Please Note: Your Episodic SOAP Note Assignment must be signed by Day 7 of Week 3.