skin hair nails and heent assessment essay assignment
Skin hair nails and heent assessment essay assignment
NUR 2092 – Health Assessment
Written Assignment: HEENT/Skin/Nails
Purpose: To apply assessment and documentation skills utilized for physical health assessment.
Overview: After reading/viewing the module assignment and attending lab, conduct an assessment of the
Head
Eyes
Ears
Nose
Mouth
Face
Neck
Skin
Hair
Nails
Directions: Conduct a HEENT, skin and nails assessment on a fellow student, friend, or family member. Remember to secure their permission.
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Use the HEENT documentation assignment attached to this assignment module to document your findings. Formulate a SOAP note with both subjective and objective data as indicated on the HEENT attachment.
Submit your work to the Module 7 dropbox. Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.
Save your assignment as a Microsoft Word document. (Mac users, please remember to append the “.docx” extension to the filename.) The name of the file should be your first initial and last name, followed by an underscore and the name of the assignment, and an underscore and the date. An example is shown: Jstudent_exampleproblem_101504
This skin hair nails and heent assessment essay assignment is worth 20 points and will be graded using the graded rubric below.
Components
Meets Expectations
Needs Improvement
Does Not meet Expectations
Assessment Findings and documentation
10 points
An optimal and thorough assessment and summary is present for each system.
Poorly organized/or limited summary of pertinent assessment
Information.
Less than 50% of pertinent assessment information is addressed or is grossly incomplete and or inaccurate.
Soap Note
8 points
Complete and concise summary of pertinent SOAP information.
Poorly organized/or limited summary of pertinent SOAP information.
Less than 50% of pertinent information is addressed or is grossly incomplete and or inaccurate.
Spelling and Grammar
2 point.
No grammar or spelling errors.
skin hair nails and heent assessment essay assignment
Errors in grammar or spelling.
Total: /20
Student Name:
Patient Age & Gender:
Date:
SKILLS ASSESSMENT
DOCUMENTED FINDINGS
Measurements and V/S
Height/Weight
Body Mass Index (BMI)
skin hair nails and heent assessment essay assignment
Blood Pressure(B/P) – Temperature
Pulse – Respirations
Pain Assessment Scale 1-10
INTEGUMENT/SKIN (throughout assessment)
Hands/Nails/Palmar creases
Capillary refill time
Color pigmentation
Temperature
Warmth/Cool to touch
S/S of inflammation/infection
Open wounds: type, size, odor, drainage present
Bruises, tattoo’s or identifying marks
skin hair nails and heent assessment essay assignment
Turgor: upper and lower extremities. Tenting?
Lesions/rashes/ dryness/moisture
Hair distribution
HEAD/FACE
Assess Scalp/hair/cranium
Hair distribution
Assess facial Overview: symmetry and couture
CN V: (Trigeminal) Facial Sensation
(Facial) Expression: CN VII: smile/frown/raise eyebrows
EYES
Inspect External Structures: eyelids/lashes/brows
Conjunctivae
Sclera and iris
skin hair nails and heent assessment essay assignment
PERRLA: pupil size equal, round & reactive to light and accommodation (see next)
CN III (Oculomotor) Pupillary Response to accommodation:
-Look near/Look far test or
-Convergence Test
(Optic) CN II Visual Acuity Tests
-Snellen Chart
-Peripheral Field of Vision Test:
How many fingers they see when fingers are presented to both sides at the same time.
Eye movements: CN III (Oculomotor), IV (Trochlear), VI (Abducens):
6 Cardinal Fields of gaze.
Note any Nystagmus
EARS
Inspect External Ear: symmetry, discharge, lesions, shape and couture, piercings
Palpate tragus/Pinna for pain
Inspect inner ear canal: obstruction, drainage, inflammation, cerumen skin hair nails and heent assessment essay assignment
Hearing test CN VIII (Vestibulocochlear) voice test out of site
NOSE
Inspect external nose: shape and symmetry, inflammation
Visualize internal nares: lesions, swelling, symmetry, discharge
Patency of nares/sense of smell CN I (Olfactory)
MOUTH/THROAT
Inspect lips: dryness, color, cracking, lesions
Inspect buccal mucosa: lesions, saliva, swelling, tears
Teeth/gums
Tongue: pink, papillae present,
visualize under to assess frenulum/vascularization
CN XII (Hypoglossal) Tongue Movement: stick tongue out
Inspect Hard/Soft palate
Inspect throat for lesions, inflammation, or post nasal drip.
Swallow test & Gag Reflex CN IX (Glossopharyngeal) & CN X (Vagus).
Inspect tonsils
Say Ahh.. Soft palate and uvula should rise at the midline CN X (Vagus)
NECK
Assess for symmetry
ROM: Chin to chest, turn head R & L
Muscle strength CN II (Accessory) Shoulder shrug against resistance
Palpate trachea in midline
LYMPHNODES
Palpate preauricular, posterior auricular, submental, submandibular, tonsillar
PULSES
Carotid, brachial, radial, popliteal, posterior tibia, dorsalis pedis
Document your findings using the SOAP note format regarding 2 impaired systems finding skin hair nails and heent assessment essay assignment. (Example: your patient had a current throat infection, ear ache, head pain or cervical FX)
S-Subjective:
O-Objective:
A-Assessment: (Formulate 2 ACTUAL nursing DX centered on the medical dx/problem. Remember, actual dx requires R/T (etiology) and AEB (signs/symptoms) factors)
P-Plan: (List at least 10 nursing interventions are you going to implement for the above assessments)
CC: Sore throat
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Mrs. Carson, 55 yo Caucasian woman presents with sore throat x few days. Patient reports onset of headache a few days ago that progressively got worse and developed a sore throat that she rates 7.5-8/10 pain. She states she feels “tired, draggy, and head feels clogged.” She complains of dry lips and having difficulty eating due to the sore throat. Unsure of weight changes. She reports a fever of 100 degrees F taken at home skin hair nails and heent assessment essay assignment. She has taken Ibuprofen and Sudafed at home with little relief. Denies ear pain, coughing, pressure in the ears, rashes, neck stiffness or tenderness, chest pain, and stomach pains.
PMH: None
Meds: None
Allergies: None
FH: Hodgkins Lymphoma- father
SH: denies current tobacco or illicit drug use, although admits to using both in the distant past. Drinks a couple of glasses of a wine per week.
ROS: General: Reports fever of 100 deg at home, fatigue, headache
Derm: no rash
HEENT: Sinus pain and pressure, nasal mucosa and throat red. No nasal d/c. Denies ear pain. Denies cough.
Resp: See HPI
CV: Denies chest pain.
GI: Poor appetite
Endocrine: Denies excessive hunger, thirst or excessive urination.
MS: Feels generalized aching of muscles.
Psych: Denies depression, thoughts of harm to self or others skin hair nails and heent assessment essay assignment.
O) Vitals: 110/72, 94bpm, RR20, temp: 101.2, O2 sat: 98% RA, ht 5’6, wt 145lb
Diagnostics: + Rapid Stress Test
General: Appears tired.
Skin: Flushed. No excessive dryness.
HEENT: Canals clear. TMs visible, translucent, gray, cone of light and landmarks visible. Nasal mucosa red, clear d/c, no polyps, septum midline. Oral mucosa pink and moist, pharyngeal erythema, no exudates, tonsils 2+. No frontal/maxillary sinus tenderness. Neck supple, trachea mid-line. +LAD. Thyroid without enlargement or nodules.
Heart: normal S1, S2, No MRG
Lungs: CTA
Extremities: No edema, pulses equal 2+ bilaterally in all 4 extremities.
A) Streptococcal Pharyngitis
P) #1. Rx: Amoxicillin 500mg BID x 10 days.
Ibuprofen 400mg Q6 PRN fever.
Cough drops/lozenges for throat pain
Gargle with warm water and salt. skin hair nails and heent assessment essay assignment.
