HEENT shadow health assessment – tina jones Subjective Data

May 30, | nursing, med, NURS, Paper

HEENT shadow health assessment – tina jones Subjective Data
Subjective Data Collection: 29 of 29 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

Found:
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Available:
Indicates an item that is available to be found.

Category

Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding:
Established chief complaint

Finding:
Reports sore throat
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
Is your throat sore?

Finding:
Reports itchy throat
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
Is your throat itchy?

Finding:
Reports itchy eyes
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:

Finding:
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.
Example Question:
Do you have a runny nose?

History of Present Illness

Finding:
Asked about onset of symptoms

Finding:
Reports sore throat began 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How long has your throat been sore?

Finding:
Reports runny nose began 1 week ago
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:

Finding:
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:

Finding:

Finding:
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:

Finding:
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
When does your sore throat feel the worst?

Finding:
Reports some soreness with swallowing
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does it hurt when you swallow?

Finding:
Asked severity of throat discomfort

Finding:
Reports sore throat discomfort as mild to moderate
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Can you rate your sore throat on a scale of 0 to 10?

Finding:
Asked about frequency and duration of runny nose

Finding:
Reports runny nose is constant
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does your nose itch?

Finding:
Denies sinus pain
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you feel any sinus pain?

Finding:
Denies sinus pressure
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you feel any sinus pressure?

Finding:
Denies sneezing
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been sneezing?

Finding:
Followed up about character of nasal discharge

Finding:
Reports clear discharge
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Is the mucus thick?

Finding:
Denies pus
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does your mucus have pus in it?

(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do your eyes constantly itch?

Finding:
Reports eye redness
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Are your eyes red?

Finding:
Asked related respiratory symptoms

Finding:
Reports breathing isn’t affected
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you had any changes in your breathing?

Finding:
Denies cough
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you have a cough?

Finding:
Denies chest tightness
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does your chest feel tight?

Finding:
Asked about related asthma symptoms

Finding:
Denies recent wheezing
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you been wheezing?

Finding:
Denies increase in recent asthma symptoms
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Has your asthma been worse lately?

Finding:
Asked about perceived cause of symptoms

Finding:
Reports symptoms are similar to allergies
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you know what’s causing your symptoms?

Finding:
Reports symptoms don’t seem like a common cold
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do you think you have a cold?

Finding:
Reports similarity to her sister’s hay fever symptoms
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.

(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you treated your eyes with anything?

Finding:
Denies treatment for nasal symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you done anything for your runny nose?

Finding:
Denies taking antihistamine
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you taken any antihistamines?

Finding:
Denies taking decongestant
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you taken any decongestants?

Finding:
Asked about relieving factors for throat symptoms

Finding:
Reports lozenges as treatment
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Have you taken anything for your sore throat?

Finding:
Reports lozenges reduce symptoms
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Do the lozenges help?

Finding:
Reports ingesting lozenges every few hours
(Available)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
How often do you have a lozenge?

Finding:
Reports drinking water reduces symptoms
(Found)
Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.
Example Question:
Does drinking water help?

Home Medications

Finding:
Confirmed home medications

Finding:
Reports no new medications
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
Have you started taking any new medications?

Finding:
Followed up about inhaler use

Finding:
Reports using an inhaler to treat asthma symptoms
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.

(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
What is the name of the inhaler you are currently using?

Finding:
Reports last use of inhaler was 1 week ago
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
When did you last use your inhaler?

Finding:
Reports typical inhaler use is 2 – 3 times a week
(Found)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How often do you use your inhaler?

Finding:
Reports using 2 – 3 puffs of inhaler when used
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How many puffs of your inhaler do you use?

Finding:
Reports prescribed dosage is 2 puffs
(Available)
Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation.
Example Question:
How many puffs of your inhaler are you supposed to do?

Social Determinants of Health

Finding:
Asked about environmental exposure to allergens

Finding:
Denies exposure to cats
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you been recently exposed to any allergens?

Finding:
Denies exposure to mold or mildew
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have mold in your house?

Finding:
Denies exposure to dust
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have dust in your house?

Finding:
Denies exposure to irritants in work environment
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Are you allergic to anything at work?

Finding:
Reports changing bedding once a week
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
How often do you change your bedding?

Finding:
Denies history of cigarette smoking
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you smoked cigarettes recently?

Finding:
Denies recent exposure to secondhand smoke
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Have you been exposed to secondhand smoke recently?

Finding:
Asked about healthcare access

Finding:
Reports last vision exam was in childhood
(Found)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
When was your last vision test?

Finding:
Reports last hearing test was in childhood
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
When was your last hearing test?

Finding:
Reports dental visit within the last 2 years
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
When did you last see the dentist?

Finding:
Reports regular dental visits in childhood
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
How often did you see the dentist when you were a child?

Finding:
Denies vision insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have vision insurance?

Finding:
Denies dental insurance
(Available)
Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.
Example Question:
Do you have dental insurance?

Relevant Medical History

Finding:
Confirmed allergies

Finding:
Reports known allergy to cats
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Can you confirm that you’re allergic to cats?

Finding:
Reports known allergy to dust
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Are you allergic to dust?

Finding:
Denies seasonal allergies
(Found)
Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment.
Example Question:
Do you have seasonal allergies?

Review of Systems

Finding:
Asked about constitutional health

Finding:
Denies recent or frequent illnesses
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you been sick recently?

Finding:
Denies chills
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had any chills?

Finding:
Denies fever
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you had a fever?

Finding:
Reports low energy level
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you felt fatigued?

Finding:
Denies nausea or vomiting
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you felt nauseous?

Finding:
Asked about review of systems for head

Finding:
Reports occasional headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get headaches?

Finding:
Denies current headache
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have a headache currently?

Finding:
Denies history of head injury
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Have you ever had a head injury?

Finding:
Denies lightheadedness
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you ever get lightheaded?

Finding:
Followed up on headaches

Finding:
Reports headaches occur once a week
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How often do you get headaches?

Finding:
Reports headaches last a few hours
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How long do your headaches last?

Finding:
Reports headaches feel tight and throbbing
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How would you describe your headaches?

Finding:
Reports headache location is behind her forehead
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Where do you feel your headaches?

Finding:
Reports headache pain as a 3 or 4
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How would you rate your headache pain on a scale of 0 to 10?

Finding:
Reports treating headaches with acetaminophen (Tylenol)
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
How do you treat your headaches?

Finding:
Reports reading and studying seem to cause headaches
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
What seems to cause your headaches?

Finding:
Asked about review of systems for eyes

Finding:
Reports occasional blurry vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Do you have blurry vision?

Finding:
Reports worsening vision
(Found)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require.
Example Question:
Has your vision gotten worse?

Finding:
Denies eye pain
(Available)
Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptom

nursing care plan for ear infection essay

May 30, | nursing, med, NURS, Paper

nursing care plan for ear infection essay
Holistic Assessment of an Adult Ear Using an Otoscope (Observation) and Palpation
Assessment or examination of the ear for appropriate and correct diagnosis uses the techniques of inspection or observation as well as palpation. Because there are internal structures in the ear, the inspection aspect is facilitated by the use of an otoscope (Ball et al., 2019). This paper presents some of the findings that may come out of the examination of an adult patient’s ears.
Table 1: Examination of an adult ear

Part/ Procedure
Findings

Inspection of the external ear structures (including the auricle, tragus, and lobule)
·       The gross structure of the ears including the lobules of the auricles appears the same in size and shape on both sides.
·       The tragus and antitragus do not appear swollen or inflamed bilaterally.
·       There are no piercings bilaterally on the lobule, the helix, or the tragus.
·       The intertragic notch shows no sign or evidence of otorrhea or ear discharge bilaterally.
·       There are no visible lesions bilaterally on both ears, and the color of the ears is homogeneous with the rest of the body.
·       There is no discoloration on both sides.

Palpation of the external structures of the ear (including the auricle and mastoid process)
·       The auricle, the helix, the tragus, and antitragus all do not show any tenderness or swelling bilaterally.
·       Also, there are no masses that are palpable bilaterally.
·       On palpation of the mastoid process, the patient denies any tenderness on both sides.
·       The auricle feels soft and flexible bilaterally on palpation.

Bilateral inspection of the external auditory canal using the otoscope
·       The patient denies any discomfort when the otoscope is inserted in the external auditory canal on both sides.
·       Inspection of the external auditory canal reveals a clear canal with just a little cerumen that is brown in color.
·       There is no otorrhea visible bilaterally.
·       The canal walls are smooth with no evidence of nodules or inconsistencies bilaterally.

Bilateral inspection of the tympanic membranes
·       The tympanic membrane shows no perforation or sclerosis on both sides.
·       There are also no visible fluid levels behind the tympanic membrane bilaterally.
·       However, there are bubbles that are visible on otoscopy on the right side.
·       There is no cholesteatoma in the attic area of the membrane bilaterally.
·       The tympanic membrane shows a visible bulge and demonstrates reduced mobility on pneumatic otoscopy on the right side too.
·       The tympanic membrane on the left is round, smooth, and has no bulge or any other visible abnormality.

A common ear disorder or abnormal finding discoverable in an ear assessment
Acute otitis media (AOM)
·       In this condition, the tympanic membrane shows an opaque reaction to light and may also bulge.
·       Fluid may be demonstrated in the middle ear through otoscopy and visible through the tympanic membrane.
·       There is inflammation shown by redness of the tympanic membrane and the patient may have fever and tenderness on inserting the otoscope.
·       The fluid behind the tympanic membrane may also be pus at times (Hammer & McPhee, 2018).

Nursing Diagnoses for AOM in Adults

A health promotion nursing diagnosis for AOM
A risk nursing diagnosis for AOM
A collaborative problem or actual nursing diagnosis for AOM

Readiness for enhanced learning on the prevention of acute otitis media
Risk for developing intra-temporal abscess if AOM is left untreated
Risk for complications of intracranial and intra-temporal conditions

 
 
 
References
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.
 
OTOSCOPE Assignment
Ear Assessment and appropriate nursing diagnoses (Do assessment on an adult) In the boxes, describe your findings. Do not use the word “Normal” or approximations of it, such as N/A, expected, etc. State what you found using terminology appropriate for the area. See the textbook for appropriate wording. If there are no signs or symptoms of any problems, for instance, it would be appropriate to write: Denies tenderness, pain, and paresthesia; no lesions or breakdown observed. No evidence of pathology noted. Then proceed to describe what you assess in terms of observation, (auscultation and percussion are not used in ear assessments) and palpation. Weber and Kelley’s textbook has a helpful guide with pictures and verbiage you may find helpful: Assessment Guide 17-1, in the chapter on ear assessment (note especially the textbook verbiage in the center and right columns.) You may use textbook terminology in this class because it is expected. Many videos are also available to assist you. There is one on Blackboard in the current module, and YouTube has a number of them as well. Do not use the work of other students. That is plagiarism, and our detection program will flag it. If confirmed it will mean the grade of F in the class: It isn’t worth it!
Current Symptoms: Ears Assessment Findings External Ear Structures 1. Inspect the auricle, tragus, and lobule for size and shape, bilaterally. Describe bilateral position, lesions/discoloration, and discharge. Auricle is 6.5 cm vertical dimension, rounded, and light brown flesh-colored bilaterally (in keeping with client’s skin color.) No lesions or tenderness bilaterally. Tragus is triangular, non-tender, no lesions, color consistent with auricle, no piercings bilaterally. Lobules are attached, with one piercing bilaterally, nontender without lesions bilaterally.
2. Palpate the auricle and mastoid process bilaterally. Describe findings, including symptomatology or tenderness if they are present. Auricle and mastoid process are without lesions, and client denies tenderness; auricle is flexible and soft.
Otoscopic Examination 3. Bilaterally inspect the external auditory canal with the otoscope for discharge, color and consistency of cerumen, color and consistency of canal walls, and any nodules. (Address each of these items bilaterally.) Auditory canals: smooth walls, slightly pink color, no nodules bilaterally. Dark brown cerumen is present in the right canal, left canal has no visible cerumen.
4. Inspect and describe the tympanic membranes bilaterally, using the otoscope, for color and shape, and The tympanic membranes on the right cannot be visualized due to brown cerumen blocking the ear canal; the left tympanic membrane appears round, smooth, and pearly gray. The cone-shaped reflection of the otoscope light is landmarks. reflected at 7 O’clock.
5. List a common ear disorder or abnormal assessment finding that would be discoverable in an ear or hearing assessment on a hypothetical patient. (You may include the medical diagnosis, but it is not required. You may select a problem that has not yet been diagnosed since this is a very realistic scenario—often nurses are the one who discover problems first and then refer the client.) The patient has been diagnosed with a basal cell carcinoma on his right auricle, but has not yet been treated. Surgical removal and use of fluorouracil cream are planned by dermatologist beginning next week. Skin lesion is on the very top of the auricle and extends over both the front and back of it. The lesion is rough/uneven, 6 mm at largest diameter, and has a small amount of yellow discharge dried around the edges. The edges of the lesion appear “rolled”” and pink. The lesion is non-tender. Patient states he never has used sunscreen. Adapted from Weber