NRNP 6568 WEEK 3 Assessing, Diagnosing, and Treating Patients With HEENT Conditions

NRNP 6568 WEEK 3 Assessing, Diagnosing, and Treating Patients With HEENT Conditions

Assessing, Diagnosing, and Treating Patients with HEENT Conditions

Patient Information:

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BR, 11 years old, Male, American white

S.

CC (chief complaint): “Nosebleed”

HPI: BR is an 11-year-old male whose mother brought him to the facility complaining of a nosebleed. The mother reported they had been applying pressure by pinching the nose but was unsuccessful. BR notes he woke up and experienced a nosebleed that would not stop. He described the nosebleed to be from the left nostril. He denied a history of nosebleeds or trauma to the nose.

Current Medications: BR denied current medication use

Allergies: BR denied food, drug, or environmental allergies

PMHx: BR’s immunization record is up-to-date

Soc & Substance Hx: BR is the firstborn in his family. He is a student. His hobbies are drawing and soccer. He is the only child in his family. There is no smoking or alcohol use in the family. He wears a helmet when riding a bicycle. He also wears a seat belt when in the car. Their home has smoke detectors.

Fam Hx: BR’s father has controlled hypertension. His maternal grandmother has hypertension while his paternal grandfather has asthma. His deceased aunt had cervical cancer.

Surgical Hx: BR has no history of surgeries

Mental Hx: BR has no history of mental health problems or treatments

Violence Hx: BR has no violence concerns

Reproductive Hx: Not applicable

ROS:

GENERAL: BR denies fever, weight loss, fatigue, or chills

HEENT: Eyes: BR denies eye drainage, redness, or blurred vision. He denies earing loss, pain, or loss of body balance. He reports a nosebleed since morning that has been unresponsive to pinching. He notes the left nostril is bleeding. There is no sneezing or nasal flaring. There is no sore throat or difficulty swallowing.

SKIN: BR denies skin itchiness or rashes

CARDIOVASCULAR: BR denies chest pain, palpitations, edema, or cyanosis

RESPIRATORY: BR denies cough, shortness of breath, or productive cough

GASTROINTESTINAL: BR denies nausea, vomiting, diarrhea, bloating, or constipation

GENITOURINARY: BR denies urgency, frequency, or dysuria

NEUROLOGICAL: BR denies headaches, dizziness, loss of body coordination, or paresthesia

MUSCULOSKELETAL: BR denies muscle pain, joint stiffness, or swelling

HEMATOLOGIC: BR reports a nosebleed. He denies anemia or easy bruising

LYMPHATICS: BR denies lymphadenopathy

PSYCHIATRIC: BR denies anxiety or a depressed mood

ENDOCRINOLOGIC: BR denies heat or cold intolerance, polyuria, polyphagia, or polydipsia

REPRODUCTIVE: BR denies urethral drainage

ALLERGIES: BR denies food, drug, or environmental allergies

O.

Physical exam:

HEENT: The head is atraumatic. There is no ear drainage, ear pulling, or changes in hearing. The assessment of the eyes reveals no eye drainage, redness, or poor pupillary response to the light. Active bleeding is noted in the anterior left nostril. There are no foreign bodies or signs of nose trauma. The assessment of the right nose and throat are unremarkable.

Respiratory: There is unlabored breathing. There are no flaring, crackles, wheezes, or rhonchi.

Cardiovascular: There are regular heart rhythms. There are no heart murmurs, lower limb edema, or cyanosis.

Diagnostic results: A complete blood count test was unremarkable. Diagnostic investigations were not ordered.

A.

Differential Diagnoses:

Anterior nosebleed: Anterior nosebleed is BR’s primary diagnosis. Anterior nosebleeds are the most common type of nosebleeds. They develop due to factors, including exposure to allergens, environmental dryness, coagulopathies, and use of anticoagulants. A rupture of anterior nose blood vessels causes the nosebleeds. Patients present to the hospital complaining of nosebleeds (Seikaly, 2021; Tabassom & Dahlstrom, 2024). BR’s assessment reveals an anterior left nostril bleed.

Nasal trauma: Nasal trauma is the secondary diagnosis to be considered for BR. Nasal trauma can cause fractures or damage to the blood vessels leading to epistaxis (Navaratnam, 2021). However, the history obtained from the patient and physical assessment findings did not reveal any nasal trauma. As a result, nasal trauma is the least likely diagnosis.

Bleeding disorders: Bleeding disorders are the other differential diagnoses to be deliberated for BR. Conditions, including hereditary hemorrhagic telangiectasia, can cause epistaxis by preventing blood vessel development. Patients can bleed with slight vessel trauma (Shaw, 2024; Warren, 2022). BR has no history of bleeding disorders making them the least likely causes of his bleeding.

No diagnostic studies will be obtained for BR. A complete blood count test was unremarkable. Referrals to specialized care were not considered. Nasal packing with moistened gauze was done, which stopped the bleeding. The patient was reassured to allay anxiety. He was educated on medication use, prevention of nasal trauma, and the avoidance of nose blowing and contact sports for at least 24 hours. Continued use of nasal spray at home was emphasized (Tabassom & Dahlstrom, 2024). A follow-up visit was scheduled after a week to assess treatment response. I learned the difference between anterior and posterior nosebleeds from this experience. I also discovered the blood vessels involved in anterior nosebleeds.

 

 

References

Navaratnam, R. (2021). Nasal injuries. Don’t Forget The Bubbles. https://doi.org/10.31440/DFTB.33108

Seikaly, H. (2021). Epistaxis. New England Journal of Medicine, 384(10), 944–951. https://doi.org/10.1056/NEJMcp2019344

Shaw, G. (2024). Sometimes It’s More than Just a Nosebleed. Emergency Medicine News, 46(9), 12. https://doi.org/10.1097/01.EEM.0001052172.08843.f4

Tabassom, A., & Dahlstrom, J. J. (2024). Epistaxis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK435997/

Warren, B. B. (2022). Untreated bleeds: Unveiling the subtleties and challenges of bleeding event counts and patient experience in clinical trials for bleeding disorders. Research and Practice in Thrombosis and Haemostasis, 6(7). https://doi.org/10.1002/rth2.12832

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Assessing, Diagnosing, and Treating Patients With HEENT Conditions

Most everyone has at some point experienced minor HEENT conditions, such as a head cold or seasonal allergies, and symptoms, such as a runny nose, watery eyes, or a sore throat. While they are relatively minor and short-lived, they nevertheless impair many of the simple pleasures so many enjoy.

HEENT symptoms can represent a wide variety of issues, some of which suggest problems that extend well beyond their temporary impact on life’s simple pleasures. HEENT conditions can result in dangerous respiratory impairment or be symptoms of life-threatening conditions or disease.

For this Assignment, your instructor will assign a case study, which will give you the opportunity to practice assessing, diagnosing, and treating patients with HEENT conditions.

Resources

 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

  • Leik, M. T. C. (2021). Family nurse practitioner certification intensive review (4th ed.). Springer Publishing Company.
    • Ch. 5, Head Eyes, Ears, Nose, and Throat Review
  • Buppert, C. (2021). Nurse practitioner’s business practice and legal guide (7th ed.). Jones & Bartlett.
    • Appendix 4-A “Ear, Nose, Mouth, and Throat Examination” (pp. 191–192)

Note: The textbook listed below is from NRNP 6531. Review the chapters assigned in this textbook as needed to refresh your knowledge.

  • Buttaro, T. M., Polgar-Bailey, P., Sandberg-Cook, J., & Trybulski, J. (2021). Primary care: Interprofessional collaborative practice (6th ed.). Elsevier.
    Note: Review the following chapters, as needed.

    • Ch. 52, Evaluation of the Eyes
    • Ch. 53, Cataracts
    • Ch. 54, Blepharitis, Hordeolum, and Chalazion
    • Ch. 55, Conjunctivitis
    • Ch. 56, Corneal Surface Defects and Ocular Surface Foreign Bodies
    • Ch. 57, Dry Eye Syndrome
    • Ch. 58, Nasolacrimal Duct Obstruction and Dacryocystitis
    • Ch. 59, Preseptal and Orbital Cellulitis
    • Ch. 60, Pingueculae and Pterygia
    • Ch. 61, Traumatic Ocular Disorders
    • Ch. 62, Auricular Disorders
    • Ch. 63, Cerumen Impaction
    • Ch. 64, Cholesteatoma
    • Ch. 65, Impaired Hearing
    • Ch. 66, Inner Ear Disturbances
    • Ch. 67, Otitis Externa
    • Ch. 68, Otitis Media
    • Ch. 69, Tympanic Membrane Perforation
    • Ch. 70, Chronic Nasal Congestion and Discharge
    • Ch. 71, Epistaxis
    • Ch. 72, Nasal Trauma
    • Ch. 73, Rhinitis
    • Ch. 74, Sinusitis
    • Ch. 75, Smell and Taste Disturbances
    • Ch. 76, Tumors and Polyps of the Nose
    • Ch. 77, Dental Abscess
    • Ch. 78, Diseases of the Salivary Gland
    • Ch. 79, Epiglottitis
    • Ch. 80, Oral Infections
    • Ch. 81, Peritonsillar Abscess
    • Ch. 82, Pharyngitis and Tonsillitis
  • Document: Focused SOAP Note Template (Word document)Download Focused SOAP Note Template (Word document)

Required Media

  • HEENT Review
    In this video, Dr. Jodi Duncan reviews important considerations when assessing, diagnosing, and treating patients with HEENT conditions. (18 min)
  • Develop Good Habits. (2023, May 15). 15 SMART Goals Examples for StudentsLinks to an external site. [Video]. YouTube. https://www.youtube.com/watch?v=SVBOjp2uxZE

Optional Resources

  • Adult HEENT
    Dr. Stefanie Gatica discusses how to listen to the patient and what to look for as you assess your patient. (25m)

To Prepare:

  • Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with conditions of the head, eyes, ears, nose, and throat.
  • Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
  • Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
  • Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
  • Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
  • Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions.

The Assignment

Use the Focused SOAP Note Template to address the following:

  • Subjective: What details are provided regarding the patient’s personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
  • Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
  • Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: Describe your “aha!” moments from analyzing this case.

By Day 7

Submit your focused SOAP note.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

  1. To submit your completed assignment, save your Assignment as WK3Assgn2_LastName_Firstinitial
  2. Then, click on Start Assignment near the top of the page.
  3. Next, click on Upload File and select Submit Assignment for review

Rubric

NRNP_6568_Week3_Assignment2_Rubric

NRNP_6568_Week3_Assignment2_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeCreate documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned. In the Subjective section, provide: • Chief complaint • History of present illness (HPI) • Current medications • Allergies • Patient medical history (PMHx) • Review of systems
10 to >8.0 ptsExcellent 90%–100%

The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

8 to >7.0 ptsGood 80%–89%

The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.

7 to >6.0 ptsFair 70%–79%

The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but it is somewhat vague or contains minor innacuracies.

6 to >0 ptsPoor 0%–69%

The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Objective section, provide: • Physical exam documentation of systems pertinent to the chief complaint, HPI, and history • Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
10 to >8.0 ptsExcellent 90%–100%

The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.

8 to >7.0 ptsGood 80%–89%

The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented.

7 to >6.0 ptsFair 70%–79%

Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies.

6 to >0 ptsPoor 0%–69%

The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing.

10 pts
This criterion is linked to a Learning OutcomeIn the Assessment section, provide: • At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
25 to >22.0 ptsExcellent 90%–100%

The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the conditions selected.

22 to >19.0 ptsGood 80%–89%

The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the conditions selected.

19 to >17.0 ptsFair 70%–79%

The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 ptsPoor 0%–69%

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

25 pts
This criterion is linked to a Learning OutcomeIn the Plan section, provide: • A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits. • A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors. • Reflections on the case describing insights or lessons learned.
30 to >26.0 ptsExcellent 90%–100%

The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.

26 to >23.0 ptsGood 80%–89%

The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking.

23 to >20.0 ptsFair 70%–79%

The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics.

20 to >0 ptsPoor 0%–69%

The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing.

30 pts
This criterion is linked to a Learning OutcomeProvide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.
10 to >8.0 ptsExcellent 90%–100%

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.

8 to >7.0 ptsGood 80%–89%

The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions.

7 to >6.0 ptsFair 70%–79%

Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan.

6 to >0 ptsPoor 0%–69%

Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence based or do not support the treatment plan.

10 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 ptsExcellent 90%–100%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 ptsGood 80%–89%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 ptsFair 70%–79%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 ptsPoor 0%–69%

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation
5 to >4.0 ptsExcellent 90%–100%

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 ptsGood 80%–89%

Contains 1 or 2 grammar, spelling, and punctuation errors.

3 to >2.0 ptsFair 70%–79%

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 ptsPoor 0%–69%

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list.
5 to >4.0 ptsExcellent 90%–100%

Uses correct APA format with no errors.

4 to >3.0 ptsGood 80%–89%

Contains 1 or 2 APA format errors.

3 to >2.0 ptsFair 70%–79%

Contains several (3 or 4) APA format errors.

2 to >0 ptsPoor 0%–69%

Contains many (≥ 5) APA format errors.

5 pts
Total Points: 100

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