Nurses conducting assessments of the ears, nose, and throat must be able to iden

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Review the resources link in your assignment to access the Required resources.
TO PREPARE
By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:
Review this week’s Learning Resources and consider the insights they provide.
Consider what history would be necessary to collect from the patient.
Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Case Study : Focused Nose Exam
A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.
THE ASSIGNMENT
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.
· You are making up the information for Subjective and Objective areas.
Be sure to look at the rubric for information required for grading.
**You will need to add in (MAKE UP) the missing information in the note, (some of the information you will have to MAKE UP i.e. meds, history, parts of the ROS and PE).
For Review of Systems (ROS), please DELETE the systems not associated with the CC.
For Physical Exam (PE), ADD systems related to the CC.
In the Assessment/Plan, you will document your differential diagnoses as per the assignment.
Your differential diagnoses should be HEENT conditions.
This is a Episodic/Focused Soap note with a HEENT problem and will Focus on Certain Systems ONLY to Review and Examine. Not all systems need to be included. Think about if you went to the doctor with a problem in the HEENT area, What systems were evaluated and examined.
HINT: Look at Shadow Health Template, it is a Template focused on a HEENT problem.
Please remove all directions on assignment before submitting. They do not need to remain on an assignment for Grading.
NURS_6512_Week_5_Assignment_1_Rubric
NURS_6512_Week_5_Assignment_1_Rubric
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeUsing the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.
50 to >44.0 ptsExcellent
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
44 to >38.0 ptsGood
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
38 to >32.0 ptsFair
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.
32 to >0 ptsPoor
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
50 pts
This criterion is linked to a Learning Outcome· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each.
35 to >29.0 ptsExcellent
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected.
29 to >23.0 ptsGood
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.
23 to >17.0 ptsFair
The response lists three to five 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
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.
35 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
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
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
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
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
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 ptsGood
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 ptsFair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 ptsPoor
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/in-text citations, and reference list.
5 to >4.0 ptsExcellent
Uses correct APA format with no errors.
4 to >3.0 ptsGood
Contains a few (1 or 2) APA format errors.
3 to >2.0 ptsFair
Contains several (3 or 4) APA format errors.
2 to >0 ptsPoor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
PreviousNext