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.