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
Directions: Conduct a HEENT, skin and nails assessment on a fellow student, friend, or family member. Remember to secure their permission.
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
|An optimal and thorough assessment and summary is present for each system.||Poorly organized/or limited summary of pertinent assessment
|Less than 50% of pertinent assessment information is addressed or is grossly incomplete and or inaccurate.|
|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
|No grammar or spelling errors.||skin hair nails and heent assessment essay assignment||Errors in grammar or spelling.|
Patient Age & Gender:
|SKILLS ASSESSMENT||DOCUMENTED FINDINGS|
|Measurements and V/S|
|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)|
|Capillary refill time|
|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?|
|Assess facial Overview: symmetry and couture|
|CN V: (Trigeminal) Facial Sensation
(Facial) Expression: CN VII: smile/frown/raise eyebrows
|Inspect External Structures: eyelids/lashes/brows|
|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
|(Optic) CN II Visual Acuity Tests
-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
|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|
|Inspect external nose: shape and symmetry, inflammation|
|Visualize internal nares: lesions, swelling, symmetry, discharge|
|Patency of nares/sense of smell CN I (Olfactory)|
|Inspect lips: dryness, color, cracking, lesions|
|Inspect buccal mucosa: lesions, saliva, swelling, tears|
|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).|
|Say Ahh.. Soft palate and uvula should rise at the midline CN X (Vagus)|
|Assess for symmetry|
|ROM: Chin to chest, turn head R & L
Muscle strength CN II (Accessory) Shoulder shrug against resistance
|Palpate trachea in midline|
|Palpate preauricular, posterior auricular, submental, submandibular, tonsillar|
|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)
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
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.
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
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.