Assessments of Head, Ear and Throat The nurse who assesses the patient initially usually is the one who detects signs of more serious underlying pathology (Reynolds, 2004). The health assessment histories, SOAP notes, and findings of two patients with HEENT problems will be discussed in detail. This paper will also cover tympanic membranes findings and examination of the thyroid glands. With competent and diligent nursing assessment knowledge and application, both acute and chronic HEENT problems can lead to the discovery of underlying conditions crucial to planning and treatment. Some HEENT problems can also be life-threatening requiring prompt nursing and medical interventions (Reynolds, 2004). TMJ Pain: Health Assessment History Patient …show more content…
Plan: Analgesics – continue with Nonsteroidal anti-inflammatory drugs (NSAIDs) to take along with muscle relaxants e.g. Benzodiazepines (Aguirre, Nevidjon, & Clemens, 2008). Tricyclics, opioids, and steroids may also come into play. Apply moist heat and massage of jaw muscles. X-ray may show at rest and hinge movement of the TMJ. CT scan demonstrates greater detail of facial bones and MRI is a good choice when looking for displacement or pathological source. A nerve block is helpful whether pain comes from the TMJ or not. If all other non-surgical treatment fails, arthroscopy, condylotomy, disc repositioning, and discectomy are possible procedures proven to reduce pain 90% of patients who have gone through any of the said surgeries (Robinson & Holm, 2010). When skeletal problems are not obvious and masked by orthodontics, the patient’s teeth and jaws will continue to be unstable and L.A. will continue to suffer. Her bite, because of the position of the teeth and the shape of the skull or jaws will require orthognathic surgery to correct this level of deformity found in both dental and skeletal problems (Robinson & Holm, 2010). Her orthodontist and surgeon will be working hand in hand during the course of the …show more content…
The TM through the rest of the hearing pathway, sounds become electrical impulses analyzed by the brain, hence, the sense of hearing (Jarvis, 2012). The assessment and evaluation of the tympanic membrane is vital in a complete otological screening. The otoscope allows inspection of the ear canal and TM to detect excessive cerumen buildup, inflammation, or perforation of the TM. Hearing loss is done through the use of tuning fork performing Rinne and Weber tests and the audioscope which produces a more accurate and conclusive hearing loss test result (Jarvis, 2012). There are four essential components of the TM to evaluate. The color, appearance of the light reflex or "cone of light", the bony landmarks, and mobility of the TM, most important in children can help determine the existence of a problem. TM inspection of foreign body in the ear, trauma, excessive probing, dermatitis, otitic barotraumas, parotitis, tonsillitis, adenoid problems, sinusitis, pharyngitis, otitis externa, and otitis media can lead to abnormal findings (Bradley, 2007). Inflamed TM indicated by distinct erythema and otalgia or ear pain interfering with sleep or normal activity, otorrhea, and detection of air and fluid level behind it, if left untreated can lead to rupture (Bradley,
Hospitals regularly measure patient care, which is defined as any health care service provided to an individual. It is measured in different ways according to the type of health care service provided. However, there are basic principles that guide how all patient hospital care is measured.
Excruciating jaw pain can be extremely hard to deal with on a daily basis. If you notice any pain, clicking, or popping in your jaw when you talk, chew, or yawn, you may be suffering from Temporomandibular Joint Syndrome, or TMJ. Gregory T. Grubba, DDS, understands how to treat TMJ symptoms. Their highly-trained staff in Anchorage, AK is committed to providing comfortable, affordable dental care for their patients. Whether you’re coming in for a filling or a routine teeth cleaning, you’ll always receive the highest quality treatments for your teeth at their practice!
The aim of the essay is to demonstrate the process of a patient assessment and care plan formulation in accordance with the assignment instructions. It is based on a case study, which illustrates a patient who has a diagnosis of paranoid schizophrenia, the patient was admitted to a medium secure hospital unit, please see appendix for more details of the case study. The pseudonym Peter will be used to address the patient to maintain confidentiality as required by the Nursing and Midwifery Council(NMC,2008).Firstly the essay will explore the philosophies of CPA; Care Programme Approach and then demonstrate the assessment of a patient with an assessment tool and including the formulation of a care plan.A KGV assessment tool was utilized(Lancashire,1998).In addition,the essay will examine and analyse the strengths and limitations of principles and philosophies which underpin existing service models for instance biopsychosocial model which is applied in mental health care delivery.Subsuently the essay will demonstrate an in-depth analysis of holistic assessment principles within mental health care.Futhermore the essay will analyse collaborative working in relation to planning and
To diagnose and rule out other causes of the pain, your dentist will perform a thorough oral examination. For immediate and long-term relief from pain caused by TMD, your dentist may recommend behavior modification, eating soft foods for a few days to reduce stress on the jaw joints, gentle stretching exercises, anti-inflammatory medications, muscle relaxants, biofeedback, stress management, and other conservative therapies. Surgery is usually performed when all other treatments have
The Sarah self-referred for assessment at am outpatient clinic. She subsequently requested a referral to a psychologist in Chicago, IL. Sarah is a 24-year-old adult Caucasian female who identified as a lesbian. She reported a history of depressive symptoms that have worsened in the last few months. She is seeking treatment for these intensified depressive symptoms. She described having “depression” many years ago, but became evasive when asked to clarify. In addition, she noted a concern with experiencing anger and hostility towards others; she stated that these emotions are “uncomfortable” for her. She clarified that in the past three months she has perceived herself as “grumpier than usual.” She reported having experienced anhedonia, fatigue, and insomnia.
The tympanic membrane and thyroid gland are two of the many features that will assessed on a patient. When abnormalities or disruption in the normal function of either of these persist, permanent damage can occur. To know if there is a disruption in the normal function, we must know what the normal function and purpose is. This paper will review possible finding for the tympanic membrane, how to examine the thyroid gland, and give an assessment note using the subjective, objective, assessment, and plan (SOAP) note format.
If you suspect you have a hearing loss, your doctor can refer you to an Otorhinolaryngology’s, more commonly referred to as Ear, Nose and Throat specialists or ENT’s. This physician will examine your ears to see if there is any underlying disease, abnormality or possible undiagnosed condition that is causing your hearing loss and needs to be treated.
Trauma one Pediatric Emergency Department! Trauma one Pediatric Emergency Department responding over! Rescue Unit 29 transporting a 12 year-old boy, named Mike, hit by a car while riding his bicycle. This is a hit and run accident, but other motorists called a rescue unit. The child was not wearing a helmet. Facial bleeding is under control, but he suffered facial and head trauma. There appeared to be no facture of the extremities. Presently he is awake and semi-alert. Vitals signs: BP 120/56, Pulse 120, Oxygen
Strengths of the evaluation tool is strong because it is given to all new hires, it has many subdivisions, includes other health care providers interactions, along with critical care thinking in reference to knowing limits and how they evaluate situations. Before a preceptor is given a new nurse to precept, they must attend a series of classes. These classes elaborate the teaching and evaluation concepts of checklist for evaluation. This brings consistency, that everyone is educated in the same manner as how to approach and evaluate a new RN. The focus is on approachable nurses and also on those individuals that are strong and difficult to teach. A weakness that is obvious, is that the evaluation is subjective in nature. After all, we
Mr. Douglass was advised to cut back on red meat intake and try to eat leaner meats such as chicken, fish and nuts.
This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has
The goal of the patient gaining more confidence in health care professionals transferring him by 02/10/16, was partically met, however, he still gets anxiety and will occasionally move too quickly, therefore, he is still at risk for the patient falling. The patient met the goal of notifying the nurse or the nursing assistant when he needed to use the restroom. He would properly notify us as the healthcare providers by pushing his call light.
The purpose of this research group is to evaluate the effectiveness of bed/chair alarms in the prevention/intervention of adults 65 years and older in inpatient settings. The majority of the articles that were reviewed were conducted on inpatients, while the age of adults 65 years and older was not adhered to in every inclusion article.
According to Smeltzer, Bare, Hinkle and Cheever (2010), “the ear is a sensory organ with dual functions – hearing and balance. The delicate structure and function of the ear make early detection and accurate diagnosis of disorders necessary for preservation of normal hearing and balance.” (p. 1802). For infants and children, during regular check-ups, the inner and outer ear are examined and hearing tests are incorporated to identify any abnormalities, for example, watery or bloody discharge. Otitis media (OM) is commonly identified in children.
Pain is an internal and subjective experience that cannot be directly observed, assessed and measured by others. Hence, an assessment of a patient’s pain is critical to optimal pain management interventions. A systematic process of pain assessment, measurement and re-evaluation would help to achieve a reduced experience of pain, increased comfort, improved physiological, psychological and physical function, and lastly increased the satisfaction with pain management in the patients with arthritis (Sharon Wood, 2008).