NRS 420 Shadow Health HEENT Assessment

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NRS 420 Shadow Health HEENT Assessment

In this assignment you will assess the Head, Eyes, Ears, Nose and Throat (HEENT) system of Tina Jones, a Digital Standardized Patient. Interview and examine the patient, document your findings, and complete post-exam activities. Within the Shadow Health platform, complete HEENT. Students spend, on average, an hour and fifteen minutes on this assignment. Some students may need additional time GCU.

You can attempt this assignment as many times as you would like. After completing the HEENT, you will be awarded a Digital Clinical Experience (DCE) score. The DCE score will appear on your Lab Pass which you will submit to the classroom drop box. The DCE score will be used as your percentage grade for this assignment GCU.

You are not required to submit this assignment to LopesWrite.

What to include at the end of the shift report related to the HEENT assessment and the Skin, Hair & Nails assessment performed.

Inclusion of the patient biodata, such as name, age, gender, and admission number. The patient is Ms. Jones Tina, 28 a 28-year-old female. The inclusion of biodata serves as an important tool in patient identification. Correct identification helps in the prevention of medication errors and other medical errors that can occur (Rodziewicz et al., 2021). The patient should ideally be identified with three names and hospital admission numbers.

 I would include the patient’s history of having a sore, itchy throat, itchy eyes, and a runny nose. I would elaborate on the symptoms; all the symptoms started spontaneously. Tina has moderate throat pain (4/10) and throat soreness (5/10). She has used throat lozenges, and she is a known asthmatic on the inhaler. The last attack was when she was sixteen years old. She reports worsening vision in the recent past, but she does not wear glasses. The patient’s history will help the healthcare providers know the patient’s situation on admission and progress, should there be a change.

The patient’s admission date must be included, as this will serve as a reference point for assessing the symptoms of the patient’s progression. Asking about the patient’s allergies helps determine whether the condition is due to allergies. However, other signs of allergies, such as hay fever and eczema, are absent in the patient. A positive history of her sister having allergic symptoms indicates a high probability of the condition due to asthma. It is essential to characterize the symptoms. The short duration of patient complaints with a lack of systemic effects indicates a local issue rather than a systemic problem.

Since the patient presented with complaints of a runny nose, throat itchiness, and pains, and poor vision, including the affected system, exams are essential. I would include a nose examination, which for the patient showed boggy and pale nasal mucosa bilaterally and postnasal discharge. An increased nasal paleness and postnasal discharge indicate an inflammatory process (Varricchio et al., 2020). Examination of the nose shows the presence of rhinitis. Being clear indicates the possibility of it being due to allergies or a virus.

I would include posterior examination, which was slightly erythematous with mild cobblestoning on examination. The presence of erythematous with mild cobblestoning explains the patient’s throat symptoms and indicates inflammatory conditions (Varricchio et al., 2020). Lastly, I would include eye examination results. The right eye vision was 20/40, and fundoscopic examination showed mild retinopathic changes. The left eye was normal with the vision of 20/20 and fundoscopic exams of sharp disc margins, no hemorrhages.

SMART goals for Tina

  1. Determine the need for medication such as antihistamines and analgesics to control the symptoms.
  2. Determine triggers and allergens for the patient’s symptomatic attacks.
  3. Develop a follow-up plan for the patient.

Evidence-based practice nursing interventions for the SMART goals.

  1. The healthcare provider will prescribe the patient a medication agent that will help control the patient’s symptoms. Antihistamines such as loratadine help in the control of asthmatic symptoms, reducing the patient’s runny nose, throat itchiness, and pains  (Kawauchi et al., 2019). Additionally, the health care provider should prescribe medication that will help reduce the patient’s headaches. 
  2. Allergic reactions are primarily caused by hypersensitivity of the body toward allergens such as proteins, pollen, and dust, among others (Vaillant et al., 2021). An allergic reaction can be worsened by triggers such as a cold. Healthcare providers should help the patient determine the cause of allergies and help them develop effective allergen prevention strategies. Triggers such as cold can be reduced by keeping the house warm, while allergens such as protein and dust can be controlled.
  3. Allergic rhinitis, when poorly controlled, leads to complications such as nasal polyps, rhinosinusitis, and allergic conjunctivitis (Akhouri & House, 2019). Healthcare providers should develop an effective patient follow-up that will allow for patient evaluation if the symptoms have resolved. The patient should come for follow-up in the next two weeks, during which a medication review will be done, and the need for additional medication will be assessed. There might be a need to install prophylactic care during the subsequent follow-up in case of high risks of developing allergic reactions, especially if the patient’s exposure to allergens is uncontrolled.

References.

Akhouri, S., & House, S. A. (2019). Allergic rhinitis. https://www.ncbi.nlm.nih.gov/books/NBK538186/

Kawauchi, H., Yanai, K., Wang, D. Y., Itahashi, K., & Okubo, K. (2019). Antihistamines for Allergic Rhinitis Treatment from the Viewpoint of Nonsedative Properties. International Journal Of Molecular Sciences, 20(1), 213. https://doi.org/10.3390/ijms20010213

Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2021). Medical error reduction and prevention. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK499956/ 

Vaillant, A. A. J., Vashisht, R., & Zito, P. M. (2021). Immediate Hypersensitivity Reactions. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK513315/ 

Varricchio, A., La Mantia, I., Brunese, F. P., & Ciprandi, G. (2020). Inflammation, infection, and allergy of upper airways: new insights from national and real-world studies. Italian Journal of Pediatrics, 46(1), 1-10. https://doi.org/10.1186/s13052-020-0782-z

Also Read: NRS 420 Shadow Health: Health History