Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper NURS 6531

Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper

Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper

In clinical settings, advanced practice nurses may initiate a physical examination of a patient by examining the components of the HEENT system. Assessing primary diagnoses and differential diagnoses as they concern the HEENT system are important in informing your practice in providing optimal care.

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For this Discussion, consider the following three case studies of patients presenting with head, eyes, ears, nose, and throat disorders. Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper

Case Study 1

An 86-year-old widowed female is brought to the office by her daughter-in-law. The patient complains of constant tearing and an itchy, burning sensation in both eyes. The patient states this is not a new problem, but it has worsened in the past week and is affecting her vision. The patient complains that her eyes are dry. She thinks the problem must be caused by one of her medications. Her patient medical history is positive for hypertension, atrial fibrillation, and heart failure. She has an allergy to erythromycin that causes rash and elevated liver enzymes. Medications currently prescribed include Furosemide 40 milligrams po twice a day, diltiazem 240 milligrams po daily, lisinopril 20 milligrams po daily, and warfarin 3 milligrams po daily. The physical examination reveals a frail older female with some facial dryness and slight scaling. Her visual acuity is 20/60 OU, 20/40 OD, 20/60 OS. The eyelids are erythematous and edematous with yellow crusting around the lashes. Sclera are injected, conjunctiva are pale, and pupils are equal and reactive to light and accommodation. Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper

Case Study 2

A middle-aged male presents to the office complaining of a two-day history of a left earache. The onset was gradual, but has steadily been increasing. It has been constantly aching since last night, and his hearing seems diminished to him. Today he thinks the left side of his face may even be swollen. He denies upper respiratory infection, known fever, or chills. His patient medical history is positive for Type 2 diabetes mellitus, hypertension, and hyperlipidemia. The patient has a known allergy to Amoxicillin that results in pruritus. Medications currently prescribed include Metformin 1,000 milligrams po twice a day, lisinopril 20 milligrams po daily, Aspirin 81 milligrams po daily, and simvastatin 40 milligrams po daily. The physical exam reveals a middle aged male at a weight of 160 pounds, height of 5’8”, temperature of 98.8 degrees Fahrenheit, heart rate of 88, respiratory rate of 18, and blood pressure of 138/76. Further examination reveals the following:

Face: Faint asymmetry with left periauricular area slightly edematous

Eyes: sclera clear, conjwnl

L ear: + tenderness L pinna, + edema, erythema, exudates left external auditory canal, TM not visible

R ear: no tenderness, R external auditory canal clear without edema, erythema, exudates

+ tenderness L preauricular node, otherwise no lymphadenopathy

Cardiac: S1 S2 regular. No S3 S4 or murmur.

Lungs: CTA w/o rales, wheezes, or rhonchi. Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper.

Case Study 3

A middle-aged female presents to the office complaining of strep throat. She states she suddenly developed a sore throat yesterday afternoon, and it has gotten worse since then. During the night she felt like she was chilled and feverish. She denies known recent contact with anyone else who had strep throat, but states she has had strep before and it feels like she has strep now. She takes no medications, but is allergic to penicillin. The physical examination reveals a slender female lying on the examination table. She has a temperature of 101 degrees Fahrenheit, heart rate of 112, respiratory rate of 22, and blood pressure of 96/64. The head, eyes, ears, nose, and throat evaluation is positive for bilateral tonsillar swelling without exudates. Her neck is supple with bilateral, tender, enlarged anterior cervical nodes. Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper.

NURS 6531  Week 3 Discussion: Diagnosing HEENT Disorders Essay Paper

Week 5 Discussion: Examining Chest X-Rays

Chest x-rays are an invaluable diagnostic tool as they can help identify common respiratory disorders such as pneumonia, pleural effusion, and tumors, as well as cardiovascular disorders such as an enlarged heart and heart failure. As an advanced practice nurse, it is important that you are able to differentiate a normal x-ray from an abnormal x-ray in order to identify these disorders. The ability to articulate the results of a chest x-ray with the physician, radiologist, and patient is an essential skill when facilitating care in a clinical setting. In this Discussion, you practice your interprofessional collaboration skills as you interpret chest x-rays and exchange feedback with your colleagues.

Consider the three patient case studies and x-rays

Note: By Day 1 of this week, your Instructor will assign you to post on one of these patient case studies and x-rays:

Case Study 1

35-year-old Asian male presents to your clinic complaining of productive cough for two weeks. Stated he has had mild intermittent fever with myalgia, malaise and occasional nausea.

SH: works as a law clerk

PE: NP noted low grade fever (99 degrees), with very mild wheezing and scattered rhonchi.

An x-ray film is presented which shows a cloudy lung that appears slightly distended.

Case Study 2

This is a 44-year-old Caucasian male being seen at your clinics with complaints of complaints of cough for 4 days and worsening. Stated he has had high grade fever. States he feels weak and has been in bed most of the last two days. Complains of exertional dyspnea, followed by dyspnea at rest, non-productive cough and pleuritic chest pain

MEDS: Zovirax, Diflucan, magic mouth wash, Zofran, mycostatin, filgrastin

PMH: HTN, Hep C, HIV/AIDS, thrush

SH: Past IV Drug abuse; lives in a group home;

PE: VS: Ht: 5’7, Wt: 150#, BMI 23,

Anorexic male, febrile, tachypneic, tachycardic, with rales and rhonchi. You note decreased in breath sounds, dullness, and egophony

An x-ray film is presented which shows petechial markings on the lungs and which are cloudy in appearance.

Case Study 3

A 50 year old Caucasian female presents to the clinic with complaints of cough for almost 2 weeks. Positive productive green sputum with associated chills, sweating, and fever up to 101.5. She manages a daycare and states that many of the children have had upper respiratory symptoms in the last two weeks. PMH: DM diagnosed 7 years ago, controlled on medications.

MEDS: Glyburide 10mg qd

PE: She looks ill with continuous coughing and chills.

BP 100/80, T: 102, HR: 110; O2Sat 97% on RA.

Lungs: +Crackles, increased fremitus

Labs: CBC 17,000 cells/mm3 , blood sugar is 120

An x-ray film is presented which shows cloudiness on the lungs and which also shows some scarring on the lungs.

NURS 6531 Week 7 Discussion: Urinary Frequency

Urinary frequency is a genitourinary disorder that presents problems for adults across the lifespan. It can be the result of various systemic disorders such as diabetes, urinary tract infections, enlarged prostates, kidney infections, or prostate cancer. Many of these disorders have very serious implications requiring thorough patient evaluations. When evaluating patients, it is essential to carefully assess the patient’s personal, medical, and family history prior to recommending certain physical exams and diagnostic testing, as sometimes the benefits of these exams do not outweigh the risks. In this Discussion, you examine a case study of a patient presenting with urinary frequency. Based on the provided patient information, how would you diagnose and treat the patient?

Case Study 1

A 52-year-old African American male presents to an urgent care center complaining of urinary frequency and nocturia. The symptoms have been present for several months and have increased in frequency over the past week. He has been unable to sleep because of the need to urinate at least hourly all day and night. He does not have a primary care provider and has not seen a doctor in more than 10 years. His father died when he was a child in an automobile accident, and his mother is 79 years old and has hypertension. The patient has no siblings. His social history includes the following: banker by profession, divorced father of two grown children, non-smoker, and occasionally consumes alcohol on weekends only.

Case Study 2

This is a 40 year old Hindu married male complaining of sudden high grade fever for the last 2 days. He is complaining of right flank pain with some burning on urination. PMH: diabetes, HTN. Current meds: metformin 500mg bid, Lisinopril 10mg QD

Case Study 3

A 52 year old woman presented to the clinic for ongoing fatigue and weight loss during the last 6 weeks. She thinks she’s loss at least “10 pounds”. For the past week and a half she’s noted some progressing ‘muscle cramping’ tetany, as well as ‘tingling’ sensation around her mouth and lower extremities. She’s also noted some intermittent colicky abdominal pain. On your exam, you noted a positive Chvostek’s sign. PMH: 20 year history of Crohn’s disease. She also tells you that she is a practicing vegan.

NURS 6531  Week 9 Discussion: Diagnosing Neurological Disorders

As an advanced practice nurse, you will likely observe patients who experience neurological disorders. Challenging to the diagnosis of neurological disorders is the realization that many manifestations of disease may not be overt physically.

For this Discussion, consider the following three case studies of patients presenting with neurological disorders.

Case Study 1

80-year-old male Caucasian male brought to the clinic by his wife concerned about his “memory problems”. Per the wife, she has noticed his memory declining but has never interfered with his daily activities until now. He is unable to remember his appointments and heavily relies on written notes for reminder. Just last week, he got lost driving and was not found by his family until 8 hours later. He is unable to use his cell phone or recall his home address or phone number. He has become a “hermit” per his wife. He has withdrawn from participating with church activities and has become less attentive.

PMH: HTN, controlled

Prostate cancer 20 years ago

Dyslipidemia

SH: no alcohol or tobacco use; needs assistance with medications

PE: VS stable, physical exam unremarkable

Case Study 2

A 30-year-old Asian female presents to the clinic with headaches. History of headaches since her teen years. Headaches have become more debilitating recently. Describes the pain as sharp, worsens with light and accompanied by nausea and at times vomiting. Rates the pain as 7/10. Typically takes 2 tabs of OTC Motrin with ‘some help’. “Sleeping it off in a darkened room’ helps alleviate the headache. VS WNL, physical exam unremarkable. NURS 6531 Discussions and Assignment Essay Papers.

Case Study 3

A 50-year-old African American male presents with complaints of dizziness left arm weakness and fatigue. PMH: poorly controlled diabetes, hypertension, hyperlipidemia

PE: Upon exam, you noted a very mild dysarthria, he understands and follows commands very well. Mild weakness on the left side of the face is noted, and left sided homonymous hemianopsia but no ptosis or nystagmus or uvula deviation.

Week 10 Discussion: Examining Endocrine, Metabolic, and Hematologic Disorders

In the United States, 25.6 million adults age 20 years or older have diabetes (American Diabetes Association, 2011). If not properly treated and managed, these millions of diabetic patients are at risk for several alterations including heart disease, stroke, kidney failure, neuropathy, and blindness. Proper treatment and management is the key for diabetic patients, and as the advanced practice nurse providing care for these patients, it is your responsibility to facilitate this process. Patient education is critical, as is working with patients to establish a regular pattern for daily activities such as eating and taking medications. When developing care plans for patients, you must keep the projected outcomes of treatment in mind, as well as patient preferences and other factors that might impact adherence to treatment and management plans. In this Discussion, you draw from your Practicum Experience and consider factors that impact the education and treatment of patients with diabetes.

For this Discussion, consider the following three case studies of patients presenting with endocrine, metabolic, and hematological disorders.

Case Study 1

An 82-year-old female presents to the office complaining of fatigue, dizziness, weakness, and increasing dyspnea on exertion. She has a past medical history of atrial fibrillation, hypertension, and hyperlipidemia. Medications include warfarin 2 milligrams po daily, lisinopril 10 milligrams po daily, and simvastatin 10 milligrams po daily. There are no known drug allergies. The physical exam reveals a 5’2” older female. Her weight is 128 pounds, blood pressure is 144/80, heart rate is 98, temperature is 98 degrees Fahrenheit, and O2 saturation is 98%. Further examination reveals the following:

Eyes: + pallor conjunctiva

Cardiac: irregular rhythm. No S3 S4 or M. NO JVD

Lungs: CTA w/o rales, wheezes, or rhonchi

Abdomen: soft, BS +, + epigastric tenderness. No organomegaly, rebound, or guarding

Rectal: no stool in rectal vault. NURS 6531 Discussions and Assignment Essay Papers.

Case Study 2

A 78-year-old female presents to the emergency room after a fall 3 days ago. She recently had a right above-the-knee amputation and was leaning over to pick something up when she fell. She did not want to come to the hospital, but she is having difficulty managing at home because of the pain in her left leg where she fell. Her patient medical history reveals RAKA, peripheral vascular disease, Type 2 diabetes, and stage 3 chronic kidney disease. Current medications include quinapril 20 milligrams PO daily, Lantus 30 units at bedtime, and Humalog to scale before meals. There are no known drug allergies. The physical exam is negative and x-rays reveal no acute injuries. Laboratory studies reveal a normal white blood cell count: Hgb of 8 and HCT 24. The MCV is normal.

Case Study 3

V.G. is a 47 year old African American male with type 2 diabetes diagnosed two years ago. He is for a follow up and complaining of increased tingling to the lower extremities. PMH: obesity, dyslipidemia, HTN. He quit smoking smoking two years ago. Denies any alcohol use. SH: lives with alone in a subsidized housing. He is a veteran and relies on food stamps and welfare. Works occasionally. MEDS: he lost his medications and hasn’t taken any in about a week. His chart indicates his is on Lisinopril 20mg, Januvia 50mg QD, Lipitor 40mg QD, PE: 5’9, BP: 160/100 RBG: 415.

Week 1 Assignment – Practicum Experience – Journal Entry

As a future advanced practice nurse, it is important that you are able to connect your classroom experience to your Practicum Experience. By applying the concepts that you study in the classroom to clinical settings, you enhance your professional competency. Each week, you will reflect on your Practicum Experiences and relate them to the material presented in the classroom. This week, you begin your Practicum Experiences and will write your first Practicum Journal.

To prepare for this course’s Practicum Experience, address the following in your first Practicum Journal:

Select and describe a nursing theory to guide your practice.

Develop goals and objectives for your Practicum Experience in this course. When developing your goals and objectives, be sure to keep the seven domains of practice in mind.

Create a timeline of practicum activities based on your practicum requirements.

In a one-page journal entry (250-300 words), you should do the following:

Describe your practicum goals and objectives using the seven domains of practice

Discuss a nursing theory that would be used to guide your practice.

Include APA-style citations and references

Week 3 Assignment: Practicum Experience – Episodic SOAP Note #1

In addition to Journal Entries, SOAP Note submissions are a way to reflect on your Practicum Experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to the Seidel, et. al. book excerpt and the Gagan article located in this week’s Learning Resources for guidance on writing SOAP Notes.

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies. NURS 6531 Discussions and Assignment Essay Papers.

To Prepare:

Review the Episodic SOAP Note Exemplar provided in this week’s Resources in preparation for this Assignment.

Use the Episodic SOAP Note Template to complete this Assignment.

After completing this week’s Practicum Experience, select a patient that you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient provide regarding his or her personal and medical history?

Objective: What observations did you make during the physical assessment?

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management including alternative therapies?

Reflection notes: What would you do differently in a similar patient evaluation?

Please Note: Your Episodic SOAP Note Assignment must be signed by Day 7 of Week 3.

By Day 7 of Week 3

This Assignment is due. You will submit two files for the Week 3 Episodic SOAP Note, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3.

Week 6 Assignment: Practicum Experience – Episodic SOAP Note #2

After completing this week’s Practicum Experience, reflect on a patient who presented with abdominal pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care.

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

By Day 7 of Week 6

This Assignment is due. You will submit two files for the Week 6 Episodic SOAP Note #2, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6.

Week 8 Assignment: Practicum Experience – Comprehensive SOAP Note #3

After completing this week’s Practicum Experience, review the Comprehensive SOAP Note Exemplar and Template in this week’s Resources, and reflect on a patient who presented with musculoskeletal disorders or pain. Describe the patient’s personal and medical history, drug therapy and treatments, and follow-up care.

All SOAP notes must be signed and each page must be initialed by your preceptor. When you submit your SOAP Notes, you should include the complete SOAP Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your SOAP Notes using SAFE ASSIGN.

Please Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

By Day 7 of Week 8

This Comprehensive SOAP Note #3 is due. You will submit two files for the Week 8 Comprehensive SOAP Note #3, including a Word document and pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 6. NURS 6531 Discussions and Assignment Essay Papers.

Week 10 Assignment: Practicum Experience – Journal Entry

To follow up on this course’s Practicum Experience, address the following in your Practicum Reflective Journal:

Select and describe a nursing theory that was used to guide your practice.

What goals and objectives were used for your Practicum Experience in this course? When developing your goals and objectives were the seven domains of practice in mind?

Were you able to meet the timeline of practicum activities that you set at the beginning of the course in your initial journal based on your practicum requirements? If not, why and how do you plan to meet them in your next practicum experience?

By Day 7

Submit your Reflective Journal.by day 7 of week 10.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

Please save your Assignment using the following naming convention: “WK11Assgn1+lastname+first initial”.

Click the Week 11 Assignment 1 link.

Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK11Assgn1+last name+firstinitial.(extension)” and click Open. If you are submitting multiple files, repeat until all files are attached.

Click on the Submit button to complete your submission.

 

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