NRNP 6565 Assessing Diagnosing and Treating Patients with HEENT Conditions Assignment Example

NRNP 6565 Assessing Diagnosing and Treating Patients with HEENT Conditions Assignment ExampleAssignment 2: Assessing, Diagnosing, and Treating Patients with HEENT Conditions

NRNP 6565 Assessing Diagnosing and Treating Patients with HEENT Conditions Assignment Brief

Assignment Instructions Overview

This assignment focuses on assessing, diagnosing, and treating conditions related to the Head, Eyes, Ears, Nose, and Throat (HEENT). HEENT conditions range from common minor complaints, such as seasonal allergies, to more severe or life-threatening conditions like epistaxis or obstructive pathologies. The primary goal is to simulate clinical scenarios to enhance diagnostic and treatment skills while utilizing evidence-based guidelines.

The assignment requires students to complete a Focused SOAP Note using an assigned case study, incorporating subjective and objective data, differential diagnoses, a treatment plan, and reflective insights. The task emphasizes clinical reasoning, patient-centered care, and adherence to best practices.

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Understanding Assignment Objectives

  • Clinical Application: Develop competency in collecting comprehensive patient histories, performing physical assessments, and interpreting findings to guide diagnostic decision-making.
  • Diagnostic Accuracy: Apply critical thinking to establish differential diagnoses, prioritize conditions, and justify the primary diagnosis using evidence-based guidelines.
  • Treatment Planning: Formulate tailored treatment plans, including pharmacological and non-pharmacological interventions, and patient education strategies.
  • Health Promotion: Emphasize preventive care and patient education to reduce the risk of recurrent or severe conditions.
  • Professional Reflection: Analyze clinical scenarios for lessons learned, enhancing both diagnostic acumen and therapeutic approach.

The Student’s Role

Students are tasked with stepping into the role of a healthcare provider, utilizing the Focused SOAP Note framework to:

  • Gather Comprehensive Data: Document relevant subjective and objective findings.
  • Analyze and Diagnose: Propose a differential diagnosis, justify a primary diagnosis, and correlate findings to current clinical guidelines.
  • Develop a Management Plan: Design a treatment and follow-up strategy that includes education, preventive care, and culturally sensitive interventions.
  • Reflect and Integrate Knowledge: Share insights gained during case analysis to improve future clinical practice.

Competencies Measured

This assignment evaluates the following key competencies:

  1. Assessment and Diagnosis: Accurately identify HEENT conditions through comprehensive assessment techniques.
  2. Critical Thinking: Apply reasoning skills to analyze clinical data and prioritize diagnoses effectively.
  3. Evidence-Based Practice: Integrate current peer-reviewed evidence into diagnostics, treatment plans, and patient education.
  4. Communication Skills: Document findings clearly and concisely, ensuring all sections of the SOAP note are professionally written.
  5. Patient-Centered Care: Develop individualized management strategies that consider patient history, preferences, and preventive care needs.

You can also read these assignment examples for the NRNP 6565 – Synthesis in Advanced Nursing Practice Care of Patients in Primary Care Settings Course:

NRNP

Expectations for Completion

Students should ensure their documentation in the SOAP Note template includes:

  • Subjective Data: Chief complaint, history of present illness, medical history, medication use, allergies, and a system review relevant to the complaint.
  • Objective Data: Physical examination findings, pertinent diagnostic tests, and observations related to the case.
  • Assessment: At least three differential diagnoses, including ICD-10 and CPT codes, with supporting evidence for each.
  • Plan: Comprehensive management, including diagnostics, therapies, referrals, patient education, and follow-up care.
  • Reflection: Insights on the case’s challenges, “aha!” moments, and lessons to enhance future clinical skills.

Deliverables

Students are to submit a detailed Focused SOAP Note along with a reference list of at least three current, peer-reviewed, evidence-based articles to substantiate their approach. Proper academic formatting and adherence to APA guidelines are required.

This assignment not only measures students’ ability to manage HEENT conditions but also prepares them for real-world application of advanced nursing practice.

NRNP 6565 Assessing Diagnosing and Treating Patients with HEENT Conditions Assignment Example

Focused SOAP Note

Patient Information:

Name: Branch

Age: 11 years old

Sex: Male

Subjective

Chief Complaint:

Continuous nosebleed from the left nostril since waking up this morning, unresponsive to pressure.

History of Present Illness (HPI):

Branch is an 11-year-old male brought in by his mother due to a persistent nosebleed from the left nostril. The bleeding began spontaneously upon waking and has not resolved despite applying pressure as instructed at home. There is no reported trauma, and Branch denies nasal pain or previous episodes of epistaxis. He describes no other associated symptoms, including congestion, fever, or respiratory distress. His mother expresses concern as this is his first episode, and no identifiable triggers are apparent.

Current Medications:

None.

Allergies:

No known drug, environmental, or food allergies.

Past Medical History (PMHx):

No significant medical history reported.

Family History:

No history of bleeding disorders, clotting abnormalities, or frequent epistaxis in the family.

Social History:

Branch is a school-aged child with no reported exposure to irritants, allergens, or recent illnesses. He is active, attends school regularly, and has no history of tobacco or alcohol exposure.

Review of Systems (ROS):

  • General: No fever, fatigue, or recent weight changes.
  • HEENT: Continuous nasal bleeding from the left nostril, denies nasal pain or obstruction. No headache, facial pain, sore throat, or visual changes.
  • Respiratory: No shortness of breath, wheezing, or cough.
  • Cardiovascular: No chest pain or palpitations.
  • Skin: No bruising or rashes reported.
  • Neurological: No dizziness, confusion, or weakness.

Objective

Vital Signs:

BP: 110/70 mmHg | P: 84 bpm | R: 14/min | T: 97.8°F (oral) | SpO₂: 99%

Physical Examination:

  • General: Alert, cooperative, and in no acute distress.
  • HEENT:
    • Head: Normocephalic, atraumatic.
    • Eyes: Conjunctiva and sclera clear, no discharge or jaundice.
    • Ears: Tympanic membranes intact, no erythema or effusion noted.
    • Nose: Bleeding observed from the left nostril; no septal deviation or trauma noted. Inspection with nasal speculum revealed bleeding localized to the anterior septum (Kiesselbach’s plexus).
    • Throat: Mucosa moist, no erythema or exudate.
  • Cardiovascular: Regular rate and rhythm, no murmurs or extra heart sounds.
  • Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
  • Skin: No petechiae, bruising, or rashes.

Diagnostic Results:

Hemoglobin: Normal (if ordered, pending results).

Platelet count: Normal (if ordered, pending results).

PT/INR: Normal (if ordered, pending results).

No imaging required at this time.

Assessment

Differential Diagnoses:

  • Anterior Epistaxis (Primary Diagnosis):
    • ICD-10 Code: R04.0 (Epistaxis)
    • Rationale: Bleeding localized to Kiesselbach’s plexus, which is the most common site for nosebleeds. No trauma, systemic symptoms, or history of coagulopathy to suggest posterior epistaxis or systemic causes.
    • Pertinent positives: Continuous unilateral nasal bleeding, normal vital signs, absence of systemic or traumatic indicators.
    • Pertinent negatives: No signs of posterior bleeding, trauma, or infection.
  • Allergic Rhinitis:
    • ICD-10 Code: J30.9 (Allergic Rhinitis, Unspecified)
    • Rationale: Possible irritation of nasal mucosa due to environmental allergens, though the absence of other symptoms like sneezing, itching, or nasal congestion makes this less likely.
  • Foreign Body in the Nasal Passage:
    • ICD-10 Code: T17.1XXA (Foreign Body in Nasal Cavity)
    • Rationale: Common in children; however, denied by the patient and not observed during nasal inspection.

Plan

Diagnostics:

 

  • Hemoglobin and platelet levels to rule out anemia or coagulopathy (if bleeding persists or if indicated).
  • PT/INR if there is any suspicion of clotting disorders.

Treatment and Management:

Intervention for Bleeding Control:

    • Position the patient at a 45-degree angle and inspect the nasal cavity.
    • Apply vasoconstrictive solution (oxymetazoline spray) via cotton swab or soaked gauze.
    • Cauterize the bleeding site with a silver nitrate stick for 5–10 seconds, ensuring minimal application time to avoid tissue damage.
    • Protect the cauterized site with antibiotic ointment applied lightly to prevent infection.

Medications:

    • Prescribe mupirocin nasal ointment to be applied twice daily for 5 days to promote healing.
    • Recommend acetaminophen 10–15 mg/kg for pain relief if needed, avoiding NSAIDs to prevent further bleeding.

Health Promotion and Education:

    • Advise the mother and Branch to avoid nose-picking, strenuous activities, or blowing the nose for 48 hours.
    • Educate on maintaining humidified air to prevent mucosal dryness.
    • Discuss the importance of proper hydration and avoiding irritants like smoke or strong odors.

Follow-Up:

    • Reassess in 7–10 days to ensure resolution and healing.
    • Advise immediate return to the clinic or emergency care if bleeding recurs or does not respond to home interventions.

Reflection Notes

This case underscores the importance of a systematic approach in managing pediatric epistaxis. The observation that anterior epistaxis accounts for most nosebleeds simplified the diagnostic process. An “aha!” moment occurred when reviewing the significance of proper nasal speculum use, as vertical application risks trauma to delicate nasal tissues. Effective patient education remains crucial in preventing recurrence and complications.

References

Smith, M. L., & Rosenfeld, R. M. (2018). Epistaxis: Evidence-based management. Otolaryngology Clinics of North America, 51(5), 727–737.

Schlosser, R. J. (2020). Epistaxis management in children. Journal of Pediatric Otorhinolaryngology, 130, 109801.

National Institute for Health and Care Excellence (NICE). (2021). Management of epistaxis in children. NICE Guidelines.

Detailed Assessment Instructions for the NRNP 6565 Assessing Diagnosing and Treating Patients With HEENT Conditions Assignment Example

Week 3 Assignment 1

Assignment 2: Assessing, Diagnosing, and Treating Patients With HEENT Conditions

Most everyone has at some point experienced minor HEENT conditions, such as a head cold or seasonal allergies, and symptoms, such as a runny nose, watery eyes, or a sore throat. While they are relatively minor and short-lived, they nevertheless impair many of the simple pleasures so many enjoy.

HEENT symptoms can represent a wide variety of issues, some of which suggest problems that extend well beyond their temporary impact on life’s simple pleasures. HEENT conditions can result in dangerous respiratory impairment or be symptoms of life-threatening conditions or disease.

For this Assignment, your instructor will assign a case study, which will give you the opportunity to practice assessing, diagnosing, and treating patients with HEENT conditions.

Photo Credit: Getty Images/iStockphoto

To Prepare:

  • Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with conditions of the head, eyes, ears, nose, and throat.
  • Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
  • Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
  • Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
  • Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
  • Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions.

The Assignment

Use the Focused SOAP Note Template to address the following:

  • Subjective: What details are provided regarding the patient’s personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
  • Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
  • Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: Describe your “aha!” moments from analyzing this case.

To Prepare:

  • Consider what physical assessments and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis. 
  • Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 
  • Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. 
  • Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions. 

The Assignment

Case study

A mother brings in her 11 year old son, Branch, because he has had a nosebleed.  She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop.  He has no history of nosebleeds.  He has no significant medical history and no known allergies.  He is on no medications.  Mom and Branch deny trauma to the nose.  He says he just woke up with a nosebleed and it won’t stop.  He tells you that the left side is the side that is bleeding.

Vital signs:  BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%

You recognize that simple pressure is not going to stop the nosebleed so you know that you will not have to intervene. 

Prior to any      type of procedure, you have the mother sign an informed consent for a      procedures.  What are the three major areas you must discuss      when doing any type of procedure?

Nosebleeds can      be divided into three groups.  What are they? 

90% of      nosebleeds fall into which group? 

Name 4 indications      for intervention by a provider for a nosebleed. 

You place      Branch on the assessment table at approximately 45 degrees.  You      drape him appropriately.  You have him blow his nose gently to      remove clots.  You then inspect the right side to familiarize      yourself with his anatomy.  You then inspect the left side using      a nasal speculum.  When using the nasal speculum, it      is important to use it ______________ (HORIZONTALLY/VERTICALLY).

Why is it      important to use the nasal speculum a certain way?

You note that the      bleeding is coming from an area on the septum.  You know that      the next step is to apply a vasconstrictive solution to the      nose.  What are two ways you can deliver      the vasoconstrictive solution? 

You note that      the area that is the source of the bleeding is about 3 mm in      diameter.  You make the decision to use a silver nitrate      stick.    How long should you apply pressure with the      stick?

Why it is it      important not to use the silver nitrate for over that time frame? 

After hemostasis is      obtained, what are three types of treatment methods that can be used to      protect the cauterization site? 

If that had not      stopped the bleeding and you had to make the decision to use a nasal      sponge or nasal tampon, the sponge/tampon should be coated in      _____________ and left in place for __________ hours. 

After putting in the      nasal sponge/tampon, approximately 2 ml of ________ or _______ should be      dripped onto the tip to help the sponge expand. 

After placing the      nasal sponge/tampon, the patient should be closely monitored for 3-5      minutes.  Why is that?

After the close      monitoring, the patient should be kept in observation status for ______      minutes. 

If a sponge/tampon      is used, it is not necessary to use antibiotics. 

If it is      necessary to pack the nose, it may be advisable to give the patient a      narcotic or sedative medication (unless a contraindication      exists).  Why? 

Name 5 complications      of the above procedures. 

After the procedure,      you tell the pt and his mother that he can take acetaminophen for any      pain/discomfort.  Why is it important not to have him take      ibuprofen? 

What is the leading      cause of nosebleeds in adolescents? 

What CPT code would      you use for the above procedure? 

What is the      definition of the above code?

Address the following:

Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.

In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications
• Allergies
• Patient medical history (PMHx)
• Review of systems

In the Objective section, provide:
• Physical assessment documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses

In the Assessment section, provide:
• At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned.

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.

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