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Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics

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Documentation of problem based assessment of the nose, throat, neck, and regional lymphatics. Purpose of Assignment: Learning the required components of documenting a problem based subjective and objective assessment of nose, throat, neck, and regional lymphatics. Identify abnormal findings. Course Competency: Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics. Instructions: Content: Use of three sections: o o o Subjective Objective Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Format: • Standard American English (correct grammar, punctuation, etc.) Resources: Chapter 5: SOAP Notes: The subjective and objective portion only Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book]. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=nlebk&AN=495456&site=eds-live&ebv=EB&ppid=pp_91 Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30. Retrieved from http://ezproxy.rasmussen.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&d b=rzh&AN=107055742&site=eds-live Documentation Grading Rubric- 10 possible points Levels of Achievement Criteria Subjective (4 Pts) Emerging Competence Proficiency Mastery Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. Objective (4 Pts) contain objective data. detail. No objective data. detail. No objective data. Information is solely what “client” provided. No objective data. Information is solely what “client” provided. Points: 1 Points: 2 Points: 3 Points: 4 Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, “okay”, and “good”. Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. Points: 2 Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information Points: 3 Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information Points: 4 Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. Points: 1 Points: 1.5 Points: 2 Points: 1 Actual or Potential Risk Factors (2 pts) Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. Points: 0.5 Documentation of the Nose, Mouth, and Throat Examiner: Date: Patient: Age: Reason for Visit: Health History – Nose 1. Any nasal discharge noted? 2. Unusually frequent of severe colds? 3. Any sinus pain or sinusitis? 4. Any trauma or injury to the nose? 5. Any nosebleeds? How often? 6. Any allergies or hay fever? 7. Any changes or loss in the sense of smell? Health History – Mouth 1. Any sores in the mouth or on the tongue? 2. Any sore throat? How often? 3. Any bleeding gums or toothache? 4. Any hoarseness or voice change? 5. Any difficulty swallowing? 6. Any change in the sense of taste? 7. Do you smoke? How much per day? How long? 8. Drink alcohol? How many times per week? How many drinks per occasion? 9. Do you use nasal sprays? 10. Do you get regular dental checkups? Brush your teeth and floss daily? Health History – Throat 1. Any neck pain? 2. Any lumps or masses in the neck? 3. Any surgery on the neck? 4. Any history of thyroid problems? Physical Assessment 1. Inspect the nose and palpate sinuses a. Symmetrical? b. Nares patent? c. Deviated septum? d. Mucous membranes pink and moist? e. Discharge or inflammation? f. Any tenderness in frontal or maxillary sinuses? 2. Inspect the mouth a. Lips symmetrical? Lesions? Dry or chapped? b. Dentition intact? Caries? c. Gums inflamed? d. Any lesions in the mouth? Membranes pink and moist? e. Tongue midline? Able to move? f. Uvula rises with phonation? g. Hard palate intact? h. Tonsils present? Inflamed? 3. Inspect and palpate the neck a. Trachea midline? b. Thyroid enlarged or nodules present? c. Perform ROM d. ROM against resistance – head and shoulders e. Palpate lymph nodes – any tenderness or inflammation? Regional Write-Up 1. Subjective (Health History) 2. Objective (Physical Assessment) 3. Assessment of Risks and Plan (Include two risks)