HEENT/Skin, Hair & Nails Activity Shadow Health Essay

HEENT/Skin, Hair & Nails Activity Shadow Health Essay

 

What to include at the end of 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 years old female. The inclusion of biodata serves as an important tool in patient identification. Correct identification help 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 complaints of sore, itchy throat, itchy eyes, and 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. She reports worsening vision in the recent past, but she doesn’t wear glasses. The patient’s history will help the healthcare providers know the patient’s situation on admission and progress should there be change. The patient’s admission date must be included as this will serve as a reference point assessing the symptoms of the patient progression. Asking about the patient’s allergies help in determining 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 conditions 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 running 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. The presence of an increased nasal paleness and postnasal discharge indicates an inflammatory process (Varricchio et al., 2020). Examination of the nose shows the presence of rhinitis. Being clear indicate the possibility of it being due to allergies or viral. 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 for controlling 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 patient symptoms. Use of antihistamine such as loratadine help in the control of asthmatic symptoms reducing the patient running nose, throat itchiness, and pains (Kawauchi et al., 2019). Additionally, the health care provider should prescribe medication that will help in reducing patient 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, lead to complication 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 medication review will be done, and the need for additional medication will be done. 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 are not controlled

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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

HEENT Assignment and Skin, Hair, & Nails Assignment for Tina Jones assignment in shadow health. Base your response to the activity assignment on the findings in the Shadow Health assessments and read chapters 3-18 in Jarvis, C. (2018). Physical examination and health assessment (8th ed.). St. Louis, MO: Saunders.

After your HEENT and Skin, Hair, & Nails assessment of Tina:

o Discuss what would you include in your end of shift report that relate to the HEENT assessment and the Skin, Hair & Nails assessment performed?

o Identify three SMART goals for Tina

o Discuss three evidence-based practice nursing interventions, with rationales for each that relate to this assessment (one for each SMART goal).

Read Chapters 3-18 in Jarvis, C. (2018). Physical examination and health assessment (8th ed.). St. Louis, MO: Saunders. 

Additional Instructions:

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Adhere to grammar, spelling and punctuation criteria.
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