NRNP 6565 Assessing, Diagnosing, and Treating Patients With HEENT Conditions
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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources. NRNP 6565 Assessing, Diagnosing, and Treating Patients With HEENT Conditions
WEEKLY RESOURCES
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.
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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.
By Day 7
Submit your focused SOAP note.
submission information
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK3Assgn2+last name+first initial.
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
Rubric
NRNP_6565_Week3_Assignment2_Rubric
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning Outcome 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 | 10 to >8.0 pts Excellent 90%–100% The response throughly and accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.
8 to >7.0 pts Good 80%–89% The response accurately describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis.NRNP 6565 Assessing, Diagnosing, and Treating Patients With HEENT Conditions 7 to >6.0 pts Fair 70%–79% The response describes the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis, but it is somewhat vague or contains minor innacuracies. 6 to >0 pts Poor 0%–69% The response provides an incomplete or inaccurate description of the patient’s subjective complaint, history of present illness, current medications, allergies, medical history, and review of all systems that would inform a differential diagnosis. Or, subjective documentation is missing. |
10 pts |
| This criterion is linked to a Learning Outcome In the Objective section, provide: • Physical exam 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 | 10 to >8.0 pts Excellent 90%–100% The response thoroughly and accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are thoroughly and accurately documented.
8 to >7.0 pts Good 80%–89% The response accurately documents the patient’s physical exam for pertinent systems. Diagnostic tests and their results are accurately documented. 7 to >6.0 pts Fair 70%–79% Documentation of the patient’s physical exam is somewhat vague or contains minor innacuracies. Diagnostic tests and their results are documented but contain minor innacuracies. 6 to >0 pts Poor 0%–69% The response provides incomplete or inaccurate documentation of the patient’s physical exam. Systems may have been unnecessarily reviewed, or objective documentation is missing. |
10 pts |
| This criterion is linked to a Learning Outcome 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. | 25 to >22.0 pts Excellent 90%–100% The response lists in order of priority at least three distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides a thorough, accurate, and detailed justification for each of the conditions selected.
22 to >19.0 pts Good 80%–89% The response lists in order of priority at least three different possible conditions for a differential diagnosis of the patient in the assigned case study, and it provides an accurate justification for each of the conditions selected. 19 to >17.0 pts Fair 70%–79% The response lists three possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 17 to >0 pts Poor 0%–69% The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected. |
25 pts |
| This criterion is linked to a Learning Outcome 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. | 30 to >26.0 pts Excellent 90%–100% The response thoroughly and accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. A thorough and accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate strong critical thinking and synthesis of ideas.
26 to >23.0 pts Good 80%–89% The response accurately outlines a treatment plan for the patient that addresses each diagnosis and includes diagnostic studies neeed, referrals, therapeutic interventions, patient education and disposition, and planned follow-up visits. An accurate discussion of health promotion and disease prevention related to the case is provided. Reflections on the case demonstrate critical thinking. 23 to >20.0 pts Fair 70%–79% The response somewhat vaguely or inaccurately outlines a treatment plan for the patient. The discussion on health promotion and disease prevention related to the case is somewhat vague or contains innaccuracies. Reflections on the case demonstrate adequate understanding of course topics. 20 to >0 pts Poor 0%–69% The response does not address all diagnoses or is missing elements of the treatment plan. The discussion on health promotion and disease prevention related to the case is vague, innaccurate, or missing. Reflections on the case are vague or missing. |
30 pts |
| This criterion is linked to a Learning Outcome 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. | 10 to >8.0 pts Excellent 90%–100% The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents the latest in standards of care and provides strong justification for treatment decisions.
8 to >7.0 pts Good 80%–89% The response provides at least three current, evidence-based resources from the literature to support the treatment plan for the patient in the assigned case study. Each resource represents current standards of care and supports treatment decisions. 7 to >6.0 pts Fair 70%–79% Three evidence-based resources are provided to support treatment decisions, but may not represent the latest in standards of care or may only provide vague or weak justification for the treatment plan. 6 to >0 pts Poor 0%–69% Two or fewer resources are provided to support treatment decisions. The resources may not be current or evidence based or do not support the treatment plan. |
10 pts |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. | 5 to >4.0 pts Excellent 90%–100% Paragraphs and sentences follow writing standards for flow, continuity, and clarity. <br/><br/> A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts Good 80%–89% Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. <br/><br/> Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 to >2.0 pts Fair 70%–79% Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. <br/><br/> Purpose, introduction, and conclusion of the assignment are vague or off topic. 2 to >0 pts Poor 0%–69% Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. <br/><br/> No purpose statement, introduction, or conclusion were provided. |
5 pts |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – English Writing Standards: Correct grammar, mechanics, and proper punctuation | 5 to >4.0 pts Excellent 90%–100% Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts Good 80%–89% Contains 1 or 2 grammar, spelling, and punctuation errors. 3 to >2.0 pts Fair 70%–79% Contains several (3 or 4) grammar, spelling, and punctuation errors. 2 to >0 pts Poor 0%–69% Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding. |
5 pts |
| This criterion is linked to a Learning Outcome Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/narrative in-text citations, and reference list. | 5 to >4.0 pts Excellent 90%–100% Uses correct APA format with no errors.
4 to >3.0 pts Good 80%–89% Contains 1 or 2 APA format errors. 3 to >2.0 pts Fair 70%–79% Contains several (3 or 4) APA format errors. 2 to >0 pts Poor 0%–69% Contains many (≥ 5) APA format errors. |
5 pts |
Total Points: 100