NRNP 6568 Week 3 Assignment 2; Assessing, Diagnosing, and Treating Patients with HEENT Conditions

Assessing, Diagnosing, and Treating Patients with HEENT Conditions Mercedes Perez Walden University NRNP-6568-19-Syn Adv Nurs Pr Patient Family September Session Assessing, Diagnosing, and Treating Patients with HEENT Conditions 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: Blood Pressure 110/70 Pulse 84 RR 14 Temp. 97.8 oral O2 99% Patient Information: Initials: B, Age:14 years old, Sex: Male S. CC: Nosebleed HPI: A mother brings in her 11-year-old son with complaint of a nosebleed that started when he woke up and has not stopped since despite applying pressure. He has no past medical history for nosebleeds. He also has no other significant medical history. He has no known drug allergies. He is on no medications. Current Medications: None Allergies: NKDA PMHx: None SurgHx: Unknown Soc Hx: 11-years-old, presumably lives with parents, vaccination history unknow per scenario presented Fam Hx: Information unknown ROS: (Information not provided, could change after further interviewing mother and patient) GENERAL: Denies fever. Denies chills. Denies fatigue. Reports no weight loss. Denies night sweats. SKIN: Denies rash. Denies itching. Denies skin changes. CARDIOVASCULAR: Denies chest pain. Denies chest pressure/chest discomfort. Denies palpitations. Reports no visualized edema. RESPIRATORY: Denies being short of breath. Denies cough. No sputum production. GASTROINTESTINAL: Denies stomach upset. Denies bowel incontinence. Reports no bloody stools. Denies diarrhea. GENITOURINARY: Reports no dysuria. Denies hematuria. Denies urgency. Denies frequency of urine. Denies urinary incontinence. Denies color changes in urine or urine with foul odor. O. Physical exam: BP: 110/70 Pulse: 84 bpm RR: 14, T: 97.8F SpO2: 99% GENERAL: 14-year-old well appearing young male Nosebleed noted. Appropriate hygiene noted. Patient is alert and responds to conversation appropriately. HEENT: Head: symmetrical shape and facial movements. Eyes: Pupils equal/round/reactive to light. Ears: Not examined Nose: Nosebleed present Throat: No missing teeth noted on exam. No evidence of edema or erythema noted in the oropharynx. SKIN: No evidence of rash present. No Jaundice or skin noted. CARDIOVASCULAR: Heart rate regular. S1 and S2 heard upon auscultation. No presence of murmur appreciated. RESPIRATORY: Lung sounds clear to auscultation in all lobes. Respiratory rate even and regular. GASTROINTESTINAL: Bowel sounds normoactive in all 4 quadrants. No pain with palpation. No abdominal distention noted. No liver or splenic enlargement noted upon palpation. LYMPHATICS: No cervical lymphadenopathy noted upon palpation. No inguinal lymphadenopathy palpated. Diagnostic results: CBC (H&H) reports normal findings A. Differential Diagnoses Allergic Rhinitis. NSAID Toxicity Nasal Foreign body P. Prior to any type of procedure, you have the mother sign an informed consent, what are the three major areas