Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates.

 

 

 

 

Title:

 

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:

 

· 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&db=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&db=rzh&AN=107055742&site=eds-live

 

 

 

Documentation Grading Rubric- 10 possible points

 

Levels of Achievement
Criteria	Emerging	Competence	Proficiency	Mastery
Subjective (4 Pts)	Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data.	Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided.	Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided.
	Points: 1	Points: 2	Points: 3	Points: 4
Objective (4 Pts)	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.	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	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: 1	Points: 2	Points: 3	Points: 4
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.	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: 0.5	Points: 1	Points: 1.5	Points: 2

 

 

 

USEFUL NOTES FOR:

 

Demonstrate physical examination skills of the head, ears, and eyes, nose, mouth, neck, and regional lymphatics.

 

Introduction

 

The examination of the head, ears, and eyes is an important part of the physical examination. It allows you to identify disease processes in these regions as well as assess other health concerns such as hearing loss and balance disorders. In this section we will demonstrate skills specific to assessing these areas including: palpation for lymph nodes; inspection of the front teeth; visual acuity assessment using Snellen charts or near vision cards; use of an ophthalmoscope on fundi (eye exam), lens and retina; pupil size assessment including equal size, shape, mobility/constriction light reflexes direct/consensual light reflexes pupils response when tested with cotton-wool bud or tuning fork ability clench teeth together test corneal reflex external auditory meatus discharge redness inspect external auditory meatus for discharge or redness

 

Demonstrate the assessment of the head and scalp and palpate for lymph nodes.

 

Palpate the head and scalp for lymph nodes.

 

Palpate for size, shape, and consistency of lymph nodes.

 

Palpate for tenderness of lymph nodes.

 

Palpate for location of lymph nodes (i.e., external jugular or axillary) in order to identify areas that may be infected with tuberculosis or other diseases while they are still localized (i.e., non-healing).

 

Use a mirror so that you can see exactly where you’re palpating on your own body as well as what part of it looks like when viewed from above!

 

Demonstrate assessment of the eyes.

 

Use an ophthalmoscope to assess the fundi, lens and retina.

 

Demonstrate how to assess pupils including equal size, shape, mobility, constriction and direct/ consensual light reflexes.

 

Demonstrate eye movements when assessing cranial nerves III, IV and VI

 

Demonstrate the use of an ophthalmoscope to assess the fundi, lens and retina.

 

An ophthalmoscope is the gold standard for visualizing the inside of the eye. It uses a lens to magnify objects and a light source to illuminate them, allowing you to examine structures such as the retina, lens, vitreous chamber or choroid plexus.

 

When using an ophthalmoscope:

 

Hold it steady without touching it with your fingers or other objects that might cause motion blur. If necessary, put on gloves and leave them on until after you have done all examinations on an eye because they allow a better grasp of what’s being observed during examination by preventing oily fingerprints from interfering with vision (the oil doesn’t collect in the microscope). It also reduces shaking caused by sweaty hands making everything more difficult to see clearly; however this does not apply if there are no gloves available so always ask first if anyone else wants one before putting one on yourself!

 

Demonstrate how to assess pupils including equal size, shape, mobility, constriction and direct/ consensual light reflexes.

 

Have the patient look at a light, then away from it.

 

Compare pupil size and shape.

 

If pupils are unequal in size or shape, measure them with a ruler or gauge (1). If there is no change in pupil size and shape after looking at a light source for five seconds, repeat steps 1-4 on another day when you see his or her eyes open wide enough for direct examination.

 

Demonstrate a facial nerve examination.

 

Demonstrate a facial nerve examination.

 

To demonstrate this skill, you will need to be able to perform the following tasks:

 

Assess pupils including equal size, shape and mobility

 

Assess facial symmetry (a normal face) and symmetry of eyelids with no visual impairment.

 

Determine if there is any evidence of extraocular muscle palsy or other ocular disease (e.g., cataracts).

 

On the head alone:

 

Identify cranial nerves III, IV, VI and VII at their origin from outside ear canal or mastoid antrum through pterygopalatine fossa toward midline; locate hypoglossal nerve at its origin in midline temporal bone just behind parietal bone; locate glossopharyngeal nerve on posterior surface just above middle turbinate ridge medially; locate vagus nerve within cervical triangle anteriorly above sternocleidomastoid muscle laterally below auricular point anteriorly towards trapezius muscle laterally towards scalene ligament below sternohyoid notch laterally towards medial clavicle distally across upper chest wall onto medial aspect of biceps tendon between humerus extensor digitorum muscles anteriorly into fascia lata onto frontalis muscle laterally onto corrugator supercilii capitis superficialis superioris superficialis capitis superficialis inferioris superficialis anterior interosseous tibial apophyses proximal end phalanx metacarpophalangeal joint metatarsophalangeal joint interphalangeal joint toe tip flexor digitorum muscles tendons short toe flexor hallucis longus hallucid hallux plantaris calcaneus talon cuneiform tuberosity navicular navicula cuboid cuneiform tuberosity scaphoideus major posterior deltoid latissimus dorsi rhomboids levator scapula serratus anterior rhomboids inf

 

Demonstrate eye movement when assessing cranial nerves III, IV and VI.

 

Demonstrate eye movement when assessing cranial nerves III, IV and VI.

 

You should demonstrate how to assess pupils including equal size, shape, mobility, constriction and direct/ consensual light reflexes.

 

Assess cranial nerve II (optic nerve) by demonstrating assessment of visual acuity using the Snellen chart or near vision card.

 

The optic nerve is the largest cranial nerve in the human body. It carries information from the cornea to the inner ear, where it can be processed by visual input.

 

To demonstrate this skill, you’ll need:

 

A Snellen chart or near vision card (available at most drugstores) that has lines of letters printed on it that represent letters of varying sizes. These should be large enough so that you can read them when they appear at an angle of 45 degrees or less without straining your eyes too much; smaller than this will make it harder for you to assess how good someone’s vision actually is!

 

A ruler with millimeters marked on one side and centimeters marked on another side (this will help measure distances).

 

Assess cranial nerve V (trigeminal nerve) by demonstrating how to examine anterior teeth and gums, palate and buccal mucosa, floor of mouth; sensation over face using cotton-wool bud or tuning fork; palpate trigeminal ganglion, jaw movements; ability to clench teeth together; test corneal reflex; inspect external auditory meatus for discharge or redness.

 

The trigeminal nerve (V) is responsible for the sensation of pain and temperature in the face. It provides sensory information from the skin, mucous membranes, muscles, and joints to the brain.

 

The first step in examining this nerve is to examine your anterior teeth and gums. This involves looking at each tooth with an eye-dropper or cotton bud dipped in sterile water. You should also get a sense of how far back you can feel each tooth by stroking along its length with your finger while feeling for any abnormal sensation on either side of it. You can also use a tuning fork (0-2 Hz) over any abnormalities you may find during this examination process – remember that these are only examples; other people may experience different sensations when feeling their own teeth!

 

Assess cranial nerve VII (facial nerve) by demonstrating inspection of facial symmetry at rest, pouting lips and showing teeth; ability to raise eyebrows, close eyes tightly and wrinkles forehead.

 

To assess cranial nerve VII (facial nerve), you should observe symmetry of facial muscles at rest, pouting lips and showing teeth; ability to raise eyebrows, close eyes tightly and wrinkles forehead.

 

Conclusion

 

There are many more physical examination skills to be learned, but it is important not to get overwhelmed. Remember that physical examination skills can be learned gradually and over time with practice.