Use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up.
A mother brings in her 14-year-old son, Branch, to the Urgent Care where you are as a nurse practitioner. He has had a nosebleed. You learn that Branch and his mother live nearby the UC but they do not live near his school. He must take the train to the school and there also is a walk. Her first concern was that he had been attacked during the walk. Branch denied that and reminded them that he has no bruises. The nosebleed began during his sleep and continues this morning so that he could not go to school. The bleeding is bright and a small but steady stream from his right nostril. He has no history of nosebleeds, sinus or allergy problems and uses no nasal sprays. The mother asks how much the cost will be at the UC as she has no health insurance and just lost her Medicaid for them because she received a raise at her job. She says he needs to be seen, even if it is expensive, because they have been applying pressure by pinching it and the nosebleed won’t stop. You ask for additional information and learn that he has no significant medical history and no known allergies. He is on no medications. Branch does play sports at school, depending on the season. He does not recall any facial injuries at all. He says he just woke up with a nosebleed and it won’t stop. He tells you he is worried he will faint.
Vital signs: BP 108/70 P 88 R 18 T 97.8 oral Pulse ox 99%
You recognize that simple pressure is not going to stop the nosebleed so you know that you will have to intervene.
Prior to any type of procedure, you have the mother sign an informed consent. What are the three major areas you must discuss when doing any type of procedure?
- What are the three groups of nosebleeds and which is most common?
- Name 4 indications for intervention by a provider for a nosebleed.
- You place Branch on the exam table at approximately 45 degrees. You drape him appropriately. You have him blow his nose gently to remove clots. You then inspect the right side to familiarize yourself with his anatomy. You then inspect the left side using a nasal speculum. How should the nasal speculum be used and why is it important to use the nasal speculum a certain way?
- You note that the bleeding is coming from an area on the septum. You know that the next step is to apply a vasoconstrictive solution to the nose. What are two ways you can deliver the vasoconstrictive solution?
- You note that the area that is the source of the bleeding is about 3 mm in diameter. You make the decision to use a silver nitrate stick. How long should you apply pressure with the stick? Why it is it important not to use the silver nitrate for over that time frame?
- After hemostasis is obtained, what are three types of treatment methods that can be used to protect the cauterization site?
- If that had not stopped the bleeding and you had to make the decision to use a nasal sponge or nasal tampon, what should the sponge/tampon be coated in and how long should it be left in place?
- After putting in the nasal sponge/tampon, approximately 2 ml of ________ or _______ should be dripped onto the tip to help the sponge expand.
- After placing the nasal sponge/tampon, the patient should be closely monitored for 3-5 minutes. Why is that?
- How long should the patient be kept in observation status?
- If a sponge/tampon is used, is it necessary to use antibiotics?
- If it is necessary to pack the nose, it may be advisable to give the patient a narcotic or sedative medication (unless a contraindication exists). Why?
- Name 5 complications of the above procedures.
- After the procedure, you tell Branch and his mother that he can take acetaminophen for any pain/discomfort. Why is it important not to have him take ibuprofen?
- What is the leading cause of nosebleeds in adolescents?
- What CPT code would you use for the above procedure? What is the definition of the code?Replies to this email will be posted as a reply to the announcement,
- 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.
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.
How to solve
NRNP 6565 WU Patient with Urgent Care with A Nosebleed Paper
Nursing Assignment Help
When discussing any type of procedure with a patient, it is important to obtain informed consent from the patient or their guardian. This involves providing information about the procedure and obtaining the patient’s agreement to proceed. There are three major areas that should be discussed when obtaining informed consent for a procedure.
1. Nature of the Procedure: The first major area to discuss is the nature of the procedure. This includes explaining to the patient or guardian what the procedure entails, including the steps involved and any potential risks or complications. It is important to provide a clear and understandable explanation, ensuring that the patient or guardian has a good understanding of what will be done.
2. Risks and Benefits: The second major area to discuss is the risks and benefits of the procedure. This involves informing the patient or guardian about any potential risks or complications that could arise as a result of the procedure, as well as the potential benefits or positive outcomes. It is important to provide a balanced explanation of both the risks and benefits, allowing the patient or guardian to make an informed decision.
3. Alternatives and Consent: The third major area to discuss is the alternatives to the procedure and the consent process. This involves explaining to the patient or guardian any alternative options or treatments that may be available, as well as the potential consequences of not proceeding with the procedure. It is important to ensure that the patient or guardian understands that they have the right to refuse the procedure or seek a second opinion, and that their consent is voluntary and without coercion.
By discussing these three major areas with the patient or guardian, healthcare providers can ensure that the patient’s rights are respected and that they have a clear understanding of the procedure and its implications.
1. The three groups of nosebleeds are anterior, posterior, and both anterior and posterior. Anterior nosebleeds, which originate from the front of the nose, are the most common.
2. Four indications for intervention by a provider for a nosebleed include:
a. Persistent bleeding that does not respond to conservative measures.
b. Profuse bleeding that results in hemodynamic instability.
c. Bleeding associated with trauma or facial fractures.
d. Recurrent nosebleeds.
3. The nasal speculum should be used to inspect the inside of the nose. It is important to use the nasal speculum correctly to visualize the nasal cavity and identify any abnormalities. The speculum is inserted gently into the nostril and then opened to provide a wide view of the nasal mucosa. This allows for a thorough examination of the nasal passages and identification of the source of bleeding.
4. Two ways to deliver a vasoconstrictive solution to the nose are by spray or nasal drops. The solution can either be sprayed or administered in drops directly onto the affected area. This helps to constrict the blood vessels, reducing bleeding.
5. When using a silver nitrate stick, pressure should be applied for approximately 5 to 10 seconds. It is important not to use the silver nitrate for over that time frame because prolonged application can cause tissue damage and scarring.
6. After hemostasis is obtained, three types of treatment methods that can be used to protect the cauterization site include:
a. Nasal saline rinses: These help to keep the nasal passages clean and moist, promoting healing.
b. Application of antibiotic ointment: This helps to prevent infection at the cauterization site.
c. Use of a nasal lubricant: This helps to prevent dryness and irritation of the nasal passages.
7. If a nasal sponge or nasal tampon is required, it should be coated in petroleum jelly before insertion. The sponge or tampon should be left in place for approximately 48 to 72 hours.
8. After placing the nasal sponge or tampon, approximately 2 ml of saline or water should be dripped onto the tip to help the sponge expand. This ensures that the sponge fits snugly inside the nasal cavity and provides adequate pressure to stop the bleeding.
9. The patient should be closely monitored for 3-5 minutes after placing the nasal sponge or tampon to ensure that bleeding is adequately controlled and there are no signs of complications such as difficulty breathing or increased bleeding.
10. The patient should be kept in observation status for at least a few hours to monitor for any recurrence of bleeding or other complications.
11. If a sponge or tampon is used, it is necessary to use antibiotics to prevent infection.
12. Giving the patient a narcotic or sedative medication may be advisable to help manage pain and discomfort associated with packing the nose. This can help to ensure patient comfort during the procedure.
13. Complications of the above procedures may include:
b. Nasal obstruction
c. Recurrent bleeding
d. Septal perforation
e. Allergic reactions to medications used
14. Acetaminophen should be recommended for pain/discomfort instead of ibuprofen because ibuprofen can increase the risk of bleeding, which is undesirable in this situation.
15. The leading cause of nosebleeds in adolescents is trauma to the nose, such as a blow to the face or picking the nose.
16. The CPT code that would be used for the above procedure is 30901. This code represents control of nasal hemorrhage by cauterization, anterior or posterior, electrosurgical, or chemical.