NRNP 6540F- Advanced Practice Care of Older Adults- Week 4 Assignment -Dr. Doctura. .do, Exams of Nursing

Download NRNP 6540F- Advanced Practice Care of Older Adults- Week 4 Assignment -Dr. Doctura. .do and more Exams Nursing in PDF only on Docsity! 1 NRNP 6540 F- Advanced Practice Care of Older Adults- Week 4 Assignment - Dr. Doctura. Head, Neck, and Face Disorders in the Older Population Nancy S. Doctura Walden University NRNP 6540F Advanced Practice Care of Older Adults Dr. Donna Petko September 27, 2020 2 Head, Neck, and Face Disorders in the Older Population Older adults face many age-related disorders that involve the head, neck, ad face. Advanced practice nurses should assess older patients appropriately, as many of these conditions significantly affect their quality of life. The goal of this paper is to discuss a focused subjective, objective, assessment, and plan (SOAP) for a geriatric patient with complaints of upper respiratory tract symptoms. The paper also aims to present diagnostic tests, differential diagnoses, treatment plans, and reflect learnings from analyzing the medical condition affecting the older patient. Focused SOAP Note Subjective Patient Information: Mrs. A, 76, White, Female Chief Complaint: Mrs. A came to the clinic complaining of persistent “runny nose” for 3 weeks now, associated clearing of throat, and nasal congestion on awakening in the morning. History of Present Illness: Mrs. A is a 76-year-old white female who comes to the clinic with complaints of nasal drainage, clearing of throat, and occasional nasal congestion that usually occurs when walking in the morning. The said symptoms usually occur to her during spring, in which she associated the nasal discharge with pollination. Being now in the winter season, the patient could not associate 5 Ears: Symmetrical. Patent external auditory canal with no swelling noted. No abnormal ear discharges noted. Tympanic membranes intact with no erythema or effusion. Nose: Symmetrical. Clear nasal discharges noted with mild swelling of the nasal mucosa. No nasal deviation, flaring, or nasal polyps noted. Throat: Patient noted attempts to clear throat occasionally. No erythema or exudates noted. Gag reflex intact. Neck: Supple with full range of motion. Carotid arteries wit no bruits or jugular vein distention. No masses palpated. No tracheal deviation noted. Respiratory: Clear lung sounds in all lung fields to auscultation with inspiration and expiration. Equal chest with rise and fall bilaterally, upon inspiration and expiration. Integumentary: No significant rash or lesions noted. Skin color appropriate for age. Skin warm to touch with skin turgor appropriate for age. No clubbing or cyanosis noted to nails. Lymphatics: No enlarged lymph nodes palpated. Diagnostic tests: 1. Skin testing – The test determines sensitivity to allergens that cause AR. According to Health Quality Ontario (2016), since skin prick testing is easy to implement and less invasive, it is recommended to diagnose AR, then followed by intradermal testing to confirm the skin prick test results. Skin testing is reliable tool to diagnose AR. In a meta- analysis performed by researchers, its sensitivity was 85% and specificity was 77% (Health Quality Ontario (2016). 2. Total serum IgE testing If skin testing cannot be performed due to medications or skin conditions, total serum IgE testing is an alternative. Small et al. (2015) explained that allergen-specific IgE tests 6 provide an in vitro titer of a patient’s specific IgE levels against specific allergens. If the patient in the case study cannot stop the antihistamine or has extensive eczema that prevents skin testing, serum IgE testing can be done. 3. Sinus CT Scan CT scan will confirm the presence of nasal polyp (Stevens et al., 2016). In chronic sinusitis with nasal polyps, the polyps that develop in the bilateral sinonasal cavity are usually benign, but are causing the symptoms. The CT scan will determine the phenotype and any unilateral polyp should concern for a possible malignancy (Stevens et al., 2016). Assessment Differential diagnoses: 1. Allergic Rhinitis A broad definition of rhinitis is an inflammation of the nasal mucosa. AR is the most common classification of chronic rhinitis that affects 10%-20% of the population affecting the quality of life, sleep, and work performance (Small et al., 2018). Traditionally, AR either occurs during specific seasons (seasonal) or throughout the year (perennial). The patient in the case study reports that she usually has symptoms during spring, attributing the symptoms from pollens; hence, the provider can initially classify her AR as seasonal. However, it is already winter; the practitioner can start ruling out seasonal and suspect a perennial type of AR. Classic symptoms of rhinitis include clear, watery nasal discharge, nasal congestion, itching, and sneezing (Kennedy-Malone et al., 2019). Pertinent positives pointing to AR are the patient’s symptoms of nasal drainage, nasal congestion, and clearing of the throat, possibly due to itching or attempt to clear posterior drainage, which is all typical of AR. Exposure to environmental pollutants like 7 dust, animal dander, and indoor or outdoor molds would trigger perennial AR (Kennedy- Malone et al., 2019). Mrs. A recently moved to an independent living center, and it would be good to identify the possible environmental pollutant that triggered the patient’s symptoms. 2. Viral Upper Respiratory Tract Infection (URI) The common cold is a type of URI, usually caused by a virus that causes inflammation of the nasal passages (Kennedy-Malone et al., 2019). Viral URI is generally self-limiting with minor bodily complaints. Common cold symptoms are typically characterized as nasal congestion and drainage, sneezing, sore throat or scratchy throat, cough, and general malaise (Barrett, 2018). Pertinent positives for Mrs. A include nasal drainage, congestion, and clearing of throat that point to URI as a differential diagnosis. The patient did not report sneezing, cough, and general malaise; however, Barrett (2018) explained that cough might be present in URI, but it tends to appear late in the disease and usually lasts for weeks after other symptoms have resolved. 3. Acute Sinusitis Acute rhinosinusitis (also called sinusitis) is defined as the temporary inflammation of the mucosal lining of the paranasal sinuses occurring less than four weeks (Ah-See, 2015). Typical clinical presentation are nasal congestion, rhinorrhea, facial pain, sneezing, facial pain, and malaise with fever in severe conditions (Ah-See, 2015). Again, pertinent positives for Mrs. A are her rhinorrhea and nasal congestion in addition to the duration that is less than four weeks. Sneezing, malaise, and fever were not reported, but the provider should keep in mind that bodily weakness and fever are usual symptoms when 10 3. Follow up After the patient starts her pharmacologic therapy, the patient will be advised to return in two to four weeks to evaluate the medication response and effectiveness of the control of the triggers. 4. Referral The patient will be referred to an allergy specialist for skin prick testing to identify the patient’s sensitivities and possibly place the patient on immunotherapy. With chronic rhinitis, referral to an otolaryngologist will be performed. The specialist may prescribe antibiotics short term to be taken with the corticosteroid and recommend sinus surgery to correct obstruction, if indicated (Kennedy-Malone et al., 2019). Reflection From this exercise, the author realized the need to obtain adequate information when evaluating a patient. There was limited information that would be very useful in creating in identifying differential diagnoses and treatment plans. The medication history was not provided. It is important to compare the patient’s medications, once obtained, to the Beers criteria to ensure that the older patient is protected from potentially inappropriate drugs that are regarded as high risk or less effective in the aging population. It is crucial to ask the patient specific questions to obtain a good subjective assessment. Asking if the symptoms are associated with a season, place, time of day, or activity will help determine the cause of the symptoms. Mrs. A reported that her symptoms usually occur during spring, but now, symptoms happen when she wakes up in the morning since moving to an independent living facility. Knowing this information will help identify the triggers of the allergy. The social history should focus on asking common and potential allergens in the 11 environment where she currently lives, including pollens, animals, textile flooring, tobacco smoke, humidity levels, and other potential allergens that she may be exposed to at home or within the environment. It is also vital to ask if the patient uses recreational drugs because intranasal cocaine use can lead to rhinitis (Small et al., 2015). Asking any family history of atopic diseases is also vital because AR has a significant genetic component. A thorough, objective assessment is also vital in this exercise. With no information provided in the case study, it is crucial to note ocular findings such as watery discharge, swollen conjunctivae, and scleral injection (Seidman et al., 2015). Allergic shiners, which are dark circles under the eyes, may be expected due to the nasal congestion (Seidman et al., 2015). The advanced practice nurse can evaluate for nasal crease commonly associated with AR (Seidman et al., 2015). Specific objective findings are beneficial in identifying the appropriate diagnosis for the patient. Summary AR is a disorder that can significantly affect an older patient’s quality of life. To obtain a definitive diagnosis, a complete and comprehensive history and focused physical examination is crucial. Not many diagnostic tests are available, but again, a thorough history and physical evaluation are necessary to establish a clinical diagnosis of AR. Tests are essential to confirm the underlying allergies causing the nasal symptoms. Treatment options are geared towards the relief of symptoms. The advanced practice nurse should also give the appropriate patient education to ensure the older patient’s safety and improve their sleep and quality of life. References 12 Ah-See, K. (2015). Sinusitis (acute rhinosinusitis). BMJ Clinical Evidence, 2015(511). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4400653/ Barrett, B. (2018). Viral upper respiratory infection. Integrative Medicine, 170– 179. https://doi.org/10.1016/B978-0-323-35868-2.00018-9 DeRhodes, K. H. (2019). The dangers of ignoring the Beers criteria: The prescribing cascade. JAMA Internal Medicine, 179(7), 863– 864. https://doi.org/10.1001/jamainternmed.2019.1288 Health Quality Ontario. (2016). Skin testing for allergic rhinitis: A health technology assessment. Ontario Health Technology Assessment Series, 16(10), 1- 45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4897001/ Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 127-151). F. A. Davis. Seidman, M. D., Gurgel, R. K., Lin, S. Y., Schwartz, S. R., Baroody, F. M., Booner, J. R., & Nnacheta, L. C. (2015). Clinical practice guideline: Allergic rhinitis. Otolaryngology— Head and Neck Surgery, 152(1), S1– S43. https://doi.org/10.1177/019459984561600 Small, P., Keith, P. K., & Kim, H. (2018). Allergic rhinitis. Allergy, Asthma Clinical Immunology, 14(51). https://doi.org/10.1186/s13223-018-0280-7 Stevens, W. W., Schleimer, R. P., & Kern, R. C. (2016). Chronic rhinosinusitis with nasal polyps. The Journal of Allergy and Clinical Immunology in Practice, 4(4), 565– 572. https://doi.org/10.1016/j.jaip.2016.04.012