NURSING > Class Notes > Week 4 iHuman - Notes (All)

Week 4 iHuman - Notes

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During history collection, when going through patient’s symptoms with her mother, I failed to further investigate an ear problem, because patient is a 2 year old, she was not able to communicate and presented with discomfort during visit. I asked about ear pain or discomfort such as the child tugging at her ear and mother replied that there were no signs of that, but I failed to ask if there were any signs of discharge or bleeding of the ears. The collection of these signs are clinically important because that could lead to a better understanding initially, prior to physical exam, as bleeding discharge from the ears can indicate and external ear canal wound, skull fracture, or traumatic perforation of the tympanic membrane (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 127). Discharge of the purulent type can also be a sign of infection or a foreign body in the ear (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 127). Another question that was missed during history collection was if patient had a flu shot. I stopped at asking if when her last immunizations were given and if they were up to date, but failed evaluate mother’s answers further and ask about the flu vaccine. This is very important to assess and document because children are a target population in receiving flu vaccine due to the benefits of reducing rates of pneumonia in children and reducing the incidence of influenza in the community and should be offered to all children older than 6 months that have no contraindications (Seasonal influenza vaccine in children, n.d). NSG 6020 Emma Ryan iHuman Case study, 2 year old with chief complaint of runny nose, cough, and fever Discussion Question 2 Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client. During physical exam, I went through all the systems and was able to accomplish the exam with more ease than last week, however, I added a mental state on vital signs that was not necessary and in looking back I understand why it was not necessary since patient is 2 years old, cannot verbally express what she is feeling, and although I can observe that she is awake or alert and in discomfort, it is not necessary in gathering the information needed. Another error in my exam performance that was not a required exam was looking up nostrils, or internal examination. Initially I felt this may be important to check if there were any abnormalities, however, this is an exam that is more appropriate for those experiencing significant nasal symptoms, the internal examination of the nose is best accomplished after asking the patient to blow his or her nose (Goolsby, Jo, M., Grubbs, Laurie., 2014, p. 128). I also realize it would not be the most appropriate or comfortable exam for a “fussy” two year old. .....................................CONTINUED..................................

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