Nursing case study assignment: assessing the head, eyes, ears, nose,

soaprubric.pdf

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 4/6

Criteria Ratings Pts

50 pts

35 pts

Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

50 to >44.0 pts Excellent

The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

44 to >38.0 pts Good

The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

38 to >32.0 pts Fair

The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

32 to >0 pts Poor

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

· List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.

35 to >29.0 pts Excellent

The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five

29 to >23.0 pts Good

The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 pts Fair

The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts Poor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 5/6

Criteria Ratings Pts

5 pts

conditions selected.Written Expression

and Formatting - Paragraph Development and Organization: Paragraphs make clear points that support well- developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused-- neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text

5 to >4.0 pts Excellent

Uses correct APA format with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts Poor

Contains many (≥ 5) APA format errors.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 6/6

Total Points: 100

Criteria Ratings Pts

citations, and reference list.

Question.docx

Case Study 1: Focused Nose Exam

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

TO PREPARE

· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

· Review this week's Learning Resources and consider the insights they provide.

· Consider what history would be necessary to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

THE ASSIGNMENT

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.

soaprubric.pdf

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 4/6

Criteria Ratings Pts

50 pts

35 pts

Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

50 to >44.0 pts Excellent

The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

44 to >38.0 pts Good

The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

38 to >32.0 pts Fair

The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

32 to >0 pts Poor

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

· List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.

35 to >29.0 pts Excellent

The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five

29 to >23.0 pts Good

The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 pts Fair

The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts Poor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 5/6

Criteria Ratings Pts

5 pts

conditions selected.Written Expression

and Formatting - Paragraph Development and Organization: Paragraphs make clear points that support well- developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused-- neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text

5 to >4.0 pts Excellent

Uses correct APA format with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts Poor

Contains many (≥ 5) APA format errors.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 6/6

Total Points: 100

Criteria Ratings Pts

citations, and reference list.

Question.docx

Case Study 1: Focused Nose Exam

A 28 year old female comes in complaining of a runny nose and itchy eyes. States runny nose, itchy eyes, and ears felt full approximately 9 days ago. “I get this every spring and it seems to last six to eight weeks”. Describes nose is runny with clear mucus. Sneezes on and off all day. Eyes itch so bad she just wants to scratch them out, sometimes feels a tickle in her throat and ears feel full and sometimes pop. Last year took Claritin with relief. Charlotte is alert and oriented. He has pale, boggy nasal mucosa with clear thin secretions and enlarged nasal turbinates, which obstruct airway flow but his lungs are clear. His tonsils are not enlarged but his throat is mildly erythematous.

Nurses conducting assessments of the ears, nose, and throat must be able to identify the small differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.

In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

TO PREPARE

· By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements” section of the classroom for your assignment from your Instructor.

· Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

With regard to the case study you were assigned:

· Review this week's Learning Resources and consider the insights they provide.

· Consider what history would be necessary to collect from the patient.

· Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient's condition. How would the results be used to make a diagnosis?

· Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

THE ASSIGNMENT

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient's differential diagnosis and justify why you selected each.

soaprubric.pdf

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 4/6

Criteria Ratings Pts

50 pts

35 pts

Using the Episodic/Focused SOAP Template: · Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned. · Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.

50 to >44.0 pts Excellent

The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

44 to >38.0 pts Good

The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

38 to >32.0 pts Fair

The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected.

32 to >0 pts Poor

The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.

· List five different possible conditions for the patient's differential diagnosis, and justify why you selected each.

35 to >29.0 pts Excellent

The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five

29 to >23.0 pts Good

The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected.

23 to >17.0 pts Fair

The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each.

17 to >0 pts Poor

The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 5/6

Criteria Ratings Pts

5 pts

conditions selected.Written Expression

and Formatting - Paragraph Development and Organization: Paragraphs make clear points that support well- developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused-- neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

5 to >4.0 pts Excellent

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.

4 to >3.0 pts Good

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.

3 to >2.0 pts Fair

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.

2 to >0 pts Poor

Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.

Written Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation

5 to >4.0 pts Excellent

Uses correct grammar, spelling, and punctuation with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) grammar, spelling, and punctuation errors.

3 to >2.0 pts Fair

Contains several (3 or 4) grammar, spelling, and punctuation errors.

2 to >0 pts Poor

Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.

Written Expression and Formatting - The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text

5 to >4.0 pts Excellent

Uses correct APA format with no errors.

4 to >3.0 pts Good

Contains a few (1 or 2) APA format errors.

3 to >2.0 pts Fair

Contains several (3 or 4) APA format errors.

2 to >0 pts Poor

Contains many (≥ 5) APA format errors.

12/26/23, 10:13 PM Week 5: Assignment 1

https://waldenu.instructure.com/courses/95695/assignments/1028227?module_item_id=3176984 6/6

Total Points: 100

Criteria Ratings Pts

citations, and reference list.

Nursing CASE STUDY ASSIGNMENT: ASSESSING THE HEAD, EYES, EARS, NOSE, AND THROAT

Question.docx

soaprubric.pdf

Question.docx

soaprubric.pdf

Question.docx