Nursing

You will perform a history of a head, ear, or eye problem that your instructor has provided you or one that you have experienced and perform an assessment including head, ears, and eyes. You will document your findings and identify actual or potential risks. *** I want to make sure that you guys follow the highlighted part of the Rubric and describe what they expect from the Rubric. ***

ANSWER

Infection-related conjunctiva irritation

Evaluation of the head, ears, and eyes:

In a physical examination, the subject’s body is examined by techniques like auscultation, palpation, massage, and observation. Physical examination includes a critical component called head evaluation, which includes the eyes and ears.

Gathering medical history related to the condition:

Subjective data

Mr. M, an 18-year-old, complained of headache, itchiness, redness, itching of the eyes, and more tears than usual.

Head examination

There is no dandruff, and the scalp is clean.

No alopecia, symmetrical distribution of hair

Palpation: There is no discomfort or trauma.

Facial nerve: requested the patient to flinch, smile, or puff up their cheeks. He completed it quickly. Since there is no difficulty, the facial nerve is functioning appropriately.

Reports of headaches were noted.

Ears examination

No crust or discharge from the external ear

Pinna: unharmed

No swelling or discomfort in the mastoid process

Tip of the eardrum: Block one ear, whisper two syllables in the other, and ask the patient to repeat the phrases as part of an intact vestibulocochlear nerve test. The patient said the same two words twice. There is no Vestibulocochlear nerve dysfunction.

There were no reports of ear pain or hearing loss.

Eyes examination

Eyelid, the inner eyelid is red.

Conjunctivitis: Inflammation and redness in the eye’s white region

Eye lesions yellow discharge that is thick and has crusts

Excessive tears were seen

Eyesight blurred as a result of excess tearing

Complaints of light sensitivity and burning

(Light sensitivity in the patient’s eyes precluded doing a light test. No PERRLA testing: “Pupil,” “Equal,” “Reactive,” “Round,” “Light,” and “Accommodation.”

Potential and actual risks

The person is restricted from recreational and social activities due to eye discomfort, itching, pain, and tearfulness. There is a potential risk of infection spreading. It is contagious to have pink eye or conjunctivitis, spreading to family members. He must maintain his distance from others, wash his hands, and refrain from touching.

References

Azari, A. A., & Barney, N. P. (2013). Conjunctivitis: a systematic review of diagnosis and treatment. Jama, 310(16), 1721-1730.