health assessment histories

Using the classroom resources or South University Online Library, research the tympanic membrane and the thyroid gland. In a Microsoft Word document of 4-5 pages formatted in APA style, address each of the following criteria.

  • Two focused health assessment histories
    • One assessment related to the tympanic membrane and the other focused on the thyroid gland.
    • The assessments can be hypothetical patients or patients you have had in the past (remember HIPAA if you are describing a previous patient).
  • A description of the normal and abnormal findings of the tympanic membrane.
  • Information on how to examine the thyroid gland using both the anterior and posterior methods.
  • A concise note in the subjective, objective, assessment (be sure to include the NANDA diagnosis as well as the medical diagnosis), and plan (SOAP) format with each patient’s encountered findings.
  • Information about laboratory/diagnostic tests used for screening clients with tympanic membrane or thyroid gland issues.
    • Include the expected normal results for each test.

On a separate references page, cite all sources using APA format. Please note that the title and reference pages should not be included in the total page count of your paper.

SOAP documentation

SOAP documentation is a problem-oriented technique whereby the nurse identifies and lists the patient’s health concerns. It is commonly used in primary health-care settings. Documentation is generally organized according to the following headings:

S = subjective data Example: What is the patient experiencing or feeling, how long has this been an issue, what is the frequency, intensity, duration, what makes it worse or better, any past history, family history, home monitoring results (BP, weight, glucose monitoring), etc.

O = objective data Example: Results of the physical exam, relevant vital signs, what the nurse observes, etc.

A = assessment Example: What is the nursing diagnosis or medical diagnosis (for existing problems), identification of the problem, etc. P = plan Example: What interventions are done during the visit, what is the follow-up, what medications have been prescribed or changed, what further testing or investigations are required, when will the patient be seen again, etc. Sample chart note: S: In for refills and review of diabetes. Home glucose monitoring – taking BG readings 3 times/week in morning only (fasting). Average BG 7-8. Has been trying to avoid sugary snacks but has just quit smoking so is finding this difficult. Walking 5 times/week for 30 minutes.

O: Blood work – A1C 7.2 (was 7.3), LDL 1.9, Ratio 3. BP 118/70. HR 72 regular. A: Diabetes (A1C not at target)

P: Provided with information on A1C, diabetes and targets. Provided with support and information related to nutrition and strategies to reduce sugary snacks. Reviewed blood glucose testing and will check postprandial sugars 2/week until next visit. 1. Encouraged to book eye exam 2. Due for foot exam next visit 3. Increase metformin to 1000mg bid 4. Repeat BW in 3/12 (annual inc nephropathy screening) – encouraged to check glucometer with bloodwork 5. RTC 3/12

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