Introduction

Health assessment is a plan of care that pin points certain needs of an individual and how those needs will be tackled by the healthcare system. It is carried out by trained medical personnel. The importance of health assessment is to make precise diagnosis and correct establishment of an illness (Beth, 2020). This paper will focus on thyroid gland and tympanic membrane histories of health assessment.

Histories of health assessment

Health assessment is the analysis of medical requirements and services of the needed care of a patient depending on the need. The needs of a patient are identified through systemic examination in a health care facility. It is advocated that a nurse or a doctor attending to the patient should write down the patient’s medical history before performing physical examination. The patient’s health history will assist the health care practitioner to identify a health sequence that is vital in drawing the relationship between treatment and wellness paradigm.

Patient A

A 3yr old girl was presented by his father for medical assistance. The father reports the patient is choosy, has no appetite, has nasal drainage, and is twitching at her left ear.

After I introduced myself, the father identified the patient using her name and age. I verified the information offered by the father against the chart after which I applied an identifying wristband to the patient. The father is also given a wristband to help the health facility staff in identifying the father and the patient. The father reported that the patient has progressively become irritable over the past two days, has no appetite, and her left ear is tugging. Additionally, the girl was sent home from a day care due to fever. The father confirms that he administered kids Tylenol and Benadryl but the symptoms persisted.

I went ahead to ask the father about the patient health history and medical allergies. He stated that the girl has no allergies and has no prescription medications. He further reported that the girl has been healthy since she was born. I started performing physical assessment on the patient after obtaining subjective data from the father. The girl sat on the father’s lap so as to avoid unnecessary stress to the patient. The patient’s vital signs were as follows: 100% oxygen saturation, temperature of 99.7F, heart rate of 127 beats per minute, respiration 23 per minute, and a weight of 13 kilograms. I observed the girl tugging at her left ear during the physical assessment. The left ear is assessed using an otoscope. The otoscope assessment is carried out on a patient by pulling the auricle of the year backward and downward gently. Other physical assessments were conducted as well.



Patient B

A 50-year-old male presents himself to a health care facility with difficulty in swallowing, fatigue, more sensitivity to cold, significant weight gain and general body weakness. The patient is accompanied to an exam room by a customer care staff. I introduced myself and appropriately identified the patient by name and age. The patient is asked to sit in a place where the patient to keep eye contact easily with him or her. I managed to develop a good rapport with the patient so that I could get sufficient medical history of the patient. A wristband was then applied on the patient. I asked him about medication allergies and he reported that he has no allergies and is currently under high blood pressure medication. The physical assessments began after interviewing him.  I obtained the following vital signs: heart rate 51 beats per minute, blood pressure of 117/82, temperature 97.9 degrees, 17 respirations per minute, and a weight of 181 pounds.

The patient denies visual problems, congestion, cough, or hearing problems. All organs are observed including the patient’s teeth, lips and tongue. All are in good condition with a good dentition. His neck is supple with motion and a midline trachea. I assessed the thyroid closely based on his subjective data. After palpating the left lobe of the thyroid gland, the patient complained of sharp pain. I performed the all necessary test and found out that there was a palpable abnormality in the patient thyroid gland.

Findings for the Tympanic Membrane

Tympanic membrane can also be referred to the eardrum or myringa. It is a thin cone shaped membrane that differentiates the outer part of the year from the middle part. Tympanic membrane transmits sound from the surrounding to the oval window. The tympanic membrane can transmit sound using two different ways. It can convert sound vibrations into signals and amplify the vibration signal. Secondly, it can amplify sound by allowing vibration signals to travel through the fluid in the cochlea. The tympanic membrane cannot get damaged easily because it has three layers. The cutaneous layer is the outer layer, the mid layer is the fibrous layer, and the inner layer is the mucus layer. However, tympanic membrane also has a risk of rupturing despite having three layers. The rupturing of the tympanic membrane is called tympanic membrane perforation (Steven, 2020). The main causes of tympanic membrane perforation are exposure to pressure, infections, and trauma. Other causes include careless removal of wax, intense ear blows, and high atmospheric pressure.



Tympanic membrane perforation can become either temporary or permanent. This solely depends on the size of the surface of the tympanic membrane. Tympanic membrane perforation is very painful when it is caused by an infection. Cholesteatoma is uninfected tympanic membrane perforation that is depicted to partial or no hearings which may be infected if it is not treated.  Acute or chronic tympanic membrane perforation may lead to drainage of sanguineous copious purulent. Internal cause of uninfected tympanic membrane perforation is cell growth in the tympanic membrane. Massive cell growth can lead to permanent ear infection and drowsiness. If the problem is not treated early, it can lead to deadly diseases such as meningitis and brain abscess.

Examinations of the thyroid gland

Thyroid gland is an endocrine gland that is responsible for protein synthesis, metabolic rate, and management of the body sensitivity towards other hormones. Normally, a thyroid gland weighs between 10-20 grams. A patient with thyroid disease has a very large thyroid. The thyroid condition is commonly called goiter. Thyroid gland assessment has three important parts. These assessment parts are inspection, data analysis, and palpation.

There are two main methods which can be used to assess the thyroid glands. The first strategy involves examination of the thyroid gland from the frontal method. The patient is asked to sit or stand in a straight position with the neck in a slightly protracted position during anterior examination. Cross-lighting is provided so as to enlarge shadows besides thus making it easier to pin point masses. Frontal approach provides advanced visualization of the thyroid. The visual image of the thyroid gland can be enhanced by asking the patient to stretch out their neck hence stretching out their overlying tissues. The patient is then asked to swallow water to ensure that the thyroid gland makes upward movements.



Lateral inspection is then carried out after anterior examination. The contours of the cricoids cartilages are estimated downwards to the suprasternal notch through observation. The contours prominence should also be measured using a ruler. After the examination, the healthcare practitioner should then proceed to the palpation stage.  The healthcare provider will use their fingers to touch a specific surface of the body. The main purpose of palpation is to figure out the size, tenderness, consistency, texture, and location of the part affected.

Soap Notes

Patient A SOAP Notes

ComponentContent
SThe patient’s father reports the patient is choosy, has no appetite, has nasal drainage, and is twitching at her left ear.  
OThe patient is a 3-year-old healthy white girl. She is slightly feverish and has sinus drainage. The left ear shows an erythematous and bulging tympanic membrane. Regular respirations.
AThe patient seems to be suffering from acute otitis media and sinusitis. An RSV specimen is extracted from nares and sent to the lab. The lab results came out negative for RSV.
PThe patient was administered with two doses of  25mg  per kilogram amoxicillin suspension for five days. The patient was also given 10mg per kilogram of children’s ibuprofen. Ibuprofen was prescribed to reduce fever and prevent stomach upset. The father was also told to keep the child hydrated always and to return to ER if the child condition doesn’t improve.


Patient B SOAP Note

ComponentContent
SThe patient reports fatigue, rising sensitivity to cold, difficulty in swallowing, weight gain, and weakness for the past 4 months.
OA healthy appearing 50 years old male. The neck is supple and trachea is midline.  The left thyroid is tender and swollen to palpation. The radial pulses are healthy and equal bilaterally.
AThe patient is most likely to be suffering from hypothyroidism.  TSH and T4 blood tests are ordered. The lab test results indicate that the pituitary gland is producing thyroid stimulating hormone. However, thyroid is not producing thyroxin, thus indicating thyroid gland is not functioning properly.
PThe patient to be referred to endocrinologist for further testing. The patient will be prescribed with levothyroxine to raise her metabolism to counteract the low output of his thyroid.

Nanda diagnosis for hyperthyroidism

AssessmentDiagnosisInferencePlanningInterventionRationaleEvaluation
Subjective: Fatigue, rising sensitivity to cold, difficulty in swallowing, weight gain, and weakness. Objective: Supple neck left thyroid is tender and swollen to palpation. Rapid pulse rate Vital signs: heart rate 51 beats per minute, blood pressure of 117/82, temperature 97.9 degrees, 17 respirations per minuteFatigue related to hyper metabolic state with increased energy requirements.Hyperthyroidism is an of thyroid hormone which creates far reaching metabolic effects. Hypertrophy and hyperplasia of the thyroid gland occurs with increased vascularity. Most manifestations result from  increased metabolic rate, excessive heat production, increased neuromuscular and cardiovascular activity and hyperactivity of the sympathetic nervous system.After 8 hours of nursing interventions, the patient will display enhanced ability to participate in desired activities.Monitor vital signs, noting down pulse rate at rest. Provide comfort measures. Encourage patient to restrict activity. Provide quiet environment, cool roomElevated pulse rate even at rest. Help counteract effects of metabolism. Increased irritability of the CNS may cause the patient to be easily excited. Oxygen consumption and demand are increased in hypermetabolic state  After eight hours of nursing interventions the patient was able to display improved ability to participate in desired activities.

Laboratory Tests for screening patients and the expected normal outcomes

The information from anterior and lateral inspection should be laboratory analyzed and from the data examined the gland may be categorized as: –

Probability of goiter is ruled out to be small with lateral prominence less than 2mm

Probability of goiter ruled in due to be large with a lateral prominence of greater than 2mm

The tests were inconclusive.

Nanda diagnosis for acute otitis media and sinusitis

AssessmentNursing diagnosisGoal/expected outcomeInterventionImplementationrationale
Subjective data The patient’s father reports the patient is choosy, has no appetite, has nasal drainage, and is twitching at her left ear. Objective data The patient is a 3-year-old healthy white girl. She is slightly feverish and has sinus drainage. The left ear shows an erythematous and bulging tympanic membrane. Regular respirations. The patient’s vital signs were as follows: 100% oxygen saturation, temperature of 99.7F, heart rate of 127 beats per minute, respiration 23 per minute, and a weight of 13 kilograms  Acute pain Related to ear problemGoal The patient will indicate absence of pain by the end of 4 hrs. Expected outcome. Patient to report pain reduction Patient to be able to get relaxed and sleep.    Have the patient sit up and raise the head on a pillow or lie on unaffected ear. Have the patient chew gum. Encourage the patient to listen to music. Administer analgesic eardropsElevation lowers pressure from fluids Heat increases blood supply and lowers discomfort To distract attention and reduce tension towards pain.Goal was achieved as evidence by: Patient reported pain reduction of 2/10. Patient was relaxed and was able to sleep comfortably. Patient was able to sleep in any position.  


References

Beth, M. K. (2020). Health Assessment and Diagnostic Tests.

Javris, C. (2012). Physical Examination and Health Assessment.

Steven, B. L. (2020). Diagnostic Hearing Health Assessment System and Method. US Patent App. 16/493,817.