NURS 6541: Primary Care of Adolescents and Children | Week 4

Patients with disorders of the eye, ear, nose, and throat (EENT) often present with a variety of symptoms that can be associated with multiple disorders. This makes diagnosis difficult because what may appear to be a gastrointestinal or respiratory disorder, for example, might actually be an EENT disorder such as otitis media. Consider 8-month-old Melissa, who presents with a complaint of tugging on her left ear, fussiness, and decreased appetite over the last 3 days. She does not have a fever, and her physical examination is normal. As the advanced practice nurse caring for patients like Melissa, you must always consider the differential diagnoses and perform the appropriate assessments and diagnostics prior to providing treatment and management recommendations for patients and their families.

This week you explore eye, ear, nose, and throat disorders in pediatric patients. You also examine differential diagnoses for these disorders, as well as the impact of patient culture on treatment, management, and education.

Learning Objectives

By the end of this week, students will:

• Assess pediatric patients for eye, ear, nose, and throat disorders
• Evaluate differential diagnoses for pediatric eye, ear, nose, and throat disorders
• Analyze treatment and management plans for pediatric patients with eye, ear, nose, and throat disorders
• Analyze strategies for educating parents on their children’s disorders
• Evaluate the impact of culture on the treatment and management of eye, ear, nose, and throat disorders
• Understand and apply key terms, principles, and concepts related to eye, ear, nose, and throat disorders in pediatric patients
• Assess pediatric patients with signs of eye, ear, nose, and throat disorders

Learning Resources – NURS 6541:Week 4: Evaluation and Management of HEENT Disorders

Required Readings

• Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L.  (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.
• • Chapter 29, “Eye Disorders” (pp. 703-735)This chapter reviews the development, physiology, and pathophysiology of the eye. It provides guidelines for eye care including assessment and management strategies for common eye disorders, injured eyes, and deformities of the eyelids.

• Chapter 30, “Ear Disorders” (pp. 736-755)This chapter reviews the structure and function of the ear and presents guidelines for the assessment and management of ear problems.

American Academy of Pediatrics. (2004). Clinical practice guideline: Diagnosis and management of acute otitis media. Pediatrics, 113(5), 1451–1465.

This article examines the diagnosis and management of uncomplicated acute otitis media in patients from 2 months to 12 years of age. It focuses on defining acute otitis media, pain management, assessment, and selection of appropriate antibacterial treatments.

Chow , A.W., Benninger, M.S., Brook, I., Brozek, J.L., Goldstein, E.J.C., Hicks, L.A., Pankey, G.A., Seleznick, M., Volturo, G., Wald, E.R., & File Jr, T.M. (2012). IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases , 54(8), 72-112.

Note: Retrieved from the Walden Library databases.

Shulman, S.T, Bisno, A.L., Clegg, H.W., Gerber, M.A., Kaplan, E.L., Lee ,G., Martin, J.M., & Van Beneden, C. (2012). Infectious Diseases Society of America. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 58(10), 86-102.

Discussion: Evaluation & Management of HEENT Disorders

In clinical settings, head, eye, ear, nose, and throat (HEENT) disorders account for the majority of pediatric visits. With the prevalence of these disorders, you must be familiar with their signs and symptoms as well as evidence-based practices for assessment and treatment. Although many pediatric patients present with common HEENT disorders such as ear infections, allergies, and strep throat, some patients present with rare disorders requiring specialist care. In your role, making this distinction between when to treat and when to refer is essential. For this Discussion, examine the following case studies and consider potential diagnoses and management strategies.

Discussion board posting assignments are assigned alphabetically by FIRST NAME to ensure all cases are covered and discussed.

• Case Study 1: A-F
• Case Study 2: G-M
• Case Study 3 N-Z

Case Study 1:

HPI: A mother presents with her 2-year-old African American male child with complaints of ear pain and decreased sleep. Earlier this week, he had a runny nose and congestion with a mild cough that occurred mostly when lying down. His temperature is 100.7.

PE: Pt is walking around room, exploring in no acute distress.
HEENT: Mild nasal congestion, clear postnasal drainage, and lungs clear to auscultation. Ear exam reveals right tympanic membrane erythematous, translucent, in a neutral position, with no pus or fluid noted. Left tympanic membrane is full, reddish/orange in appearance, and opaque with pus.
Neck: Shotty anterior cervical adenopathy
Lungs: Clear to auscultation

Case Study 2

HPI: Kevin is a 5-year-old Asian American boy with an intermittent 2-day history of nasal congestion and cough in the early morning. His mother reports thick, green nasal discharge. He is afebrile, and appetite and sleep are normal.

PE: A smiling male patient sitting on mom’s lap.
HEENT: Tympanic membranes pearly gray without fluid in a neutral position, no cervical adenopathy, nasal turbinates are red, and clear rhinorrhea and postnasal drip.
CV: RRR, no murmurs or gallop
PULM: clear to auscultation

Case Study 3

HPI: Marcus is an 8-year-old with a 36-hour complaint of headache (frontal), sore throat, fever to 102°F, and nausea. Mom says his appetite is decreased and his breath smells “like a puppy dog’s.”

PMH: A Polish 8-year-old boy, in mild distress.
HEENT: Tympanic membranes partially obscured by cerumen but in neutral position and transparent, 2+ enlarged and red tonsils with exudate, strawberry tongue, and petechiae on the soft palate enlarged tonsillar and anterior cervical lymph nodes.
CV: RRR
PULM: Clear to auscultation bilaterally

To prepare: NURS 6541:Week 4: Evaluation and Management of HEENT Disorders

• Review “Eye Disorders” and “Ear Disorders” in the Burns et al. text.
• Review the three case studies focusing on the case that is assigned to you. Analyze the patient information, including the parent’s perspective.
• Consider a differential diagnosis for the patient in the case study you selected. Think about the most likely diagnosis for the patient.
• Think about a treatment and management plan for the patient. Be sure to consider appropriate dosages for any recommended pharmacologic and/or non-pharmacologic treatments.
• Consider strategies for educating parents on the child’s disorder and reducing any concerns/fears presented in the case study.

By Day 3

Post an analysis of your assigned case by responding to the following:

• • What additional questions will you ask?
    • Has the case addressed the LOCATES mnemonic? If not, what else do you need to ask? What additional history will you need? (Think FMH, allergies, meds and so forth, that might be pertinent in arriving to your differential diagnoses).
  • What additional examinations or diagnostic tests, if any will you conduct?
  • What are your differential diagnoses? What historical and physical exam features support your rationales? Provide at least 3 differentials.
  • What is your most likely diagnosis and why?
  • How will you treat this child?
    • Provide medication treatment and symptomatic care.
    • Provide correct medication dosage. Use the knowledge you learned from this week’s and previous weeks’ readings as well as what you have learned from pharmacology to help you with this area.
  • Patient Education, Health Promotion & Anticipatory guidance:
    • Explain strategies for educating parents on their child’s disorder and reducing any concerns/fears presented in the case study.
    • Include any socio-cultural barriers that might impact the treatment and management plans.
    • Health Promotion:
      • What immunizations should this child have had?
      • Based on the child’s age, when is the next well visit?
      • At the next well visit, what are the next set of immunizations?
      • What additional anticipatory guidance should be provided today?

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in both of the ways listed below. Respond to a colleague who chose one of the first three case studies and a second colleague who chose one of the last three case studies. Choose colleagues who selected a different case study than you did.

• Explain how culture might impact the diagnosis, management, and follow-up care of patients with the respiratory, cardiovascular, and/or genetic disorders your colleagues discussed.
• Based on your personal and/or professional experiences, expand on your colleagues’ postings by providing additional insights or different perspectives.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. NURS 6541:Week 4: Evaluation and Management of HEENT Disorders

 

 

ADDITIONAL INFORMATION 

Evaluation & Management of HEENT Disorders

Introduction

The hematology and clinical chemistry areas of the laboratory are responsible for performing tests to evaluate a patient’s blood, urine and other body fluids. In addition, they provide interpretation of these results and make recommendations regarding possible diagnoses and management strategies. The evaluation process begins with a history taking from you or your child known as an interview. For example, the patient may have been in a car accident or had a recent flu shot which may cause an immune response leading to fever, chills or sore throat (thrush). The doctor will then perform physical examination looking at eyes, ears, nose and throat as well as neck scars etc… This is followed by analysis of blood parameters such as complete blood count (CBC) cell count metabolic panel electrolyte panel etc…

History

• Ask the patient about symptoms.

• Ask about the past illness and how it affected their eyes.

• Ask about their lifestyle, including nutrition and exercise habits, stress levels and sleep patterns.

Physical Examination

The physical examination should be conducted by the physician, who is experienced in the diagnosis and management of ocular, ear and throat disorders. The following tests are often used:

• Otoscope – used to look into the external auditory canal (ear)

• Tongue depressor – used to depress soft tissue of the tongue while observing it from above with an otoscope

• Nasal speculum – a flexible metal or plastic instrument that helps open up the nose so that you can see inside it using an endoscope or laryngoscope; may also help confirm if there is any obstruction along one side of your sinuses

Head

Headache is a term used to describe pain in the head. It can be either unilateral or bilateral and affects both sides of the head, as well as other areas around it. Headaches may also be accompanied by nausea and sensitivity to light, noise or odors.

Headaches are often caused by pressure on an area of your brain called the sinus nerve, which runs from your forehead down through your cheeks and into each temple (the bony bumps near your ears). In some cases this pressure might cause you to have sharp pain followed by throbbing that lasts for hours at a time; otherwise it may feel like mild discomfort that comes on suddenly but goes away quickly after being relieved by movement such as bending over or taking a nap. The severity of these headaches can vary widely depending on where they occur along this nerve path.*

Eyes

You can check for redness, swelling, discharge, eyelid abnormalities and pain.

• Ask the patient to open their eyes wide and look at an object near them (like a book or magazine) for 20 seconds. Then close their eyes and repeat the procedure. If there is no improvement in this test – then you should consider another diagnosis.

• Check vision by asking them to read a line on a chart while wearing glasses or contact lenses that have been covered with a small piece of paper so that they do not block out any light when reading off the chart; if this test shows that the patient’s vision is better than 20/20 in both eyes then no further tests will be needed at this time but if it shows otherwise then further investigations may be necessary depending on what signs are present in either eye(s). If no treatment has been started yet then these tests should be repeated after 24 hours have passed since starting treatment so as not to confuse symptoms caused by medication side effects with those caused by other causes such as infection etc..

Ears

The examination of the ears is done through an external otoscope and internal ear probe. An aural examination involves hearing tests, while an ophthalmic exam can help diagnose eye diseases that affect hearing as well.

Otoscopic examination

The outer ear canal (external auditory canal) is examined by inserting a lighted pen into your outer ear canal with a gentle pressure until you see it reflected in white light from within the closed organ. If it doesn’t appear illuminated, then you may have damaged or diseased tissue inside your canal which could lead to severe problems such as deafness in some cases! You may also experience pain when taking out one of these objects due to its size and shape; however this should only last for around 10 minutes at most before going back home where we can continue with our next step regarding your inner ear problems

Nose and Sinuses

To examine the nose, you should first look for any obvious signs of injury or illness. Some common injuries include:

• Broken nose

• Deviated septum (when one nostril is slightly larger than the other)

If you find anything that appears to be wrong with your nose and sinuses, take some time to evaluate what happened leading up to this condition. Ask yourself questions like “What did I do? How often did I do it? Was there anything else going on at this time?” You can also ask friends or family members who have had similar experiences if they have any helpful tips on managing these issues themselves.

Mouth and Throat

The mouth and throat are examined for a number of conditions, including:

• Tongue – yellowish-white discoloration due to a condition called glossitis

• Teeth – white spots on the crowns (crowns are the parts of your teeth that touch) may be caused by periodontal disease or an infection in your gums or mouth. They can also be caused by an injury to the gum tissue; if this happens, it may require treatment from a dentist or oral surgeon. These infections can affect anyone but tend especially toward older people who have had dental work done previously. If you’re concerned about these symptoms, see a doctor immediately!

Neck

The neck is a common site for swelling and tenderness. Swelling can be due to infection or cancer, while tenderness may be a sign of inflammation or arthritis.

The lymph nodes in your neck are relatively small compared to other parts of the body; they only contain about 3 mm3 (millilitres) of fluid. Lymph nodes are important because they filter fluid from nearby tissues, so if there’s excess fluid in these areas it could cause problems with breathing or swallowing. If you notice that any part of your jaw hurts when swallowing food or liquids, this could indicate an enlarged lymph node on one side of your mouth—a condition called primary lateral lymph node metastasis (PLM).

If you have PLM or another type of hematological cancer such as Hodgkin’s disease (Hodgkin’s Lymphoma), make sure that someone at work knows how long ago symptoms began so they can refer back later if necessary

Takeaway:

• Avoid over-the-counter eye drops and other products that can cause dryness or irritation to the eye.

• If you have any questions about your eyes, talk with an ophthalmologist or optometrist right away to determine if there is a problem with them and what treatment options might be available for it.

Conclusion

The most important thing to remember is that there are no “magic” tests for these conditions. A thorough history and physical exam performed by a trained professional can help you identify the problem, but it will not guarantee a diagnosis.