NSG 3012 Week 2 Project – Assessment of the Tympanic Membrane and Thyroid Gland

Health assessment is essential and often the first step in examining the patient’s problem. It helps to identify the key needs and interests of patients. In fact, through health assessment, the health professional is able to conduct the appropriate examination and come up with a clear determination of a medical condition (Jarvis, 2015). That being said, this paper focuses on health assessment, mainly the assessment components, possible conditions, and SOAP documentation of the tympanic membrane and thyroid gland to enhance its diagnosis and management.

Health Assessment Histories

A health assessment can be defined as a care plan that identifies the particular requirements of an individual and how those requirements will be addressed through a methodical consideration of a well-versed nursing facility or healthcare system (Jarvis, 2015). It involves the evaluation of health conditions by conducting a physical examination after looking at health history. The purpose of obtaining a health history is to collect subjective information regarding the patient so that the health care team and the patient can supportively come up with a care plan that will promote health, address acute health complications, and reduce chronic health conditions.

When conducting a health assessment, there are various health histories obtained. These include the demographics, historical background of the existing health problem, past health history, family history, and functional assessment (Martini et al., 2018). Demographic information comprises the name, age, occupation and marital status of the patient. Then, the history of the present health concern focuses on the key complaint, the start of the current health concern, duration, the progress of the health concern, causes, symptoms and comorbidities, medications, and approaches to manage the present health concern. The past history is all about the reactions, latest hospitalizations, chronic disease, emotional or psychological complications, present treatment and substance use (Wilson & Giddens, 2013). Family history involves the related health condition of family members and related family history of chronic diseases. Last but not least, the functional assessment includes activities or exercises, rest, interpersonal relations, nutrition, stress management, and environmental risks.

Findings for the Tympanic Membrane

The tympanic membrane is a structure in the human ear, usually referred to as the eardrum. It is a thin, circular structure that splits the middle ear and the external ear. This component enables the transmission of sound from the external environment to the internal parts of the ear. The membrane not only converts vibration in the environment into a signal that is detected in the ear and human brains. With its insignificant mass and size, the tympanic membrane is extremely strong and flexible and hard to damage beyond repair (Schweinfurth, 2018).

Tympanic membrane perforation is one of the major conditions that affect the membrane due to trauma, external damage or infection. The condition is either chronic or temporary, with effects that differ in position and size on the eardrum’s surface. Cordas et al. (2012) assert that most cases of tympanic membrane perforation arise because of contamination of the eardrum; however, other risk factors can cause this condition. This may include exposure to high-pressure liquid, inconsiderate wax removal or ear cleaning, and blows to the ears. An early tympanic perforation is not painful even though it leads to decreased hearing, the spread of infection and perceptible hooting sounds. On the other hand, acute tympanic perforation leads to serious effects and even causes deafness. Treating a tympanic membrane perforation involves minor surgery.

Cholesteatoma is another condition related to the tympanic membrane. The condition involves the growth of skin cells in the middle ear behind the eardrum (Schweinfurth, 2018). It is normally caused by a recurrent infection that brings about ingrowth of the skin in the eardrum. At the beginning of this condition, the ear may drain, occasionally with a foul stench. As it escalates, the condition leads to increased pressure in the ear, along with tinnitus and hearing loss. There may be a slight pain behind or inside the ear, and this may generate significant uneasiness. Over time, the cholesteatoma can enlarge and damage the adjacent subtle bones of the middle ear. A persistent cholesteatoma growth can result in dizziness, hearing loss and facial muscle paralysis. The condition should not be ignored as the infection can spread to the inner ear and brain, further leading to brain inflammation, deafness, meningitis and even death (Cordas et al., 2012). Initial treatment may encompass the use of antibiotics and thorough cleaning of the ear. Therapy is purposed to prevent more drainage in the ear by reducing the infection.

NSG 3012 Week 2 Project – Assessment of the Tympanic Membrane and Thyroid Gland

Thyroid Gland Examination

The thyroid gland is a butterfly-shaped component on the neck that is responsible for generating and discharging thyroid hormones into the blood veins. Hyperthyroidism is a condition related to the thyroid gland, involving extreme production of thyroid hormones in the bloodstream (Stanford Medicine, 2019). The condition is treatable using various medications.

The examination of the thyroid gland involves two key stages: inspection and palpation. Inspection is carried out using an anterior approach and lateral examination of the anterior gland. During the inspection, the patient is asked about the history of thyroid concerns, thyroid levels, and the previous treatment approach. Palpation involves the physical assessment of the body surface (Jarvis, 2015). Through palpation, the practitioner can examine a part of an organ or body by feeling its tenderness, texture, and size. Similar to inspection, this approach comprises both anterior and posterior examination.

There is no benefit of using either the anterior method or posterior method during thyroid gland examination. In fact, it depends on which approach is preferred by the practitioner. While using the anterior method, the physician would identify the thyroid isthmus by palpating between the suprasternal notch and the cricoid cartilage using the fingers. On the contrary, when using the posterior method, the practitioner stands behind the patient and tries to locate the thyroid isthmus using his or her hands to feel the texture and size of the thyroid (Stanford Medicine, 2019).

SOAP Documentation

SOAP is a recording approach used by practitioners for writing down notes in the patient’s charts. It comprises four components: subjective, objective, assessment, and plan (Jarvis, 2015). These elements are used differently and control the patient’s medical examination from the start of the condition to the treatment and diagnosis. The subjective element is focused on the intentions of a patient to seek medical help and involves the identification of the patient’s chief complaint. The objective component consists of the information that the physician obtains from the patient, such as present signs and symptoms. The assessment element is concerned with the previous diagnosis and the etiologies of the patient’s illness. Lastly, the plan contains the treatment approach implemented by the physician to address the patient’s problems. This component can also encompass lab reports, referrals, procedures and medications. The following is an example of hyperthyroidism SOAP:

Subjective: The patient reports diminutive but continual discomfort at the neck part and swelling of the neck.

Objective: Goiter detected on palpation, no apparent distress, no edema.

Test checks for levels of thyroxine (T4), triodothyronine (T3), and thyroid-stimulating hormone (TSH) (Cordas et al., 2012).

Assessment: Hyperthyroidism, with family history or lab test or past medical history symptomatic of Grave’s disease.

Plan: Prescribe antithyroid medications, proper diet, monitor thyroid-stimulating hormone (TSH) after one to three months, prefer radioactive iodine treatment if necessary, and consider thyroid lobectomy if the levels of thyroid hormones do not change (Cordas et al., 2012).

Laboratory tests that may be used for screening clients:

Data obtained from inspection using the anterior and posterior method Slight indications of Goiter with a level less than 2mm

Goiter detected, perhaps two times normal, with a level more than 2mm Indecisive

NSG 3012 Week 2 Project – Assessment of the Tympanic Membrane and Thyroid Gland

Conclusion

Indeed, a health assessment is an essential medical activity which results in an effective treatment approach. As discussed in this project, it is important to obtain the patient’s health assessment history before carrying out a physical examination and eventually conducting a laboratory test for a decisive diagnosis to be developed. The discussion has also included the assessment components, possible conditions, and SOAP documentation of the tympanic membrane and thyroid gland. With the insights from this project, it would be easy to come up with a proper care plan.

References

Cordas, E. A., Ng, L., Hernandez, A., Kaneshige, M., Cheng, S. Y., & Forrest, D. (2012).

Thyroid hormone receptors control the developmental maturation of the middle ear and the size of the ossicular bones. Endocrinology, 153(3), 1548–1560. doi:10.1210/en.2011- 1834

Jarvis, C. (2015). Physical examination & health assessment. St. Louis, Mo: Saunders Elsevier.

Martini, F., Nath, J. L., Bartholomew, E. F., Ober, W. C., Ober, C. E., Welch, K., & Hutchings, T. (2018). Fundamentals of anatomy & physiology. New York: Pearson.

Schweinfurth, J. (2018). Myringitis (Middle Ear, Tympanic Membrane, Inflammation): Practice Essentials, Pathophysiology, Epidemiology. Retrieved from https://emedicine.medscape.com/article/858558-overview

Stanford Medicine. (2019). Thyroid Exam. Retrieved from https://stanfordmedicine25.stanford.edu/the25/thyroid.html

Wilson, S. F., & Giddens, J. F. (2013). Health assessment for nursing practice. St. Louis, Mo: Mosby.

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

Question

For this assignment, perform a complete head-to-toe assessment on someone of your choice or a hypothetical person who has at least two (2) systems issues. Use the head-to-toe template here to document your assessment (add more lines as needed). In a Microsoft Word document of 4-5 pages