SOAP NOTE NOSE notes are the typical format for documenting your…

Question Answered step-by-step SOAP NOTE NOSE notes are the typical format for documenting your… SOAP NOTE NOSE notes are the typical format for documenting your findings and interactions with patients and other providers.  S is subjective; please write 5 subjective questions you can ask your patient-specific to this topicO is objective, please list 5 objective assessments to aid in making a clinical judgment A is assessment please list 5 potential red flags that one can find during this assessmentP is the plan, please list 5 things you can educate your patient on specific to this topicSUBJECTIVE:1. Have you noticed any change in your smelly lately?2. Have you had any drainage from your nose?3. Do you have a history of frequent nose infections?4. Does anyone smoke in your household?5. Have you ever experienced ringing or Tinnitus in your nose?OBJECTIVE:1. Perform any smelling inspection of nose looking insides your nose2. Perform nose inspection with otoscope of tympanic membrane looking for size, shape, color and intactness of tympanic membrane.3. Perform Rhinne and Weber test to assess for bone conduction versus air conduction of smeling.4. Conduct whisper voice test assessing for auditory acuity.5. Palpate external nose for pain and presence of lesions or nodules.ASSESSMENT:1. On inspection patient may have area of erythema or edema relating to an infectious process or lesion and moles that could be secondary to over exposure of area to sun.2. Tympanic membrane could appear pink or red via otoscope indicating infection or may have scarring due to old infection. Tympanic membrane could also have tear or distorted shape due to ruptured membrane from untreated infection.3. If air conduction is not greater than bone conduction, possible indication of significant hearing loss and patient should be referred to audiologist for further evaluation.4. A failed whisper voice test could indicate that the patient has a hearing impairment that they have been compensating for by reading lips or facial cues and now should be further evaluated by audiologist.5. By palpating the external nose, the nurse is assessing for pain or tenderness and might also be able to detect any mass or lesion on the external nose.Plan:1. Educate patient that annual smelly test should be performed at primary care providers exam.2. Educate patient to use nose protection such as nose plugs is they work in an environment that has noise pollution.3. Educate patient that smells aids should be removed each night and to reach out to specialist if they feel irritation at site of device.4. Educate patient that proper sun protective aids should be used on all exposed areas of skin to prevent the development of carcinomas.5. Educate patient regarding the importance of cleaning external nose with soap and water, especially any area of nose that might have piercings and discourage patient from using products such as Q tips to clean inner nose . Health Science Science Nursing Share QuestionEmailCopy link Comments (0)