NRNP 6568 Epistaxis SOAP Note/Case Study: Synthesis in Advanced Nursing Practice Care of Patients in Family Care Settings 2021

Epistaxis SOAP Note/Case Study NRNP 6568: Synthesis in Advanced Nursing Practice Care of Patients in Family Care Settings 2021 CC: Nosebleed Onset: 1 hour ago Location: left nare Duration: after waking up this morning from bed Characteristics: active nasal bleeding Aggravating factors: no known Relieving factors: no known Treatment: pinching nares Severity: 0/10 Current medications/supplements: No medications Allergies: NKA PMHx: No medical history. Reports all immunizations up to date and had flu shot this year. Soc & Substance Hx: Pt is a middle school student who lives at home with his parents and older brother. He has no history of tobacco, alcohol or illicit drug use. He enjoys playing outdoors with his horses. He reports wearing seatbelt, no smokers in home, smoke detectors in home, CO detector in home, no guns/locked firearms in the home, appropriate supervision, uses proper safety for horse riding. Mother reports monitoring of computer and cell phone use. Fam Hx: Denies pertinent familial history. No history of cancer, asthma, allergies, or cardiac disease. Surgical Hx: No surgical history. Mental Hx: No history of anxiety, depression, suicidality or psychological disorders. Violence Hx: No concern or issues about safety in the home or at school. ROS: GENERAL: Denies fever, abnormal weight loss or gain, night sweats, headache, and fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. No itchiness, no discharge, no swelling, no redness, no blurred vision, and no photophobia. Ears, Nose, Throat: Denies hearing loss bilateral. Reports active nosebleed from left nare. Denies sneezing, nasal congestion, runny nose, or sore throat. SKIN: Denies rash, hives, swelling, eczema rash, insect bites, dry skin, flaking, and skin lesions. Reports pruritis bilateral ears. CARDIOVASCULAR: He reports no chest pain, cyanosis, palpitations, fainting, edema, rapid heart rate, and no heart murmurs. RESPIRATORY: No cough, wheezing, trouble breathing, chest tightness, chest pain, noisy breathing, and no stridor. NEUROLOGICAL: He reports no seizures, lethargy, dizziness, weakness, headache, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Vital signs: Ht: 57.5in Wt: 119 lbs BMI: 26.7 (overweight) General Appearance: General: healthy-appearing male, well-nourished, well-developed, and no acute distress. Skin: Skin in warm, dry and intact without rashes or lesions. Appropriate color for ethnicity. Nailbeds pink with no cyanosis or clubbing.