Present a nursing situation in which you performed an initial assessment, including a pain assessment of a patient.

Present a nursing situation in which you performed an initial assessment, including a pain assessment of a patient. Describe the environmental feature(s), equipment, and cardinal technique(s) you used during the assessment. As you remember the patient and nursing situation, describe his/her general survey and mental status at the time of initial assessment. Also identify and describe the type of pain the patient had in this situation. How was this pain resolved? (3:1-7)

APA format in a SOAP Note format.  1 page long with questions as to which diagnosis would be accurate and why.  I have included the references I need 3 peer review articles to be included

Patient Information:

Initials: JS  Age: 11   Sex: M  Race: Caucasian

SJ

CC: Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.

HPI: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear.  The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.

Current Medications:

1.  Ibuprofen 600mg PRN for earache pain

Allergies: NKA

PMHx: Up to date on all immunizations. No significant PMH.

Soc Hx: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer.

Fam Hx: Maternal grandmother died of a stroke at the age of 70. No other significant family history.

ROS:

GENERAL: No fever, fatigue or chills. No weight loss.

HEENT: Eyes:  No visual loss, blurred vision, double vision or yellow sclerae. Ears: Patient reporting pain in right ear and hearing loss. Nose, Throat:  No sneezing, congestion, runny nose or sore throat.

SKIN: No rashes or itching.

RESPIRATORY:  No shortness of breath, cough or sputum.

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

LYMPHATICS:  No enlarged nodes. No history of splenectomy.

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

 
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