Axilla: No palpable nodules (bilaterally). Cardiovascular: Neck: The jugular veins are inspected, the carotid pulse is heard, no evidence of impairment. Pulses are regular. No JVD observed. Heart: Regular rhythm and the heart rate is 69/min. Spotlights the aortic, pulmonary and tricuspid are heard, no abnormal heart sounds are find. No murmurs found. Upper and lower extremities inspected, no edema observed. Abdomen: Abdomen is flat, follows respiratory movements and coughing fits regularly. No visible or palpable hernia, but presence some stretch mark were observed. No presence of collateral circulation, lesions and/or surgeries. Bowel sounds present at auscultation (11/min). No hepatomegaly, no distension, no hyper bloat or hypersensitivity at percussion and palpation. No painful on palpation superficially or deep, is soft and non-tender to palpation. Genitourinary : No abnormal findings in palpation and percussion. No sensitivity or pain at pressure in the hypogastria area. The bilateral flanks are negative to palpation and percussion. Genitalia (female genitalia): Not examined but patient denies discharges, hematuria, lymphadenopathies, lesions, rash, pruritus or inguinal hernia.
SOAP NOTE: PEDICULOSIS 6 Rectal: No examined but patient denies warts, hemorrhoids or bleeding. Diagnostic tests Dunphy, Windland-Brown, Porter and Thomas (2011) explains that diagnosis of pediculosis is based on both, the history of pruritus and the finding of white nits or lice on the hair shaft. The practitioner should search for lice and/or nits where the patient is complaining of pruritus. Gloves should be worn during this procedure. A Wood’s light exam can be done in a darkened room for mass screening but it requires a darkened room and protective eyewear for both the clinician and the child. Nits are much easier to see that live lice. If secondary bacterial infection (impetigo) is suspected (not in this patient), then bacterial cultures should be done with a standard culturette. Assessment Diagnosis Pediculosis : Dunphy et al. (2011) explains that it is estimated that to 10 million American children are infested with head lice alone each year. Pediculus humanus capitis (the head louse) is one of the three species of lice that infest humans and occur in people of all ages. Head lice are commonly seen in school-age children. The lice are blood-obligate parasites that obtain all their nutritional requirements from the host, reside, and reproduce on the human host. The outbreaks usually occur at the start of the school year and after winter and spring breaks. Head lice infestation averages about 10 lice per patient. In severe cases, they can number in the hundreds. Mayo Clinic (2016) explains that the infestation results from the direct transfer of lice from the hair of one person to the hair of another. The head lice infestation is not a sign of poor personal hygiene or an unclean living environment. Head lice do not carry bacterial or viral infectious diseases. Dunphy et al. (2011) inform that the head lice can survive just over 2 days off a human host, in which time die from dehydration. The louse may lay from 7-10 eggs per day for
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- Spring '18
- Nursing, Head louse, Pediculosis, Body louse, Louse, SOAP NURSE PRACTITIONER