EENT System Case Study

 
 
 
   
                 

You are the RN on a busy orthopedic nursing unit.  Ward Schreiner, a 23 year old who is three days a post op for an open reduction and internal fixation (ORIF) for a left femur fracture. He broke his leg while snowboarding in the mountains over his college Spring Break !
Today, he is complaining of a “sore throat and feels all stuffed up”.  You assess for this new symptom. 

NOTE:  In another module, you will focus on the assessment of his circulatory, musculoskeletal, skin/wound and pain related to his left leg.  But for now…lets think EENT assessment. 

Current Vital Signs
Temperature 99.8
Pulse 76
Respiration 18
Blood pressure 135/70
Height 5’11”
Weight 165
BMI: 23
Alert, oriented. Attentive to questions and responds appropriately
   

 

Chief complaint: "My throat is sore and I’m all stuffed up ." 

traction guy

Past history: History of environmental allergies, primarily dust, mold and pollen. Takes allergy medications (Allegra, Benadryl). 

Allergic to Penicillin.

Recent travel to Rocky Mountains and exposure to extreme cold weather temperatures. 

Fractured nose in soccer game in high school.

Respirations: No increased effort in breathing noted. He does sniffle frequently and blow his nose several times during the interview.
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