Previous Medical:
TB- (as a child)- “was told it is sleeping”
Family Hx– mum- alive- diabetic, sleeping TB, dad- died 2 years ago in a snowmobile accident
Medications: None,
Immunizations: Fully immunized and up to date
Allergies: Penicillin- rash reaction
Presenting complaint:“I noticed this lump on my face” (LEFT SIDE OF FACE)
History of complaint:
Onset- “started last week, just keeps getting bigger”
Provocative: “chewing makes it sore” “tried ice pack and cedar tea” “cedar is good for the immune system”
Quality: “dull, sharp when I chew” “even hurts my teeth”
Radiation: “moved from here (point to left side) and down my neck, into my jaw”
Severity: now- 5/10, worse 8/10
Taken Tylenol and Ibuprofen “helped a little bit”
**No night sweats, no change in weight
ON EXAMINATION (Objective)
Temp- 37.6, RR 16, HR- 100, BP 122/71, 02- 98%
Sitting up, rubbing left side of face and neck at times. Appears uncomfortable. Skin warm and dry. Well perfused.
Skull: normocephalic, TMJ opens smooth, but pain on opening and closing. Face: swelling to left side of face, no redness, no lesions or wounds noted.
Neck: symmetrical, trachea midline, full ROM- painful jaw when turning head to left side
Lymphodes:
Enlarged, nontender, but moderately painful partoid glands. (Golf ball sized)
Nodes in periaricular, submental and submandibular palpable, > 1cm by 1cm, tender to touch, mobile and soft.
- Write a SOAP note using the information provided above.
| Section | Information |
| Subjective | (TB)”was told it is sleeping”,
“I noticed this lump on my face” (LEFT SIDE OF FACE) “started last week, just keeps getting bigger” “chewing makes it sore” “tried ice pack and cedar tea” “cedar is good for the immune system” “dull, sharp when I chew” “even hurts my teeth”, “moved from here (point to left side) and down my neck, into my jaw” (Tylenol and Ibuprofen) “helped a little bit” |
| Objective | No night sweats, no change in weight
Temp- 37.6, RR 16, HR- 100, BP 122/71, 02- 98% Sitting up, rubbing left side of face and neck at times Appears uncomfortable. Skin warm and dry. Well perfused. Skull: normocephalic, TMJ opens smooth, but pain on opening and closing. Face: swelling to left side of face, no redness, no lesions or wounds noted. Neck: symmetrical, trachea midline, full ROM- painful jaw when turning head to left side Lymphodes: Enlarged, nontender, but moderately painful parotid glands. (Golf ball sized) Nodes in periaricular, submental and submandibular palpable, > 1cm by 1cm, tender to touch, mobile and soft.
|
| Assessment | Acute Pain related to swelling of parotid gland as evidenced by pain and tenderness |
| Plan | Contact physician regarding finding and solution to reduce pain.
Educate patient on proper steps to take to reduce swelling
Monitor swelling, pain levels and vital signs to make they remain stable |
- Write one priority NANDA diagnosis. Please use the NANDA Diagnosis Definitions and Classification 2021-2023 (Twelfth Edition) to support the development of your NANDA statement.
- Ineffective lymphedema self-management related to pain as evidenced by swelling.
- Risk for infection related to swelling and pain getting worse as evidenced by uncomfortable appearance.