SHADOW HEALTH: FOCUSED EXAM: COUGH - WEEK 7 (DANNY RIVERA)

SUBJECTIVE DATA COLLECTION

PATIENT DATA

CHIEF COMPLAINT

Established chief complaint

What brings you to the Nurse's office today?

EMPATHIZE

I am sorry you're not feeling well.

Can you rate your current pain level on a scale of 0 to 10?

HISTORY OF PRESENT ILLNESS

Asked about onset of cough

Asked about frequency and duration of cough

When did the cough start?

How often are you coughing?

How long does the coughing last?

Asked about character of cough

Is your cough wet or dry?

Do you cough up sputum?

Asked about aggravating factors of cough?

Do you know what is making the cough worse?

Asked about exposure to germs

Asked about hand hygiene

Asked about cough etiquette

Have you been around anyone sick?

EDUCATE

Hand hygiene is very is very important. Make sure to wash your hands with soap and water before, during, and after preparing food, before and after eating food, before and after treating a cut or wound, or after contact with someone who is ill.

Do you cover your mouth when you cough?

EDUCATE

It is important to cover your mouth and nose when you cough or sneeze to help stop the spread of germs.

Asked about relieving factors for cough

What helps relieve your cough?

Followed up on cough medicine

What color is the medicine?

How often are you taking the cough medicine?

EMPATHIZE

I am sorry to hear that. Thanks for telling me what you know about the medications you take. I will ask your mom for more information.

***Patient answers***

EDUCATE

Make sure your mom is present while you are taking your cough medication and your vitamins. It is important to take the correct dosage.

Do you take any vitamins or supplements?

EDUCATE

Taking vitamins can be good for you. However, taking too many vitamins can be bad for you. It is best to take the amount of vitamins your mother gives you.

Asked about activity level

Are you usually active?

Have you been less active since getting sick?

Are you able to keep up when you play with your classmates?

Are you able to focus in class?

Asked about nasal symptoms

Are you having any nasal symptoms?

Have you been sneezing?

How often do you have a runny nose?

Followed up on nasal discharge

What color is your snot?

What is the consistency of your nasal discharge?

Asked about ear symptoms

Followed up on ear pain

Do you have ear pain?

Have you ever had ear infections?

Do you have ear discharge?

Do you have any hearing problems?

Asked about throat symptoms.

Do you have a sore throat?

Do you have trouble swallowing?

EMPATHIZE

I am sorry your throat is sore. I will look at your throat and see if we can help you feel better.

Asked about allergies

Do you have any seasonal allergies?

Do you have any food allergies?

Are you allergic to any medications?

Do you have any animal allergies?

Do you have a latex allergy?

PAST MEDICAL HISTORY

Asked about relevant medical history

Does your family have a history of asthma?

Do you have a family history of allergies?

EDUCATE

It is unfortunate that your father smokes at home. It sounds like it bothers you. Breathing in smoke is not healthy, so it is good to stay out of rooms or other places where you can smell cigar smoke.

REVIEW OF SYSTEMS

Asked about constitutional health

Do you have fever?

Do you have chills?

Do you have night sweats?

Have you lost weight loss recently?

Do you have an appetite?

Asked about review of systems for HEENT

Do you have any ear popping or crackling?

Do you have a history of ear infections?

Do you have headaches?

Do you have nosebleeds?

Do you have any vision problems?

Are you experiencing dizziness?

Do you have watery eyes?

Do you have eye redness?

Do you have eye pain?

Do you have sinus pain?

Asked about review of systems for respiratory

Do you have difficulty breathing?

Do you have chest tightness?

Do you have chest pain?

VITAL SIGNS

Temp (<38 C)

37.2 C/ 99.0 F

BP (<120/80)

120/76

HR (60-100)

100

Pulse Rate

91 mmHg

RR (12-20)

28

O2 Sat (>94%)

96%

SPIROMETER

FEV1: 1.549 L, FVC 1.78 L (FEV1/FEVC: 87%)

OBJECTIVE DATA COLLECTION

PATIENT DATA

Inspected eyes and orbital area

Orbital Area

No visible abnormal findings

Sclera

White

Conjunctiva

Moist and Pink

Conjunctival Discharge

No discharge

Inspected ears

Right: Auditory Canal Color

Pink

Right: Tympanic Membrane Color

Pearly gray

Right: Tympanic Membrane Appearance

No visible abnormal findings

Right: Cone of Light

5:00

Right: Discharge

No discharge

Left: Auditory Canal Color

Pink

Left: Tympanic Membrane Color

Pearly gray

Left: Tympanic Membrane Appearance

No visible abnormal findings

Left: Cone of Light

7:00

Left: Discharge

No discharge

Inspected nasal cavities

Color

Pink

Discharge

Clear discharge

Turbinate patency

Patent

Observations

No additional visible abnormal findings

Inspected mouth and throat

Oral Mucosa

Moist and pink

Tonsils

No visible abnormal findings

Throat Color

Red

Throat Texture

Cobblestoning

Post Nasal Drip

No discharge

Inspected neck

Symmetry

Symmetric

Appearance

No visible abnormal findings

Inspected chest

Symmetry

Symmetric

Appearance

No visible abnormal findings

Palpated sinuses

Frontal

None reported

Maxillary

None reported

Palpated lymph nodes

Head And Neck

Palpable nodes on right side

Supraclavicular

No palpable nodes

Axillary

No palpable nodes

Palpated fremitus

Symmetry

Equal bilaterally

Vibration

Expected fremitus

Palpated chest expansion

Symmetry

Equal bilaterally

Auscultated breath sounds

Breath Sounds

Present in all areas

Adventitious Sounds

No adventitious sounds

Location

All areas clear

Auscultated for bronchoscopy

Bronchophony

Negative

Auscultated heart sounds

Heart Sounds

S1 and S2 audible

Extra Heart Sounds

No extra sounds

Percussed chest wall

Observations

All areas resonant

Location

No areas of dullness

Measured diaphragmatic excursion

Range

3-5 cm

CARE PLAN

DATA

Nursing Diagnosis

Diagnosis

Risk for infection

Signs & Symptoms

Exposure to sick classmate

Excessive mucus production (cough, sore throat, mild pain with swallowing, nasal discharge)

Lack of infection prevention strategies

Exposure to parasitic infection

Planning

Short-Term Goal

Ask patient and famiy members to verbalize and agree to their instructions on infection prevention and respiratory hygiene.

Six (6) Interventions

Instruct family and patient to wash hands for 20 seconds or use hand sanitizer before eating and after using the restroom.

Instruct family and patient that patient should increase fluid intake.

Instruct family to keep their house smoke-free, reducing exposure to respiratory irritants.

Instruct patient to wash hands for 20 seconds or use hand sanitizer after coughing or being near someone sick.

Instruct patient to avoid touching fingers to eyes, nose or mouth.

Instruct patient to cough into tissue, or sleeve if tissue is unavailable.

Rationale

These interventions will teach Danny and his guardian(s) how to keep themselves healthy and prevent the spread of germs and infections.

Data Collections

Ask patient and family members to verbalize and agree to their instructions on infection prevention and respiratory hygiene.

Intervention and Evaluation

Partially