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Shadow Health Asthma Exacerbation Gabriel Martinez Subjective Data
PTCntrdCare:Chldbearing family (NURS 438)
Shepherd University
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Focused Exam: Asthma Exacerbation Results | Turned In
Patient Centered Care Child and Families - Fall 2022, NURS 430
Return to Assignment (/assignments/659600/)
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Subjective Data Collection: 31 of 31 (100%)
Chief Complaint Patient
History of Present Illness Patient
Your Results Lab Pass (/assignment_attempts/13286927/lab_pass.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care Plan
Student Survey
Indicates an item that you found. Indicates an item that is available to be found.
Category Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yie better patient data. The following details are facts o patient's case.
Asked about patient's status Reports breathing is better Reports chest soreness
Followed up on symptoms Reports wheezing Reports coughing is less frequent Reports chest does not feel as tight
Followed up on onset of symptoms Reports symptoms started after playing kickball Reports full-on asthma attack began when he go home
Followed up on aggravating factors Reports secondhand smoke exposure Denies being around secondhand smoke normal
Hover To Reveal...
Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
Home Medications Patient
Social History Patient
Review of Relevant Systems Patient
History of Present Illness Guardian
Home Medications Guardian
Followed up on rescue inhaler adherence Reports carrying rescue inhaler with him in the past Reports throwing away the rescue inhaler a few weeks ago Reports disliking rescue inhaler because of side effects
Asked about side effects of rescue inhaler Reports rescue inhaler made him feel shaky Reports rescue inhaler made his heart beat fast
Asked about exercise Reports being mostly sedentary
Asked about living situation Reports living with mother in an apartment
Asked about patient's substance use Denies alcohol use Denies using tobacco products
Asked about education Reports being in 3rd grade
Asked about cardiovascular system Reports heart is racing
Asked about integumentary system Denies current skin problems Reports using prescription cream to treat skin
Asked about mental health Reports frustration with diagnosis
Followed up on patient's asthma diagnosis Reports patient has mild asthma Reports patient was diagnosed at age 5
Asked guardian to elaborate on severity of symptoms
Reports peak flow meter readings at home were 55%, 59%, and 60%
Asked guardian about pharmacological relieving factors for current exacerbation
Reports giving patient an extra dose of daily maintenance inhaler
Confirms home medications with guardian Confirms patient is prescribed a rescue inhaler Confirms patient is prescribed a maintenance inhaler
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Family Medical History Guardian
Review of Relevant Systems Guardian
Asked about relevant family medical history Denies family history of respiratory illness
Followed up on patient's integumentary system Reports patient is diagnosed with eczema
Comments
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Shadow Health Asthma Exacerbation Gabriel Martinez Subjective Data
Course: PTCntrdCare:Chldbearing family (NURS 438)
University: Shepherd University
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Students also viewed
- Newborn Case Study 2023-2024
- Shadow Health Asthma Exacerbation Gabriel Martinez Objective Data
- Shadow Health Asthma Exacerbation Gabriel Martinez Documentation
- Shadow Health Non-Reassuring Fetal Status Subjective Data
- Shadow Health Postpartum Care Objective Data
- Shadow Health Postpartum Care Education and Empathy