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Shadow Health - Danny - Focused Exam Cough
West Chester University of Pennsylvania
Related Studylists
Shadow health, Tina jonesPreview text
Subjective Assessment
Chief Complaint Established chief complaint Reports cough History of Presenting Illness Asked about onset of cough Reports cough started 3 days ago Asked about characteristics of cough Reports cough is wet Reports clear sputum with coughing Asked about frequency and duration of cough
Reports coughing every few minutes Reports coughs last a few seconds (ex. How long do your coughs last?) Asked about aggravating factors for cough
Reports cough is worse at night Denies smoking (ex. Do you smoke?) Reports being exposed to secondhand smoke through father Reports he doesn’t’ know what triggers the cough Asked about exposure to germs Reports playing with an ill classmate Asked about hand hygiene Reports infrequent hand washing (ex. How often do you wash your hands?) Reports occasionally putting fingers in eyes, nose, or mouth (ex. Do you ever touch your eyes, nose, or mouth?) Asked about cough etiquette Denies covering mouth when coughing (ex. Do you cover your mouth when you cough?) Asked about relieving factors for cough Reports cough is temporarily relieved by cough medicine Followed up on cough medicine Reports cough medicine was purple Reports taking one spoonful of cough medicine (ex How much medicine did you take?) Reports mother gave him the medicine (ex. Who gave you the medicine for your cough?”) Reports only took the medicine this morning (ex. How many times have you taken the cough medicine?) Denies home remedies (ex. Have you tried any home remedies for your cough?) Ask about typical medication use Denies taking medication (ex. Do you take any medications from a doctor?) Reports taking daily vitamin (ex. Do you take vitamins?) Asked about activity level Reports typical high activity level (ex. Are you usually active?) Reports activity level low since getting sick (ex. Have you been less active since getting sick?) Reports still able to run or play (ex. Are you able to keep up when you play with your classmates?) Reports focusing in class is difficult (ex. Are you able to focus in class?) Asked about nasal symptoms Reports current runny nose Denies sneezing Followed up on nasal discharge Reports nasal discharge is clear (ex. What color is your snot?) Reports nasal discharge is thin (ex. What is the consistency of your nasal discharge?) Asked about ear symptoms Denies ear pain Reports history of frequent ear infections (ex. Have you ever had ear infections?) Denies ear discharge (ex. Do you have any ear discharge?) Denies hearing problems (ex. Do you have any hearing problems?)
Asked about throat symptoms Reports sore throat Reports a little pain with swallowing (ex. Does it hurt when you swallow?) Past Medical History Asked about relevant medical history Reports frequent runny nose Reports past frequent cough (ex. Do you have coughs very often?) Reports past pneumonia Denies asthma diagnosis Reports immunizations as current (Do you have current immunizations?) Asked about allergies Denies seasonal allergies (ex. Do you have seasonal allergies?) Denies food allergies (ex. Do you have food allergies?) Denies medication allergies (ex. Are you allergic to any medication?) Asked relevant family history Reports father has history of asthma Denies family history of allergies (ex. Do you have a family history of allergies?) Review of Systems Asked about constitutional health Denies chills (ex. Do you have chills?) Denies fever Reports feeling somewhat fatigued Denies night sweats (ex. Do you have night sweats?) Reports cough makes it difficult to sleep Denies swelling (ex. Have you noticed any swelling?) Asked about additional review of systems for HEENT
Reports frequent colds (ex. Do you have unusually frequent colds?) Denies headaches Denies nosebleeds (ex. Do you have nosebleeds?) Denies vision difficulty Denies dizziness (ex. Do you have any dizziness?) Denies watery eyes (ex. Do you have watery eyes?) Denies eye redness Denies eye pain Denies sinus pain Asked about review of systems for respiratory
Denies chest tightness (ex. Do you have chest tightness?) Denies chest pain Denies difficulty breathing Objective Assessment
Inspected eyes and orbital area Orbital area o No visible abnormal findings Sclera o White
Conjunctiva o Moist and pink Conjunctival discharge o No discharge
Inspected nasal cavities Color o Pink Discharge
o Clear discharge Turbinate Patency o Patent
Frontal o None reported
Maxillary o None reported
Palpated lymph nodes Head and neck o Palpable nodes on right side Supraclavicular o No palpable nodes
Axillary o No palpable nodes
Palpated fremitus Symmetry o Equal bilaterally
Vibration o Expected fremitus
Palpated chest expansion Symmetry o Equal bilaterally
Education & Empathy
Symptoms
o Empathy – “I’m sorry you’ve not been feeling well these past few days. Being sick isn’t fun, especially when it affects lots of different parts of your body. Let’s talk about what’s been happening, and we’ll figure out how to make you better.”
Family medical history
o Empathy – “Thank you for telling me about your family’s health. It’s completely understandable that you care for your family and don’t like hearing that their health isn’t perfect, especially with how your Papi smokes. You were really brave to tell us about that.”
Vitamins
o Education – “You’re right; taking vitamins can be good for you. However, sometimes taking too many vitamins can be bad for you. It’d be better if you don’t sneak extra vitamins – just take the amount that your mom gives you.”
Model Documentation
Subjective
Danny reports a cough lasting two to three days. He describes the cough as “watery and gurgly”. He reports the cough is worse at night and keeps him up. He reports general fatigue due to a lack of sleep. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.
Objective
General survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.
HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the tongue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva.
Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs
Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation.
Care Plan
Status - Is at risk for
Diagnosis - Infection
Etiologies - Played w/sick peer; Secondhand smoke; Touches face often; Rare hand washing
Signs & Symptoms – N/A
Self Assessment
While a cough can be unpleasant and frequent, it is actually a symptom of something more alarming: the immune system being at risk for an infection. The most effective nursing care you should prioritize is to educate your patient on avoiding this more serious outcome.
Planning
Short-Term Goal – To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit.
Interventions – Instruct family and patient on washing hands or using 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 environmental pathogens); Instruct patient on washing hands or using 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.
Intervention Rationale - These interventions will teach Danny and his guardian how to keep their hands and lungs clean in a variety of ways, so that Danny’s risk for infection is reduced as pathogens are eliminated.
Data Collections - Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene
Discussion of Care
Danny, given that you aren’t feeling well, we want to make sure you don’t develop an infection, with for you just means getting even sicker. We’re going to talk about the ways we can work to prevent that, especially focusing on your risk factors, which are just things that give you a bigger chance of being sick. Some of your risk factors are that you were near a sick friend, have been exposed to cigar smoke, could stand to wash your hands more, and have touched your face with your fingers. I know that sounds like a lot, but if we work together, reducing your risk factors for infection can be easy and effective.
Let’s talk about how we’re going to help you not get sicker! So, I’m going to have a conversation with you and your father about things to do to ensure your health. You, he, and I will work together to discuss, and then have you agree to your goals. Then I’m going to have you and your father repeat what you’ve learned, so we can make extra sure you’ve got it down pat!
Does this plan I just talked about sound good to you?
Danny, if you don’t have any other questions, we can start our discussion now!
Intervention & Evaluation
Partially – While Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of the house. One of his
Shadow Health - Danny - Focused Exam Cough
University: West Chester University of Pennsylvania
