Shadow Health: Focused Exam on Cough

SHADOW HEALTH: FOCUSED EXAM SUBJECTIVE DATA COLLECTION PATIENT DATA What brings you to the Nurse's office today? CHIEF COMPLAINT Established chief complaint 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? Have you been around anyone sick? Asked about exposure to germs Asked about hand hygiene Asked about cough etiquette 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? 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*** Followed up on cough medicine 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? Do you have ear pain? Have you ever had ear infections? 1/5 Asked about ear symptoms Followed up on ear pain Do you have ear discharge? Do you have any hearing problems? Do you have a sore throat? Do you have trouble swallowing? Asked about throat symptoms. EMPATHIZE I am sorry your throat is sore. I will look at your throat and see if we can help you feel better. 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? Asked about allergies Does your family have a history of asthma? Do you have a family history of allergies? PAST MEDICAL HISTORY Asked about relevant medical history 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? Temp (<38 C) 37.2 C/ 99.0 F BP (<120/80) 120/76 HR (60-100) 100 VITAL SIGNS 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 2/5 Orbital Area No visible abnormal findings Sclera White Inspected eyes and orbital area Conjunctiva Moist and Pink Conjunctival Discharge No discharge 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 Inspected ears 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 Color Pink Discharge Clear discharge Inspected nasal cavities Turbinate patency Patent Observations No additional visible abnormal findings Oral Mucosa Moist and pink Tonsils No visible abnormal findings Inspected mouth and throat Throat Color Red Throat Texture Cobblestoning 3/5 Post Nasal Drip No discharge Symmetry Symmetric Inspected neck Appearance No visible abnormal findings Symmetry Symmetric Inspected chest Appearance No visible abnormal findings Frontal None reported Palpated sinuses Maxillary None reported Head And Neck Palpable nodes on right side Supraclavicular No palpable nodes Palpated lymph nodes Axillary No palpable nodes Symmetry Equal bilaterally Palpated fremitus Vibration Expected fremitus Symmetry Equal bilaterally Palpated chest expansion Breath Sounds Present in all areas Adventitious Sounds No adventitious sounds Auscultated breath sounds Location All areas clear Bronchophony Negative Auscultated for bronchoscopy Heart Sounds S1 and S2 audible Auscultated heart sounds Extra Heart Sounds No extra sounds Observations All areas resonant Percussed chest wall Location No areas of dullness Measured diaphragmatic excursion Range 3-5 cm CARE PLAN DATA 4/5 Diagnosis Risk for infection Nursing Diagnosis 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 Short-Term Goal Ask patient and famiy members to verbalize and agree to their instructions on infection prevention and respiratory hygiene. Planning 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 5/5