Respiratory Completed Shadow Health Tina Jones PDF

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Shadow health completed assessment - Tina Jones - respiratory...

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7/7/2021

Respiratory | Completed | Shadow Health

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Respiratory Results | Turned In Advanced Health Assessment - Summer 2021, NURS 6621 Return to Assignment (/assignments/482350/)

Your Results

Overview

Lab Pass (/assignment_attempts/10039731/lab_pass.

Subjective Data Collection: 21 of 21 (100.0%)

Transcript Subjective Data Collection

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy Documentation

Category

Scored Items

Patient Data Not Scored

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yi better patient data. The following details are facts o patient's case.

Chief Complaint

Established chief complaint

Reports increased breathing problems and shortness of breath Reports decreased effectiveness of inhaler

History of Presenting Illness

Asked about onset of symptoms

Asked about frequency and duration of SOB episodes

Reports symptoms began two days ago

Reports exacerbations lasting several minutes Reports exacerbated breathing about every 4 hours since original episode Reports waking up twice a night with asthma the past 2 nights

Asked about severity of symptoms

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Describes asthma severity as "not full attack," bu worse than usual

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Respiratory | Completed | Shadow Health Reports asthma has been interfering with activities of daily life

Asked about character of symptoms

Reports recent wheezing Reports chest tightness Denies chest pain

Asked about cough

Reports cough Cough has persisted since original asthma exacerbation 2 days ago Describes cough as "dry" Describes cough as "small" and not severe Reports cough slightly relieved by drinking water Has not treated cough with medication or home remedies

Asked about aggravating factors

Reports symptoms worse at night Reports symptoms increase when lying flat on back Reports symptoms aggravated by movement

Medical History

Confirmed use of medications

Followed up about inhaler use

Confirms medications (no new medications reported)

Uses an inhaler to treat asthma symptoms Inhaler is Proventil Reports most recent inhaler use was this mornin Reports using inhaler every 4 hours or so since exacerbation Prescribed usage is 2 puffs Reports needing more than 2 puffs to resolve asthma symptoms

Confirmed allergies

Followed up on exposure to allergy and asthma triggers

Confirms allergies (no new allergies reported)

Reports cat allergy triggered recent episodes Reports dust as a known trigger Reports activity such as walking up stairs as a known trigger Denies seasonal pattern Denies changes in weather as a trigger Reports minimal exposure to asthma triggers at work

Asked detailed questions about asthma history

No current asthma doctor Diagnosed with asthma in childhood Age of diagnosis was 2 1/2 years old

Asked about hospitalizations for asthma

Reports prior hospitalizations for asthma Reports last hospitalization was age 16 Estimates 5 total hospitalizations for asthma Reports she has never been intubated

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Respiratory | Completed | Shadow Health Followed up about non-medication forms of asthma management

Denies record keeping of asthma exacerbation o shortness of breath episodes Denies using peak flow meter Denies nebulizer use

Social Determinants of Health

Asked about environmental control

Reports living situation is tidy and free of dust Reports hypoallergenic bedding hygiene Reports avoiding animals and has no pets at home Reports avoiding exposure to secondhand smok

Social History

Asked about exercise and activity level

Reports general low activity level Reports diminished activity due to asthma

Asked about possible contributing factors in health history

Denies history of eczema Denies history of sinus problems Denies history of GERD, heartburn, or indigestion Denies history of COPD or emphysema

Asked about smoking, inhalants, or tobacco

Denies history of tobacco use, including cigarettes Reports past history of marijuana use Last use of marijuana was age 20 or 21 Denies inhaling substances

Review of Systems

Asked about general symptoms

Denies recent respiratory or other illness Denies fever Denies nausea or vomiting Denies chills Reports low energy level Denies night sweats

Asked review of systems for respiratory

Denies phlegm or sputum Denies sore throat, swelling, or difficulty swallowing Denies nasal drainage

Family History

Asked about relevant family history

Reports no recent illnesses with family members at home Reports younger sister as only family with asthm Reports younger sister as only family member with allergies Reports no family history of eczema Reports no family history of chronic nasal or sinu problems Reports no family history of COPD or emphysem

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7/7/2021

Respiratory | Completed | Shadow Health

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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