Shirley Williamson PDF

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ati debreifing questions...

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**Please type your answers in BLUE **Type NA if the category is Not Applicable

Date: 10/22/20 Student Name: Elizabeth Diaz

ATI Health Assess Patient:

1. What subjective data did you collect prior to beginning the physical assessment? ASSESSMENT DATA Comments/Responses:

Subjective: HEENT

GI

(i.e. Patient states, “my head has been hurting. Patient denies difficulty hearing. Patient reports increasing hair loss.) NA (i.e. Patient denies SOB.) Client states, “have trouble catching breath”, Client reports a thick yellow sputum with a productive cough. States cough has improved with admission. (i.e. Patient reports palpitations.) Client states that she has little to no energy since becoming ill with bronchitis. NA

GU

NA

NEURO

NA

MUSCULOSKELETAL

NA

INTEGUMENT

Client states “has a rash from eczema on her neck.” Client states “has redness on cheeks from steroids prescribed from doctor.” Pain is caused by soreness in chest from coughing. 2/10 on a number scale.

PULMONARY

CARDIOVASCULAR

PAIN (use symptom analysis: PQRST)

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2. What objective data did you collect during the physical assessment? PHYSICAL EXAMINATION Objective: GENERAL SURVEY: Appearance: Body Structure: Behavior

Client appears to be reported age. Alert and oriented. Symmetric facial features. N signs of acute distress. Patient sits comfortably. Full mobility of joints. Client maintains eye contact with appropriate expressions. Cooperative. Speech is clear. Client appears clean and well-groomed.

HEENT:

(i.e. Head in normocephalic, eyes are PERRLA, hearing are within normal limits, no drainage present on eyes, ears, or nose, Nose are patent, no palpable lymph nodes, the tongue is midline, buccal mucosa pink and moist, and trachea is midline.) NA RR 26. Breathing is symmetrical and the client is moving air efficiently. Chest expansion is equal. Wheezing heard anterior, right, and left lung at 4th and 5th mid-clavicular line and posterior, right and left lung at 6th, 7th, 8th, and 9th at scapular and post-axillary line. NA

PULMONARY:

CARDIOVASCULAR:

**Please type your answers in BLUE **Type NA if the category is Not Applicable GI:

NA

GU:

NA

NEURO:

NA

MUSKULOSKELETAL:

NA

SKIN/MUCOUS MEMBRANES:

Client has a rash from eczema on her neck measuring 4cm long and 2cm wide. Client has erythema on cheeks from steroids prescribed from HCP. Skin was warm to the touch, intact, and symmetrical. Client is alert and orientated. Communication was clear.

PSYCHO-SOCIAL: EDUCATION: What did you teach this client & family and how did they respond?

Activity will resume as the doctor sees fit. Sitting up will assist in breathing.

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3. What did you chart in the EHR? Client’s Initials: _ SW_ DOB:6/1/1952 Age: _68._ Sex: _F _ Allergies: _None _ Ht: _ _ Wt: _ _ Culture/Religion: __ Marital Status: _Divorced_ Family support: yes or no

ETOH use: yes or no

Tobacco: yes or no

Other disciplines/consults caring for the client (e.g. Physical Therapy, OT, dietitian, Cardiology, etc) Vital Signs: T __

HR _90_

R _26_

BP__

Monitors: __

Code Status: _Full Code_

SPO2: _91_ Oxygen Therapy: 2L/min given by nasal cannula. 94 SP02 after given Reason for hospitalization: Clinical Diagnosis: Acute Bronchitis Nursing Problems: Summarize client’s past medical history & history of present illness:

Rate: _RR 26_

**Please type your answers in BLUE **Type NA if the category is Not Applicable (i.e. Age, gender, chief complaint, Location: Quality: Severity: Duration: Timing: Context: Modifying Factors: Associated Signs and Symptoms: Of Chief Complaints (PQRST), Past medical history, Past family history, Social History) Eczema. Age of diagnosis: 28. Exacerbations common on neck, torso, and upper extremities. Reports one-week history of fever, generalized fatigue, headache and gradually increasing dyspnea. Cough was initially dry but progressed to productive cough with mucopurulent, bloodstreaked sputum. Sternal area discomfort due to frequent coughing. Reports history of edema. __ Summarize hospital course/events from admission to present: (i.e. When did they arrive. Through what means? When were they admitted? Why were they admitted? Why are they still in the hospital? What is the plan of care?) __ Before admission, patient reports coughing up blood. Since admission, client states there is no longer blood but a thick yellow sputum. Therapeutic orders for day of care: Diet: __ Activity: __ IV Type & Site: __ Other (dressings, etc.) __ Education needs/discharge planning: (Include client and family) __ To help prevent the spread of this virus, wash your hands for 20 seconds with soap and water, or use an antibacterial hand sanitizer. Use a tissue or your elbow to cover a cough or sneeze, and wash your hands after. Drink lots of fluid. “A nonsteroidal anti-inflammatory drug,” (File, 2019).

File, T. M., Jr., MD. (2019). Patient education: Acute bronchitis in adults. Retrieved October 23, 2020, from https://www.uptodate.com/contents/acute-bronchitis-in-adults-beyond-thebasics...