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focused exam cough transcript...

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Focused Exam: Cough Results | Turned In Health Assessment - Remediation/Refresher - January 2021, CCE 705 and 701 Return to Assignment (/assignments/432174/)

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Transcript Started: Apr 21, 2021 | Total Time: 125 min Subjective Data Collection All Lines (152)

Interview Questions (42)

Statements (9)

Exam Actions (101)

Objective Data Collection Education & Empathy

Hello!

Question 04/21/21 5:52 AM EDT

Documentation Care Plan Program Competency Progress

Hi. I'm Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.

What is the situation?

Question 04/21/21 5:53 AM EDT

Your patient is Danny Rivera, an 8-year-old Puerto Rican boy presenting with a cough in the Shadowville Elementary nurse's office. Your role in this simulation is that of a healthcare provider who will perform a focused history and physical examination in order to collect data, assess Danny's condition, and transfer care. In this simulation, you will be able to perform procedures not always typical to a school setting so you can gather as much data as possible.

What are my objectives in this assessment?

Question 04/21/21 5:53 AM EDT

Danny is very health literate and a good historian of his own health history; he can answer questions that not every child may be able to. In your interview with Danny, you will ask about the history of his presenting illness and the functioning of relevant systems in order to obtain subjective data related to his cough. If you discover any disease states, ask about symptoms and the patient's experiences of them. Your questioning should cover a broad array of the symptoms' characteristics. You will also inquire into the health history of Danny's family so you can determine his genetic predisposition to any diseases. In addition to collecting subjective data, you will perform a physical exam on Danny to gather objective data about his health and physiology. Throughout the conversation, you should educate and empathize with Danny when appropriate to increase his health literacy and sense of well-being. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.

What else will this exam involve?

Question 04/21/21 5:54 AM EDT

Because Danny is a pediatric patient, you will also be required to make a phone call to his guardian's home to gather additional information. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. You will then move onto the Care Plan activity, in which you will synthesize your subjective and objective data to complete the nursing process. You will develop a nursing diagnosis for Mr. Rivera's condition, identify a treatment goal, plan your interventions and evaluations, and finally assess if your goal was achieved. You may also need to call Danny's guardian again to involve them in his treatments. The Care Plan is just as important as your assessment, and the patient's well-being will be greatly affected by your diagnosis and interventions.

How will I be evaluated?

Question 04/21/21 5:54 AM EDT

The activities evaluated by the simulation are Subjective and Objective Data Collection, Education and Empathy, and the Care Plan activity. Nursing tasks and Documentation, while they provide valuable practice for their real-world counterparts, are not automatically evaluated by the simulation. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. Your success in Education and Empathy is based on whether you promptly respond after identifying a moment worthy of therapeutic communication. Your success in the Care Plan activity is based on whether you accurately identify Mr. Rivera's nursing diagnosis, select a goal most immediately beneficial to him, select and prioritize the most effective treatments, and accurately evaluate your results. The Care Plan will make up a signficant part of your grade, so be sure to carefully choose your answers based on evidence. This assignment takes on average between 80 and 100 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.

How does this assignment prepare me for the real world?

Question 04/21/21 5:54 AM EDT

In this assessment, you will familiarize yourself with the structure and content of a cough focused exam so that with real-life patients, you can: º ask effective and comprehensive questions º obtain and assess objective data º educate and empathize with the patient º develop a nursing diagnosis º create an effective and expedient care plan º and evaluate your results to determine your goal's achievement. In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: What strategies can you use to develop rapport with a pediatric patient? Build relationships with the patient, get on their level, do your homework, create a comfortable environment

Statement 04/21/21 5:59 AM EDT

Time to begin.

Hello, my name is emily and i'll be your nurse today.

Greet 04/21/21 5:59 AM EDT

Hi.

Can you tell me your name and date of birth?

Question 04/21/21 6:00 AM EDT

My name is Danny, and I was born on March 4th in, um . . . [Danny reports correct birth year.]

Perfect. What brings you in today danny?

Question 04/21/21 6:00 AM EDT

My music teacher Mr. Hillman sent me here because he said I look sick. I have been coughing a lot. . . and I feel kinda tired.

Oh no i'm sorry to hear this

Empathize

Thank you.

When did you first start coughing?

Question 04/21/21 6:01 AM EDT

I think the cough started two . . . No, it started three days ago.

Are they consistent or is it every now and then? (No matching questions found.)

Question 04/21/21 6:02 AM EDT

How often are you coughing?

Question 04/21/21 6:02 AM EDT

I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.

Is there any mucus? (Clarified to Does your cough produce mucus?.)

Question 04/21/21 6:02 AM EDT

Is that the gross, slimy stuff? Yeah, I've been coughing some of that up. It's clear. (Clarified to if I cough up mucus.)

Is there any smell to the mucus?

Question 04/21/21 6:03 AM EDT

No way. [AUDIO COMING SOON]

Have you been around anyone that has been sick?

Question 04/21/21 6:03 AM EDT

I think my friend, Cindy, might have been sick when we were hanging out the other day. She kept coughing and her nose was runny.

how often do you wash your hands?

Question 04/21/21 6:04 AM EDT

Not a lot. I only wash them if they're really dirty, or Abuela says we're about to eat.

deo you cover your mouth when you couch (Clarified to Do you cover your mouth when you cough?.)

Question 04/21/21 6:04 AM EDT

When I cough, I like to let it all out. (Clarified to if I cover my mouth when I cough.)

Its very important to always wash your hands, this can help to get rid of germs

Educate 04/21/21 6:05 AM EDT

OK, now I'm smarter, thanks!

Also make sure you are covering your mouth with a napkin or your sleeve to help prevent the spread

Educate 04/21/21 6:05 AM EDT

Oh, that's smart.

Have you taken any medicine?

Question 04/21/21 6:06 AM EDT

My mom gave me some medicine this morning. . . that helped my cough a little. I don't remember what it was called though, sorry.

What typical medication do you use at home?

Question 04/21/21 6:06 AM EDT

My mom gave me some medicine this morning. . . that helped my cough a little. I don't remember what it was called though, sorry.

Do you take any other medications at home?

Question 04/21/21 6:07 AM EDT

I don't take any medicines every day. I take my vitamins though. I eat a lot of them to be really healthy. And my mom gave me cough medicine this morning. It's purple and tastes gross, but it makes my cough better for a little while.

Do you exercise or play sports? (Clarified to Do you exercise?.)

Question 04/21/21 6:07 AM EDT

I have gym class every day. I do all my exercises there. Abuela always has to remind me to play outside for a little bit on the weekends. . . I guess I like to play inside more. (Clarified to if I exercise.)

Do you play sports?

Question 04/21/21 6:07 AM EDT

I don't really play any sports on a team or anything. I like to shoot hoops and ride my skateboard with Tony sometimes. But most of the time we play video games.

Have you had any ear problems?

Question 04/21/21 6:08 AM EDT

Mom said I had ear infections a lot. . . when I was baby, but not now. Now they're fine.

Thats good to hear!

Empathize 04/21/21 6:08 AM EDT

Yeah, thank you.

Have you had a sore throat at all?

Question 04/21/21 6:08 AM EDT

It feels a little bit sore, yeah.

Do you know your past medical history? (Clarified to Have you had health problems in the past?.)

Question 04/21/21 6:09 AM EDT

I had to go to a doctor last year when I had pneumonia. My mom was really worried. (Clarified to if I have had past health problems.)

Do you have any allergies

Question 04/21/21 6:09 AM EDT

I don't think I have any allergies.

does your family have any health problems

Question 04/21/21 6:10 AM EDT

My mom's got diabetes, cholesterol, and high blood pressure. Papi talks about his cholesterol sometimes, and he smokes cigars. I know that's bad, especially because mom says he had asthma when he was little. Probably my age. Uch, it sounds like a lot when I say it altogether like that. . .

What did your throat feel like when it was sore? (Clarified to Describe your sore throat?.)

My throat is a little bit sore, but just a little bit. (Clarified to what my sore throat is like.)

Question 04/21/21 6:10 AM EDT

Have you had any breathing problems

Question 04/21/21 6:11 AM EDT

I breathe OK, but my nose is always kinda runny.

When does your nose run the most

Question 04/21/21 6:11 AM EDT

I don't know what makes it run; it just does sometimes.

What color is your nose drainage?

Question 04/21/21 6:11 AM EDT

You mean like when I blow my nose? It's clear.

okay thats good

Empathize 04/21/21 6:11 AM EDT

Thanks.

Washed hands.

do you have headaches

Exam Action 04/21/21 6:12 AM EDT

Question 04/21/21 6:12 AM EDT

I don't usually get headaches.

any nose bleeds

Question 04/21/21 6:12 AM EDT

Just one time. Tony and I were kicking a ball at recess and I got hit in the nose.

and vision changes (Clarified to Has your vision changed?.)

Question 04/21/21 6:13 AM EDT

No, I see really good. Oh, I mean, I see well. I think glasses are kind of cool though. My friend Tony has them. (Clarified to if my vision has changed.)

do you ever get dizzy

Question 04/21/21 6:13 AM EDT

I only get dizzy if I'm spinning around a lot at recess.

do your eyes ever hurt

Question 04/21/21 6:13 AM EDT

No, my eyes don't hurt, but they kind of feel like they do when I'm tired.

how are you sleeping

Question 04/21/21 6:13 AM EDT

Most times I sleep OK, but I haven't been able to sleep much because of my cough.

have you been tired

I've been tired the past few days since my cough started. I can't fall asleep much because I cough more at night.

Question 04/21/21 6:13 AM EDT

have you had a fever at all (Clarified to Have you had a fever?.)

Question 04/21/21 6:14 AM EDT

My mom said I didn't have a fever before I came to school. . . she took my temperature. (Clarified to if I have had a fever.)

do you have any food allergies

Question 04/21/21 6:14 AM EDT

I'm pretty sure I'm not allergic to any foods. I think I would know about that!

have you ever had asthma

Question 04/21/21 6:14 AM EDT

No. But my mom says Papi had asthma when he was a little kid. He shouldn't be smoking cigars because of it, but he does, and it makes me upset.

have you gotten your flu shot?

Question 04/21/21 6:15 AM EDT

I don't think I have had a flu shot. . . at least not this year.

im going to take your vitals

Question 04/21/21 6:16 AM EDT

Yep!

Measured blood pressure

Exam Action 04/21/21 6:16 AM EDT

Measured heart rate

Exam Action 04/21/21 6:16 AM EDT

Measured pulse oximetry

Exam Action 04/21/21 6:17 AM EDT

Measured respiratory rate

Exam Action 04/21/21 6:17 AM EDT

Measured temperature

Exam Action 04/21/21 6:17 AM EDT

Tested lung capacity with spirometer: FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%)

Exam Action 04/21/21 6:18 AM EDT

Inspected right orbital area and sclera

Exam Action 04/21/21 6:19 AM EDT

Inspected upper conjunctiva

Exam Action 04/21/21 6:19 AM EDT

Inspected lower conjunctiva

Exam Action 04/21/21 6:19 AM EDT

Inspected left orbital area and sclera

Exam Action 04/21/21 6:21 AM EDT

Performed otoscopic examination of right ear

Exam Action 04/21/21 6:23 AM EDT

Performed otoscopic examination of left ear

Exam Action 04/21/21 6:23 AM EDT

Performed otoscopic examination of right naris

Exam Action 04/21/21 6:29 AM EDT

Performed otoscopic examination of left naris

Exam Action 04/21/21 6:29 AM EDT

Inspected mouth

Exam Action 04/21/21 6:29 AM EDT

Inspected left orbital area and sclera

Exam Action 04/23/21 3:39 PM EDT

Inspected right orbital area and sclera

Exam Action 04/23/21 3:39 PM EDT

Performed otoscopic examination of left ear

Exam Action 04/23/21 5:50 PM EDT

Performed otoscopic examination of right ear

Exam Action 04/23/21 5:50 PM EDT

Inspected front of neck

Exam Action 04/23/21 5:50 PM EDT

Inspected left side of neck

Exam Action 04/23/21 5:50 PM EDT

Inspected back of neck

Exam Action 04/23/21 5:50 PM EDT

Inspected right side of neck

Exam Action 04/23/21 5:50 PM EDT

Inspected anterior chest wall

Exam Action 04/23/21 5:51 PM EDT

Inspected posterior chest wall

Exam Action 04/23/21 5:51 PM EDT

Inspected anterior chest wall

Exam Action 04/23/21 5:51 PM EDT

Palpated maxillary sinuses: No tenderness reported

Exam Action 04/23/21 5:57 PM EDT

Palpated frontal sinuses: No tenderness reported

Exam Action 04/23/21 5:57 PM EDT

Palpated axillary lymph nodes: Not palpable

Exam Action 04/23/21 5:57 PM EDT

Palpated supraclavicular lymph nodes: Not palpable

Exam Action 04/23/21 5:57 PM EDT

Palpated lymph nodes of head and neck: Enlarged and reported tenderness on the right side

Palpated fremitus in anterior lower chest wall: Present and equal bilaterally

Exam Action 04/23/21 5:58 PM EDT

Exam Action 04/23/21 5:59 PM EDT

Ninety-nine.

Palpated fremitus in anterior upper chest wall: Present and equal bilaterally

Exam Action 04/23/21 5:59 PM EDT

Ninety-nine.

Palpated fremitus in posterior upper chest wall: Present and equal bilaterally

Exam Action 04/23/21 5:59 PM EDT

Ninety-nine.

Palpated fremitus in posterior middle chest wall: Present and equal bilaterally

Exam Action 04/23/21 5:59 PM EDT

Ninety-nine.

Palpated fremitus in posterior lower chest wall: Present and equal bilaterally

Exam Action 04/23/21 5:59 PM EDT

Ninety-nine.

Palpated chest expansion: Both sides rise symmetrically

Exam Action 04/23/21 5:59 PM EDT

Auscultated breath sounds in anterior left middle lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior right middle lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior right upper lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior right upper lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior left upper lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior left middle lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior left lower lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in anterior right lower lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior left upper lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior left mid-back (lower lobe)

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior right mid-back (lower lobe)

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior right upper lobe

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior right lower lobe near spine

Exam Action 04/23/21 6:00 PM EDT

Auscultated breath sounds in posterior left lower lobe near spine