Shadow health respiratory assessment transcript Pre Brief
Tina had an asthma episode 2 days ago. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had ten episodes of wheezing and has shortness of breath approximately every four hours. Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.
Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
NB: We have all the questions and documented answers as listed and attached below. All you need to do is ORDER NOW for an equivalent of 4 pages for this assignment and all other iHuman/Shadow Health Assignments.
DON’T STRESS YOURSELF, JUST CHAT US AT THE RIGHT CORNER BELOW.
Hello my name sara an FNP student and I will be interviewing you today.
Hey.
Can you please state your name for me?
Tina Jones.
Your date of birth?
February 17th.
Year of birth please? (Clarified to What year were you born.)
I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO
COMING SOON]
How old are you ms. Jones? (Clarified to how old are you.)
I’m 28.
What brings you in today?
I came in because I’ve been having breathing problems, and my
inhaler just isn’t working the way it normally does.
Why did you XXX
I XXX normally does.
I’m XXX.
XXX that. Shadow health respiratory assessment transcript.
What XXX?
Well. . . I’ve hadxxxx since I was really little, though for a while
there it wasn’t really much of a problem. And I have xxxx,
too.
What XXX?
It’s XXX.
How XXX?
I’ve XXX.
XXX start?
I don’t know if I’d call it an asthma attack, but XXX house. She has cats, and I’m
allergic, so I’m used to it being a problem there, but usually the
inhaler fixes it. . . it doesn’t feel totally under control, though.
I’m sorry you’re having difficulty with your breathing problems.
Thanks.
How XXX problems?
My breathing’s been acting up off and on for the past two days.
How XXX?
Maybe XXX? It’s a lot.
And how XXX? (Clarified to
how long does an episode last.)
I haven’t had a XXX normal. .
. that’s not what’s been happening recently, though.
How xxxx?
I haven’t had a xxx, but usually once I use xxx
it only takes a minute or two for my xxxck to normal. .
. that’s not what’s been happening recently, though.
How manyxxxx
Well. . . it’s kind of hard to count because my breathing’s been at
least a little bad most of the past two days, but it’s really acted up,
like with wheezing and everything, probably every four hours or so–
like five times each day.
Is your ?
My
How xxx.)
My asthma used to be really scary. I haven’t had a full attack in
years, and if you had asked me before this I would have said my
asthma wasn’t that bad anymore, but the last couple days I’ve had a
lot of trouble breathing.
How xxx?
My asthma used to be really scary. I haven’t had a full attack in
years, and if you had asked me before this I would have said my
asthma wasn’t that bad anymore, but the last couple days I’ve had a
lot of trouble breathing.
Is there xxx?
There usually xxxx. . . I
guess I try to avoid things that make my breathing worse, but that’s
about it. The past couple days, though, it’s been hard to do anything.
Do you wheeze during an asthma exacerbation?
During a full attack, I would wheeze a lot, like I couldn’t breathe at all,
but until the past couple days, I would usually just wheeze a little
when I had breathing problems.
Are you having any chest tightness? Shadow health respiratory assessment transcript.
It’s not so bad right this second, but it’s been pretty tight lately, like I
can’t take in air.
Have you xxx?
I’ve been xxxxa lot, yeah.
How long have you had the xxxx?
Since my asthma acted up two days ago.
How would you describe the xxx?
Um. . . I guess I’d describe it asxxx.
What makes your xxxbetter?
Drinking some water helps a little, as long as the water isn’t too cold.
Have you tried txxx your xxx?
I haven’txxx.
Is your xxx?
It has been the past cxxx, yeah.
Does lxxx worse?
Just recently lying on my back has definitely made my breathing
worse.
To try to help your breathing you may want to elevate your head with
two pillows.
OK, I understand.
Inspected anterior chest wall
Inspected anterior chest wall
Inspected left side chest wall
Inspected anterior chest wall
Inspected right side chest wall
Inspected anterior chest wall
Palpated chest expansion: Both sides rise symmetrically
Palpated fremitus in anterior upper chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in anterior lower chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior upper chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior middle chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Palpated fremitus in posterior lower chest wall: Equal bilaterally,
expected vibration
Ninety-nine.
Percussed anterior left upper lobe
Percussed anterior right upper lobe
Percussed anterior left mid-chest (upper lobe)
Percussed anterior right middle lobe
Percussed anterior left lower lobe
Percussed anterior right lower lobe
Percussed posterior right upper lobe
Percussed posterior left upper lobe
Percussed posterior right mid-back (lower lobe)
Percussed posterior left mid-back (lower lobe)
Percussed posterior right lower lobe
Percussed posterior left lower lobe. Shadow health respiratory assessment transcript.
Percussed posterior left lower lobe on side
Percussed posterior left lower lobe near spine
Percussed posterior right lower lobe near spine
Percussed posterior right lower lobe on side
Auscultated breath sounds in anterior left upper lobe
Auscultated breath sounds in anterior right upper lobe
Auscultated breath sounds in anterior right middle lobe
Auscultated breath sounds in anterior left mid-chest (upper lobe)
Auscultated breath sounds in anterior left lower lobe
Auscultated breath sounds in anterior right lower lobe
Auscultated breath sounds in posterior right upper lobe
Auscultated breath sounds in posterior left upper lobe
Auscultated breath sounds in posterior left mid-back (lower lobe)
Auscultated breath sounds in posterior right mid-back (lower lobe)
Auscultated breath sounds in posterior right lower lobe
Auscultated breath sounds in posterior left lower lobe
Auscultated breath sounds in posterior left lower lobe on side
Auscultated breath sounds in posterior left lower lobe near spine
Auscultated breath sounds in posterior right lower lobe near spine
Auscultated breath sounds in posterior right lower lobe on side
Auscultated voice sounds in anterior left upper lobe
Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior right upper lobe
Ninety-nine.
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Ninety-nine.
Ninety-nine.
Auscultated voice sounds in anterior left upper lobe
Auscultated voice sounds in anterior left mid-chest (upper lobe)
Ninety-nine.
Auscultated xxx
Auscultated xxxx
Ninety-nine.
Auscultated voice sounds in anterior left lower lobe
Ninety-nine.
Ninety-nine.
Ninety-nine.
Auscultated xxxx
Ninety-nine.
Auscultated voice sounds in posterior left upper lobe
Shadow health respiratory assessment transcript
Ninety-nine.
Auscultated voice sounds in posterior right mid-back (lower lobe)
Ninety-nine.
Auscultated voice sounds in posterior left mid-back (lower lobe)
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe on side
Ninety-nine.
Auscultated voice sounds in posterior left lower lobe near spine
Ninety-nine.
Auscultated voice sounds in posterior right lower lobe near spine
Ninety-nine.
Shadow health respiratory assessment transcript
Auscultated voice sounds in posterior right lower lobe on side
Ninety-nine.
Checked pulse xxx
Check pulse xx
Checked xxxx
Checked xxx
Always make sure yourxxxx
Sure, I think I understand what you mean.
Make sure to read all instructions and store as indicated (No
matching questions found.)
Make sure to read all instructions and store as indicated
Alright, thanks for letting me know.
Always shake well before using.
Thanks for telling me.
Also after every complete use you should always rinse out your
mouth with water.
Shadow health respiratory assessment transcript.
That makes sense.
What medications do you take?
My xxx is the only prescription I always have, but I usually don’t
need it everyday, except for recently. . .
When did you last use your xxx?
I had to use it early this morning.
How is your xxx prescribed?
Yes.
How often is your xxx?
Yes.
How many times have you use xxx?
I’ve been needing my xxx about every four hours, I’d say.
How many xxxx 4 hours? (Clarified to how xxxx are you prescribed.)
I’m supposed to just do twoxxx [Nurse confirmed with Pharmacy:
xxx]
How many xxx are you doing?
I’m supposed to just do xxx. [Nurse confirmed with Pharmacy:
xxx]
Make sure to follow thexxx instructions as prescribed
Thanks for telling me.
Are you taking any other medications?
No, all I really use is xxx.
You take any over-the-counter medications?
I take xxx, but not
often.
How much xxxdo you take?
I just take a couple. I usually get them at night from reading–
squinting I guess–and so I take one and go to bed. [Nurse confirmed
with Pharmacyxxx ]
How much xxx do you take for cramps?
I take three at a time. And I’d bet I take it up to three times a day.
[Nurse confirmed with Pharmacy: xxx]
Do you have xxxx?
Yeah, I’mxxx.
Do you have axxx?
No, not that I know of.
When didxxx
This all started at my cousin’s house. Shexxxxalways goes crazy when I’m there.
Does being around dust trigger asthma?
Yeah, being around a lot of dust, especially hanging out in a really
dusty house, can make my asthma act up.
Sorry to hear that about your asthma
Thanks for understanding.
Does cxxxa?
Only when I’m in a rush and have to hurry up them.
Do you have xxxx? (Clarified to do you have
seasonal allergies.)
A little while ago, I had some seasonal allergies, but it didn’t really
bother my asthma, and it’s better now.
Does xxxe?
Well. . . sometimes when txxx often.
Do you xxx?
I used to go to Dr. Dewitt, but she moved her practice recently.
Luckily she’s still been able to call in refills of my inhaler, but I haven’t
actually been in to see her in about two years.
Since you have asthma it is important to follow up on a regular basis
with your asthma specialist
Alright, thanks for letting me know.
How xxx?
I’ve had xxxle.
How xxxx?
My xxx.
Have you everxxx?
I xxx?
I used to go to thexxxt not since I
was sixteen.
Have yoxxx?
You mean like, did they ever have to put me on a breathing machine?
No, I haven’t had an asthma attack that serious.
Do you use a xxx?
Not really. . .
Do you cxxx?
I’ve heard of that, but no, I don’t do it.
Do you use xxx
No, but I have before.
We may cxxx
That makes sense.
Also a way to track your asthma symptoms and episodes. (No
matching questions found.)
Also a way to track your s and episodes.
OK, I understand.
BUY A PLAGIARISM-FREE PAPER HERE
Sending you home with a peak flow meter and document regularly.
I’ve heard of that, but no, I don’t do it.
We will also teach you how to use nebulizer at home.
Sure, I think I understand what you mean.
How often do you change your sheets?
I change my bedding once a week, I’d say.
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Do you have pets at home?
No. . . I’m too busy to take care of a dog, and I can’t have cats
because of my allergies.
Does ?
No, nobody at home .
If exposed to secondhand smoke it is definitely a Asthma trigger.
Alright, thanks for letting me know.
Have you ever had eczema?
No, I don’t have that kind of skin problem.
history of sinus problems? (Clarified to do you have a history of sinus
problems?.)
I don’t really have a problem with my sinuses.
Do you have xxx?
I don’t know what that is, so I guess probably not?
Have you ever been xxx
Have you xxx?
Shadow health respiratory assessment transcript
No, I’ve never done that. I think it’s gross.
I’m glad you think that
Thanks for understanding.
Smoking is a known trigger for asthma
OK, I understand.
Have you xxx
Well, I used to xx. . . but I don’t do that anymore.
When was the xxx?
I haven’t sxxx.
Have you ever experimented with xxxx?
No, no way. That’s a nasty thing to do.
Have you been sick recently?
No, I’m usually healthy.
Have you had any xxx?
No, I haven’t had a xxx.
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Have you had any nausea or vomiting?
I haven’t had thrown up, or even had an upset stomach, in a long
time.
Have you had chills?
No, I haven’t.
Are you fatigued?
I feel tired, yeah, probably because I haven’t been able to sleep very
well.
Do you have any xx?
I don’t getxxx, but sometimes I wake up hot and have to kick off
my xxx.
Sometimexxxybe an indication of being sick
That makes sense.
Have you been cxxx anything?
No, nothing’s coming up.
Have you had any problemsxxx?
Nope.
Do you have any nasal drainage?
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No, my nose has been fine.
Has anyone been sick at home?
No, no one at home has been sick.
Does anyone in your family have asthma?
It’s just me and my baby sister that have asthma, but she really
doesn’t have problems with it.
Does anyone in your family have allergies?
My sister has hay fever, I think, and it sometimes makes her asthma
get pretty bad.
Does anyone in your family have eczema?
No. . .
Do you have a family history of sinus problems?
I don’t think anyone in the family has sinus problems.
Are you in any pain right now?
It doesn’t hurt. . . it’s just hard to breathe, but there’s no pain.
Is there pain when you wheeze? (No matching questions found.)
are you in pain when you wheeze?
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Right now it doesn’t sound too bad, but I’ve definitely been
wheezing the past couple days.
Any changes in your appetite?
I wouldn’t say it’s changed recently, but I do feel hungry a lot.
When was your last chest x-ray?
The last time I went to the hospital for an asthma attack, when I was
still in high school, they did a chest x-ray.
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
shadow health respiratory transcript
APPROACH
Overview
| Transcript
| Subjective Data Collection
| Objective Data Collection
| Education & Empathy
| Documentation / Electronic Health Record
| Student Pre-Survey
| Lifespan Activity
| Review Questions
| Self-Reflection Activity
Model Documentation
Subjective
Social History: She is not aware of any environmental exposures or irritants at her job or home……
Review of Systems:
Objective
Assessment
Plan
Diagnostics
Education
Referral/Consultation
Follow-up Planning
The treatment plan for this child would be to….
Common significant deviations of the chest for older adults include xxxx (Hogstel & Curry, 2005). xxxx become thinner, more rigid, and change shape, and muscles may become weakened. This results in a lower oxygen level with less carbon dioxide removed from the body, and decreased ability to cough. xxxx causes decreased xxx height. xxx also causes thexxxto lose their shape causing shortness of xxx. Due to diminishedxxxwith decreased sensitivity, large amounts of particles that are more difficult to expectorate can collect in the xxx. In addition, the xxxx is less sensitive to xxxx and xxx and higher residual volume. As a result of these changes, xxx are at increased risk for xxxx and xxxx (Minaker, 2011; Sharma & Goodwin, 2006). Shadow health respiratory assessment transcript.
In the respiratory assessment of this patient, I expect to find xxx, increased xxxx of the xxx, diminished chest expansion, and xxxx. The weakened muscles will result in xxx levels and lower xxxx leading to decreased xxxx capacity. xxx will also will also lose their shape leading toxxx. Therefore, x goals will hxave to take in cognizance these realities and advise the patient accordingly. Consequently, efforts to increase exercise tolerance, treat complication, and relieve symptoms will be initiated.
Dyspnea can be assessed both……
The examination…..
My performance could be improved by seeking more history from the patient…..
Pre-brief
Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.
In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
Purpose
As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role. Shadow health respiratory assessment transcript.
Course Outcomes
This assignment is guided by the following Course Outcomes (COs):
The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).
NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.
Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.
Preparing the Paper:
NR 509 Week 2 Quiz
Identifying and Reliability:
Ms. Jones is an obese 28-year-old female who is
presenting to the office today with an athma
exacerbation. She is the primary and only source of
personal and medical data. Pleasent, cooperative
and readily open to freely dissiminate health
information. Good eyeye contact, well-groomed,
good posture, and comunicates clearly with logical
flow of ideas.
General Survey:
Upon entering the patient’s examination room,
patient was found to be sitting straight and erect,
good posture, well-groomed, well nourished with a
pleasent demeanor and manner of communicating.
Reason for Visit:
“Breathing problems and my inhaler just isn’t
working the way it normally does.”
HPI: Ms. Tina Jones is a 28-year-old African
American woman who walked in to the clinic
complianing of SOB and wheezing after nearly
haveing a “bad” asthma attack two days ago. Pt.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
reports xxx which triggered her asthma
symptoms while she was visitn her cousins house.
Initially, at the time of the climax of her near asthma
attack, xxx It lasted for 5 minutes,
following the use of her rescuexxx . Pt.
reports only chest tightness at the time, which has
continued to the present with no increase in
tightness. Pt. denies all other allergic symptoms
during the exaccerbation of her asthma. The inhalor
had amild to moderate effect, not fully resolving the
asthma symptoms. Pt. reports that since the initial
exacerbation, she has had ten similar asthma
episodes consisting of SOB, “not able to get
enough air in” to her lungs, chest tightness all occur
every 4 hours, even through the night, awakinging
her from sleep. Her symptomsare worsoned when
laying supine, including coughing fits each time she
lays down, which easily resolves once sitting
backup. Instead of using the xxx, pt. has been using xxxx with minimal to moderate relief. Most
recent episode was this morning prior to her arrival.
xxx are aggrevated by exposure
to cats, perhaps dust, and currently exacerbated by
exertion and laying supine with a subsequent
coughing fit. occur Cough is non-productive.
Pt. concerned her new albuterol inhaler is ineffective
compared to previous device. Her asthma has been
slowly interferring with her life the past year or so,
while still being manageable. Over the past 2 days,
her asthma has interferred with her daily life,
including her response that if she had not had these
past two days off of work, she “would have called in
sick for sure.” Pt. feels minimal asthma symptoms
curretly, following her xxx over an hour
ago.
Diagnosed with asthma at 2.5-years-old, She
frequented hospital visits and including five
hospitalizations before she was 16-years-old. Since
then she hasn’t been hospitalized. Pt. xxxx. Pt. doesn’t keep
asthma record of exacerbations and triggers; denies
asthma medication usage excet for albuterolresuce
inhaler. Pt. not currrently beingmanaged by a
pulmonologist or someone for her allergies. Pt.
denies using a vaporizer or nebulizer at home.
PMH:
Pt. reports Type 2 Diabetes, possible borderline
hypertension (no actual dx).
Allergies:
Cats: Develops itchy, watery eyes; an itchy, “runny
nose”; an itchy, sometimes a sore throat, and often
an asthma exacerbation – SOB, DOE, wheezing,
coughing, and chest tightness.
Dust: Develops a rash, no tiching.
Penicillin: “Rash, like, hives.”
HPI: Ms. Jones is a pleasant 28-year-old African
American woman who presented to the clinic with
complaints of xxxxx attack that she had two
days ago. She reports that she was xxxx and was exposed to cats which triggered her
asthma symptoms. At the time of the incident she
notes that her wheezes were a 6/10 severity and her
shortness of breath was a 7-8/10 severity and
lasted five minutes. She did not experience any
chest pain or allergic symptoms. At that time she
used her albuterol inhaler and her symptoms
decreased although they did not completely resolve.
Since that incident she notes that she has had 10
episodes of wheezing and has shortness of breath
approximately every four hours. Her last episode of
shortness of breath was this morning before coming
to clinic. She notes that her current symptoms seem
to be worsened by lying flat and movement and are
accompanied by a non-productive cough. She
awakens with night-time shortness of breath twice
per night. She complains that her current symptoms
are beginning to interfere with her daily activities
Medications:
Rx: xxx.
OTC: xxxfor occasional
xxxx related to readingfor prolonged periods
of . xxxx
Social History:
Pt. reports fairly severe xxx (xxx);
A moderate allergic reaction to excessive dust
accumulation (axxx); and Penicillin (report from
mom when pt.was a child, mother reports
development of a rash only; unknown if xxx and axx
occured as well. Pt. is meticullus about dust,
allergins, mildew accumulation; using hypoallergenic
practices with bed, sheets, pillows and spead.
Mattress is 12 months old. Pt. denies ever using
tabacco in any form, as well as illicit drugs and
prescription medicaton abuse. Pt. does report that
from 15-16-years old she smoked marijuana, but
hasn’t partaken in it since 21-years-old. Pt. states
she doesn’t exercise, eats “whatever”, with some
restrint in high sugar beverages and treats.
Family History: Pt. states sister has history of
asthma and hayfever.
Surgical History: Pt. denies previous surgeries.
ROS:
General: Pt. states recent changes in appetite as
she is “always hungry” even after she has eaten a
large meal. Reports exercise intolerance, usually
feels fatigued. Pt. denies recent weight changes,
fevers, chills. body aches, sweats. feels she is
generally a healthy person.
Skin: Pt. reports skin color and pigment changes
localized only around her neck – which has been
changeing the past couple of years now. Pt. reports
that moles on her back have not changed in size or
color.Skin is dryer than usual and feels dehydrated
and always thirsty. Denies sores, lesions, scabs.
Pulmonary: Pt. states that she has coughing fits
when exposed to allergens like dust adn especially
cats. Coughing also occurs when asthma “acts up”
and anytime she lays down in the past month she
begins to cough. Lately she will wake up twice a
night because of uncontrolable coughing which
resolves after she has been in a sitting or upright
position for a few minutes. Denies productive cough
or coughing up blood. Denies being exposed to
anyone sick, has not traveled.
Reports SOB when she has to hurry somewhere or
whan she climbs a large flight of stairs. Has
orthopnea twice a night with coughing fits. xxxx and denies OSA.
xxx: Pt. state she may have borderline
and she is concerned that her xxxx
seems to be less effective than previous. Currently
she states that her breathing is normal. Diagnosed
with asthma at age 2.5 years. She has no recent use
of spirometry, does not use a peak flow, does not
record attacks, and does not have a home nebulizer
or vaporizer. She has been hospitalized five times
for asthma, last at age 16. She has never been
intubated for her asthma. She does not have a
current pulmonologist or allergist.
xxx: She is not aware of any
environmental exposures or irritants at her job or
home. She changes her sheets weekly and denies
dust/mildew at her home. She uses a hypoallergenic
pillow cover and her mattress is one year old. She
denies current use of tobacco, alcohol, and illicit
drugs. She did smoke marijuana for 5 or 6 years,
her last use was at age 21 years. She does not
exercise.
Review of Systems: General: Denies changes in
weight, fatigue, weakness, fever, chills, and night
sweats.
• xxx: Denies rhinorrhea with this episode.
Denies stuffiness, sneezing, itching, previous allergy,
epistaxis, or sinus pressure.
• Gastrointestinal: No changes in appetite, no
nausea, no vomiting, no symptoms ofxxx
• xxx: Complains of shortness of breath and
cough as above. Denies sputum, xxx,
pneumonia, bronchitis, emphysema, tuberculosis.
She has a history of asthma, last hospitalization was
age 16, last chestxxxx.
hypertension. Pt. denies xxxx,
palpitations, tachycardia or racing heart, orthostatic
changes, edema, heart arrythmias and denies
sickle-cell disease.
Endocrine: Pt. reports having previous diagnosis of
diabetesxxxx, xxx,
lethargy. Pt. reposrts having xxx, dxxx,
being overweight. Pt. denies changes in hair
pattern, weight changes, node enlargement, breast
changes, galactorhea, never been pregnant,
tremors. Shadow health respiratory assessment transcript.
GI: Pt. denies N/V, anorexia, diarhea, GERD, ulcers,
colonoscopy, constipation, hematamesis,
hematechezia, recent changes in bowel evacuation
habits, dysphagia, flatulance.
GU: Pt. reports xxxx, feels
thirsty all the time now, drinks a lot of fluids which
doesn’t seem to quench thirst. She has now been
experiencing nocturia 2-3 times per night. Denies
xxx, chronic or recent xxxx, history
of or knowlingly being xxxx. Reports
haveing three sexual partners in her life, all of which
are men. Has been absinent for over a year now.
Denies incontinence.
Neurologic: Pt. denies changes in sensation,
weakness, light-headedness, dizziness, chronic
xxxxchanges in mentation,
long or short term memory, concussions,xxxx
HEENT: Pt. denies history of xxx, except for
occassionally occuring when she reads too long xxx
changes, except for “blurry eyes” after reading for
too long. Denies other visions problems, hearing
issues, nasal discharge, epistaxis, gingivitis, mouth
sores. Pt. doesn’t see dentist annually nor teetch
professionally cleaned – hasn’t been to the dentist
for “years.”
Objective
Tina is an obese 28-year-old African American
woman who does not seem to be in any acute
distress. Alert and oriented, sitting upright, ,
maintains appropriate eye contact, is
conversational, and answers questions approprietly.
Respiratory: Respiratory examination found Tina’s
chest expansion to be symetrical with respiration.
Bilaterally symetrical tactile fremitous, negative
broncophony anteriorly and posteriorly in all lung
fields. Chest resonent when percussed, devoid of
any dullness. Bilateral lower lxxxx. All other
lung fields clear to auscultation. No crackles,
rhonchi, coarseness noted in lung auscultation.
Muffled words bilaterally with prominent expiratory
wheezes in the posterior lower lobes only.
Spirometry yielded xxxxon room air, xxxx, BP
General: Ms. Jones is a pleasant, xxx 28-year-old
African American woman in no acute distress. She
is alert and oriented and sitting upright on exam
table. She maintains eye contact throughout
interview and examination.
• Respiratory: Chest expansion is symmetrical with
respirations. Normal fremitus, symmetric bilaterally.
Chest resonant to percussion; no dullness. Bilateral
expiratory wheezes in posterior lower lobes.
Bilateral muffled words with notable expiratory
wheezes in posterior lower lobes. No crackles. In
office xxx%.
x
140/81, Temperature xxxdegrees Farenhiet.
Assessment
Mild-Persistent Asthma with Exacerbation. Mild-persistent asthma with exacerbation
Plan
Diagnostics: Obtain oxygen saturation and baseline
spirometry and peak flow readings.
Medication: NMI at office one time. Continue
albuterol rescue inhalor. Initiate step up inhaled
corticosteroid.
Education: Encourage Tina to log her asthma
symptoms and episodes of exacerbation every day
and bring log in to next visit. Monitor trigger
exposures adn resultant asthma symptoms and
severity of exacerbations. Encourage Tina to
remove and/or clean all possible harborers of
allergens, including bedding, seats, pillows carpet.
Change air filters in home and car to incrased
allergiin removal from the air. Encourage an incrase
in fluid consumption, especially water. Help guide
pt. indeveloping an asthma action plan and assess
effectiveness and apropriateness of plan in next
visit.
Orders: xxxx
after each exacerbation for purposes of comparison
and establishing pt. trends.
Instruct Tina to return to clinic if ongoing symptoms.
Also inform xxx if
worsoning asthma symptoms, xxxx that is
unresolved by a short rest. Also go to xxxis
unresolved xxx, wheezing not allevaited
xxx and xxx.
Follow-Up: Return to clinic in 3 weeks for follow-up
evaluation regarding coarse of illness, medication
use and needs, as well as medication effectivenss.
Diagnostics
• Obtain office oxygen saturation
Medication
• xxxin office x 1
• Initiate step-up medication therapy with xxxx
• Continue xxx
Education
• Encourage Ms. Jones to continue to xxx
symptoms and wheezing with associated factors
and bring log to next visit
• Encourage to wash xxx and consider xxx to decrease axxe
symptoms
• Educate to increase intake of water and other
fluids
• Create Axxx
Referral/Consultation
• Refer to allergy specialist for evaluation and testing
Follow-up Planning
• Order PFTs to be completed after exacerbation to
have baseline available for future comparison
• Instruct Ms. Jones on when to seek emergent care
including episodes of chest pain or shortness of
breath unrelieved by rest, worsening asthma
symptoms or wheezing, or the sense that rescue
inhaler is not helping
• Revisit clinic in 2-4 weeks for follow up and
evaluation
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
Start by reading and following these instructions:
You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the discussion question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing.The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.
Discussion Question:
In your professional opinion, what is the difference between chronic and acute pain? How is the assessment for each type of pain different? What must you keep in mind when assessing acute pain? What must you keep in mind when assessing chronic pain? Reflect upon a time when you assessed a patient in pain. What did you do well? What points could you have improved upon? How did the pain impact the patient? What specific treatments could have lessened the impact of the pain on the patient?
Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.
When you are ready for the discussion, do the following:
To reply to a classmate’s post:
Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.
Start by reading and following these instructions:
1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
3. Consider the discussion and the any insights you gained from it.
4. Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.
Assignment:
Exercises:
Professional Development
BUY A PLAGIARISM-FREE PAPER HERE
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) | 25.0 ptsAbove Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.21.0 ptsAverage- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.10.0 ptsBelow Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.0.0 ptsUnsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing. | 25.0 pts |
| This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation | 20.0 ptsAbove Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.16.0 ptsAverage- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).8.0 ptsBelow Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).0.0 ptsUnsatisfactory- No physical assessment documentation or no treatment plan. | 20.0 pts |
| This criterion is linked to a Learning OutcomeSelf-Reflection | 5.0 ptsAbove Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.3.0 ptsAverage- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.2.0 ptsBelow Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight0.0 ptsUnsatisfactory- No reflection posts for the assignment. | 5.0 pts |
| Total Points: 50.0 |
,
Model Documentation
Subjective
Social History: She is not aware of any environmental exposures or irritants at her job or home……
Review of Systems:
Objective
Assessment
Plan
Diagnostics
Education
Referral/Consultation
Follow-up Planning
The treatment plan for this child would be to….
Common significant deviations of the chest for older adults include xxxx (Hogstel & Curry, 2005). xxxx become thinner, more rigid, and change shape, and muscles may become weakened. This results in a lower oxygen level with less carbon dioxide removed from the body, and decreased ability to cough. xxxx causes decreased xxx height. xxx also causes thexxxto lose their shape causing shortness of xxx. Due to diminishedxxxwith decreased sensitivity, large amounts of particles that are more difficult to expectorate can collect in the xxx. In addition, the xxxx is less sensitive to xxxx and xxx and higher residual volume. As a result of these changes, xxx are at increased risk for xxxx and xxxx (Minaker, 2011; Sharma & Goodwin, 2006). Shadow health respiratory assessment transcript.
In the respiratory assessment of this patient, I expect to find xxx, increased xxxx of the xxx, diminished chest expansion, and xxxx. The weakened muscles will result in xxx levels and lower xxxx leading to decreased xxxx capacity. xxx will also will also lose their shape leading toxxx. Therefore, x goals will hxave to take in cognizance these realities and advise the patient accordingly. Consequently, efforts to increase exercise tolerance, treat complication, and relieve symptoms will be initiated.
Dyspnea can be assessed both……
The examination…..
My performance could be improved by seeking more history from the patient…..
Pre-brief
Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice.
In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
Purpose
As a family nurse practitioner, you must possess excellent physical assessment skills. This alternative writing assignment mirrors the discussion content of the debriefing session and will allow the student to expand their knowledge of physical health assessment principles specific to the advanced practice role. Shadow health respiratory assessment transcript.
Course Outcomes
This assignment is guided by the following Course Outcomes (COs):
The purposes of this assignment are to: (a) identify and articulate advanced assessment health history and physical examination techniques which are relevant to a focused body system (CO 1), (b) differentiate normal and abnormal findings with regard to a disease or condition that impacts the body system (CO 2), and (c) adapt advanced assessment skills if necessary to suit the needs of specific patient populations (CO 4).
NOTE: You are to complete this alternative writing assignment ONLY if you had not participated or do not plan to participate in a debriefing session for the given week.
Due Date: This alternative written assignment is due no later than the Sunday of the week in which you did not attend the weekly debriefing session. The standard MSN Participation Late Assignment policy applies to this assignment.
Preparing the Paper:
NR 509 Week 2 Quiz
Identifying and Reliability:
Ms. Jones is an obese 28-year-old female who is
presenting to the office today with an athma
exacerbation. She is the primary and only source of
personal and medical data. Pleasent, cooperative
and readily open to freely dissiminate health
information. Good eyeye contact, well-groomed,
good posture, and comunicates clearly with logical
flow of ideas.
General Survey:
Upon entering the patient’s examination room,
patient was found to be sitting straight and erect,
good posture, well-groomed, well nourished with a
pleasent demeanor and manner of communicating.
Reason for Visit:
“Breathing problems and my inhaler just isn’t
working the way it normally does.”
HPI: Ms. Tina Jones is a 28-year-old African
American woman who walked in to the clinic
complianing of SOB and wheezing after nearly
haveing a “bad” asthma attack two days ago. Pt.
Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
reports xxx which triggered her asthma
symptoms while she was visitn her cousins house.
Initially, at the time of the climax of her near asthma
attack, xxx It lasted for 5 minutes,
following the use of her rescuexxx . Pt.
reports only chest tightness at the time, which has
continued to the present with no increase in
tightness. Pt. denies all other allergic symptoms
during the exaccerbation of her asthma. The inhalor
had amild to moderate effect, not fully resolving the
asthma symptoms. Pt. reports that since the initial
exacerbation, she has had ten similar asthma
episodes consisting of SOB, “not able to get
enough air in” to her lungs, chest tightness all occur
every 4 hours, even through the night, awakinging
her from sleep. Her symptomsare worsoned when
laying supine, including coughing fits each time she
lays down, which easily resolves once sitting
backup. Instead of using the xxx, pt. has been using xxxx with minimal to moderate relief. Most
recent episode was this morning prior to her arrival.
xxx are aggrevated by exposure
to cats, perhaps dust, and currently exacerbated by
exertion and laying supine with a subsequent
coughing fit. occur Cough is non-productive.
Pt. concerned her new albuterol inhaler is ineffective
compared to previous device. Her asthma has been
slowly interferring with her life the past year or so,
while still being manageable. Over the past 2 days,
her asthma has interferred with her daily life,
including her response that if she had not had these
past two days off of work, she “would have called in
sick for sure.” Pt. feels minimal asthma symptoms
curretly, following her xxx over an hour
ago.
Diagnosed with asthma at 2.5-years-old, She
frequented hospital visits and including five
hospitalizations before she was 16-years-old. Since
then she hasn’t been hospitalized. Pt. xxxx. Pt. doesn’t keep
asthma record of exacerbations and triggers; denies
asthma medication usage excet for albuterolresuce
inhaler. Pt. not currrently beingmanaged by a
pulmonologist or someone for her allergies. Pt.
denies using a vaporizer or nebulizer at home.
PMH:
Pt. reports Type 2 Diabetes, possible borderline
hypertension (no actual dx).
Allergies:
Cats: Develops itchy, watery eyes; an itchy, “runny
nose”; an itchy, sometimes a sore throat, and often
an asthma exacerbation – SOB, DOE, wheezing,
coughing, and chest tightness.
Dust: Develops a rash, no tiching.
Penicillin: “Rash, like, hives.”
HPI: Ms. Jones is a pleasant 28-year-old African
American woman who presented to the clinic with
complaints of xxxxx attack that she had two
days ago. She reports that she was xxxx and was exposed to cats which triggered her
asthma symptoms. At the time of the incident she
notes that her wheezes were a 6/10 severity and her
shortness of breath was a 7-8/10 severity and
lasted five minutes. She did not experience any
chest pain or allergic symptoms. At that time she
used her albuterol inhaler and her symptoms
decreased although they did not completely resolve.
Since that incident she notes that she has had 10
episodes of wheezing and has shortness of breath
approximately every four hours. Her last episode of
shortness of breath was this morning before coming
to clinic. She notes that her current symptoms seem
to be worsened by lying flat and movement and are
accompanied by a non-productive cough. She
awakens with night-time shortness of breath twice
per night. She complains that her current symptoms
are beginning to interfere with her daily activities
Medications:
Rx: xxx.
OTC: xxxfor occasional
xxxx related to readingfor prolonged periods
of . xxxx
Social History:
Pt. reports fairly severe xxx (xxx);
A moderate allergic reaction to excessive dust
accumulation (axxx); and Penicillin (report from
mom when pt.was a child, mother reports
development of a rash only; unknown if xxx and axx
occured as well. Pt. is meticullus about dust,
allergins, mildew accumulation; using hypoallergenic
practices with bed, sheets, pillows and spead.
Mattress is 12 months old. Pt. denies ever using
tabacco in any form, as well as illicit drugs and
prescription medicaton abuse. Pt. does report that
from 15-16-years old she smoked marijuana, but
hasn’t partaken in it since 21-years-old. Pt. states
she doesn’t exercise, eats “whatever”, with some
restrint in high sugar beverages and treats.
Family History: Pt. states sister has history of
asthma and hayfever.
Surgical History: Pt. denies previous surgeries.
ROS:
General: Pt. states recent changes in appetite as
she is “always hungry” even after she has eaten a
large meal. Reports exercise intolerance, usually
feels fatigued. Pt. denies recent weight changes,
fevers, chills. body aches, sweats. feels she is
generally a healthy person.
Skin: Pt. reports skin color and pigment changes
localized only around her neck – which has been
changeing the past couple of years now. Pt. reports
that moles on her back have not changed in size or
color.Skin is dryer than usual and feels dehydrated
and always thirsty. Denies sores, lesions, scabs.
Pulmonary: Pt. states that she has coughing fits
when exposed to allergens like dust adn especially
cats. Coughing also occurs when asthma “acts up”
and anytime she lays down in the past month she
begins to cough. Lately she will wake up twice a
night because of uncontrolable coughing which
resolves after she has been in a sitting or upright
position for a few minutes. Denies productive cough
or coughing up blood. Denies being exposed to
anyone sick, has not traveled.
Reports SOB when she has to hurry somewhere or
whan she climbs a large flight of stairs. Has
orthopnea twice a night with coughing fits. xxxx and denies OSA.
xxx: Pt. state she may have borderline
and she is concerned that her xxxx
seems to be less effective than previous. Currently
she states that her breathing is normal. Diagnosed
with asthma at age 2.5 years. She has no recent use
of spirometry, does not use a peak flow, does not
record attacks, and does not have a home nebulizer
or vaporizer. She has been hospitalized five times
for asthma, last at age 16. She has never been
intubated for her asthma. She does not have a
current pulmonologist or allergist.
xxx: She is not aware of any
environmental exposures or irritants at her job or
home. She changes her sheets weekly and denies
dust/mildew at her home. She uses a hypoallergenic
pillow cover and her mattress is one year old. She
denies current use of tobacco, alcohol, and illicit
drugs. She did smoke marijuana for 5 or 6 years,
her last use was at age 21 years. She does not
exercise.
Review of Systems: General: Denies changes in
weight, fatigue, weakness, fever, chills, and night
sweats.
• xxx: Denies rhinorrhea with this episode.
Denies stuffiness, sneezing, itching, previous allergy,
epistaxis, or sinus pressure.
• Gastrointestinal: No changes in appetite, no
nausea, no vomiting, no symptoms ofxxx
• xxx: Complains of shortness of breath and
cough as above. Denies sputum, xxx,
pneumonia, bronchitis, emphysema, tuberculosis.
She has a history of asthma, last hospitalization was
age 16, last chestxxxx.
hypertension. Pt. denies xxxx,
palpitations, tachycardia or racing heart, orthostatic
changes, edema, heart arrythmias and denies
sickle-cell disease.
Endocrine: Pt. reports having previous diagnosis of
diabetesxxxx, xxx,
lethargy. Pt. reposrts having xxx, dxxx,
being overweight. Pt. denies changes in hair
pattern, weight changes, node enlargement, breast
changes, galactorhea, never been pregnant,
tremors. Shadow health respiratory assessment transcript.
GI: Pt. denies N/V, anorexia, diarhea, GERD, ulcers,
colonoscopy, constipation, hematamesis,
hematechezia, recent changes in bowel evacuation
habits, dysphagia, flatulance.
GU: Pt. reports xxxx, feels
thirsty all the time now, drinks a lot of fluids which
doesn’t seem to quench thirst. She has now been
experiencing nocturia 2-3 times per night. Denies
xxx, chronic or recent xxxx, history
of or knowlingly being xxxx. Reports
haveing three sexual partners in her life, all of which
are men. Has been absinent for over a year now.
Denies incontinence.
Neurologic: Pt. denies changes in sensation,
weakness, light-headedness, dizziness, chronic
xxxxchanges in mentation,
long or short term memory, concussions,xxxx
HEENT: Pt. denies history of xxx, except for
occassionally occuring when she reads too long xxx
changes, except for “blurry eyes” after reading for
too long. Denies other visions problems, hearing
issues, nasal discharge, epistaxis, gingivitis, mouth
sores. Pt. doesn’t see dentist annually nor teetch
professionally cleaned – hasn’t been to the dentist
for “years.”
Objective
Tina is an obese 28-year-old African American
woman who does not seem to be in any acute
distress. Alert and oriented, sitting upright, ,
maintains appropriate eye contact, is
conversational, and answers questions approprietly.
Respiratory: Respiratory examination found Tina’s
chest expansion to be symetrical with respiration.
Bilaterally symetrical tactile fremitous, negative
broncophony anteriorly and posteriorly in all lung
fields. Chest resonent when percussed, devoid of
any dullness. Bilateral lower lxxxx. All other
lung fields clear to auscultation. No crackles,
rhonchi, coarseness noted in lung auscultation.
Muffled words bilaterally with prominent expiratory
wheezes in the posterior lower lobes only.
Spirometry yielded xxxxon room air, xxxx, BP
General: Ms. Jones is a pleasant, xxx 28-year-old
African American woman in no acute distress. She
is alert and oriented and sitting upright on exam
table. She maintains eye contact throughout
interview and examination.
• Respiratory: Chest expansion is symmetrical with
respirations. Normal fremitus, symmetric bilaterally.
Chest resonant to percussion; no dullness. Bilateral
expiratory wheezes in posterior lower lobes.
Bilateral muffled words with notable expiratory
wheezes in posterior lower lobes. No crackles. In
office xxx%.
x
140/81, Temperature xxxdegrees Farenhiet.
Assessment
Mild-Persistent Asthma with Exacerbation. Mild-persistent asthma with exacerbation
Plan
Diagnostics: Obtain oxygen saturation and baseline
spirometry and peak flow readings.
Medication: NMI at office one time. Continue
albuterol rescue inhalor. Initiate step up inhaled
corticosteroid.
Education: Encourage Tina to log her asthma
symptoms and episodes of exacerbation every day
and bring log in to next visit. Monitor trigger
exposures adn resultant asthma symptoms and
severity of exacerbations. Encourage Tina to
remove and/or clean all possible harborers of
allergens, including bedding, seats, pillows carpet.
Change air filters in home and car to incrased
allergiin removal from the air. Encourage an incrase
in fluid consumption, especially water. Help guide
pt. indeveloping an asthma action plan and assess
effectiveness and apropriateness of plan in next
visit.
Orders: xxxx
after each exacerbation for purposes of comparison
and establishing pt. trends.
Instruct Tina to return to clinic if ongoing symptoms.
Also inform xxx if
worsoning asthma symptoms, xxxx that is
unresolved by a short rest. Also go to xxxis
unresolved xxx, wheezing not allevaited
xxx and xxx.
Follow-Up: Return to clinic in 3 weeks for follow-up
evaluation regarding coarse of illness, medication
use and needs, as well as medication effectivenss.
Diagnostics
• Obtain office oxygen saturation
Medication
• xxxin office x 1
• Initiate step-up medication therapy with xxxx
• Continue xxx
Education
• Encourage Ms. Jones to continue to xxx
symptoms and wheezing with associated factors
and bring log to next visit
• Encourage to wash xxx and consider xxx to decrease axxe
symptoms
• Educate to increase intake of water and other
fluids
• Create Axxx
Referral/Consultation
• Refer to allergy specialist for evaluation and testing
Follow-up Planning
• Order PFTs to be completed after exacerbation to
have baseline available for future comparison
• Instruct Ms. Jones on when to seek emergent care
including episodes of chest pain or shortness of
breath unrelieved by rest, worsening asthma
symptoms or wheezing, or the sense that rescue
inhaler is not helping
• Revisit clinic in 2-4 weeks for follow up and
evaluation
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
,
Start by reading and following these instructions:
You are responsible for minimally at least 3 posts for each question in your discussion boards; your initial post and reply to two of your classmates. Your initial post(s) should be your response to the questions posed in the discussion question. You should research your answer and cite at least one scholarly source when appropriate, and always use quality writing.The discussion board is never a place to use text language or emoticons. You will also be asked to respond to your classmates. This is designed to enhance the academic discussion around the topic. It is all right to disagree with something posted by another, however your responses should always be thoughtful and respectful and reflect your opinions professionally.
Discussion Question:
In your professional opinion, what is the difference between chronic and acute pain? How is the assessment for each type of pain different? What must you keep in mind when assessing acute pain? What must you keep in mind when assessing chronic pain? Reflect upon a time when you assessed a patient in pain. What did you do well? What points could you have improved upon? How did the pain impact the patient? What specific treatments could have lessened the impact of the pain on the patient?
Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.
When you are ready for the discussion, do the following:
To reply to a classmate’s post:
Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.
Start by reading and following these instructions:
1. Quickly skim the questions or assignment below and the assignment rubric to help you focus.
2. Read the required chapter(s) of the textbook and any additional recommended resources. Some answers may require you to do additional research on the Internet or in other reference sources. Choose your sources carefully.
3. Consider the discussion and the any insights you gained from it.
4. Create your Assignment submission and be sure to cite your sources, use APA style as required, check your spelling.
Assignment:
Exercises:
Professional Development
BUY A PLAGIARISM-FREE PAPER HERE
,
| Criteria | Ratings | Pts |
|---|---|---|
| This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript) | 25.0 ptsAbove Average- DCE Score greater than or equal to 93; Comprehensive introduction with expectations of exam verbalized; questions worded in a non-judgmental way; professional language exercised; questions well-organized; appropriate closing with summary of findings verbalized to patient.21.0 ptsAverage- DCE Score greater than or equal to 86-92; Adequate introduction; some questions worded in a non-judgmental way; professional language mostly exercised; questions generally organized; somewhat complete closing.10.0 ptsBelow Average- DCE Score greater than or equal to 80-85; Incomplete introduction; many questions worded in a judgmental way; some professional language exercised; questions somewhat organized; incomplete closing.0.0 ptsUnsatisfactory- DCE Score less than or equal to 79; Introduction missing; questions worded in a judgmental way; little professional language; questions unorganized; closing missing. | 25.0 pts |
| This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation | 20.0 ptsAbove Average- Physical assessment documentation includes all relevant body systems; all pertinent normal and abnormal findings identified; documentation reflects professional language; treatment plan includes each of the following components: diagnostics, medication, education, consultation/referral, and follow-up planning.16.0 ptsAverage- Physical assessment documentation lacks sufficient details pertaining to one or two relevant body systems; or identifies ≥ 50% of the pertinent normal and abnormal findings; or documentation lacks professional language; or treatment plan lacks one or two components (diagnostics, medication, education, consultation/referral, or follow-up planning).8.0 ptsBelow Average- Physical assessment documentation lacks sufficient details pertaining to three or more relevant body systems; or identifies < 49% of the pertinent normal and abnormal findings; or documentation includes unprofessional language; or treatment plan lacks three or more components (diagnostics, medication, education, consultation/referral, or follow-up planning).0.0 ptsUnsatisfactory- No physical assessment documentation or no treatment plan. | 20.0 pts |
| This criterion is linked to a Learning OutcomeSelf-Reflection | 5.0 ptsAbove Average- Responds to three of the three reflection post questions; and provides analysis of performance; and reflection posts written using professional language; and reflection posts demonstrate insight.3.0 ptsAverage- Responds to two of the three reflection post questions; or provides limited self-analysis of performance; or reflection posts are somewhat unclear related to the assignment and the student’s experience; or reflection posts lack insight.2.0 ptsBelow Average- Responds to one of the three reflection post questions; or does not provide self-analysis of performance; or reflections are not related to the assignment and the student’s experience; or does not provide insight0.0 ptsUnsatisfactory- No reflection posts for the assignment. | 5.0 pts |
| Total Points: 50.0 |
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