nr 509 week 2 shadow health respiratory physical assessment assignment
nr 509 week 2 shadow health
shadow health respiratory physical assessment
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NRNP 509
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Respiratory Physical Assessment Assignment | Completed | Shadow Health
NR 509 WEEK 2 SHADOW HEALTH RESPIRATORY PHYSICAL
ASSESSMENT ASSIGNMENT
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Transcript
Overview
Transcript
Started: Nov 08, 2018 | Patient Exam Time: 442 min
Subjective Data Collection
All Lines (193) Interview Questions (100) Statements (10) Exam Actions (83)
Objective Data Collection
Greet
Education & Empathy
Hi Tina, what brings you in to the clinic today? 11/08/18 10:04 PM
CST
Documentation
Student Pre-Survey Hey.
Lifespan
Question
Review Questions Hey....what brings you in today? 11/08/18 10:04 PM
CST
Self-Reflection
I came in because I've been having breathing problems, and
my inhaler just isn't working the way it normally does.
Question
can you tell me what you mean by 11/08/18 10:05 PM
breathing problems? CST
It feels like it's been hard to take in air. My chest feels all tight and I've
been wheezing... I've had to use my inhaler a lot, and it doesn't feel
like it's totally working.
Empathize
I am sorry to hear that you have been having these issues. I will
11/08/18 10:11 PM
do my best to help you feel better.
CST
I appreciate you telling me that.
1/24
,how long have you been having the breathing issues (Clarified to How long ago
Question
did your breathing problems start?.)
11/08/18 10:16 PM
CST
All of these breathing problems started two days ago, at my cousin's house.
(Clarified to how long ago my breathing problems started.)
Question
where are you feeling the discomfort
11/08/18 10:25 PM
CST
My chest has been feeling tight, but it doesn't hurt or anything.
Question
How long does the chest tightness last
11/08/18 10:28 PM
CST
Once my asthma starts to act up, I just use my inhaler, and then I feel better
within a minute or two.
How often are you having to use your inhaler in a day (Clarified to how many Question
times have you used your inhaler in the past two days.) 11/08/18 10:29 PM
CST
I've been needing my inhaler about every four hours, I'd say. (Clarified to how
many times I have used my inhaler in the past two days.)
Question
what inhaler are you using
11/08/18 10:30 PM
CST
It's just a regular Proventil inhaler.
Question
what is the dosage of the proventil
11/08/18 10:30 PM
CST
Sometimes I have to take three puffs instead of two, and the past couple days,
always three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]
how would you rate the chest tightness?
Question
11/08/18 10:33 PM
CST
It doesn't hurt. . . it's just hard to breathe, but there's no pain.
Question
what severity would you rate it at?
11/08/18 10:33 PM
CST
, It doesn't hurt. . . it's just hard to breathe, but there's no pain.
Question
11/08/18 10:33 PM
how difficult is it to breathe 0-10? CST
Yeah, I have asthma.
Question
11/08/18 10:34 PM
would you rate difficulty 0-10? CST
At its worst it's been like a 7 or 8 out of 10, probably.
Question
11/08/18 10:36 PM
how would you describe the difficulty breathing? CST
Oh, hmm, gosh--that's always hard to describe. I think I'm friendly, and I'd say
I'm pretty driven. I'd say I'm funny too.
that has nothing to do with my question, but thanks for that! (No matching Question
questions found.) 11/08/18 10:37 PM
CST
Educate
11/08/18 10:37 PM
that has nothing to do with my question, but thanks for that! CST
Alright, thanks for letting me know.
Question
11/08/18 10:37 PM
so your breathing feels tight in your chest? CST
made your breathing better.)
what seems to help your breathing the past two days (Clarified to What has
It's not so bad right this second, but it's been pretty tight lately, like I can't take
in air.
Question
11/08/18 10:38 PM
what seems to make your breathing worse CST
Usually it acts up around cats. . . sometimes dust, or running quickly up a flight
of stairs. But the past couple days my breathing has just been getting bad on its
own, it seems like. Question
11/08/18 10:40 PM
CST
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