Exam (elaborations)
Danny Rivera Documentation Focused Exam Cough Completed Shadow Health
- Course
- NR509 NR 509
- Institution
- Chamberlain College Of Nursing
Danny Rivera Documentation Focused Exam Cough Completed Shadow Health
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Focused Exam: Cough | Completed | Shadow Health 7/10/20, 12(24 AMBecome a paid student tester for Shadow Health! Click here for more information (/site_notice_dismissals?from_flash=true&site_notice_id=4
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Focused Exam: Cough Results | Turned In
Fundamentals of Nursing Practice - June 2020, N3604
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Overview
Documentation / Electronic Health Record
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Transcript
Subjective Data Collection
rs e
Document: Vitals Document: Nursing Notes
ou urc
Objective Data Collection
Document: Nursing Notes
Education & Empathy
o
Documentation Student Documentation Model Documentation
aC s
Care Plan Subjective
vi y re
Danny Rivera is an 8-year-old male who presents for evaluation of a
cough of onset 3 days ago. Patient reports a productive cough with
"slimy, clear" sputum. The patient reports a sensation to cough
"every few minutes" and his coughing spells last "a couple
seconds". The patient reports an exacerbation of his symptoms at
ed d
night causing him to have difficulty sleeping. The patient reports that
ar stu
his friend he played with a few days ago is also sick with symptoms
of a cough and rhinorrhea. The patient reports that his mother has
been giving him cough medicine which was noted by his
grandmother to be children's Dimetapp daytime formula. The child
last received the Dimetapp this morning and noted improvment of
his symptoms after taking the medication. The patient notes
is
associated symptoms of "feeling tired" but notes that he is able to
play at school normally until he feels the urge to cough. He also
Th
notes associated "clear" watery rhinorrhea and a sore throat with
exacerbation with swallowing. The patient notes a normal level of
focus at school but reports it is "harder than normal" to pay attention
due to freqwuent coughing. The patient denies any symptoms of
sneezing, ear pain, ear drainage, hearing changes, fever, chills, night
sweats, HA, vision changes, dizziness, eatery eyes, sinus pain, chest
sh
pain, or difficulty breathing. The patient was sent to my office for
evaluation by his teacher due to persistent cough. He reports no
other associated sx or complaints at this time.
Danny reports a cough lasting two to three days. He describes the
Contacted guardian: Patients grandmother reports a cough for the cough as “watery and gurgly.” He reports the cough is worse at night
past 3 days and states that Danny "hasn't been himself". Reports and keeps him up. He reports general fatigue due to lack of sleep.
that patient was given children's Dimetapp, daytime formula this He is experiencing mild soreness in his throat. He reports his mother
morning before going to school. Grandmother confirms that the treated his cough symptoms with over-the-counter medicine, but it
patient has had a normal temperature the past few days. Reports Support
was only temporarily effective. He reports frequent cold and runny
history of a pneumonia one year ago and frequent ear infections but nose, and he states that he had frequent ear infections as a child. He
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