Focused Exam: COPD - Week 12 Results | Turned In
Advanced Pharmacotherapeutics - Maryville University - August 2019, nurs_615
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Overview Transcript
Subjective Data Collection: 32 of 32 (100.0%)
Subjective Data Collection Objective Data Collection Education & Empathy Documentation
Debrief
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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.
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Medication Selection Patient Teaching Prescription Writing Student Survey
Categor y
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
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A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case.
Chief Complaint
Established chief complaint and reason for admittance
Reports a bronchospasm three days ago Reports increased difficulty breathing Reports desire for smoking cessation aids
History of Present Illness
Asked about additional symptoms Reports fatigue and weakness Reports purulent sputum Reports cough
Reports feeling anxious about symptoms and worsening health issues
Asked about onset and duration of symptoms Reports most severe fatigue and difficulty
breathing began three days ago
Reports purulent sputum production started two weeks ago
Reports respiratory symptoms increased in the last four months
Followed up on characteristics of respiratory distress
Reports sputum is mostly clear with occasional yellow, gray, or dark color
Reports wheezing
Reports cough sounds like crackling
Asked about aggravating factors Reports exertion worsens symptoms
Reports coughing fits after smoking
Asked about treatment and relieving factors of respiratory symptoms
Reports trying to hold off on smoking cigarettes as long as possible
Asked about severity of respiratory distress Reports breathing difficulty and associated
discomfort is a 6/10
Asked about effects of health on social activity Reports low social activity - doesn't feel up to
getting out and about
Past Medical History
Asked about existing health conditions Reports chronic bronchitis related to COPD
Followed up on chronic bronchitis COPD diagnosis
Reports diagnosed with "Class B" COPD Reports diagnosed after respiratory distress
episode
Asked about ER visits or hospitalizations Reports hospitalization after miscarriage at age 24
Reports most recent hospitalization was two years ago
Reports most recent hospitalization was for respiratory distress episode
Home Medications
Asked about home medications Reports taking a long-acting beta-agonist (LABA)
Followed up on LABA Reports the LABA is formoterol inhaler Reports formoterol dose of 12 micrograms
Reports only using once every 12 hours, once in the morning and once at night
Reports using LABA this morning Reports the LABA is not very effective Denies medication side effects
Asked about supplements and vitamins Denies use of supplements or vitamins
Asked about medication regimen adherence Denies missing doses
Asked about spirometry Reports sporadic spirometry readings at home Reports most recent FEV1 reading was 1.37 L,
49% of her predicted FEV1
Asked about oxygen use Denies oxygen therapy due to cigarette smoking
Asked about allergies Denies allergies
Asked about vaccines Denies recent influenza vaccine Denies recent pneumococcal vaccines [Show Less]