NR 509 WEEK 2 SHADOW HEALTH RESPIRATORY PHYSICAL
ASSESSMENT ASSIGNMENT
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Transcript
Overview
Started: Nov
... [Show More] 08, 2018 | Patient Exam Time: 442 min
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
Hi Tina, what brings you in to the clinic today?
Hey.
Hey....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.
Greet
11/08/18 10:04 PM
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Question
11/08/18 10:04 PM
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can you tell me what you mean by
breathing problems?
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11/08/18 10:05 PM
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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.
I am sorry to hear that you have been having these issues. I will
do my best to help you feel better.
Empathize
11/08/18 10:11 PM
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I appreciate you telling me that.
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Transcript
All Lines (193) Interview Questions (100) Statements (10) Exam Actions (83)
Your text here 1
All of these breathing problems started two days ago, at my cousin's house.
(Clarified to how long ago my breathing problems started.)
My chest has been feeling tight, but it doesn't hurt or anything.
Once my asthma starts to act up, I just use my inhaler, and then I feel better
within a minute or two.
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.)
It's just a regular Proventil inhaler.
It doesn't hurt. . . it's just hard to breathe, but there's no pain.
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11/08/18 10:16 PM
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11/08/18 10:25 PM
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11/08/18 10:28 PM
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11/08/18 10:29 PM
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11/08/18 10:30 PM
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11/08/18 10:30 PM
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11/08/18 10:33 PM
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11/08/18 10:33 PM
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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?
how long have you been having the breathing issues (Clarified to How long ago
did your breathing problems start?.)
where are you feeling the discomfort
How long does the chest tightness last
How often are you having to use your inhaler in a day (Clarified to how many
times have you used your inhaler in the past two days.)
what inhaler are you using
what is the dosage of the proventil
what severity would you rate it at?
Yeah, I have asthma.
would you rate difficulty 0-10?
At its worst it's been like a 7 or 8 out of 10, probably.
how would you describe the difficulty breathing?
that has nothing to do with my question, but thanks for that!
Alright, thanks for letting me know.
so your breathing feels tight in your chest?
what seems to make your breathing worse
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.
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11/08/18 10:33 PM
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11/08/18 10:34 PM
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11/08/18 10:36 PM
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11/08/18 10:37 PM
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Educate
11/08/18 10:37 PM
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11/08/18 10:37 PM
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11/08/18 10:38 PM
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11/08/18 10:40 PM
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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.
It's not so bad right this second, but it's been pretty tight lately, l [Show Less]