NR 509 Week 2 Shadow Health Respiratory Assessment

Sample Answer for NR 509 Week 2 Shadow Health Respiratory Assessment Included After Question

NR 509 Week 2 Shadow Health Respiratory Assessment

NR 509 Week 2 Shadow Health Respiratory Assessment

HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house 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 and she is concerned that her albuterol inhaler 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.

Social History: 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.

• Nose/Sinuses: 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 of GERD or abdominal pain
• Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.

 

Objective

 

General: Ms. Jones is a pleasant, obese 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 spirometry: FVC 3.91 L, FEV1/FVC ratio 80.56%. SpO2: 97%.

 

NB: We have all the questions and documented answers in the SUBJECTIVE DATA, OBJECTIVE DATA, ASSESSMENT AND CARE PLAN format. All you need to do is ORDER NOW for an equivalent of 4 pages and score 100% in this assignment and all other Shadow Health Assignments. By placing this order, the only thing you will do is ask Tina the questions that we will give you and then use our documentation  to create yours!!!

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.

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

ORDER NOW FOR INSTRUCTIONS-COMPLIANT, ORIGINAL PAPER

SAMPLE Shadow Health Respiratory Assessment

A Sample Answer for The Assignment: NR 509 Week 2 Shadow Health Respiratory Assessment

Title: NR 509 Week 2 Shadow Health Respiratory Assessment