NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

A Sample Answer For the Assignment: NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

Title: NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

OBJECTIVE DATA:

Physical Exam:

Vital Signs:  

Heart rate: 65 beats per minute.

Blood pressure: 118/78 mm Hg (measured in the left arm while sitting)

The response rate is 28%.

The oral temperature is 98 degrees Fahrenheit.

The SpO2 reading is 92.2.

The patient’s height is 4 feet and 8 inches. Weight: 50 kg. Body mass index (BMI) is 24.71 kg/m².

The growth chart displays the BMI of males aged 2 to 20 at the 75th percentile.

General: Throughout the interview, the patient coughs and seems exhausted. He also radiates steadiness.

HEENT: The skull seems to be of a normal size and form, and there are no indications of any injuries. The patient has been noted to have a wet mucus membrane and a clear nasal discharge, erythema, and cobblestones in the posterior part of the throat. The individual’s eyes lack luster, while the conjunctiva appears to be of a pink hue. The right tympanic membrane displays signs of erythema and inflammation. The patient exhibits enlarged and tender right cervical lymph nodes.

Respiratory: The patient does not exhibit severe distress. Their respiratory rate is elevated at 28 breaths per minute. When using a stethoscope to listen, breath sounds are typical. The patient can speak in complete sentences. The bronchoscopy’s findings are unfavorable. Upon percussion, the chest wall showed resonance, and the fremitus was bilaterally predicted and equal.

Cardiology: No abnormal heart sounds were detected during the auscultation of S1 and S2.

Lymphatics: Tenderness is observed upon palpation of the right cervical lymph nodes.

Psychiatric: No depression or anxiety.

Diagnostics/Labs: Regular lab tests such as complete blood counts and WBC were requested to look for any symptoms of infection. The patient’s cough was evaluated using spirometry and peak expiratory flow measurements. To rule out other potential diagnoses, bronchoprovocation testing was performed. Upper airway provocation investigations, sinus imaging, thoracic CT scans, and bronchoscopies are additional tests to evaluate the cough and cold. To further assess the ear pain, a nasolaryngoscopy, and a brain and neck CT scan were ordered (Shoukat et al., 2019).

NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

Patient Information

Initials: D.R

Age: 8 years old

Gender: Male

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SUBJECTIVE DATA:

Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot’

History of Present Illness (HPI): The patient Danny Riviera is a boy aged 8, who comes to the clinic reporting that he has had a cough for the past 4 days. His description of the cough states that it is watery and clear. His cough becomes worse at night, which affects his sleep. As such, he does not focus at school and suffers from fatigue. His right ear has pain. His mother decided to use over-the-counter cough medicine, which offered temporal relief. Danny states that he suffers from a frequent runny nose as well as a cold and sore throat. He is also exposed to secondhand smoke from his father. He has also suffered pneumonia in the past year. However, he does not have a fever, breathing difficulties, abdominal pain, and chest tightness and chills.

Medications: The patient admits to taking home medications. He also takes a daily vitamin. He also takes a purple cough medication.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Reports immunizations as current. Reports past frequent coughs and pneumonia.

Past Surgical History (PSH): None reported.

Sexual/Reproductive History: No history of reproductive disorders.

Personal/Social History: Reports living in a house with his parents and grandparents. Reports feeling safe at home. Reports park with playground near home. Reports father smokes at home. Denies pets at home

Immunization History: Immunizations are current.

Significant Family History: He has a father, mother, and both grandparents. Reports father with a history of asthma as a child. Denies family history of allergies.

Review of Systems:

General: The patient looks fatigued and also coughs whilst having the interview. He also appears stable. Denies fever, appetite loss, weight loss, chills, or night sweats.

HEENT: The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient’s right cervical lymph nodes appear enlarged with a certain tenderness.

Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.

Cardiovascular/Peripheral Vascular: No chest pain, chest tightness, palpitations, edema, cyanosis, dyspnea.

Psychiatric: No depression, anxiety, or history of psychotic disorders.

Neurological: Report’s headache. Denies dizziness, loss of consciousness, or vision changes.

Lymphatics: Right cervical lymph nodes are tender on palpation.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure	120/76
O2 Sat	96%
Pulse	100
Resp. Rate	28
Temperature	37.2 c

 

General: The patient looks fatigued and also coughs whilst having the interview. He also appears stable.

HEENT: Head is normocephalic and atraumatic. The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient’s right cervical lymph nodes appear enlarged with a certain tenderness.

Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.

Cardiology: No murmurs, gallops, or rubs in S1 and S2.

Lymphatics: Right cervical lymph nodes are tender on palpation

Psychiatric: No mental issues noted.

Diagnostics/Labs: Routine lab works were ordered including complete blood count, and white blood cell count to determine any signs of infection. Spirometric and peak expiratory flow measurements were collected to further evaluate the patient’s extend of cough. Bronchoprovocation testing was done to rule out differential diagnosis. Other investigations are done to assess the cough and cold include upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy (Malesker et al., 2017). For further assessment of the ear pain, nasolaryngoscopy and MRI of the head and neck were ordered.

ASSESSMENT:

Priority Diagnosis: Acute Viral Rhinitis: It is also known as common cold. It is associated with inflammation of the nasal mucosa lining as a result of respiratory viral infection. It is common among children, characterized by sneezing, running nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear pain, difficulties in swallowing, and fatigue among others (Malesker et al., 2017). The patient in the case study displayed most of the above symptoms, qualifying for a common cold diagnosis.

Differential Diagnosis:

1. Acute sinusitis: This normally occurs when a cold virus infects the patient’s sinuses. The patient may display headache, fever, cough which is worse at night, severely stuffed up nose, green, or thick yellow mucus, itchy and watery eyes, and ear pain. The patient in the case study displayed most of these symptoms (Shoukat et al., 2019). However, he denied fever, and the nasal discharge is clear and thin, which disqualifies the diagnosis.
2. Influenza (flu): This is a common viral infection of the respiratory tract among children. It is characterized by fever, headache, running nose, fatigue, cough, eye, and ear pain. The patient in the case study displayed most of the above symptoms (Badyda et al., 2020). Consequently, this condition is common among patients with a history of pneumonia, just like in the provided case study.
3. Ear Infection: Sinus and cold infections can lead to the accumulation of fluids in the patient’s ears behind the eardrum. As a result, viruses and bacteria can grow leading to infection of the ears. Patients may display ear pressure or fullness, ear pain, drainage, muffled hearing, and loss of balance (Badyda et al., 2020). Given that most ear infections among children might start as a common cold, then the patient’s right ear pain and associated upper respiratory symptoms may be as a result of ear infection.

Treatment Plan:

Previous Diagnosis: Pneumonia and cough which were managed appropriately.

Present Diagnosis: Acute Viral Rhinitis

Pharmacological Intervention: Cold remedies such as Dimetapp 10mL every 4 hours to a maximum of 6 doses/24 hours (Malesker et al., 2017). Acetaminophen to manage the pain and fever. Dexamethasone/gentamicin drops for ear pain.

Non-pharmacological Intervention: Honey and saline nose spray to help with soothing the sore throat and cough, and managing congested nose respectively (Fernandez, & Olympia, 2017). Extra fluid and a cool-mist humidifier are also necessary for helping manage the patients’ cold symptoms.

Patient Education: Inform the patient’s mother on the importance of sticking to the treatment plan. It is also important to educate the patient’s parents on expected side effects, and adverse reactions which might call for medical attention (Malesker et al., 2017).

Health Promotion: Encourage the patient’s mother to ensure that he is always warm, with a healthy diet, and enough sleep (Badyda et al., 2020).

Follow-up: The patient should be advised to report back to the clinic in case of worsened symptoms, or if the prescribed drugs fail to relieve the patient’s symptoms within one week.

References

Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed on different levels of ambient particulate matter. DOI: 10.1183/13993003.congress-2020.1303

Fernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT CARE MEDICINE, 77.

Badyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164/ajrccm-conference.2020.201.1_

Malesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., … & Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest, 152(5), 1021-1037. https://doi.org/10.1016/j.chest.2017.08.009

Shoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology (PAB), 8(2), 1084-1091. http://dx.doi.org/10.19045/bspab.2019.80050

Care Plan : 9.5 of 10 (95.0%)

 Nursing Diagnosis

3.5 out of 3.5

 Nursing Diagnoses: Definitions & Classifications 2018-2020 © NANDA-International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. All rights reserved. Authorized translation from the English language edition published by Thieme Medican Publishers Inc. No part of this material may be reproduced in any form without the written permission of the agent of the copyright holder, NANDA-International. Direct inquires to [email protected]. Link for more information: http://www.nanda.org/.

Status

Student Response	Model Answer	Explanation	Points Earned
is at risk for	is at risk for	The correct status for the nursing diagnosis is “is at risk for,” because Danny’s most pressing vulnerability is to an infection that he has not yet, but could, develop.	0.5 out of 0.5

Diagnosis

Student Response	Model Answer	Explanation	Points Earned
infection	infection	While a cough can be unpleasant, the most alarming thing it indicates about Danny’s health is that he is at risk for an infection.	0.5 out of 0.5

Etiologies

Student Response	Model Answer	Explanation	Points Earned
played w/ sick peer	played w/ sick peer	Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke.	0.5 out of 0.5
touches face often	touches face often	Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke.	0.5 out of 0.5
rare hand washing	rare hand washing	Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke.	0.5 out of 0.5
secondhand smoke	secondhand smoke	Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke.	0.5 out of 0.5

Signs & Symptoms

Student Response	Model Answer	Explanation	Points Earned
N/A	N/A	Because the infection that Danny may develop hasn’t happened yet, he is not currently presenting with any signs or symptoms, so the correct answer here is “N/A.”	0.5 out of 0.5

 Self Assessment

 

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt	Student Response	Model Answer	Explanation
Why would a nursing diagnosis of a cough be incorrect, compared to a risk for infection? Consider the difference between nursing and medical diagnoses.	Whereas the cough can be unpleasant and a bother, it is a symptom of something more severe in the sense that it shows that the immune system could be at risk of getting an infection. The most effective nursing care you should prioritize is to educate the patient on avoiding the more serious outcome.	While a cough can be unpleasant and frequent, it is actually a symptom of something more alarming: the immune system being at risk for an infection. The most effective nursing care you should prioritize is to educate your patient on avoiding this more serious outcome.	Your nursing diagnosis should always take into account what condition is most serious, receiving the greatest benefit from your help. This diagnosis may not be the most obvious physical symptom to you or your patient, so always consider what is jeopardizing a patient’s health the most.

 Planning

3.5 out of 4

Short-Term Goal

Student Response	Model Answer	Explanation	Points Earned
To have patient report decreased discomfort and coughing by end of clinic visit.	To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit.	A risk-based diagnosis does not require medical interventions as the problem is hypothetical; the goal that does suit the diagnosis involves teaching the patient and his guardian about risk-reduction methods.	0 out of 0.5

Interventions

Student Response	Model Answer	Explanation	Points Earned
Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom	Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5
Instruct family and patient that patient should increase fluid intake	Instruct family and patient that patient should increase fluid intake	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5
Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens)	Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens)	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5
Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick	Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5
Instruct patient to avoid touching fingers to eyes, nose, or mouth	Instruct patient to avoid touching fingers to eyes, nose, or mouth	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5
Instruct patient to cough into tissue, or sleeve if tissue is unavailable	Instruct patient to cough into tissue, or sleeve if tissue is unavailable	Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again.	0.5 out of 0.5

Intervention Rationale

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt	Student Response	Model Answer	Explanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal.	Ask patients and family memebers to verbalize and agree to their instructions on infection prevention and respiratory hygiene.	These interventions will teach Danny and his guardian how to keep their hands and lungs clean in a variety of ways, so that Danny’s risk for infection is reduced as pathogens are eliminated.	Infection can be caused by multiple culprits, so it’s important that your patient teaching covers a thorough and specific array of anti-infection habits.

Data Collections

Student Response	Model Answer	Explanation	Points Earned
Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene	Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene	It is important that your patient and his guardian agree to their instructions, as changing lifestyle habits can be intimidating but necessary for the patient’s health. Having Danny and his father verbalize back their instructions also assures they remember and understand the details.	0.5 out of 0.5

 Discussion Of Care

 Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt	Student Response	Model Answer	Explanation
Explain the rationale behind your nursing diagnosis.	Hello Danny, since you have been feeling unwell for the last three days, it is my responsibility to ensure that you get in the habit of practicing hand hygiene. Because you are at risk for developing an upper respiratory infection. My goal to you is to you and your family to avoid unnecessary infections by following these instructions. Some of the things that make you sicker are being near sick friend, being exposed to second hand smoke, washing your hands more, and touching your face with hands. I know it sounds like a lot of things but working together, we can reduce the infections in an effective manner.	Danny, given that you aren’t feeling well, we want to make sure you don’t develop an infection, which for you just means getting even sicker. We’re going to talk about the ways we can work to prevent that, especially focusing on your risk factors, which are just things that give you a bigger chance of being sick. Some of your risk factors are that you were near a sick friend, have been exposed to cigar smoke, could stand to wash your hands more, and have touched your face with your fingers. I know that sounds like a lot, but if we work together, reducing your risk factors for infection can be easy and effective.	A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement.
Explain your goal for Danny and the interventions and data collections through which you will achieve it.	All right. In order to talk to you about how you are not going to get sicker, I will have a conversation with you and your father. Him, you and myself are going to work together to discuss and then have to agree to your goals. And then I am going to have you and your father repeat what you have learned so we can make sure that you have got it down pat.	Let’s talk about how we’re going to help you not get sicker! So, I’m going to have a conversation with you and your father about things to do to ensure your health. You, he, and I will work together to discuss, and then have you agree to your goals. Then I’m going to have you and your father repeat what you’ve learned, so we can make extra sure you’ve got it down pat!	You should communicate the Care Plan to the patient, allowing them to exercise involvement and agency in their own healthcare.
Explicitly ask for Danny’s consent to the Care Plan.	Does this sound like a plan?	Does this plan I just talked about sound good to you?	A patient must consent to all interventions in their Care Plan. Disagreements are opportunities to provide further patient education and to consider alternative options.
Inform Danny you will now begin educating him and will then call to educate his guardian.	Now, Danny, if you lack other questions, we can start now!	Danny, if you don’t have any other questions, we can start our discussion now!	It’s time to begin your education interventions, so let your patient know!

 Intervention & Evaluation

2.5 out of 2.5

 

Student Response	Model Answer	Explanation	Points Earned
Partially	Partially	While Danny correctly verbalizes and agrees to his instructions for reducing infection risks, his father only agrees to some of his instructions, expressing apprehension toward not smoking inside the house. Your goal has been partially achieved.	2.5 out of 2.5

 Intervention & Evaluation Rationale

 

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt	Student Response	Model Answer	Explanation
Did you achieve your goal for your patient and his guardian by the end of the visit, getting each of them to agree to and verbalize your instructions for avoiding infection and practicing respiratory hygiene?	Whereas Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of his house. One of his instructions was to keep the house smoke free so as to reduce Danny’s risk of infection so this aspect of the goal has not been achieved. However, the paties verbally agree to most of the other interventions, which implies that the overall goal has been achieved partially.	While Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of the house. One of his instructions was to keep the house smoke-free in order to reduce Danny’s risk of infection, so this aspect of your goal has not been achieved. However, both parties verbally agree to most of their other instructions, so your overall goal has been partially achieved.	Even with progress being made in almost all aspects of your patient teaching, you must adhere to your goal and consider your work incomplete if certain agreements have not been reached.

Week 5 Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

Patient Information

Initials: D.R

Age: 8-years old

Gender: Male

 SUBJECTIVE DATA:

Chief Complaint (CC): Patient reports of chronic coughing which makes him feel he is sick and needs immediate medical attention.

History of Present Illness (HPI): The patient’s condition Danny Riviera, an 8-year-old boy, arrives at the clinic complaining of a cough that has lasted four days. His cough is watery and clear, according to his description. It worsens at night, interfering with his sleep. As a result, he struggles to concentrate at school and suffers from fatigue. His right ear hurts. The mother chose over-the-counter cough medicine, which provided temporary relief. Dan claims to have a persistent runny nose, as well as a cold and sore throat.

Mr. Riviera, his father exposes him to secondhand smoke. He also had a bout of pneumonia last year. The patient does not report of feeling chills, fever or difficulty in breathing.

Medications: Danny acknowledges that he has been taking some medication at home. He takes a daily dose of vitamin and a cough syrup.

Allergies: The patient has no known drug allergy.

Past Medical History (PMH): Danny has no previous history of asthma however; he acknowledges his battle with pneumonia and coughs in the past.

Past Surgical History (PSH): He has no past history of nay surgical procedure.

Sexual/Reproductive History: There is no known history of reproductive diseases or disorders.

Personal/Social History: Danny acknowledges of a safe upbringing, with a safe home that is near a park where he visits frequently. There are no bets at home and he lives together with his parents and grandparents. His father, Mr. Riviera often smokes in the house.

Immunization History: His immunization record is up to date.

Significant Family History: The family is composed of a father, mother and both grandparents. He is the only child, and their family has no known history of allergies. Though his father battled with asthma attacks during his childhood.

Review of Systems:

General: While having the interview, the patient appears tired and coughs.

He also appears to be in good health. Fever, loss of appetite, weight loss, chills, or nocturnal sweats are all denied.

HEENT: The mucus membrane is wet, and the nasal discharge is clear, but the back of his neck is red and cobblestone. The conjunctiva of his eyes is pink, and his eyes are dull. The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarging and painful.

Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation.

When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.

Cardiovascular/Peripheral Vascular: Chest discomfort, tightness, palpitations, edema, cyanosis, and dyspnea are not present.

Psychiatric: There is no history of depression, anxiety, or psychotic problems.

Neurological: He experiences some headache but dizziness, loss of consciousness, or vision problems are denied.

Lymphatics: On palpation, the right cervical lymph nodes are tender.

OBJECTIVE DATA:

On physical examination, the following data was collected.

Vital signs:

Blood Pressure	120/76
O2 Sat	96%
Pulse	100
Resp. Rate	28
Temperature	37.2 c

 

General: During the interview, the patient appears tired and coughs. But appears to be in good health.

HEENT: The head is normocephalic and unaffected by trauma.

He has a moist mucus membrane, clear nasal discharge, and redness and cobblestone at the back of his throat. His eyes are dull, with a pink conjunctiva.

The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarged and tender.

Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation.

When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.

Cardiology: In both S1 and S2, there were no murmurs, gallops, or rubs.

Lymphatics: On palpation, the lymph nodes in the right cervical region are sensitive.

Psychiatric: There were no signs of mental illness.

Diagnostics/Labs: To assess any evidence of illness, routine lab tests were done, including a complete blood count and a white blood cell count. To assess the extent of the patient’s cough, spirometry and peak expiratory flow measures were taken. To rule out any other possibilities, bronchoprovocation testing was performed. Upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy are among the other tests used to detect cough and cold symptoms (Malesker et al., 2017). Nasal-laryngoscopy and a head-and-neck MRI were recommended for a more thorough examination of the ear pain.

ASSESSMENT:

Priority Diagnosis: Acute Viral Rhinitis, generally known as the common cold, is a viral infection that affects the nose and sinuses. As a result of a respiratory virus infection, it is linked to nasal mucosa lining inflammation. Sneezing, runny nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear ache, swallowing difficulty, and exhaustion are some of the symptoms that youngsters experience (Malesker et al., 2017). Most of the symptoms listed above were present in the patient in the case study, indicating a common cold.

Differential Diagnosis:

1. Acute sinusitis: This happens when the patient’s sinuses are infected by a cold virus.

Headache, fever, cough that worsens at night, excessively congested nose, green or thick yellow mucus, itchy and watery eyes, and ear pain are some of the symptoms that the patient may experience. Most of these symptoms were present in the case study patient (Shoukat et al., 2019).

He denied having a temperature, and the nasal discharge was clear and thin, therefore the diagnosis was ruled out.

2. Influenza (flu) is a frequent respiratory viral infection in youngsters.

Fever, headache, runny nose, lethargy, cough, eye, and ear pain are all symptoms of this infection. Most of the aforesaid symptoms were present in the patient in the case study (Badyda et al., 2020). As a result, people with a history of pneumonia, such as those in the case study, are more likely to develop this illness.

3. Ear Infection: Fluids can accumulate behind the eardrum due to sinus and cold infections.

Viruses and bacteria might proliferate as a result, resulting in ear infection. Ear pressure or fullness, ear pain, leakage, distorted hearing, and loss of balance are some of the symptoms that patients may experience (Badyda et al., 2020). Given that most children’s ear infections begin with a common cold, the patient’s right ear pain and concomitant upper respiratory symptoms could be due to an ear infection.

A Plan for the Treatment of the Patient

Previous Diagnosis: The patient’s previous bouts of pneumonia and cough were well treated.

Present Diagnosis: Acute Rhinitis which is a type of viral rhinitis.

Pharmacological Intervention: Cold medicines such as Dimetapp 10mL every 4 hours up to 6 doses every 24 hours are recommended (Malesker et al., 2017). Acetaminophen is used to relieve pain and fever. Drops containing dexamethasone and gentamicin for ear discomfort.

Non-pharmacological Intervention: The use of honey and saline nose spray can help with sore throats, coughs, and congested noses, respectively (Fernandez, & Olympia, 2017).

Extra fluids and a cool-mist humidifier are also required to help manage the patients’ cold symptoms.

Patient Education: Explain to Mrs. Riviera the importance of following the treatment plan. It’s also crucial to inform the patient’s parents about possible side effects and adverse responses that may necessitate medical intervention (Malesker et al., 2017).

Health Promotion: To emphasize to Mrs. Riviera the need to keep the son warm, eat a nutritious diet, and get enough sleep (Badyda et al., 2020).

Follow-up Plan: If the patient’s symptoms increase or if the prescribed drugs do not improve the patient’s symptoms within one week, the patient is advised to return to the clinic.

Reference

Badyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164/ajrccm-conference.2020.201.1_

Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed on different levels of ambient particulate matter. DOI: 10.1183/13993003.congress-2020.1303

Fernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT CARE MEDICINE, 77.

Malesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., … & Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest, 152(5), 1021-1037. https://doi.org/10.1016/j.chest.2017.08.009

Shoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology (PAB), 8(2), 1084-1091. http://dx.doi.org/10.19045/bspab.2019.80050

Sample Answer for NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough Included

Assignment 2: Digital Clinical Experience: Focused Exam: Cough

To Prepare

Focused Exam: Cough Assignment:

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

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By Day 7 of Week 5

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Week 5 Assignment 2 DCE Rubric

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To submit your Lab Pass:

Week 5 Lab Pass

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Week 5 Documentation Notes for Assignment 2

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Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot’

History of Present Illness (HPI): The affected person A young boy named Danny Riviera, who is only 8 years old, visits the medical center because he has been coughing for the past few days. According to what he says, the cough is very clear and has a watery quality to it. His cough is worse at night, which prevents him from getting adequate rest. As a consequence of this, he has trouble concentrating in class and often comes home exhausted. It’s painful in his right ear. The decision his mother made to use over-the-counter cough medicine, which only provided temporary relief, was made. Danny claims that he has a cold and that he suffers from a runny nose on a regular basis. Additionally, he inhales his father’s secondhand smoke on a regular basis. Within the past year, he has also been diagnosed with pneumonia. However, he does not have a fever, difficulty breathing, abdominal pain, chest tightness, or chills. He also does not have chest tightness.

Medications: The patient acknowledges that they do take their medications at home. In addition to that, he takes a vitamin every day. In addition to that, he takes a medication for coughing that is purple.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Identifies immunizations as being up to date. Previous symptoms include chronic coughing and pneumonia.

Past Surgical History (PSH): None reported.

Sexual/Reproductive History:

Personal/Social History: Identifies himself as a member of a household that also includes his parents and grandparents. avers having a sense of well-being while at home. Describes a park with a playground in the neighborhood. It is reported that the father smokes in the house.

Immunization History: Immunizations are current.

Significant Family History: He is supported by his biological parents as well as both sets of grandparents.

 Review of Systems:

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

                Cardiovascular/Peripheral Vascular:

               

                Psychiatric:

                Neurological:

                Lymphatics:

               

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure	120/76
O2 Sat	96%
Pulse	100
Resp. Rate	28
Temperature	37.2 c

 

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The head is atraumatic and has a normocephalic shape. The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

Cardiology: In S1 and S2, there were no murmurs, gallops, or rubs.

Lymphatics: When palpated, the lymph nodes in the right cervical region are tender.

Psychiatric: No mental issues noted.

 

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the                 differential diagnoses.)

ASSESSMENT:

 Based on the findings of the completed physical examination and the observations that were made, the following possible diagnoses can be made.

1. Common cold: The patient complains of having a stuffy nose and a sore throat, which are both symptoms of a common cold. This observation was also supported by the findings of a physical examination, which showed that the patient had swollen lymph nodes.
2. Streptococcus throat infection: The patient’s complaint of a sore throat suggests that they may have strep throat. On the other hand, symptoms like nausea, vomiting, headaches, and fever did not present themselves at any point.

iii. Rhinitis is another condition that could have been causing the patient’s symptoms, as they included stuffy nose, sore throat, and drainage from the nose. In addition to this, the patient has a history of recurrent ear infections throughout their lifetime.

1. Allergies and asthma: The patient does not have a history of allergic reactions. Nevertheless, it is possible that this condition will occur. This condition may have been the cause of the persistent cough. On the other hand, the patient does not exhibit any symptoms of wheezing, chest pain or tightness, or difficulty breathing.

Thank you for sharing your thoughts and targeted questions for this patient. Overall, I think you did a great job explaining all aspects of this patient’s cultural considerations as well as explaining how the provider can ask questions based on sensitive topics. Your targeted questions are specific and provide a good foundation for health history. Regarding the questions about smoking and substance use, the patient may interpret these questions as “poking and prying” and might become defensive. Although the question “why” was not asked, the patient may feel judged or attacked when asked the reasons behind smoking marijuana.

Since the patient has a green card for medical cannabis use, this may provoke a defensive response and hinder the patient-provider relationship. A suggestion to this question is first determining the patient’s readiness to learn. This can be achieved by asking about his outlooks, attitudes, and motivations regarding smoking and substance use (Dugdale, 2021). For example, the question could be revised to ask, what is your outlook on smoking cessation? Or, do you have a desire to learn more about smoking cessation and its benefits?

Another suggestion to add to your targeted questions includes asking the patient if he would feel safe if family/friends were present during the interview. According to Ball et al. (2019), welcoming a patient’s friend, partner, and/or family can support cultural competency and reduce health disparities. Further questions and assessments could be made when the family is present. For example, whether the family supports and accepts his identity could be further explored. This could also help the patient understand his family’s views, possibly strengthen family bonds, and ease anxiety regarding his feelings of being a burden.

Regarding the types of questions you asked, some of them would benefit my patient’s case. For example, asking about support systems and changes in mental health can further evaluate potential reasons for continued migraines. Although my patient came to the clinic with his father, it should not be assumed what the dynamics of the support system entail. Instead, asking about family and friend dynamics and how these relationships impact migraine episodes would be best. Evaluating the patient’s mental health is also important, especially since his current presentation is agitated. Asking about his mental health is important as this could cause, worsen, or hinder migraine pain.

Overall, you created a great discussion post with purposeful targeted questions. Thank you for sharing!

SUBJECTIVE DATA:

Chief Complaint (CC): “I have been coughing a lot.”

History of Present Illness (HPI):

Danny Rivera is an 8-year-old Puerto Rican boy that presented to the Shadowville Elementary nurse’s office with complaints of cough. He provides subjective data about his health problem. He is responsive and answers appropriately the questions asked during the assessment. Danny reports that he has been coughing a lot for the last three days. The cough is wet, productive, leading to slimy clear phlegm. The cough worsens at night affecting his sleep, as he reports he did not get enough sleep the previous night. The cough lasts a few seconds.

Danny resides in the same house with his grandfather who is a smoker, exposing him to cigar smoke. Danny reports that her mother gave her a table spoonsful of a purple-ish medicine, which soothed his cough. He has no history of using any home remedies for cough. He recently took syrup prescribed by his doctor for cough. He takes multivitamins daily. Danny is usually physically active. However, the cough has reduced his ability to engage in active physical activity, as he feels fatigued. The cough has also affected his ability to concentrate in class since he does not get enough sleep at night. Danny also reported worsening running nose ever since the cough started. The patient reports sore throat but denies sneezing.

Medications: Danny reports that his mother gave him a purple-ish medicine to sooth his cough this morning. He is not on any other medication.

Allergies: Danny does not have any history of food, drug, or environmental allergic reactions.

Past Medical History (PMH): Danny has a history of pneumonia. He also has a frequent experience of cold, since his rose is runny most of the times.

Past Surgical History (PSH):Danny has no history of surgeries

Sexual/Reproductive History: Danny is an 8-year-old boy with unremarkable sexual or reproductive history.

Personal/Social History: Danny resides with his mother and grandfather. He is a student. He likes engaging in active physical activity. His grandfather smokes cigarette, exposing him to harmful smoke at home.

Immunization History: Danny’s immunization history is up-to date.

Significant Family History (Include history of parents, Grandparents, siblings, and children): There is a history of asthma (his grandfather).

Review of Systems:

General: The patient is alert, responsive, and answers asked questions appropriately. He reports fatigue and denies fevers and chills.

            HEENT: Danny denies headache, vision changes, dizziness, watery eyes, eye redness, eye pain, and sinus pain. The patient reports sore throat, running nose, and itchy nose at times.

Respiratory: The client denies difficulty in breathing. He reports wet productive cough. He also reports occasional sneezing

OBJECTIVE DATA:

Physical Exam:

Vital signs: Not given

General: The patient is alert and oriented to self, place time. He is well groomed for the occasion.

HEENT: The sclera is white with most and pink conjunctiva with no discharge. The nasal cavities are pink with clear discharge. The turbinate is patent. The ears have no abnormal visible findings with cone of light being 7.00, no discharge, and tympanic membranes being pearly grey. The oral mucosa appears moist and pink with erythematous tonsils. The posterior oropharynx appears pink with cobble stoning in the posterior oropharynx texture. There is no postnasal drip.

Respiratory: The breath sounds are present in all the areas with absent adventitious sounds. The lung sounds are clear with fremitus symmetrical bilaterally. Lung function tests: : FEV1: 1.549 L, FVC 1.78 L (FEV1/FVC: 87%)

Cardiology: Auscultation of the bronchoscopy negative with no extra sounds. There is resonance on chest wall percussion with no dullness.

Lymphatics: No lymphadenopathy

Diagnostics/Labs: The additional laboratory and diagnostic investigations needed to develop diagnoses include nasal culture and chest x-ray should the patient demonstrate worsening symptoms. The chest x-ray may be needed to rule out other causes such as tuberculosis and pneumonia if the symptoms worsen.

ASSESSMENT:

Danny’s priority diagnosis is common cold. Common cold is a term used to refer to mild upper respiratory illness. The disease has viral origin. It is self-limiting disease that mainly affects the upper respiratory tract. In severe cases, patients may develop spread of the viral infection to other organs and complications such as those caused by the bacteria. Patients affected by common cold present the hospital with complaints that include sneezing, nasal discharge and stuffiness, sore throat, cough, and fatigue. The additional symptoms that patients may exhibit include hoarseness, headache, lethargy, and myalgia. The symptoms often last between 1 and 7 days with them peaking within 2-3 days of the infection (Ibrahim et al., 2021; Montesinos-Guevara et al., 2022; Wilson & Wilson, 2021). Danny has present with symptoms that align with those of common cold. For example, he complains of cough, sore throat, and running nose for the last three days, hence, common cold being his primary diagnosis.

Danny’s secondary diagnosis is rhinosinusitis. Rhinosinusitis is a disorder characterized by the inflammation of the nasal cavities and passages. Patients develop this condition following their exposure to potential causes such as smoke, lowered immunity, and asthma. Patients often report symptoms such as nasal congestion, toothache, loss of smell, halitosis, postnasal drip, and runny nose (Chandy et al., 2019; Utkurovna et al., 2022). Danny is frequently exposed to tobacco smoke, which may have led to the development of rhinosinusitis. However, the absence of additional symptoms such as postnasal drip, toothache, loss of smell, and sinus pain or pressure, makes rhinosinusitis the least likely cause of his problem.

The last differential diagnosis that should be considered for the patient is whooping cough or pertussis. Pertussis is a disorder of the upper respiratory system that is characterized by severe hacking cough accompanied by whooping breath sounds. The disease is highly contagious and requires immediate patient isolation to prevent its spread in the population. The symptoms associated with whooping cough include cough, fever, red, watery eyes, nasal congestion, and runny nose. The affected populations are increasingly predisposed to complications such as pneumonia, seizures, brain damage, and dehydration (Zhang et al., 2020). However, pertussis is Danny’s least likely diagnosis because of the lack of hacking, whooping cough and red, watery eyes.

References

Chandy, Z., Ference, E., & Lee, J. T. (2019). Clinical Guidelines on Chronic Rhinosinusitis in Children. Current Allergy and Asthma Reports, 19(2), 14. https://doi.org/10.1007/s11882-019-0845-7

Ibrahim, A. E., Elmaaty, A. A., & El-Sayed, H. M. (2021). Determination of six drugs used for treatment of common cold by micellar liquid chromatography. Analytical and Bioanalytical Chemistry, 413(20), 5051–5065. https://doi.org/10.1007/s00216-021-03469-3

Montesinos-Guevara, C., Buitrago-Garcia, D., Felix, M. L., Guerra, C. V., Hidalgo, R., Martinez-Zapata, M. J., & Simancas-Racines, D. (2022). Vaccines for the common cold. Cochrane Database of Systematic Reviews, 12. https://doi.org/10.1002/14651858.CD002190.pub6

Utkurovna, S. G., Farkhodovna, S. Z., &Furkatjonovna, B. P. (2022). OPTIMIZATION OF THE TREATMENT OF ACUTE RHINOSINUSITIS IN CHILDREN. Web of Scientist: International Scientific Research Journal, 3(3), Article 3. https://doi.org/10.17605/OSF.IO/GYBM7

Wilson, M., & Wilson, P. J. K. (2021). The Common Cold. In M. Wilson & P. J. K. Wilson (Eds.), Close Encounters of the Microbial Kind: Everything You Need to Know About Common Infections (pp. 159–173). Springer International Publishing. https://doi.org/10.1007/978-3-030-56978-5_10

Zhang, J.-S., Wang, H.-M., Yao, K.-H., Liu, Y., Lei, Y.-L., Deng, J.-K., & Yang, Y.-H. (2020). Clinical characteristics, molecular epidemiology and antimicrobial susceptibility of pertussis among children in southern China. World Journal of Pediatrics, 16(2), 185–192. https://doi.org/10.1007/s12519-019-00308-5