Shadow Health: Focused Exam: Cough Results Danny Riviera

Shadow Health: Focused Exam: Cough Results Danny Riviera

Subjective Data Collection: 21 of 21 (100.0%)

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

  • Found: Indicates an item that you found.
  • Available: Indicates an item that is available to be found.

Category

Scored Items

Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored

A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

  • Finding: Established chief complaint
  • Finding: Reports cough (Found) Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: Do you have a cough?

History of Present Illness

  • Finding: Asked about onset of cough
  • Finding: Reports cough started 5 days ago (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had a cough?
  • Finding: Asked about frequency and duration of cough
  • Finding: Reports coughing every few minutes (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How frequently have you been coughing?
  • Finding: Asked about character of cough
  • Finding: Reports cough is wet (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough a wet cough?
  • Finding: Reports clear sputum (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you produce any phlegm or sputum with your cough?
  • Finding: Asked about aggravating factors for cough
  • Finding: Reports cough is worse at night (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough worse at night?
  • Finding: Reports exposure to secondhand smoke (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you around anyone who smokes at home?
  • Finding: Denies knowing what makes the cough worse (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes your cough worse?
  • Finding: Asked about relieving factors for cough
  • Finding: Denies resting relieves cough (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does resting help your cough?
  • Finding: Denies drinking water relieves cough (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does drinking water help your cough?
  • Finding: Asked about nasal symptoms
  • Finding: Reports current runny nose (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have a runny nose?
  • Finding: Denies sneezing (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you been sneezing?
  • Finding: Reports frequent runny nose (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you get runny noses often?
  • Finding: Followed up on nasal discharge
  • Finding: Reports nasal discharge is clear (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What color is your snot?
  • Finding: Reports nasal discharge is thin (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your snot thin?
  • Finding: Asked about ear symptoms
  • Finding: Reports pain in right ear (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear pain?
  • Finding: Followed up on ear pain
  • Finding: Reports ear pain started yesterday (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had ear pain?
  • Finding: Reports ear pain is a 3 out of 10 (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you rate your ear pain on a scale?
  • Finding: Denies ear discharge (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear discharge?
  • Finding: Asked about throat symptoms
  • Finding: Reports sore throat (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your throat sore?
  • Finding: Reports “a little” pain with swallowing (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does it hurt when you swallow?
  • Finding: Asked about allergies
  • Finding: Denies seasonal allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have seasonal allergies?
  • Finding: Denies food allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have food allergies?
  • Finding: Denies medication allergies (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to any medicine?
  • Finding: Denies allergies to animals (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to animals?
  • Finding: Denies latex allergy (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to latex?
  • Finding: Asked about contact with illnesses
  • Finding: Denies being around anyone ill at home (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is anyone sick at home?

Home Medications

  • Finding: Asked about home medications
  • Finding: Confirmed home medications (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What medications do you take?
  • Finding: Reports taking a daily vitamin (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Do you take vitamins?
  • Finding: Reports taking cough medicine (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Are you taking medication for your cough?
  • Finding: Followed up on cough medicine
  • Finding: Reports cough medicine was purple (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: What color was the cough medicine?
  • Finding: Reports taking one spoonful of cough medicine (Available) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: How much cough medicine did you take?
  • Finding: Reports mother gave him the medicine (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Who gave you the cough medicine?
  • Finding: Reports cough medicine provided temporary relief (Found) Pro Tip: A patient’s home medications can provide insight into the patient’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient’s background and how it may affect their current situation. Example Question: Did the cough medicine make you feel better?

Past Medical History

  • Finding: Asked about relevant medical history
  • Finding: Denies asthma diagnosis (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have asthma?
  • Finding: Reports immunizations as current (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have current immunizations?
  • Finding: Reports past pneumonia and frequent coughs (Found) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have a history of respiratory problems?
  • Finding: Denies past hospitalizations (Available) Pro Tip: Inquiring into the patient’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever been to the hospital?

Social Determinants of Health

  • Finding: Asked about exposure to secondhand smoke
  • Finding: Reports father smokes cigars (Found) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Who smokes at home?
  • Finding: Reports father sometimes forgets to take cigars outside (Available) Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face. Example Question: Where does your father smoke?

Social History

  • Finding: Asked about living conditions
  • Finding: Reports living in a house with parents and grandparents (Found) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Where do you live?
  • Finding: Reports feeling safe at home (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you feel safe at home?
  • Finding: Reports park with playground near home (Available) Pro Tip: A patient’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Is there anywhere near your home where you can play outside?

Review of Systems

  • Finding: Asked about constitutional health
  • Finding: Denies fever (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a fever?
  • Finding: Denies chills (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chills?
  • Finding: Reports feeling “kind of tired” (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have fatigue?
  • Finding: Denies night sweats (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have night sweats?
  • Finding: Denies weight loss (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Has your weight changed?
  • Finding: Denies appetite loss (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you lost your appetite?
  • Finding: Asked about review of systems for HEENT
  • Finding: Denies ear popping or crackling (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you hear any popping sounds?
  • Finding: Reports history of frequent ear infections (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had ear infections?
  • Finding: Denies ear surgery or ear tubes (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had surgery on your ears?
  • Finding: Denies headaches (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you get headaches?
  • Finding: Denies nosebleeds (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have nosebleeds?
  • Finding: Denies vision problems (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any problems with your vision?
  • Finding: Denies dizziness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any dizziness?
  • Finding: Denies watery eyes (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have watery eyes?
  • Finding: Denies eye redness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have eye redness?
  • Finding: Denies eye pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any eye pain?
  • Finding: Denies sinus pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any sinus pain?
  • Finding: Denies hearing problems (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any hearing problems?
  • Finding: Asked about review of systems for respiratory
  • Finding: Denies difficulty breathing (Found) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have difficulty breathing?
  • Finding: Denies chest tightness (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chest tightness?
  • Finding: Denies chest pain (Available) Pro Tip: Understanding a patient’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any chest pain?
  • Finding: Denies history of inhaler use or breathing treatments

SUBJECTIVE DATA: Include what the patient tells you, but organize the information.

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Chief Complaint (CC): “I have had a cough for five days now.”

History of Present Illness (HPI): Danny is a 14-year-old African-American male who presents with the complaint of a cough for five days. The cough is wet with clear sputum. Reports coughing every couple of minutes. The cough is worse at night with no known triggering factors. The cough is not relieved by rest or upon taking water. However, it is temporarily relieved by over-the-counter cough medications. It is associated with a runny nose, ear pain, sore throat, and a little pain while swallowing. The nasal discharge is thin and clear while the right ear pain began the previous day with a severity of 3 on a scale of 0-10. There is no associated sneezing or ear discharge. Denies contact with an individual with a chronic cough.

Medications: Daily vitamin and over-the-counter cough medication that his mother gave him.

Allergies: Denies seasonal allergies and allergies to food, latex, medications, or animals.

Past Medical History (PMH): Reports frequent past pneumonia, ear infection, and cough. Denies asthma diagnosis as well as previous hospitalizations.

Past Surgical History (PSH): No previous surgeries.

Sexual/Reproductive History: No sexual debut yet.

Personal/Social History: He enjoys his studies and playing soccer. He neither smokes tobacco nor uses alcohol and other illicit drugs. However, he reports exposure to secondhand smoke as his father sometimes forgets to take cigars outside. Does not have a pet.

Immunization History: All immunizations are up to date.

Significant Family History: Both parents are alive. His father has had asthma since childhood that is well controlled with inhaler use. Mother has hypertension that is well controlled with diet and exercise. Paternal grandfather also has asthma. Paternal grandmother has type 2 diabetes and hyperlipidemia. His younger sister is alive without any known medical problems. No family history of allergies.

Shadow Health: Focused Exam: Cough Results Danny Riviera

Within the Shadow Health platform, complete the Focused Exam: Cough Results. The estimated average time to complete this assignment each time is 1 hour and 15 minutes. Please note, this is an average time. Some students may need longer.

This clinical experience is a focused exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the assignment dropbox.

Each of you will be completing a Shadow Health Assessments each week. You will need to sign into the account, and please make sure you register under the correct date. You will get all your information under the Course Materials.

If you have problems signing in, you will need to call the Help Desk for them. Make sure you are reading the rubric for each Shadow Health assignment, because sometimes you will only have 1 try to pass, and other times you may only have 3, but with significant point reduction each try.

You do not need a PIN to sign in. Go to PATH, then Course Material. You will see: Shadow Health Digital Clinical Experience. Go there and follow the instructions. Thanks

Please upload all assignment completions under your assignment due area. Thanks

  • Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 10 points
  • Students successfully scoring at the Proficiency level on the second attempt will earn a grade of 90 points
  • Students successfully scoring at the Proficiency level on the third attempt will earn a grade of 80 points.
  • Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points).

ORDER NOW FOR AN ORIGINAL PAPER ASSIGNMENT: Shadow Health: Focused Exam: Cough Results Danny Riviera

Each of you will be completing a Shadow Health Assessments each week. You will need to sign into the account, and please make sure you register under the correct date. You will get all your information under the Course Materials.

If you have problems signing in, you will need to call the Help Desk for them. Make sure you are reading the rubric for each Shadow Health assignment, because sometimes you will only have 1 try to pass, and other times you may only have 3, but with significant point reduction each try.

You do not need a PIN to sign in. Go to PATH, then Course Material. You will see: Shadow Health Digital Clinical Experience. Go there and follow the instructions. Thanks

Please upload all assignment completions under your assignment due area. Thanks

If Proficiency is not achieved on the first attempt, it is recommended that you review your answers with Shadow Health Focused Exam Cough Results Danny Rivierathe correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and the course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion. You are not required to submit this assignment to LopesWrite.

Subjective Data

Scored Items
  • Experts selected these topics as essential components of a strong, thorough interview with this patient.

Patient Data

Not Scored
  • A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.

Chief Complaint

Finding: Established chief complaint

Finding: Reports cough (Found)
Pro Tip: Asking a patient broadly about their chief complaint allows them to answer in their own words and confirm information that you may have already received from another source.
Example Question: Do you have a cough?

History of Presenting Illness

  • Finding: Asked about onset of cough

Finding: Reports cough started 3 days ago (Found)
Pro Tip: Whenever you are assessing a symptom or a health condition, in this case the patient’s cough, inquiring about onset assesses the severity and the progression of the problem.
Example Question: How long have you had a cough?

Finding: Asked about characteristics of cough

Finding: Reports cough is wet (Available)
Pro Tip: The characteristics of a cough, such as whether it is dry or wet, can indicate key information about the type of illness the patient has.
Example Question: Is your cough a wet cough?

Finding: Reports clear sputum with cough (Available)
Pro Tip: The characteristics of a cough, such as whether it is productive, can indicate key information about the type of illness the patient has.
Example Question: Do you produce any phlegm or sputum with your cough?

Finding: Asked about frequency and duration of cough

Finding: Reports coughing every few minutes (Available)
Pro Tip: Establishing how frequently Danny coughs will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question: How frequently are you coughing?

Finding: Reports coughs last a few seconds (Available)
Pro Tip: Establishing how long Danny’s coughs last will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question: How long do your coughs last?

Finding: Asked about aggravating factors for cough

Finding: Reports cough is worse at night (Available)
Pro Tip: Establishing a timeline for Danny’s coughing will illustrate how long he has been suffering these particular symptoms and might indicate possible triggers.
Example Question: Is the cough worse at night?

Finding: Denies smoking (Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking even young patients about whether they consume tobacco products helps you assess this risk factor.
Example Question: Do you smoke?

Finding: Reports being exposed to secondhand smoke through father (Available)
Pro Tip: Tobacco use puts the patient at risk for many medical conditions. Asking about whether a patient is exposed to secondhand smoke allows you to assess this risk factor.
Example Question: Are you ever around cigarette smoke?

Finding: Reports he doesn’t know what triggers the cough (Available)
Pro Tip: Asking about aggravating factors of Danny’s cough will allow you to determine potential causes and educate the patient on what to avoid.
Example Question: What makes your cough worse?

Finding: Asked about relieving factors for cough

Finding: Reports cough is temporarily relieved by cough medicine (Found)
Pro Tip: Asking about how the patient has been managing their pain assesses their current condition and their approach to self-care. The results of their previous treatment may be helpful in your diagnosis and the development of their new treatment plan, as well as a good opportunity to educate the patient on effective self-care practices.
Example Question: Have you done anything to treat your cough?

Finding: Followed up on cough medicine

Finding: Reports cough medicine was purple (Available)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the cough medicine’s color may help you identify the type of medication it is.
Example Question: What color was the cough medicine?

Finding: Reports taking one spoonful of cough medicine (Available)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the dose of cough medicine allows you to determine whether it is being taken correctly.
Example Question: How much medicine did you take?

Finding: Reports mother gave him the medicine (Found)
Pro Tip: Children should only take medication under the supervision of an adult who can assure it is taken as directed. You should ask younger patients whether the medicine was given to them and by whom.
Example Question: Who gave you the medicine for your cough?

Finding: Reports only took the medicine this morning (Found)
Pro Tip: The type of cough medicine a patient takes, and how they take it, can impact its effectiveness. Following up on the frequency Danny took cough medicine allows you to determine whether it is being taken correctly.
Example Question: How many times have you taken the cough medicine?

Finding: Denies home remedies (Available)
Pro Tip: Patients sometimes try non-medicinal home remedies to treat coughs, such as breathing steam, or drinking tea with honey. Not all home remedies are effective or advisable, so it’s important to find out what remedies the patient has tried.
Example Question: Have you tried any home remedies for your cough?

Finding: Asked about typical medication use

Finding: Denies taking medication (Available)
Pro Tip: Knowing a patient’s current medication regimen helps you determine if any future treatments will be safe and effective.
Example Question: Do you take any medications from a doctor?

Finding: Reports taking daily vitamin (Available)
Pro Tip: Some symptoms can occur as a result of a vitamin deficiency, and others as a result of vitamin excess. Vitamins can also interfere with some treatments, so it’s important to know what your patient is taking.
Example Question: Do you take vitamins?

Finding: Asked about activity level

Finding: Reports typical high activity level (Available)
Pro Tip: Establishing a patient’s typical activity level is an important baseline to help you determine how an illness is affecting his life.
Example Question: Are you usually active?

Finding: Reports activity level low since getting sick (Available)
Pro Tip: Establishing a patient’s activity level, and whether it has been impacted since becoming ill, is an important baseline to help you determine how an illness is affecting his life.
Example Question: Have you been less active since getting sick?

Finding: Reports still able to run or play (Available)
Pro Tip: Ability to remain active indicates that the patient’s breathing is not dangerously affected, and that the patient isn’t seriously fatigued.
Example Question: Are you able to keep up when you play with your classmates?

Finding: Reports focusing in class is difficult (Available)
Pro Tip: Mental lethargy and difficulty concentrating are common symptoms when a patient is sick.
Example Question: Are you able to focus in class?

Finding: Asked about nasal symptoms

Finding: Reports current runny nose (Found)
Pro Tip: Asking your patient if his nose is running will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question: Do you currently have a runny nose?

Finding: Denies sneezing (Available)
Pro Tip: Asking your patient if he has been sneezing will allow you to determine the symptoms he is experiencing and possible triggers.
Example Question: Have you been sneezing?

Finding: Followed up on nasal discharge

Finding: Reports nasal discharge is clear (Available)
Pro Tip: The color of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question: What color is your snot?

Finding: Reports nasal discharge is thin (Available)
Pro Tip: The consistency of a patient’s nasal discharge can provide you key information as to the type of condition the patient has.
Example Question: What is the consistency of your nasal discharge?

Finding: Asked about ear symptoms

Finding: Denies ear pain (Available)
Pro Tip: Ear pain is often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his ears.
Example Question: Do you have any ear pain?

Finding: Reports history of frequent ear infections (Available)
Pro Tip: Asking about Danny’s history of ear infections allows you to ascertain his risk for current and future ear infections.
Example Question: Have you ever had ear infections?

Finding: Denies ear discharge (Available)
Pro Tip: Asking Danny about ear discharge, which are often coincident with of ear infections, allows you to ascertain his risk for current and future ear infections.
Example Question: Do you have any ear discharge?

Finding: Denies hearing problems (Available)
Pro Tip: Simply talking with the patient assesses his hearing; however, some types of hearing loss are only apparent in specific settings such as noisy environments. Asking the patient about hearing problems identifies conditions that may not be readily apparent.
Example Question: Do you have any hearing problems?

Finding: Asked about throat symptoms

Finding: Reports sore throat (Available)
Pro Tip: Sore throats are often coincident with coughs and sinus problems. Asking about them allows you to ascertain if Danny needs follow-up care for his throat.
Example Question: Is your throat sore?

Finding: Reports a little pain with swallowing (Available)
Pro Tip: Pain when swallowing helps you understand how severe the patient’s sore throat is.
Example Question: Does it hurt when you swallow?

Past Medical History

  • Finding: Asked about relevant medical history

Finding: Reports frequent runny noses (Available)
Pro Tip: Asking how often Danny experiences runny noses like the one he has now may help you determine the source of the problem.
Example Question: Do you get runny noses often?

Finding: Reports past frequent coughs (Available)
Pro Tip: A patient experiencing a cough should be asked about their history of coughs so you can determine whether their current condition fits into a recurring pattern.
Example Question: Do you have coughs very often?

Finding: Reports past pneumonia (Available)
Pro Tip: Pneumonia is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question: Have you had pneumonia?

Finding: Denies asthma diagnosis (Available)
Pro Tip: Asthma is a serious medical condition that can be life-threatening if not managed appropriately. Regardless of the patient’s presenting illness, it is critical to identify current medical conditions in order to treat the patient appropriately. Specific questions should be asked about previous medical problems, even if the patient doesn’t notice current symptoms.
Example Question: Do you have asthma?

Finding: Reports immunizations as current (Available)
Pro Tip: A health assessment should include an evaluation of the patient’s immunization status in order to identify diseases to which the patient is vulnerable.
Example Question: Do you have current immunizations?

  • Finding: Asked about allergies

Finding: Denies seasonal allergies (Available)
Pro Tip: Seasonal allergies can cause symptoms like runny nose, cough, and discomfort. Asking Danny if he has seasonal allergies can help you to ascertain possible triggers for symptoms.
Example Question: Do you have seasonal allergies?

Finding: Denies food allergies (Available)
Pro Tip: Knowing if your patient has food allergies is important and relevant medical history. Asking your patient about food allergies will allow you to most effectively treat him.
Example Question: Do you have food allergies?

Finding: Denies medication allergies (Available)
Pro Tip: Knowing if your patient has allergies to medicine is important and relevant medical history. Asking your patient about medicine allergies will allow you to most effectively treat him.
Example Question: Are you allergic to any medication?

  • Finding: Asked relevant family history

Finding: Reports father has history of asthma (Available)
Pro Tip: Medical problems such as asthma that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question: Do you have a family history of asthma?

Finding: Denies family history of allergies (Available)
Pro Tip: Medical problems such as allergies that are present in a patient’s immediate family can represent increased risk factors to respiratory conditions such as the ones the patient currently has.
Example Question: Do you have a family history of allergies?

Review of Systems

  • Finding: Asked about constitutional health

Finding: Denies chills (Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has chills will illustrate the way his symptoms manifest.
Example Question: Do you have chills?

Finding: Denies fever (Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has a fever will illustrate the way his symptoms manifest.
Example Question: Do you have a fever?

Finding: Reports feeling somewhat fatigued (Found)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has fatigue will illustrate the way his symptoms manifest.
Example Question: Do you have fatigue?

Finding: Denies night sweats (Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has night sweats will illustrate the way his symptoms manifest.
Example Question: Do you have night sweats?

Finding: Reports cough makes it difficult to sleep (Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had difficulty sleeping will illustrate the way his symptoms manifest.
Example Question: Have you been sleeping okay?

Finding: Denies swelling (Available)
Pro Tip: Soliciting a shallow history of your patient’s symptoms will help you to most effectively treat him. Asking Danny if he has had swelling will illustrate the way his symptoms manifest.
Example Question: Have you noticed any swelling?

Finding: Asked about additional review of systems for HEENT

Finding: Reports frequent colds (Available)
Pro Tip: A patient such as Danny who is presenting with a cough and a runny nose may have a cold, so you should ask about his history of colds to determine whether this is part of a larger pattern.
Example Question: Do you have unusually frequent colds?

Finding: Denies headaches (Available)
Pro Tip: Headaches are a common complaint that can be caused by a variety of benign conditions. However, headaches can be an indicator of serious underlying neurological conditions such as cerebral hemorrhage, meningitis, or brain tumors. They may also be a symptom of sinus infection.
Example Question: Do you get headaches?

Finding: Denies nosebleeds (Available)
Pro Tip: When a patient presents with symptoms that are often seen with respiratory infections, you should ask about similar signs of respiratory infections such as nosebleeds.
Example Question: Do you have nosebleeds?

Finding: Denies vision difficulty (Available)
Pro Tip: Eye or vision problems can lower one’s ability to function and can be a major safety risk.
Example Question: Do you have any problems with your vision?

Finding: Denies dizziness (Available)
Pro Tip: Asking about dizziness helps you assess the risk for inner ear, neurological, or cardiovascular problems.
Example Question: Do you have any dizziness?

Finding: Denies watery eyes (Available)
Pro Tip: Whether a patient has watery eyes may help you indicate the type of sinus problem he is experiencing.
Example Question: Do you have watery eyes?

Finding: Denies eye redness (Available)
Pro Tip: Whether a patient has eye redness may help you indicate the type of sinus problem he is experiencing.
Example Question: Do you have eye redness?

Finding: Denies eye pain (Available)
Pro Tip: Eye pain can lower one’s ability to function and can be a major safety risk.
Example Question: Do you have any eye pain?

Finding: Denies sinus pain (Available)
Pro Tip: Patients with sinus problems such as a runny nose may be at greater risk for sinus pain.
Example Question: Do you have any sinus pain?

Finding: Asked about review of systems for respiratory

Finding: Denies chest tightness (Available)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest tightness is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question: Do you have chest tightness?

Finding: Denies chest pain (Available)
Pro Tip: Chest pain may indicate cardiac conditions, muscular inflammation, gastric upset, or respiratory distress. If chest pain is present, asking about its location, characteristics, and related factors helps to determine the cause of the discomfort.
Example Question: Do you have any chest pain?

Finding: Denies difficulty breathing.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

  • Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
  • Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
  • One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
  • I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

  • Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
  • In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
  • Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
  • Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

  • Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
  • Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
  • I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

  • I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
  • As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
  • It is best to paraphrase content and cite your source.

 

LopesWrite Policy

  • For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
  • Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
  • Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
  • Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

  • The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
  • Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
  • If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
  • I do not accept assignments that are two or more weeks late unless we have worked out an extension.
  • As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me: 

  • Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
  • Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

  • Qualitative data have been described as voluminous and sometimes overwhelming to the researcher. Discuss two strategies that would help a researcher manage and organize the data

In qualitative research, non-numerical data are gathered and analyzed to better comprehend ideas, viewpoints, or experiences. It might be utilized to discover intricate details about an issue or come up with new research ideas or concepts.

To analyze qualitative data, transcripts are analyzed and compare or contrast them before identifying themes and creating categories. The goal of qualitative research is to provide a thorough account of some event or unit using a number of techniques, such as in-depth interviews or in-depth analysis of historical sources (Aspers & Corte, 2019).

The qualitative material is vast and occasionally overwhelming. Two methods that would aid in managing and organizing the data for a researcher are creating a clear identification system and coding. For example, when a clear identification system is obtained the researcher can more easily categorize the files and folders by giving it a consistent name.

Overall, the method of classifying and labeling related data types in order to facilitate the creation of themes and data analysis allows for simple retrieval in data. Coding is the process of categorizing and identifying related data kinds to make it easier to develop themes and conduct data analysis.

Coding is the process of dissecting qualitative text data to examine what it can reveal before reassembling the data in a meaningful fashion (Elliott, 2018). It helps organize data as researchers dissect their data collected to produce new knowledge. It makes it easier for researchers to better evaluate and compile the research into a whole set of findings.

Shadow Health: Focused Exam: Cough Results Danny Riviera References:

RESPOND HERE

I agree with you that working with qualitative research is less tedious compared to using quantitative research. Non-numerical data are gathered and analyzed to better comprehend ideas, viewpoints, or experiences. Collecting, organizing, and interpreting non-numerical data may take a long time.

Therefore, some people may be frustrated working with crowded data in qualitative research. Data collection process in qualitative is another tedious process (Lester et al., 2020). Creating a clear identification system and coding are two types that most researchers find suitable when working with voluminous data found in qualitative studies.

A clear identification system allows researchers to categorize the data (Linneberg & Korsgaard, 2019). The categorization allows researchers to name their folders and files. As a result, access the files and orders will be easy. Coding is the process of categorizing and identifying related data kinds to make it easier to develop themes and conduct data analysis. Researchers can choose to integrate both methods to simplify qualitative research.

Shadow Health: Focused Exam: Cough Results Danny Riviera References

  • Lester, J. N., Cho, Y., & Lochmiller, C. R. (2020). Learning to do qualitative data analysis: A starting point. Human Resource Development Review19(1), 94-106. https://doi.org/10.1177/1534484320903890

Shadow Health: Focused Exam: Cough Results

REVIEW ASSIGNMENT

Assessment Description

Within the Shadow Health platform, complete the Focused Exam: Cough Results. The estimated average time to complete this assignment each time is 1 hour and 15 minutes. Please note, this is an average time. Some students may need longer. 

This clinical experience is a focused exam. Students must score at the level of “Proficiency” in the Shadow Health Digital Clinical Experience. Students have three opportunities to complete this assignment and score at the Proficiency level. Upon completion, submit the lab pass through the assignment dropbox.

Students successfully scoring within the Proficiency level in the Digital Clinical Experience on the first attempt will earn a grade of 100 points; students successfully scoring at the Proficiency level on the second attempt will earn a grade of 90 points; and students successfully scoring at the Proficiency level on the third attempt will earn a grade of 80 points. Students who do not pass the performance-based assessment by scoring within the Proficiency level in three attempts will receive a failing grade (68 points).

If Proficiency is not achieved on the first attempt, it is recommended that you review your answers with the correct answers on the Experience Overview page. Review the report by clicking on each tab to the left titled Transcript, Subjective Data Collection, Objective Data Collection, Documentation, and SBAR to compare your work. Reviewing this overview and the course resources may help you improve your score.

Please review the assignment in the Health Assessment Student Handbook in Shadow Health prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are not required to submit this assignment to LopesWrite.

Attachments

NRS-434VN-R-Childrens-functional-healt

NRS-434VN-R-Childrens-functional-health-pattern-assessment-Student.docx

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© 2016. Grand Canyon University. All Rights Reserved.

Children’s Functional Health Pattern Assessment

Functional Health Pattern Assessment (FHP)

Toddler

Erickson’s Developmental Stage:

Preschool-Aged

Erickson’s Developmental Stage:

School-Aged

Erickson’s Developmental Stage:

Pattern of Health Perception and Health Management:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Nutritional-Metabolic Pattern:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Pattern of Elimination:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Pattern of Activity and Exercise:

List two normal assessment findings that would be characteristic for each age group.

© 2016. Grand Canyon University. All Rights Reserved.

List two potential problems that a nurse may discover in an assessment of each age group.

Cognitive/Perceptual Pattern:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Pattern of Sleep and Rest:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Pattern of Self-Perception and Self-Concept:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Role-Relationship Pattern:

List two normal assessment findings that would be characteristic for each age group.

List 2 potential problems that a nurse may discover in an assessment of each age group.

© 2016. Grand Canyon University. All Rights Reserved.

Short Answer Questions

Address the following based on the above assessment findings. Expected answers will be 1-2 paragraphs in length. Cite and reference outside sources used.

1)Compare and contrast identified similarities as well as differences in expected assessment across the childhood age groups.

Sexuality – Reproductive Pattern:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

Pattern of Coping and Stress Tolerance:

List two normal assessment findings that would be characteristic for each age group.

List wo potential problems that a nurse may discover in an assessment of each age group.

Pattern of Value and Beliefs:

List two normal assessment findings that would be characteristic for each age group.

List two potential problems that a nurse may discover in an assessment of each age group.

© 2016. Grand Canyon University. All Rights Reserved.

2)Summarize how a nurse would handle physical assessments, examinations, education, and communication differently with children versus adults. Consider spirituality and cultural differences in your answer.

Communicating with children that have disabilities during an assessment can be complicated due to limitations of understanding and based on age such as an infant it can be impossible to communicate due their inability. Communication assessment and accessing the inner world of people with PIMD (profound intellectual and multiple disabilities) are inherently challenging, the need for time‐consuming observational work, involving discussion and collaboration with all key communication partners, while under organizational pressure to progress work with numerous clients can all contribute to the difficulties inherent in conducting sensitive and effective communication assessment with people with PIMD (Chadwick et al., 2019).

There are concerns with this statement such as organizational pressure to progress work in regards to numerous clients heightens a sense of awareness with how patients are handled. Patients with disabilities need adequate time with providers to ensure they are properly assessed and allotted proper time for questions. Having rushed appointments leads to missed medical issues. Also, these patients need help from parents or caregivers to adequately evaluate the questions and information received. I just thought this was an interesting issue to consider with pediatric patients.

Trivedi, M., & Denton, E. (2019). Asthma in Children and Adults—What Are the Differences and What Can They Tell Us about Asthma? Frontiers in Pediatrics7(256). https://doi.org/10.3389/fped.2019.00256

You raised some great questions! If the patient feels comfortable during the interview, those questions can reveal relevant health information for his treatment plan. Waryold & Kornahrens (2020) mentioned that it could be challenging for individuals such as those that are transgender to find culturally competent care providers. These patients often report being met with outright discrimination, inadequate/inappropriate care, and ineffective communication. For these reasons, the patient may come in to seek treatment after trying to take care of health concerns himself. This can be evidenced by the patient obtaining testosterone from the internet instead of maintaining treatment with a qualified provider. This must be addressed with the patient too, as access to appropriate treatment, monitoring, and follow-up will be important.  

       When addressing the patient with your target questions, he may have some concerns about their context depending on the patient’s current mental state and his comfort level. I think that the questions here can be examined using the RESPECT model. The RESPECT model can help providers keep communication effective by building a rapport, showing empathy, being supportive, partnering with the patient, providing explanations, utilizing cultural competence, and developing trust (Ball et al., 2019). Therefore, the questions that the patient is asked should be in line with this model.  

References 

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. 

Van Duyne, I. M., & Livingstone, J. (2019). Transgender Health: Sensitivity in Care, Treatment, and Life Care Considerations for Female to Male Transgender Individuals. Journal of Life Care Planning17(4), 17–27. 

Waryold, J. M., & Kornahrens, A. (2020). Decreasing Barriers to Sexual Health in the Lesbian, Gay, Bisexual, Transgender, and Queer Community. Nursing Clinics of North America55(3), 393–402. https://doi.org/10.1016/j.cnur.2020.06.003

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 ResponseModel AnswerExplanationPoints Earned
is at risk foris at risk forThe 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 ResponseModel AnswerExplanationPoints Earned
infectioninfectionWhile 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 ResponseModel AnswerExplanationPoints Earned
played w/ sick peerplayed w/ sick peerDanny 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 oftentouches face oftenDanny 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 washingrare hand washingDanny 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 smokesecondhand smokeDanny 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 ResponseModel AnswerExplanationPoints Earned
N/AN/ABecause 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.

PromptStudent ResponseModel AnswerExplanation
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 ResponseModel AnswerExplanationPoints 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 ResponseModel AnswerExplanationPoints Earned
Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroomInstruct family and patient on washing hands or using hand sanitizer before eating and after using the restroomMany 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 intakeInstruct family and patient that patient should increase fluid intakeMany 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 sickInstruct patient on washing hands or using hand sanitizer after coughing or being near someone sickMany 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 mouthInstruct patient to avoid touching fingers to eyes, nose, or mouthMany 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 unavailableInstruct patient to cough into tissue, or sleeve if tissue is unavailableMany 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.

PromptStudent ResponseModel AnswerExplanation
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 ResponseModel AnswerExplanationPoints Earned
Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygieneAsk patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygieneIt 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.

PromptStudent ResponseModel AnswerExplanation
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 ResponseModel AnswerExplanationPoints Earned
PartiallyPartiallyWhile 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.

PromptStudent ResponseModel AnswerExplanation
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.

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