Respiratory Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
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Overview
Transcript
Transcript
Started: Nov 08, 2018 | Patient Exam Time: 442 min
Subjective Data Collection
All Lines (193) Interview Questions (100) Statements (10) Exam Actions (83)
Objective Data Collection
Greet
Education & Empathy
Hi Tina, what brings you in to the clinic today? 11/08/18 10:04 PM
CST
Documentation
Student Pre-Survey
Hey.
Lifespan
Question
Review Questions
Hey.... what brings you in today? 11/08/18 10:04 PM
CST
Self-Reflection
I came in because I've been having breathing problems, and my
inhaler just isn't working the way it normally does.
Question
can you tell me what you mean by breathing problems? 11/08/18 10:05 PM
CST
It feels like it's been hard to take in air. My chest feels all tight and I've
been wheezing... I've had to use my inhaler a lot, and it doesn't feel
like it's totally working.
Empathize
I am sorry to hear that you have been having these issues. I will do
11/08/18 10:11 PM
my best to help you feel better.
CST
I appreciate you telling me that.
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,11/11/2018 Respiratory Physical Assessment Assignment | Completed | Shadow Health
how long have you been having the breathing issues (Clarified to How Question
long ago did your breathing problems start?.) 11/08/18 10:16 PM
CST
All of these breathing problems started two days ago, at my cousin's
house. (Clarified to how long ago my breathing problems started.)
Question
where are you feeling the discomfort 11/08/18 10:25 PM
CST
My chest has been feeling tight, but it doesn't hurt or anything.
Question
How long does the chest tightness last 11/08/18 10:28 PM
CST
Once my asthma starts to act up, I just use my inhaler, and then I feel
better within a minute or two.
Question
How often are you having to use your inhaler in a day (Clarified to
11/08/18 10:29 PM
how many times have you used your inhaler in the past two days.)
CST
I've been needing my inhaler about every four hours, I'd say. (Clarified
to how many times I have used my inhaler in the past two days.)
Question
what inhaler are you using 11/08/18 10:30 PM
CST
It's just a regular Proventil inhaler.
Question
what is the dosage of the proventil 11/08/18 10:30 PM
CST
Sometimes I have to take three puffs instead of two, and the past
couple days, always three. [Nurse confirmed with Pharmacy: albuterol
90mcg/spray MDI]
Question
how would you rate the chest tightness? 11/08/18 10:33 PM
CST
It doesn't hurt. . . it's just hard to breathe, but there's no pain.
Question
what severity would you rate it at? 11/08/18 10:33 PM
CST
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It doesn't hurt. . . it's just hard to breathe, but there's no pain.
Question
how difficult is it to breathe 0-10? 11/08/18 10:33 PM
CST
Yeah, I have asthma.
Question
would you rate difficulty 0-10? 11/08/18 10:34 PM
CST
At its worst it's been like a 7 or 8 out of 10, probably.
Question
how would you describe the difficulty breathing? 11/08/18 10:36 PM
CST
Oh, hmm, gosh--that's always hard to describe. I think I'm friendly,
and I'd say I'm pretty driven. I'd say I'm funny too.
Question
that has nothing to do with my question, but thanks for that! (No
11/08/18 10:37 PM
matching questions found.)
CST
Educate
that has nothing to do with my question, but thanks for that! 11/08/18 10:37 PM
CST
Alright, thanks for letting me know.
Question
so your breathing feels tight in your chest? 11/08/18 10:37 PM
CST
It's not so bad right this second, but it's been pretty tight lately, like I
can't take in air.
Question
what seems to make your breathing worse 11/08/18 10:38 PM
CST
Usually it acts up around cats. . . sometimes dust, or running quickly
up a flight of stairs. But the past couple days my breathing has just
been getting bad on its own, it seems like.
Question
what seems to help your breathing the past two days (Clarified to
11/08/18 10:40 PM
What has made your breathing better.)
CST
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