NR 509 SHADOW HEALTH FOCUSED EXAM CASE I RESPIRATORY PHYSICAL ASSESSMENT: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 509 SHADOW HEALTH FOCUSED EXAM CASE: RESPIRATORY PHYSICAL
ASSESSMENT
Respiratory Physical Assessment Assignment RESULTS | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
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Transcript
Overview

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 11/08/18 10:05 PM
problems? 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
11/08/18 10:11 PM
do my best to help you feel better.
CST



I appreciate you telling me that.
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,how long have you been having the breathing issues (Clarified to How long ago did your breathing prob
Question
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




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.




How often are you having to use your inhaler in a day (Clarified to how many times have you used your
Question
11/08/18 10:29 PM
CST

I've been needing my inhaler about every four hours, I'd say. (Clarified to how many times I have used




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 co




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




2/24

, 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




that has nothing to do with my question, but thanks for that! (No matching questions found.)
Question
11/08/18 10:37 PM
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 co




what seems to help your breathing the past two days (Clarified to What has made yourQuestion
breathing better
11/08/18 10:40 PM
CST




3/24