Respiratory Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Transcript
Overview
Started: Nov 08, 2018
...
Respiratory Physical Assessment Assignment Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-October-2018
Return to Assignment
Your Results Lab Pass
Transcript
Overview
Started: Nov 08, 2018 | Patient Exam Time: 442 min
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Student Pre-Survey
Lifespan
Review Questions
Self-Reflection
Hi Tina, what brings you in to the clinic today?
Hey.
Hey....what brings you in today?
I came in because I've been having breathing problems, and
my inhaler just isn't working the way it normally does.
Greet
11/08/18 10:04 PM
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Question
11/08/18 10:04 PM
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can you tell me what you mean by
breathing problems?
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11/08/18 10:05 PM
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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.
I am sorry to hear that you have been having these issues. I will
do my best to help you feel better.
Empathize
11/08/18 10:11 PM
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I appreciate you telling me that.
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Transcript
All Lines (193) Interview Questions (100) Statements (10) Exam Actions (83)
how long have you been having the breathing issues (Clarified to How long ago did your breathing problems start?.)
All of these breathing problems started two days ago, at my cousin's house. (Clarified to how long ago my breathing problems started.)
where are you feeling the discomfort
My chest has been feeling tight, but it doesn't hurt or anything.
How long does the chest tightness last
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 inhaler in the past two days.)
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.)
what inhaler are you using
It's just a regular Proventil inhaler.
what is the dosage of the proventil
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]
how would you rate the chest tightness?
It doesn't hurt. . . it's just hard to breathe, but there's no pain.
what severity would you rate it at?
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11/08/18 10:16 PM
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11/08/18 10:25 PM
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11/08/18 10:28 PM
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11/08/18 10:29 PM
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11/08/18 10:30 PM
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11/08/18 10:30 PM
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11/08/18 10:33 PM
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11/08/18 10:33 PM
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It doesn't hurt. . . it's just hard to breathe, but there's no pain.
how difficult is it to breathe 0-10?
Yeah, I have asthma.
would you rate difficulty 0-10?
At its worst it's been like a 7 or 8 out of 10, probably.
how would you describe the difficulty breathing?
that has nothing to do with my question, but thanks for that!
Alright, thanks for letting me know.
so your breathing feels tight in your chest?
what seems to make your breathing worse
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.
that has nothing to do with my question, but thanks for that! (No matching questions found.)
It's not so bad right this second, but it's been pretty tight lately, like I can't take in air.
what seems to help your breathing the past two days (Clarified to What has made your breathing better.)
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.
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11/08/18 10:33 PM
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11/08/18 10:34 PM
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11/08/18 10:36 PM
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11/08/18 10:37 PM
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Educate
11/08/18 10:37 PM
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11/08/18 10:37 PM
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11/08/18 10:38 PM
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11/08/18 10:40 PM
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Really just my inhaler. (Clarified to what has made my breathing better.)
Have you had a fever
No, I haven't had a fever.
have you been coughing
I've been coughing a lot, yeah.
have you had any sputum
No, nothing's coming up.
have you had any recent hospitalizations
I had to go to the ER for a foot injury a few months ago, but it's all better now.
does anyone else in your family have breathing problems
My baby sister has asthma, too, but no one else in the family has lung problems, I don't think.
are your immunizations up to date
Yeah, I'm pretty sure.
tdap (No matching questions found.)
is your tdap up to date (No matching questions found.)
is your mmr vaccination up to date
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11/08/18 10:42 PM
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11/08/18 10:42 PM
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11/08/18 10:42 PM
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11/08/18 10:46 PM
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11/08/18 10:46 PM
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11/08/18 10:48 PM
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11/08/18 10:48 PM
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11/08/18 10:49 PM
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I got all the required vaccines when I was a kid, but I don't remember the specifics.
have you had a pertussis vaccination
I don't remember that specific one, but I know I got all the required shots they give you when you're a kid.
where are you working
I'm a supervisor at Mid-American Copy & Ship. I've been working there since high school, and I've just kept moving up.
do you smoke
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