Chamberlain College of Nursing NR 509 W2_SH_[Dr. Documentation]-ASTHMA-Respiratory | Completed |

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Respiratory Results | Turned In Advanced Health Assessment - Chamberlain, NR509-June-2018 Return to Assignment Your Results Lab Pass Document: Provider Notes Document: Provider Notes Student Doc... umentation Model Documentation Subjective Identifying and Reliability: Ms. Jones is an obese 28-year-old female who is presenting to the office today with an athma exacerbation. She is the primary and only source of personal and medical data. Pleasent, cooperative and readily open to freely dissiminate health information. Good eyeye contact, well-groomed, good posture, and comunicates clearly with logical flow of ideas. General Survey: Upon entering the patient's examination room, patient was found to be sitting straight and erect, good posture, well-groomed, well nourished with a pleasent demeanor and manner of communicating. Reason for Visit: "Breathing problems and my inhaler just isn't working the way it normally does." HPI: Ms. Tina Jones is a 28-year-old African American woman who walked in to the clinic complianing of SOB and wheezing after nearly haveing a "bad" asthma attack two days ago. Pt. Overview Transcript Subjective Data Collection Objective Data Collection Education & Empathy Documentation Student Pre-Survey Lifespan Review Questions Self-Reflection Documentation / Electronic Health Record This study source was downloaded by 100000831988016 from CourseHero.com on 03-14-2022 05:39:54 GMT -05:00 https://www.coursehero.com/file/32326524/W2-SH-Dr-Documentation-ASTHMA-Respiratory-Completed-Shadow-Healthpdf/ Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 2 of 6 reports allergies to cats which triggered her asthma symptoms while she was visitn her cousins house. Initially, at the time of the climax of her near asthma attack, her SOB severity was a 7-8/10, wheezing severity was initially a 6/10. It lasted for 5 minutes, following the use of her rescue inhaler Provenol. Pt. reports only chest tightness at the time, which has continued to the present with no increase in tightness. Pt. denies all other allergic symptoms during the exaccerbation of her asthma. The inhalor had amild to moderate effect, not fully resolving the asthma symptoms. Pt. reports that since the initial exacerbation, she has had ten similar asthma episodes consisting of SOB, "not able to get enough air in" to her lungs, chest tightness all occur every 4 hours, even through the night, awakinging her from sleep. Her symptomsare worsoned when laying supine, including coughing fits each time she lays down, which easily resolves once sitting backup. Instead of using the prescribed 2 puffs of albuterol, pt. has been using 3 puffs each exacerbation with minimal to moderate relief. Most recent episode was this morning prior to her arrival. Asthma exacerbations are aggrevated by exposure to cats, perhaps dust, and currently exacerbated by exertion and laying supine with a subsequent coughing fit. occur Cough is non-productive. Pt. concerned her new albuterol inhaler is ineffective compared to previous device. Her asthma has been slowly interferring with her life the past year or so, while still being manageable. Over the past 2 days, her asthma has interferred with her daily life, including her response that if she had not had these past two days off of work, she "would have called in sick for sure." Pt. feels minimal asthma symptoms curretly, following her albuterol use over an hour ago. Diagnosed with asthma at 2.5-years-old, She frequented hospital visits and including five hospitalizations before she was 16-years-old. Since then she hasn't been hospitalized. Pt. denies spirometry inhalor, peak flow meter use, as well as any other asthma medication use. Pt. doesn't keep asthma record of exacerbations and triggers; denies asthma medication usage excet for albuterolresuce inhaler. Pt. not currrently beingmanaged by a pulmonologist or someone for her allergies. Pt. denies using a vaporizer or nebulizer at home. PMH: Pt. reports Type 2 Diabetes, possible borderline hypertension (no actual dx). Allergies: Cats: Develops itchy, watery eyes; an itchy, "runny nose"; an itchy, sometimes a sore throat, and often an asthma exacerbation - SOB, DOE, wheezing, coughing, and chest tightness. Dust: Develops a rash, no tiching. Penicillin: "Rash, like, hives." HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of shortness of breath and wheezing following a near asthma attack that she had two days ago. She reports that she was at her cousin’s house and was exposed to cats which triggered her asthma symptoms. At the time of the incident she notes that her wheezes were a 6/10 severity and her shortness of breath was a 7-8/10 severity and lasted five minutes. She did not experience any chest pain or allergic symptoms. At that time she used her albuterol inhaler and her symptoms decreased although they did not completely resolve. Since that incident she notes that she has had 10 episodes of wheezing and has shortness of breath approximately every four hours. Her last episode of shortness of breath was this morning before coming to clinic. She notes that her current symptoms seem to be worsened by lying flat and movement and are accompanied by a non-productive cough. She awakens with night-time shortness of breath twice per night. She complains that her current symptoms are beginning to interfere with her daily activities This study source was downloaded by 100000831988016 from CourseHero.com on 03-14-2022 05:39:54 GMT -05:00 https://www.coursehero.com/file/32326524/W2-SH-Dr-Documentation-ASTHMA-Respiratory-Completed-Shadow-Healthpdf/ Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 3 of 6 Medications: Rx: Provenal 90 mcg/spray, 2 puffs, for asthma. OTC: Acetamet:aphen 1000 mg for occasional headaches related to readingfor prolonged periods of . Iburofen OTC Social History: Pt. reports fairly severe allegies to cats (urticaria, asthma symptoms of SOB, a restrictive airway sensation, wheezing and a non-productive cough); A moderate allergic reaction to excessive dust accumulation (allergy sx's, sneezing, sometimes asthma-like reaction); and Penicillin (report from mom when pt.was a child, mother reports development of a rash only; unknown if SOB, DOE, urticara, puritis, dysphagia and angiophylaxis occured as well. Pt. is meticullus about dust, allergins, mildew accumulation; using hypoallergenic practices with bed, sheets, pillows and spead. Mattress is 12 months old. Pt. denies ever using tabacco in any form, as well as illicit drugs and prescription medicaton abuse. Pt. does report that from 15-16-years old she smoked marijuana, but hasn't partaken in it since 21-years-old. Pt. states she doesn't exercise, eats "whatever", with some restrint in high sugar beverages and treats. Family History: Pt. states sister has history of asthma and hayfever. Surgical History: Pt. denies previous surgeries. ROS: General: Pt. states recent changes in appetite as she is "always hungry" even after she has eaten a large meal. Reports exercise intolerance, usually feels fatigued. Pt. denies recent weight changes, fevers, chills. body aches, sweats. feels she is generally a healthy person. Skin: Pt. reports skin color and pigment changes localized only around her neck - which has been changeing the past couple of years now. Pt. reports that moles on her back have not changed in size or color.Skin is dryer than usual and feels dehydrated and always thirsty. Denies sores, lesions, scabs. Pulmonary: Pt. states that she has coughing fits when exposed to allergens like dust adn especially cats. Coughing also occurs when asthma "acts up" and anytime she lays down in the past month she begins to cough. Lately she will wake up twice a night because of uncontrolable coughing which resolves after she has been in a sitting or upright position for a few minutes. Denies productive cough or coughing up blood. Denies being exposed to anyone sick, has not traveled. [Show More]

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