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NR 509 Shadow Health Respiratory Physical Assessment Assignment
Tina had an asthma episode 2 days ago. 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 ten episodes of wheezing and has shortness of breath approximately every four hours.
Tina presents with continued shortness of breath and wheezing. Be sure to ask pertinent questions during the interview about related body systems. This case study will provide the opportunity to carefully assess lung sounds during the physical examination. Be sure to appropriately document your findings using correct medical terminology.NR 509 Shadow Health Respiratory Physical Assessment Assignment
Reason for visit: Patient presents complaining of a recent asthma episode that is not fully resolved.
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. ……… NR 509 Shadow Health Respiratory Physical Assessment Assignment
Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She uses a hypoallergenic pillow cover and her mattress is one year old. She denies current use of tobacco, alcohol, and illicit drugs. She did smoke marijuana for 5 or 6 years, her last use was at age 21 years. She does not exercise.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 1 of 6
Respiratory Results | Turned In
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
Asthma exacerbation are aggravated by exposure to cats
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 except for albuterolresuce inhaler. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Pt. not currrently being managed by a pulmonologist or someone for her allergies. Pt. denies using a vaporizer or nebulizer at home. NR 509 Shadow Health Respiratory Physical Assessment Assignment
PMH:
Pt. reports Type 2 Diabetes, possible borderline hypertension (no actual dx).
Allergies:CONT.
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: CONT.
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.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486
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:
Family History: Pt. states sister has history of asthma and hay fever.
Surgical History: Pt. denies previous surgeries. NR 509 Shadow Health Respiratory Physical Assessment Assignment
ROS:
General: … cont.
Review of Systems:CONT.
General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats.
• Nose/Sinuses: Denies rhinorrhea with this episode.
Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure.
• Gastrointestinal: No changes in appetite, no nausea, no vomiting, no symptoms of GERD or abdominal pain
• Respiratory: Complains of shortness of breath and cough as above. Denies sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis.
She has a history of asthma, last hospitalization was age 16, last chest XR was age 16.
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 4 of 6
… cont.
Objective
Tina is an obese 28-year-old African American woman who does not seem to be in any acute distress. Alert and oriented, sitting upright, maintains appropriate eye contact, is
conversational, and answers questions appropriately. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Respiratory: … CONT.
Muffled words bilaterally with prominent expiratory wheezes in the posterior lower lobes only.
Spirometry yielded FVC 3.91, FEV/FVC ratio
80.56%, SaO2 97% on room air, HR 89, RR 20, BP
General: … CONT.
Respiratory | Completed | Shadow Health 7/26/18, 2)20 PM
https://chamberlain.shadowhealth.com/assignment_attempts/3664486 Page 5 of 6
140/81, Temperature 98.5 degrees Farenhiet.
Assessment
Mild-Persistent Asthma with Exacerbation. Mild-persistent asthma with exacerbation
Plan
Diagnostics: Obtain oxygen saturation and baseline spirometry and peak flow readings.
Medication: NMI at office one time. Continue albuterol rescue inhalor. Initiate step up inhaled corticosteroid.
Education: … CONT.
Orders: … CONT.
Follow-Up: Return to clinic in 3 weeks for follow-up evaluation regarding coarse of illness, medication use and needs, as well as medication effectiveness. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Diagnostics
• … CONT.
Education
… CONT.
•
Referral/Consultation
• Refer to allergy specialist for evaluation and testing
Follow-up Planning … CONT.
Review of Systems: … CONT.
General: Ms. Jones is a pleasant, obese 28-year-old African American woman in no acute distress. She is alert and oriented and sitting upright on exam table. She maintains eye contact throughout interview and examination.
Mild-persistent asthma with exacerbation NR 509 Shadow Health Respiratory Physical Assessment Assignment
Plan
Diagnostics
… CONT.
Education
Referral/Consultation
Follow-up Planning
Tina’s second cousin was diagnosed with asthma at age 5. What would be included in your treatment plan? What factors might concern you related to compliance?
The treatment plan for this child would be to treat the airways of inflammation using medication to prevent asthma attacks. Further, short-acting drugs will be used to treat the asthma attacks. Also, the child will have to avoid triggers of asthma. Lastly, the child will be advised to maintain normal activity levels. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Consider that Tina’s uncle is now 68 years old and has smoked heavily every day since he was fifteen. What would you expect to find in his respiratory assessment? How would this affect your oxygenation goals for this patient? NR 509 Shadow Health Respiratory Physical Assessment Assignment
Common significant deviations …CONT.
In the respiratory assessment of this patient, … CONT.
Dyspnea can be assessed …CONT.
The examination was … CONT.
The various tasks and decisions undertaken here were to inform … CONT.
My performance could be improved by seeking more history from the patient. In terms of lessons learned, the present analysis will allow me to become even more aware of the nitty-gritties of respiratory assessment for future practice. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information.
Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness…………………… Interviewing patients is an art and should remain an essential skill for successful practice. NR 509 Shadow Health Respiratory Physical Assessment Assignment
In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem list using evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation. NR 509 Shadow Health Respiratory Physical Assessment Assignment
Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.
Reason for visit: Patient presents for an initial primary care visit today complaining of an infected foot wound.
Start by reading and following these instructions:
Your initial posting should be 200 to 300 words in length and utilize at least one scholarly source other than the textbook. Please reply to at least two classmates. Replies to classmates should be at least 100 words in length. To properly “thread” your discussion posting, please click on REPLY.
When you are ready for the discussion, do the following:
To reply to a classmate’s post:
Remember to submit your work following the file naming convention FirstInitial.LastName_M01.docx. For example, J.Smith_M01.docx. Remember that it is not necessary to manually type in the file extension; it will automatically append.
Start by reading and following these instructions:
Exercises
Professional Development
How did your assessment demonstrate sound critical thinking and clinical decision making? What could you change to make it better? NR 509 Shadow Health Respiratory Physical Assessment Assignment
Subjective
HPI: Ms.Jones is a 28 years old African american women who is presented to the clinic with complaints of sore, … Social History: patient is unaware of any environmental exposure / irritants . … CONT. Review systems : General – denies changes in weight, fever and chills. … CONT. |
HPI: Ms. Jones is a pleasant 28-year-old African American woman who presented to the clinic with complaints of sore, itchy throat, itchy eyes, and runny nose for the last week.
Social History: She is not aware of any environmental exposures or irritants at her job or home. She changes her sheets weekly and denies dust/mildew at her home. She denies use of tobacco, alcohol, and illicit drugs. She does not exercise. Review of Systems: General: Denies changes in weight, fatigue, weakness, fever, chills, and night sweats. … CONT. • Head: Denies history of trauma or headaches. • Eyes: She does … CONT. • Ears: Denies hearing loss, tinnitus, vertigo, discharge, or earache. • Nose/Sinuses: Denies rhinorrhea prior to this episode. Denies stuffiness, sneezing, itching, previous allergy, epistaxis, or sinus pressure. • Mouth/Throat: Denies bleeding gums, hoarseness, swollen lymph nodes, or wounds in mouth. No sore throat prior to this episode. • Respiratory: She denies shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, bronchitis, emphysema, tuberculosis. She has a history of asthma, last hospitalization was age 16 for asthma, last chest XR was age 16. Her current inhaler use has been her baseline of 2-3 times per week. NR 509 Shadow Health Respiratory Physical Assessment Assignment |
Objective
patient c/o 4/10 pain in her throat, … CONT. Nares appear to be swollen, patient denies difficulty breathing, … CONT. NR 509 Shadow Health Respiratory Physical Assessment Assignment
|
General:
• Head: Head is normocephalic and atraumatic. Scalp with no masses, normal hair distribution. • Eyes: Bilateral eyes with equal hair distribution, no lesions, no ptosis, … CONT. • Ears: Ear shape equal bilaterally. External canals without inflammation bilaterally. Tympanic membranes pearly grey and intact with positive light reflex bilaterally. Rinne, Weber, and Whisper tests normal bilaterally. • Nose: Septum is midline, nasal mucosa is boggy and pale bilaterally. No pain with palpation of frontal or maxillary sinuses. NR 509: Shadow Health Respiratory Physical Assessment Assignment • Mouth/Throat: •Neck: • Respiratory: CONT. |
Assessment
Patient was assessed for sore throat and runny nose … |
Allergic Rhinitis |
Plan
Refer patient for … CONT. |
NR 509 Shadow Health Respiratory Physical Assessment Assignment |
Shadow Health Physical Assessment Rubric | ||||||
Criteria | Ratings | Pts | ||||
This criterion is linked to a Learning OutcomeSubjective Data, Organization, Communication, and Summary (DCE Score or transcript)
|
|
25.0 pts | ||||
This criterion is linked to a Learning OutcomeObjective Data, Physical Examination, Interpretation of Findings, Assessment, and Documentation
|
|
20.0 pts | ||||
This criterion is linked to a Learning OutcomeSelf-Reflection
|
NR 509 Shadow Health Respiratory Physical Assessment Assignment |
5.0 pts | ||||
Total Points: 50.0 |
NR 509: Shadow Health Respiratory Physical Assessment Assignment
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304
1/23
Respiratory Results | Turned In
Advanced Health Assessment – Chamberlain, NR509-April-2018
Return to Assignment
Your Results Labb Pass
Started: May 11, 2018 | Patient Exam Time: 168 min
Greet 05/11/18 12:39 PM CDT
Question 05/11/18 12:39 PM CDT
Question NR 509 Shadow Health Respiratory Physical Assessment Assignment 05/11/18 12:39 PM
CDT
Question 05/11/18 12:40 PM CDT
Greet 05/11/18 12:39 PM CDT
Hello my name Sara an FNP student and I will be interviewing you
today.
Tina Jones: Hey.
Question 05/11/18 12:39 PM CDT
Can you please state your name for me?
Tina Jones: Tina Jones.
Question NR 509 Shadow Health Respiratory Physical Assessment Assignment 05/11/18 12:39 PM
CDT
Your date of birth?
Tina Jones: February 17th.
Question 05/11/18 12:40 PM CDT
Year of birth please? (Clarified to What year were you born.)
Tina Jones: I was born in . . . [Ms. Jones reports correct birth year.] [AUDIO
COMING SOON]
5/11/ Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 2/23
Question 05/11/ 12:40 PM CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Question 05/11/ 12:41 PM CDT
Question 05/11/ 12:42 PM CDT
Empathize 05/11/18 12:42 PM CDT
Question 05/11/ 12:43 PM CDT
Question 05/11/ 12:53 PM CDT
Question 05/11/ 12:53 PM CDT
… CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 3/23
Question 05/11/18 12:53 PM CDT
Empathize 05/11/18 12:56 PM CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Question 05/11/18 12:56 PM CDT
Question 05/11/18 12:57 PM CDT
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Question 05/11/18 1:00 PM CDT
Question 05/11/18 1:02 PM CDT
I don’t know if I’d call it an asthma attack, … CONT.
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 8/23
Exam Action 05/11/18 1:53 PM CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Exam Action 05/11/18 1:53 PM CDT
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Exam Action NR 509 Shadow Health Respiratory Physical Assessment Assignment 05/11/18 1:56 PM CDT
Exam Action 05/11/18 1:56 PM CDT
Exam Action 05/11/18 1:56 PM CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 9/23
Exam Action 05/11/18 1:56 PM CDT
Exam Action 05/11/18 1:56 PM CDT
Exam Action 05/11/18 1:56 PM CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Exam Action 05/11/18 1:57 PM CDT
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Exam Action 05/11/18 2:01 PM CDT
Auscultated … CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 10/23
Exam Action
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 11/23
Exam Action
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Ninety-nine.
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 12/23
Exam Action
05/11/18 2:02 PM
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Exam Action
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Exam Action
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Exam Action
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Educate
05/11/18 2:16 PM
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Question
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Educate
05/11/18 2:17 PM
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Educate
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Educate
05/11/18 2:18 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 13/23
Question
05/11/18 2:19 PM
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05/11/18 2:22 PM NR 509 Shadow Health Respiratory Physical Assessment Assignment
CDT
CONT. [Nurse confirmed with Pharmacy: albuterol 90mcg/spray MDI]
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 14/23
Educate
05/11/18 2:22 PM
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Question
05/11/18 2:23 PM
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05/11/18 2:25 PM
CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Question
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Question
05/11/18 2:27 PM
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CONT.
When did your recent asthma problems start? (Clarified to What started your recent asthma problems? .)
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 15/23
Question
05/11/18 2:27 PM
CDT
Question
05/11/18 2:28 PM
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Empathize
05/11/18 2:28 PM
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Question
05/11/18 2:28 PM
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Question
05/11/18 2:30 PM NR 509 Shadow Health Respiratory Physical Assessment Assignment
CDT
Question
05/11/18 2:30 PM
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Question
05/11/18 2:31 PM
CDT
CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 16/23
Educate
05/11/18 2:32 PM
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Question
05/11/18 2:50 PM
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Question
05/11/18 2:50 PM
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05/11/18 2:51 PM
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05/11/18 2:52 PM
CDT NR 509 Shadow Health Respiratory Physical Assessment Assignment
Question
05/11/18 2:53 PM
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Question
05/11/18 2:54 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 17/23
Question
05/11/18 2:54 PM
CDT
Question
05/11/18 2:55 PM
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Educate
05/11/18 2:57 PM
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Question
05/11/18 2:57 PM
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Educate
05/11/18 2:57 PM
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Question
05/11/18 2:58 PM
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Educate
05/11/18 2:59 PM NR 509 Shadow Health Respiratory Physical Assessment Assignment
CDT
Question
05/11/18 3:00 PM
CDT
I’ve heard of that, but no, I don’t do it.
Do you use a nebulizer?
No, but I have before.
We may consider a nebulizer for home treatments.
That makes sense.
Also a way to track your asthma symptoms and episodes. (No matching questions found.)
Also a way to track your asthma symptoms and episodes.
OK, I understand.
Sending you home with a peak flow meter and document regularly. NR 509 Shadow Health Respiratory Physical Assessment Assignment
I’ve heard of that, but no, I don’t do it.
We will also teach you how to use nebulizer at home.
Sure, I think I understand what you mean.
How often do you change your sheets?
I change my bedding once a week, I’d say.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 18/23
Question
05/11/18 3:01 PM
CDT
Empathize
05/11/18 3:01 PM
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Educate
05/11/18 3:02 PM
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Question
05/11/18 3:02 PM
CDT
Empathize
05/11/18 3:02 PM
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Question
05/11/18 3:03 PM NR 509 Shadow Health Respiratory Physical Assessment Assignment
CDT
Educate
05/11/18 3:03 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 19/23
Question
05/11/18 3:04 PM
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Question
05/11/18 3:06 PM
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Educate
05/11/18 3:07 PM
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05/11/18 3:07 PM
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05/11/18 3:08 PM
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Question NR 509 Shadow Health Respiratory Physical Assessment Assignment
05/11/18 3:09 PM
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Question
05/11/18 3:09 PM
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Question
05/11/18 3:12 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 20/23
Empathize
05/11/18 3:13 PM
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Educate
05/11/18 3:13 PM
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Question
05/11/18 3:13 PM
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Question
05/11/18 3:13 PM
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Question
05/11/18 3:14 PM NR 509 Shadow Health Respiratory Physical Assessment Assignment
CDT
Question
05/11/18 3:15 PM
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Question
05/11/18 3:17 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 21/23
Question
05/11/18 3:17 PM
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Question
05/11/18 3:17 PM
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Question
05/11/18 3:18 PM
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Question
05/11/18 3:18 PM
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Educate
05/11/18 3:19 PM
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Question NR 509 Shadow Health Respiratory Physical Assessment Assignment
05/11/18 3:20 PM
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Question
05/11/18 3:20 PM
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Question
05/11/18 3:20 PM
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CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 22/23
Question
05/11/18 3:27 PM
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Question
05/11/18 3:28 PM
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05/11/18 3:29 PM
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05/11/18 3:30 PM
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05/11/18 3:31 PM
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05/11/18 3:34 PM
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05/11/18 3:35 PM
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05/11/18 3:35 PM
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No, my nose has been fine.CONT.
5/11/2018 Respiratory | Completed | Shadow Health
https://chamberlain.shadowhealth.com/assignment_attempts/3498304 23/23
Question
05/11/18 3:36 PM
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Question
05/11/18 3:37 PM
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CONT.
Comments
If your instructor provides individual feedback on this assignment, it will appear here.
© Shadow Health 2018 ® NR 509 Shadow Health Respiratory Physical Assessment Assignment
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