health assessment

7/10/20, 12(24 AMFocused Exam: Cough | Completed | Shadow Health

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Focused Exam: Cough Results | Turned In Fundamentals of Nursing Practice - June 2020, N3604

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Documentation / Electronic Health Record

Document: Nursing Notes

Student Documentation Model Documentation

Subjective

Danny Rivera is an 8-year-old male who presents for evaluation of a cough of onset 3 days ago. Patient reports a productive cough with "slimy, clear" sputum. The patient reports a sensation to cough "every few minutes" and his coughing spells last "a couple seconds". The patient reports an exacerbation of his symptoms at night causing him to have difficulty sleeping. The patient reports that his friend he played with a few days ago is also sick with symptoms of a cough and rhinorrhea. The patient reports that his mother has been giving him cough medicine which was noted by his grandmother to be children's Dimetapp daytime formula. The child last received the Dimetapp this morning and noted improvment of his symptoms after taking the medication. The patient notes associated symptoms of "feeling tired" but notes that he is able to play at school normally until he feels the urge to cough. He also notes associated "clear" watery rhinorrhea and a sore throat with exacerbation with swallowing. The patient notes a normal level of focus at school but reports it is "harder than normal" to pay attention due to freqwuent coughing. The patient denies any symptoms of sneezing, ear pain, ear drainage, hearing changes, fever, chills, night sweats, HA, vision changes, dizziness, eatery eyes, sinus pain, chest pain, or difficulty breathing. The patient was sent to my office for evaluation by his teacher due to persistent cough. He reports no other associated sx or complaints at this time.

Contacted guardian: Patients grandmother reports a cough for the past 3 days and states that Danny "hasn't been himself". Reports that patient was given children's Dimetapp, daytime formula this morning before going to school. Grandmother confirms that the patient has had a normal temperature the past few days. Reports history of a pneumonia one year ago and frequent ear infections but

Danny reports a cough lasting two to three days. He describes the cough as “watery and gurgly.” He reports the cough is worse at night and keeps him up. He reports general fatigue due to lack of sleep. He is experiencing mild soreness in his throat. He reports his mother treated his cough symptoms with over-the-counter medicine, but it was only temporarily effective. He reports frequent cold and runny nose, and he states that he had frequent ear infections as a child. He

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Overview

Transcript

Subjective Data Collection

Objective Data Collection

Education & Empathy

Documentation

Care Plan

Document: Vitals Document: Nursing Notes

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7/10/20, 12(24 AMFocused Exam: Cough | Completed | Shadow Health

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"seems to be doing better this year". Grandmother reports that his cough has not worsened or improved in the past few days and the patient has been coughing more at night. Patient's grandmother has applied a "cough rub" to the patient's chest before he goes to sleep at night. The patient has not been evaluated by his primary physician. Grandmother is coming to pick up Danny at this time.

PMHx: The patient reports a history of frequent OM as a baby but denies any recent ear complaints. The patient was diagnosed with PNA one ear ago. He denies any allergies to medications or foods. Patient denies any seasonal allergies.

The patient reports that he takes a daily multivitamin and "sometimes sneakd a few extra" because they taste good. The patient has been informed to not take more than the prescribed amount of daily vitamins and verbalized understanding.

The patient reports infrequent hand hygiene throughout the day. The patient was educated on the importance of hand hygiene to prevent the spread of germs and was encouraged to practice more frequent hand washing throughout the day. Patient verbalized understanding.

FHx: The patient reports exposure to secondhand smoke at home due to his father sometimes "smoking cigars in the house". The patients father has a pmhx per patient of HTN, HLD and childhood asthma. His mother has a pmhx per patient of DM, HLD, and HTN.

reports a history of pneumonia in the past year. He reports normal bowel movements. He denies fever, headache, dizziness, ear pain, trouble swallowing, nosebleed, phlegm or sputum, chest pain, trouble breathing and abdominal pain. He denies cough aggravation with activity.

Objective

Eyes: Upon inspection, patients eyes have no visable abnormal findings bilaterally. Sclera: white bilaterally. Conjunctiva: Moist and pink bilaterally. No conjunctival drainage bilaterally.

Nose: Nasal cavities pink and patent bilaterally. Clear nasal discharge noted bilaterally. No other additional visable abnormal findings noted on inspection.

Ears: Bilateral auditory canals pink in color on inspection. Bilateral TMs pearly gray in color, no visible abnormal findings bilaterally. No discharge noted bilaterally. Right TM cone of light noted at 0500 position. Left TM cone of light noted at 0700 position.

Mouth: Oral mucosa moist and pink, no visible abnormal findings noted to bilateral tonsils. Throat is red with present of cobblestoning on inspection. No post nasal drip noted.

Sinuses: No TTP noted to frontal or maxillary sinuses.

Neck: Symmatric with no visible findings on inspection. Palpable lymph nodes with TTP to right cervical lymph nodes. Supraclavicular and axillary lymph nodes were not palpable.

Chest: Symmetric expansion and no vision abdnormal findings noted on inspection. All areas resonant with no areas of dullness on percussion. Diaphramatic excursion noted to be 3cm. On palpation, expected fremitus is noted and equal bilaterally. Palpated chest wall expansion is equal bilaterally.

Lungs: Breast sounds noted in all areas. No adventitious breathsounds noted throughout all lung fields. All areas clear.

Bronchophony: negative

Heart: S1 and S2 audible. No extra sounds noted with auscultation.

• General Survey: Fatigued appearing young boy seated on nursing station bench. Appears stable.

• HEENT: Mucus membranes are moist, nasal discharge, and boggy turbinate. Fine bumps on the tongue. Cobblestoning in the back of throat. Eyes are dull in appearance, pink conjunctiva.

• Cardiovascular: Mild tachycardia. S1, S2, no murmurs, gallops or rubs.

• Respiratory: Respiratory rate increased, but no acute distress. Able to speak in full sentences. Breath sounds clear to auscultation.

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7/10/20, 12(24 AMFocused Exam: Cough | Completed | Shadow Health

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