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Respiratory Results | Turned In
Advanced Health Assessment - Chamberlain, NR509-June-2019
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Overview
Transcript
Transcript
Started: Jul 21, 2019 | Patient Exam Time: 738 min
Subjective Data Collection
All Lines Interview Questions (216) Statements (23) Exam Actions (93)
(297)
Objective Data Collection
Greet
Education & Empathy Tina, it's good to see you again. If you don't remember me, I'm Scott,
07/21/19 11:17 PM
your nurse practitioner. I'll be doing your examination today.
CDT
Documentation
Student Pre-Survey
Hey.
Lifespan
Question
Review Questions
What brings you in today? 07/21/19 11:18 PM
CDT
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
Tell me about the breathing issues your 07/21/19 11:18 PM
experiencing? CDT
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.
Question
To make sure I understand, you feel like you can't get enough air? (No
07/21/19 11:19 PM
matching questions found.)
CDT
https://chamberlain.shadowhealth.com/assignment_attempts/
3664486
Page 1 of
, You can't get enough air in to your lungs? (No matching questions found.) Question
07/21/19 11:19 PM
CDT
Empathize
I'm sorry, thats a terrible feeling.
07/21/19 11:20 PM
CDT
Thanks for saying that.
I know that we have been through these same set of questions, so I'm sorry I'm going to ask them again. I'm not really insulting your intelligence, although it ma
Educate
07/21/19 11:22 PM
CDT
Alright, thanks for letting me know.
Question
When did your breathing issues begin?
07/21/19 11:22 PM
CDT
All of these breathing problems started two days ago, at my cousin's house.
Question
Were you around cats?
07/21/19 11:22 PM
CDT
Two days ago, at my cousin's house. She has three of them, and my asthma always goes crazy when I'm there.
Question
Because your allergic to cats, right?
07/21/19 11:22 PM
CDT
Definitely. Cats make my asthma go crazy.
How long were you exposed to these cats? (No matching questions found.) Question
07/21/19 11:23 PM
CDT
Question
Has your asthma gotten worse since you were exposed to the cats?
07/21/19 11:23 PM
CDT
, No, my asthma has definitely got better since I was little. It used to be really bad--I would get asthma attacks al
Did anything make you asthma feel better? (No matching questions found.) Question
07/21/19 11:24 PM
CDT
Your inhaler didn't help your asthma? (Clarified to what do you do if your inhaler doesn't work.) Question
07/21/19 11:24 PM
CDT
I guess I don't really have a backup plan; it's always worked in the past, though lately I've needed more puffs than usual.
Question
How many puffs do you need?
07/21/19 11:25 PM
CDT
Sometimes I have to take three puffs instead of two, and the past couple days, always three. [Nurse confirmed with Pharmacy: albuterol 90mcg/spra
Question
How many times did you use your inhaler the past two days? (Clarified to how many times have you used your inhaler in the past two days.)
07/21/19 11:25 PM
CDT
I've been needing my inhaler about every four hours, I'd say.
What have you done to treat your asthma? (Clarified to how do you manage your asthma.) Question
07/21/19 11:26 PM
CDT
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Question
Why didn't you avoid the cats this time?
07/21/19 11:26 PM
CDT
I haven't been sleeping as well because my asthma has been getting a little worse at night, and it's been waking me up, too.
Question
How many times to you wake up with asthma?
07/21/19 11:27 PM
CDT
, I feel like I've woken up at least twice each night with breathing problems the past two nights.
Question
Are you able to fall back asleep? (No matching questions found.)
07/21/19 11:27 PM
CDT
Question
Have you been sick lately?
07/21/19 11:28 PM
CDT
No, I'm usually healthy.
Question
Have you been exposed to any dust lately?
07/21/19 11:28 PM
CDT
No. . . I'm not around dust much. It mostly happens if I'm at someone's house and they don't keep it very clean, and that hasn't happened in a wh
Question
How often have you been having trouble breathing?
07/24/19 11:37 AM
CDT
Maybe as much as every four hours? It's a lot.
When is the last time you were hospitalized because of an asthma attack? Question
07/24/19 11:39 AM
CDT
I used to go to the hospital a lot for asthma attacks, but not since I was sixteen.
What have you done to avoid hospitalizations due to asthma? (No matching questions found.) Question
07/24/19 11:41 AM
CDT
That's awesome - to be able to avoid going to the hospital since 16 years old. Empathize
07/24/19 11:42 AM
CDT
I appreciate you saying that.