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Exam (elaborations)

Shadow Health Focused Exam, COPD- Subjective Data Collection

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Uploaded on
May 19, 2021
Number of pages
5
Written in
2024/2025
Type
Exam (elaborations)
Contains
Questions & answers

Subjects

  • nurs 5304

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Focused Exam: COPD Results | Turned In
Advanced Pharmacology - Summer 2019, NURS 5304
Return to Assignment




Your Results Lab Pass




Overview
Subjective Data Collection: 32 of 32 (100.0%)
Transcript

Subjective Data Collection Hover To Reveal... Indicates an item that you found.
Hover over the Patient Data items Indicates an item that is available to be
Objective Data Collection
below to reveal important information, found.
including Pro Tips and Example
Education & Empathy
Questions.
Documentation

Debrief Category Scored Items Patient Data
Not Scored
Medication Selection
Experts selected these topics as essential A combination of open and closed questions
Patient Teaching
components of a strong, thorough interview will yield better patient data. The following
with this patient. details are facts of the patient's case.
Prescription Writing


Chief Complaint


Established chief complaint and reason Reports a bronchospasm three days ago
for admittance Reports increased difficulty breathing
Reports desire for smoking cessation aids




History of Present Illness


Asked about additional symptoms Reports fatigue and weakness
Reports purulent sputum
Reports cough
Reports feeling anxious about symptoms
and worsening health issues




Asked about onset and duration of Reports most severe fatigue and difficulty

, Reports purulent sputum production
started two weeks ago
Reports respiratory symptoms increased
in the last four months



Followed up on characteristics of Reports sputum is mostly clear with
respiratory distress occasional yellow, gray, or dark color
Reports wheezing
Reports cough sounds like crackling




Asked about aggravating factors Reports exertion worsens symptoms
Reports coughing fits after smoking



Asked about treatment and relieving Reports trying to hold off on smoking
factors of respiratory symptoms cigarettes as long as possible




Asked about severity of respiratory Reports breathing difficulty and associated
distress discomfort is a 6/10




Asked about effects of health on social Reports low social activity - doesn't feel up
activity to getting out and about



Past Medical History


Asked about existing health conditions Reports chronic bronchitis related to
COPD



Followed up on chronic bronchitis COPD Reports diagnosed with "Class B" COPD
diagnosis Reports diagnosed after respiratory
distress episode



Asked about ER visits or hospitalizations Reports hospitalization after miscarriage
at age 24
Reports most recent hospitalization was
two years ago
Reports most recent hospitalization was
for respiratory distress episode




Home Medications


Asked about home medications Reports taking a long-acting beta-agonist
(LABA)



Followed up on LABA Reports the LABA is formoterol inhaler

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