Shadow Health COPD Debbie Summary NURS HEALTH ASS 32 of 32 (100.0%)

Shadow Health COPD Debbie O’Connor Subjective Data Collection: 32 of 32 (100.0%) Hover To Reveal... Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.  Found: Indicates an item that you found.  Available: Indicates an item that is available to be found. Category Scored Items Experts selected these topics as essential components of a strong, thorough interview with this patient. Patient Data Not Scored A combination of open and closed questions will yield better patient data. The following details are facts of the patient's case. Chief Complaint  Finding: Established chief complaint and reason for admittance  Finding: Reports a bronchospasm three days ago (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: When did your symptoms start?  Finding: Reports increased difficulty breathing (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: What are your symptoms?  Finding: Reports desire for smoking cessation aids (Found) Pro Tip: A patient's chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have. Example Question: What can I do for you? History of Present Illness  Finding: Asked about additional symptoms  Finding: Reports fatigue and weakness (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you feel fatigued?  Finding: Reports purulent sputum (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have purulent sputum?  Finding: Reports cough (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have a cough?  Finding: Reports feeling anxious about symptoms and worsening health issues (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How do you feel about your symptoms?  Finding: Asked about onset and duration of symptoms  Finding: Reports most severe fatigue and difficulty breathing began three days ago (Available) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did your fatigue begin?  Finding: Reports purulent sputum production started two weeks ago (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: When did your productive cough begin?  Finding: Reports respiratory symptoms increased in the last four months (Found) Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had your symptoms?  Finding: Followed up on characteristics of respiratory distress