Assessment of the respiratory status
Nelson Carson is a 62-year-old man who presents to his private practitioner’s office with a hacking, raspy cough.
Subjective Data
- PMH: HTN, CAD
- Cough is productive, bringing up green, thick phlegm
- Runny nose, sore throat
- No history of smoking or seasonal allergies
- Complains of fatigue
Objective Data
- Vital signs: T 37 P 72 R 14 BP 134/64
- Lungs: + Rhonchi bilateral upper lobes, wheezes
- O2 Sat = 98%
Medications: Metoprolol 25 mg per day, ASA 325 mg/daily
- What other questions should the nurse ask about the cough?
- What nursing diagnoses can be derived from the data?
- What should be included in the plan of care?
- What risk factors are associated with this age group?
- Based on the readings, what is the most likely cause of cough for this patient?
- Apa format
- ReferenceJarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
- Chapter 18: Thorax and Lungs
- pp. 413–441 (Structure, Function, The Thoracic Cavity, Developmental Competence, Subjective Data, Objective Data)
- Chapter 19: Heart and Neck Vessels
- pp. 459–492 (Structure and Function, Heart Wall, Chambers, and Valves, Heart Sounds, Developmental Competence, Subjective Data, Objective Data )
- Chapter 20: Peripheral Vascular System and Lymphatic System
- pp. 509–529 (Structure and Function, Lymphatics, Developmental Competence, Subjective Data, Objective Data)
- Chapter 18: Thorax and Lungs