Tina Jones – Respiratory Results Health Assessment – January 2023

Tina Jones – Respiratory Results Health Assessment – January 2023

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Transcript

Started: Feb 17, 2023 | Total Time: 44 min

All Lines (104)Interview Questions (39)Statements (0)Exam Actions (65)

Hello!
Hi. I’m Preceptor Diana. I will explain the details of this assignment and your objectives, just as a preceptor would in real life. Pay close attention to this information as it will help guide your exam. At the end of this prebrief, you will answer a short question about the upcoming assignment. During the simulation, you may return to these instructions at any time by scrolling to the top of your transcript.
What is the situation?
It’s noon on Tina Jones’ first day as a patient here at Shadow General Hospital. Your role in this simulation is that of a healthcare provider who will perform a full respiratory exam on Ms. Jones given her history of asthma.
What are my objectives in this assessment?
In your interview with Ms. Jones, you will ask about her respiratory system and identify any risk factors so that you can determine any current and potential issues. If you discover any disease states, ask about symptoms and the patient’s experiences of them. Your questioning should cover a broad array of the symptoms’ characteristics. You will also inquire into the health history of Ms. Jones’ family with regards to the respiratory system so you can determine her genetic predisposition to any diseases. Regardless of whether you have assessed Tina previously, ask all questions that are medically relevant to her respiratory system. In addition to collecting subjective data, you will perform a physical exam on Ms. Jones’ respiratory system to gather objective data about the system’s health and physiology. While you should communicate with patients using accessible, everyday language, it is standard practice to use professional medical terminology everywhere else, such as in documenting physical findings and nursing notes. You may complete the exam activities in any order and move between them as needed.
What else will this exam involve?
You will complete nursing tasks to protect the patients safety, privacy, and health. You can document your findings, including vital signs, in the Electronic Health Record. This record provides necessary information for healthcare professionals who will continue patient care. Activities other than Subjective and Objective Data Collection, such as Documentation and Education and Empathy, provide valuable practice for their real-world counterparts. However, they are not automatically graded by the simulation.
How will I be evaluated?
In this assignment, you will be evaluated on your Subjective and Objective Data Collection. The evaluation of your interview is dependent on how you word your questions therapeutically and precisely and explore all relevant topics with comprehensive breadth and depth. The evaluation of your physical exam is based on how successfully you report on your physical findings by selecting among clinical terms in the Electronic Health Record. This assignment takes on average between 40 and 50 minutes. You can pause and resume the assignment at any time; your work is always saved automatically.
How does this assignment prepare me for the real world?
In this assessment, you will become familiarized with the structure and content of respiratory exams so that with real-life patients, you can: º ask effective and comprehensive questions º use therapeutic language º evaluate the patient’s risk of disease, infection, injury, and complications º and obtain and assess objective data.
In 1 or 2 sentences, answer this question to help prepare for the upcoming exam: Based on your current knowledge, explain the pathophysiology of asthma.
airway inflammation, intermittent airflow obstruction, and bronchial hyperresponsiveness.
Time to begin.
Hi, my name is Nukol. I will be your nurse today? (No matching questions found.)
Hi, my name is Nukol. I will be your nurse today (Clarified to Hello, and I’ll be taking care of you today..)
Hi. (Clarified to to say hello and that you will be taking care of me.)
My name is Nukol
Hey, I’m Tina Jones. [AUDIO COMING SOON]
What brings you here today
I came in last night because of my foot. It just wasn’t healing, and it’s been hurting.
How can I help you today?
I got this scrape on my foot a while ago, and I thought it would heal up on its own, but now it’s looking pretty nasty. And the pain is killing me!
Do you have any respiratory issue?
My breathing’s fine right now, but I do have asthma.
How severe is the asthma?
I haven’t had a full attack in years, but I have trouble breathing sometimes.
When was the last asthma exacerbation?
I was at my cousin’s house three days ago, and my asthma acted up while I was there because of her cats.
What triggers the asthma?
Being around cats is the worst, but dust and running up stairs can make my breathing bad, too.
how do you manage your asthma?
I try to avoid things that give me breathing problems, but when my asthma starts to act up, I just use my inhaler.
Do you take asthma medication?
I just use my inhaler.
Do you use inhalers?
Yeah, I use it when my asthma acts up.
What are the exacerbation symptoms?
Being around cats is the worst, but dust and running up stairs can make my breathing bad, too. I haven’t had a full asthma attack in years, though.
How is your breathing?
My breathing is okay right now.
Do you have any cough?
I don’t have a cough, no.
Do you have sputum?
I haven’t been coughing anything up or anything.
do you have any other respiratory illness? (Clarified to Do you have a history of respiratory illnesses besides asthma?.)
No, just the asthma. (Clarified to If I have a history of respiratory illnesses besides asthma.)
When were you diagnosed with asthma?
My doctor told me when I was pretty little… I think I was about two and a half? I used to have a lot of trouble with asthma attacks back then.
Have you seen an asthma specialist?
I saw Dr. DeWitt for my asthma starting when I was diagnosed, but she moved away about two years ago.
have you ever been hospitalized?
Well, before this I went to the hospital a bunch of times when I was little, for asthma attacks. This is the first time I’ve been in the hospital since I was probably sixteen, though.
Do you have allergies?
Yeah, I’m allergic to cats.
Have taken any allergy treatment?
I’ve just been given an inhaler is all.
do you smoke tobacco?
No. I think it’s gross.
how many puffs do you take when using inhaler?
I usually use two puffs from my albuterol inhaler, but sometimes I need three. I think it’s 90 mcg per puff. [AUDIO COMING SOON]
Do you cough during asthma exacerbation?
No, I don’t cough when it’s happening.
Do you have any allergy symptoms? (Clarified to Do you have other allergy symptoms?.)
My allergies mostly just act up around cats. I start sneezing, my eyes get itchy. . . and my asthma starts to go crazy. (Clarified to if I have any other allergy symptoms.)
Do you use marijuana?
Um, yeah, I’ve done that before. In high school, and after high school… I definitely don’t anymore, though.
Are you exposed to secondhand smoke?
Some of my friends smoke when we go out drinking. But I don’t smoke, and nobody at home smokes.
When did you last smoke?
I haven’t smoked pot since I was twenty or twenty-one.
Do you have a family history of asthma?
My baby sister has asthma like me, but she’s pretty healthy. She almost never has trouble with it.
Do you have a family history of respiratory illness?
My baby sister has asthma, too, but no one else in the family has lung problems, I don’t think.
Do you have family history of tobacco use?
No, nobody at home smokes.
Do you have a family history of lung cancer?
Nobody in my family has had lung cancer and, Lord willing, no one ever will. [AUDIO COMING SOON]
 Checked vitals
 Tested lung capacity with spirometer
 Inspected anterior chest wall
 Inspected left side chest wall
 Inspected posterior chest wall
 Inspected right side chest wall
 Inspected anterior chest wall
 Inspected right side chest wall
 Inspected posterior chest wall
 Inspected left side chest wall
 Inspected anterior chest wall
 Palpated chest expansion: Both sides rise symmetrically
 Palpated fremitus in anterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in anterior lower chest wall: Present and equal bilaterally
 Palpated fremitus in posterior upper chest wall: Present and equal bilaterally
Ninety-nine.
 Palpated fremitus in posterior middle chest wall: Present and equal bilaterally
 Palpated fremitus in posterior lower chest wall: Present and equal bilaterally
Ninety-nine.
 Percussed anterior right upper lobe
 Percussed anterior left upper lobe
 Percussed anterior left mid-chest (upper lobe)
 Percussed anterior right middle lobe
 Percussed anterior right lower lobe
 Percussed anterior left lower lobe
 Percussed posterior left upper lobe
 Percussed posterior right upper lobe
 Percussed posterior left mid-back (lower lobe)
 Percussed posterior right mid-back (lower lobe)
 Percussed posterior left lower lobe
 Percussed posterior right lower lobe
 Percussed posterior left lower lobe on side
 Percussed posterior left lower lobe near spine
 Percussed posterior right lower lobe near spine
 Percussed posterior right lower lobe on side
 Auscultated breath sounds in anterior right upper lobe
 Auscultated breath sounds in anterior left upper lobe
 Auscultated breath sounds in anterior right middle lobe
 Auscultated breath sounds in anterior left mid-chest (upper lobe)
 Auscultated breath sounds in anterior right lower lobe
 Auscultated breath sounds in anterior left lower lobe
 Auscultated breath sounds in posterior left upper lobe
 Auscultated breath sounds in posterior right upper lobe
 Auscultated breath sounds in posterior left mid-back (lower lobe)
 Auscultated breath sounds in posterior right mid-back (lower lobe)
 Auscultated breath sounds in posterior left lower lobe
 Auscultated breath sounds in posterior right lower lobe
 Auscultated breath sounds in posterior left lower lobe on side
 Auscultated breath sounds in posterior left lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe near spine
 Auscultated breath sounds in posterior right lower lobe on side
 Auscultated voice sounds in anterior right upper lobe
 Auscultated voice sounds in anterior left upper lobe
 Auscultated voice sounds in anterior right middle lobe
 Auscultated voice sounds in anterior left mid-chest (upper lobe)
 Auscultated voice sounds in anterior left lower lobe
 Auscultated voice sounds in anterior right lower lobe
 Auscultated voice sounds in posterior left upper lobe
 Auscultated voice sounds in posterior right upper lobe
 Auscultated voice sounds in posterior left mid-back (lower lobe)
 Auscultated voice sounds in posterior left lower lobe
Ninety-nine.
 Auscultated voice sounds in posterior right mid-back (lower lobe)
 Auscultated voice sounds in posterior right lower lobe
 Auscultated voice sounds in posterior right lower lobe on side
 Auscultated voice sounds in posterior right lower lobe near spine
 Auscultated voice sounds in posterior left lower lobe near spine
 Auscultated voice sounds in posterior left lower lobe on side
Ninety-nine.

Subjective Data Collection: 27 of 27 (100.0%)

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:

Asked about asthma

Finding:

Reports having asthma

(Found)

Pro Tip: Asking whether Tina has had asthma will elicit information regarding any previous respiratory diagnosis.

Example Question:

Do you have asthma?

Finding:

Reports asthma exacerbations

(Found)

Pro Tip: Initially establishing a chief complaint allows the patient to express their reason for seeking care, primary concerns, or condition they are presenting with.

Example Question:

Do you have asthma attacks?

Relevant Medical History

Finding:

Asked about severity of asthma

Finding:

Reports asthma is intermittent

(Found)

Pro Tip: Establishing the severity classification of Tina’s asthma is important for understanding the impact on her life and the functioning of her respiratory system, as well as assessing the appropriateness of her medication.

Example Question:

What is the severity of your asthma?

Finding:

Asked about asthma frequency and duration

Finding:

Reports asthma exacerbations occur up to 2 times a week

(Found)

Pro Tip: Establishing a timeline for how often Tina’s asthma attacks occur will help in treatment and in understanding the severity of her asthma.

Example Question:

How many times a week do you have an asthma attack?

Finding:

Reports asthma exacerbations last around five minutes

(Available)

Pro Tip: Establishing a timeline for how long Tina’s asthma attacks last will help in treatment and in understanding the severity of her asthma.

Example Question:

How long do your asthma attacks last?

Finding:

Asked about most recent asthma exacerbation

Finding:

Reports last exacerbation was three days ago

(Found)

Pro Tip: Establishing a timeline for Tina’s asthma attacks will help in treatment and in understanding the severity of her asthma.

Example Question:

When is the last time you had an asthma attack?

Finding:

Reports last exacerbation around cats at cousin’s house

(Found)

Pro Tip: Questions about what factors might have caused an illness can point to a patient’s environmental stressors, habits, and general wellbeing. Asking Tina what caused her asthma attacks might indicate her health literacy and understanding of what factors impact her breathing.

Example Question:

What caused your last asthma attack?

Finding:

Asked about asthma triggers

Finding:

Reports cat allergy as asthma trigger

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Do cats trigger your asthma?

Finding:

Reports dust as asthma trigger

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a dust allergy can reveal one such trigger.

Example Question:

Does dust trigger your asthma?

Finding:

Denies asthma problems at work

(Available)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at work might indicate a relevant factor in her recent exacerbation.

Example Question:

Does anything at work make your asthma worse?

Finding:

Denies asthma problems at home

(Available)

Pro Tip: Environmental factors at home or work can often be primary allergy triggers. Asking Tina about possible allergens at home might indicate a relevant factor in her recent exacerbation.

Example Question:

Have you had problems with your asthma at home?

Finding:

Asked about asthma management

Finding:

Reports inhaler

(Found)

Pro Tip: Tina’s response to a question about asthma management will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How do you manage your asthma?

Finding:

Asked about asthma medication

Finding:

Reports albuterol inhaler (Proventil)

(Available)

Pro Tip: The medication that a patient takes reveals a current treatment plan and healthcare access. Asking Tina what medication she takes for her asthma will indicate her treatment plan and the degree to which she complies with it.

Example Question:

What is the name of the inhaler you are currently using?

Finding:

Reports last inhaler use was three days ago

(Available)

Pro Tip: Soliciting a shallow history of a patient’s medication history can reveal recent exacerbation. Asking Tina when she last used her inhaler will indicate when her symptoms most recently required medical treatment.

Example Question:

When did you last use your inhaler?

Finding:

Reports using inhaler no more than 2 times per week

(Available)

Pro Tip: After an asthma exacerbation, patients often will become more reliant on medical tools like inhalers. Asking Tina how many times a week she uses her inhaler will point to the severity of her recent exacerbation.

Example Question:

How many times a week are you using your inhaler?

Finding:

Asked about number of puffs when using asthma inhaler

Finding:

Reports recommended dose is 1-3 puffs as needed

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

What is the recommended dose of your asthma medication?

Finding:

Reports typically taking 2 puffs

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

How many puffs do you normally take?

Finding:

Reports sometimes needing 3 puffs to control symptoms

(Found)

Pro Tip: Tina’s response to a question about asthma medicine dosing will reveal the severity of her symptoms, her health literacy, and the way she’s complied with her treatment plans.

Example Question:

What is the most puffs you ever take?

Finding:

Asked about exacerbation symptoms

Finding:

Reports chest tightness during exacerbation

(Available)

Pro Tip: Asthma exacerbation can result in increased wheezing, shortness of breath, and chest tightness. Asking if Tina’s had chest tightness since exacerbation can indicate the severity of her symptoms since exacerbation.

Example Question:

Have you had chest tightness?

Finding:

Reports wheezing during exacerbation

(Available)

Pro Tip: Some people who experience chronic asthma may be accustomed to wheezing and, as a result, might not volunteer this information. Asking Tina if she’s been wheezing illustrates how her asthma is presenting.

Example Question:

Have you been wheezing?

Finding:

Reports shortness of breath during exacerbation

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences shortness of breath during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you have shortness of breath during an asthma attack?

Finding:

Denies coughing during exacerbation

(Found)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences coughing during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you cough during an asthma attack?

Finding:

Denies chest pain during exacerbation

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences chest pain during an attack will indicate how her individual symptoms manifest.

Example Question:

Do you have chest pains when you have asthma attacks?

Finding:

Denies painful breathing

(Available)

Pro Tip: Symptoms often vary from patient to patient. Asking Tina whether she experiences painful breathing during an attack will indicate how her individual symptoms manifest.

Example Question:

Is it painful for you to breathe?

Finding:

Asked about current breathing

Finding:

Denies current breathing problems

(Found)

Pro Tip: Asking about how Tina is currently breathing can provide a comparative baseline for assessing Tina’s current condition and previous breathing concerns or conditions.

Example Question:

Are you having breathing problems now?

Review of Systems

Finding:

Asked about cough history

Finding:

Reports only coughing when she has a cold

(Available)

Pro Tip: When a cough occurs can be indicative of its cause. Asking Tina when she coughs will allow you to determine the reason behind it and what treatment plans are appropriate.

Example Question:

When are you coughing?

Finding:

Denies coughing up blood

(Found)

Pro Tip: Coughing up blood can be indicative of a major health concern. Asking Tina if she has been coughing up blood solicits an important health history.

Example Question:

Have you been coughing up blood?

Finding:

Asked about sputum

Finding:

Denies sputum

(Found)

Pro Tip: Asthma symptoms may vary from one attack to the next. Determining which other symptoms Tina has experienced since exacerbation will more specifically illustrate the ways in which Tina’s asthma manifests.

Example Question:

Are you coughing up phlegm or sputum?

Risk Factors

Finding:

Asked about respiratory illness history besides asthma

Finding:

Denies history of bronchitis

(Available)

Pro Tip: Asking whether Tina has had bronchitis will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had bronchitis?

Finding:

Denies history of pneumonia

(Available)

Pro Tip: Asking whether Tina has had pneumonia will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had pneumonia?

Finding:

Denies history of emphysema

(Found)

Pro Tip: Asking whether Tina has had emphysema will elicit information regarding any previous respiratory diagnosis.

Example Question:

Have you had emphysema?

Finding:

Followed up on asthma diagnosis

Finding:

Reports specific age of diagnosis is 2.5 years old

(Found)

Pro Tip: By determining the onset of asthma you can get a sense for Tina’s asthma history, instance, and frequency of exacerbation.

Example Question:

When were you diagnosed with asthma?

Finding:

Asked about seeing an asthma specialist

Finding:

Reports not seeing asthma doctor in two years

(Found)

Pro Tip: Seeing a specialist, like an asthma doctor, can help patients to manage symptoms. Asking when Tina last saw an asthma doctor will allow you to assess her current treatment plan and healthcare access.

Example Question:

When did you last see a doctor for asthma?

Finding:

Asked about past hospitalizations

Finding:

Reports past hospitalizations for asthma

(Found)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina if she’s been hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

Have you been hospitalized for asthma in the past?

Finding:

Reports five past hospitalizations for asthma

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how many times she was hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

How many times have you been hospitalized for asthma?

Finding:

Reports most recent hospitalization at age 16

(Found)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina when she was last hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

When was your most recent hospitalization for asthma?

Finding:

Reports hospital treatment was usually steroids and a nebulizer

(Available)

Pro Tip: Hospitalization for a condition, like asthma, can reveal its severity. By asking Tina how she was treated when she was hospitalized, you are soliciting information about the history and severity of her condition.

Example Question:

How were you treated at the hospital for asthma?

Finding:

Asked about general allergies

Finding:

Reports allergy to cats

(Found)

Pro Tip: Environmental factors can often be primary allergy triggers. Asking whether Tina has a cat allergy can reveal one such trigger.

Example Question:

Are you allergic to cats?

Finding:

Followed up on allergy symptoms

Finding:

Reports sneezing, itchy eyes, and wheezing

(Found)

Pro Tip: Determining a patient’s reaction to an allergen is essential to gauge if the allergy is life-threatening.

Example Question:

What are your allergy symptoms?

Finding:

Asked about allergy treatment

Finding:

Reports avoiding cats when possible

(Available)

Pro Tip: Tina’s response to a question about avoiding allergy triggers will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

Do you stay away from cats?

Finding:

Reports using inhaler

(Found)

Pro Tip: Tina’s response to a question about recent allergy management will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How do you treat your cat allergy?

Finding:

Reports showering

(Available)

Pro Tip: Tina’s response to a question about recent allergy management will reveal the severity of her symptoms, her health literacy, and the way she’s complied with previous treatment plans.

Example Question:

How do you treat your cat allergy?

Finding:

Asked about tobacco use

Finding:

Denies currently smoking tobacco

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she currently smokes can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Do you use tobacco products?

Finding:

Denies history of smoking tobacco

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she has a history of smoking can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Have you ever used tobacco?

Finding:

Denies vaping

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina if she vapes can help you to discern whether smoking was a factor in Tina’s recent asthma exacerbation.

Example Question:

Do you vape?

Finding:

Asked about marijuana use

Finding:

Reports past recreational marijuana smoking

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina is she ever smoked marijuana can help you to discern whether smoking was an exacerbating factor for Tina’s asthma.

Example Question:

Have you ever smoked marijuana?

Finding:

Followed up on marijuana

Finding:

Reports smoking marijuana for 5 or 6 years

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina how long she smoked marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

How long did you smoke marijuana?

Finding:

Reports stopped smoking marijuana 6 or 7 years ago

(Found)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina when she quit smoking marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

When did you stop smoking marijuana?

Finding:

Reports stopping because of health reasons and waning interest

(Available)

Pro Tip: Smoking or inhaling substances can have adverse respiratory effects. Asking Tina why she quit smoking marijuana can help you to discern whether smoking exacerbated Tina’s asthma.

Example Question:

Why did you stop smoking marijuana?

Finding:

Asked about secondhand smoke

Finding:

Denies secondhand smoke exposure

(Found)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking how often Tina is around people who smoke might indicate a proximate environmental trigger.

Example Question:

Are you exposed to secondhand smoke?

Relevant Family History

Finding:

Asked about family history of asthma

Finding:

Reports sister has asthma

(Found)

Pro Tip: Soliciting a family history helps you to determine which, if any, conditions are inherited. In asking Tina whether anyone in her family has asthma, you’re ascertaining whether Tina’s condition is inherited.

Example Question:

Does anyone else in your family have asthma?

Finding:

Asked about family history of other respiratory illness

Finding:

Denies family history of respiratory illness

(Found)

Pro Tip: People with a family history of respiratory illness are often at a higher risk for asthma. If Tina has a family history of respiratory illness, this could suggest inherited sensitivity.

Example Question:

Does respiratory illness run in your family?

Finding:

Asked about family tobacco use

Finding:

Denies family history of tobacco use

(Found)

Pro Tip: Secondhand smoke can be particularly triggering for asthmatics. Asking whether anyone in Tina’s household smokes might indicate a proximate environmental trigger.

Example Question:

Does anyone in your family use tobacco products?

Finding:

Asked about family history of lung cancer

Finding:

Denies family history of lung cancer

Objective Data Collection: 6 of 6 (100%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Inspected chest

1 of 1 point

 

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Appearance (1/2 point)

  •  No visible abnormal findings
  •  Rash or lesion
  •  AP diameter abnormal
  •  Intercostal retraction while breathing
  •  Excessive use of accessory muscles while breathing
  •  Pectus excavatum
  •  Evidence of trauma (scar, laceration, or bruising)

 Palpated chest expansion

1 of 1 point

 

Symmetry (1/1 point)

  •  Equal bilaterally
  •  Unequal bilaterally

 Palpated tactile fremitus

1 of 1 point

 

Symmetry (1/2 point)

  •  Equal bilaterally
  •  Unequal bilaterally

Vibration (1/2 point)

  •  Expected fremitus
  •  Decreased fremitus
  •  Absent fremitus

 Percussed chest wall

1 of 1 point

 

Observations (1/2 point)

  •  All areas resonant
  •  Some areas of dullness

Location (1/2 point)

  •  No areas of dullness
  •  Dullness, anterior right upper lobe
  •  Dullness, anterior right middle lobe
  •  Dullness, anterior right lower lobe
  •  Dullness, anterior left upper lobe
  •  Dullness, anterior left lower lobe
  •  Dullness, posterior right upper lobe
  •  Dullness, posterior right lower lobe
  •  Dullness, posterior left upper lobe
  •  Dullness, posterior left lower lobe

 Auscultated breath sounds

1 of 1 point

 

Breath Sounds (1/3 point)

  •  Present in all areas
  •  Diminished in some areas
  •  Absent in some areas

Adventitious Sounds (1/3 point)

  •  No adventitious sounds
  •  Wheezing
  •  Fine crackles
  •  Stridor
  •  Rhonchi
  •  Rales

Location (1/3 point)

  •  All areas clear
  •  Adventitious sounds in anterior right upper lobe
  •  Adventitious sounds in anterior right middle lobe
  •  Adventitious sounds in anterior right lower lobe
  •  Adventitious sounds in anterior left upper lobe
  •  Adventitious sounds in anterior left lower lobe
  •  Adventitious sounds in posterior right upper lobe
  •  Adventitious sounds in posterior right lower lobe
  •  Adventitious sounds in posterior left upper lobe
  •  Adventitious sounds in posterior left lower lobe

 Auscultated for bronchophony

1 of 1 point

 

Bronchophony (1/1 point)

  •  Positive
  •  Negative

Documentation / Electronic Health Record

  • Flowsheets
  • Nursing Progress Notes

Vitals

Vitals 22:00 00:00 02:00 04:00 06:00 08:00 10:00 12:00
Temp (<38° C) 38.7 C / 101.7 F 39.1 C / 102.4 F 38.6 C / 101.5 F 37.9 C / 100.2 F 37.1 C / 98.8 F 36.7 C / 98.1 F 37 C / 98.6 F 36.7 C
BP (<120/80) 138/90 138/88 136/88 138/90 134/88 138/90 136/88
HR (60-100) 90 72 68 69 70 68 70
RR (12-20) 18 16 16 18 18 16 18
O2 Sat (>94%) 98% 98% 98% 98% 98% 98% 98%
Pain Scale 10 7 asleep asleep 9 6 8 6
Pain Reassessment after Intervention 7

@23:00

asleep 5

@07:00

4

@11:00

4
FVC 1.78 L
FEV1

 

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