NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

Patient Information

Initials: D.R

Age: 8 years old

Gender: Male

nurs 6512 week 5 assignment 2: digital clinical experience: focused exam: cough

Struggling to meet your deadline?

Get your work done on time by medical experts. Don’t wait – ORDER NOW!

Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS on NURS 6512 Week 5 Assignment 2: Digital Clinical Experience: Focused Exam: Cough

SUBJECTIVE DATA:

Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot

History of Present Illness (HPI): The patient Danny Riviera is a boy aged 8, who comes to the clinic reporting that he has had a cough for the past 4 days. His description of the cough states that it is watery and clear. His cough becomes worse at night, which affects his sleep. As such, he does not focus at school and suffers from fatigue. His right ear has pain. His mother decided to use over-the-counter cough medicine, which offered temporal relief. Danny states that he suffers from a frequent runny nose as well as a cold and sore throat. He is also exposed to secondhand smoke from his father. He has also suffered pneumonia in the past year. However, he does not have a fever, breathing difficulties, abdominal pain, and chest tightness and chills.

Medications: The patient admits to taking home medications. He also takes a daily vitamin. He also takes a purple cough medication.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Reports immunizations as current. Reports past frequent coughs and pneumonia.

Past Surgical History (PSH): None reported.

Sexual/Reproductive History: No history of reproductive disorders.

Personal/Social History: Reports living in a house with his parents and grandparents. Reports feeling safe at home. Reports park with playground near home. Reports father smokes at home. Denies pets at home

Immunization History: Immunizations are current.

Significant Family History: He has a father, mother, and both grandparents. Reports father with a history of asthma as a child. Denies family history of allergies.

Review of Systems:

General: The patient looks fatigued and also coughs whilst having the interview. He also appears stable. Denies fever, appetite loss, weight loss, chills, or night sweats.

HEENT: The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient’s right cervical lymph nodes appear enlarged with a certain tenderness.

Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.

Cardiovascular/Peripheral Vascular: No chest pain, chest tightness, palpitations, edema, cyanosis, dyspnea.

Psychiatric: No depression, anxiety, or history of psychotic disorders.

Neurological: Report’s headache. Denies dizziness, loss of consciousness, or vision changes.

Lymphatics: Right cervical lymph nodes are tender on palpation.

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure 120/76
O2 Sat 96%
Pulse 100
Resp. Rate 28
Temperature 37.2 c

 

General: The patient looks fatigued and also coughs whilst having the interview. He also appears stable.

HEENT: Head is normocephalic and atraumatic. The mucus membrane is moist; nasal discharge is clear, while he shows redness and clobbestoning at the back of his throat. His eyes are dull while the conjunctiva is pink in color. The right tympanic membrane appears red and inflamed. The patient’s right cervical lymph nodes appear enlarged with a certain tenderness.

Respiratory: Lacks acute distress, increased respiratory rate at 28, breath sounds are clear to auscultation, speaks in full sentences while the bronchoscopy is negative. His chest wall was resonant when percussed while the fremitus was expected and equal bilaterally.

Cardiology: No murmurs, gallops, or rubs in S1 and S2.

Lymphatics: Right cervical lymph nodes are tender on palpation

Psychiatric: No mental issues noted.

Diagnostics/Labs: Routine lab works were ordered including complete blood count, and white blood cell count to determine any signs of infection. Spirometric and peak expiratory flow measurements were collected to further evaluate the patient’s extend of cough. Bronchoprovocation testing was done to rule out differential diagnosis. Other investigations are done to assess the cough and cold include upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy (Malesker et al., 2017). For further assessment of the ear pain, nasolaryngoscopy and MRI of the head and neck were ordered.

ASSESSMENT:

Priority Diagnosis: Acute Viral Rhinitis: It is also known as common cold. It is associated with inflammation of the nasal mucosa lining as a result of respiratory viral infection. It is common among children, characterized by sneezing, running nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear pain, difficulties in swallowing, and fatigue among others (Malesker et al., 2017). The patient in the case study displayed most of the above symptoms, qualifying for a common cold diagnosis.

Differential Diagnosis:

  1. Acute sinusitis: This normally occurs when a cold virus infects the patient’s sinuses. The patient may display headache, fever, cough which is worse at night, severely stuffed up nose, green, or thick yellow mucus, itchy and watery eyes, and ear pain. The patient in the case study displayed most of these symptoms (Shoukat et al., 2019). However, he denied fever, and the nasal discharge is clear and thin, which disqualifies the diagnosis.
  2. Influenza (flu): This is a common viral infection of the respiratory tract among children. It is characterized by fever, headache, running nose, fatigue, cough, eye, and ear pain. The patient in the case study displayed most of the above symptoms (Badyda et al., 2020). Consequently, this condition is common among patients with a history of pneumonia, just like in the provided case study.
  3. Ear Infection: Sinus and cold infections can lead to the accumulation of fluids in the patient’s ears behind the eardrum. As a result, viruses and bacteria can grow leading to infection of the ears. Patients may display ear pressure or fullness, ear pain, drainage, muffled hearing, and loss of balance (Badyda et al., 2020). Given that most ear infections among children might start as a common cold, then the patient’s right ear pain and associated upper respiratory symptoms may be as a result of ear infection.

Treatment Plan:

Previous Diagnosis: Pneumonia and cough which were managed appropriately.

Present Diagnosis: Acute Viral Rhinitis

Pharmacological Intervention: Cold remedies such as Dimetapp 10mL every 4 hours to a maximum of 6 doses/24 hours (Malesker et al., 2017). Acetaminophen to manage the pain and fever. Dexamethasone/gentamicin drops for ear pain.

Non-pharmacological Intervention: Honey and saline nose spray to help with soothing the sore throat and cough, and managing congested nose respectively (Fernandez, & Olympia, 2017). Extra fluid and a cool-mist humidifier are also necessary for helping manage the patients’ cold symptoms.

Patient Education: Inform the patient’s mother on the importance of sticking to the treatment plan. It is also important to educate the patient’s parents on expected side effects, and adverse reactions which might call for medical attention (Malesker et al., 2017).

Health Promotion: Encourage the patient’s mother to ensure that he is always warm, with a healthy diet, and enough sleep (Badyda et al., 2020).

Follow-up: The patient should be advised to report back to the clinic in case of worsened symptoms, or if the prescribed drugs fail to relieve the patient’s symptoms within one week.

References

Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed on different levels of ambient particulate matter. DOI: 10.1183/13993003.congress-2020.1303

Fernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT CARE MEDICINE, 77.

Badyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164/ajrccm-conference.2020.201.1_

Malesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., … & Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest152(5), 1021-1037. https://doi.org/10.1016/j.chest.2017.08.009

Shoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology (PAB)8(2), 1084-1091. http://dx.doi.org/10.19045/bspab.2019.80050

Care Plan : 9.5 of 10 (95.0%)

 Nursing Diagnosis

3.5 out of 3.5

 

Nursing Diagnoses: Definitions & Classifications 2018-2020 © NANDA-International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. All rights reserved. Authorized translation from the English language edition published by Thieme Medican Publishers Inc. No part of this material may be reproduced in any form without the written permission of the agent of the copyright holder, NANDA-International. Direct inquires to nanda-i@thieme.com. Link for more information: http://www.nanda.org/.

Status

Student Response Model Answer Explanation Points Earned
is at risk for is at risk for The correct status for the nursing diagnosis is “is at risk for,” because Danny’s most pressing vulnerability is to an infection that he has not yet, but could, develop. 0.5 out of 0.5

Diagnosis

Student Response Model Answer Explanation Points Earned
infection infection While a cough can be unpleasant, the most alarming thing it indicates about Danny’s health is that he is at risk for an infection. 0.5 out of 0.5

Etiologies

Student Response Model Answer Explanation Points Earned
played w/ sick peer played w/ sick peer Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
touches face often touches face often Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
rare hand washing rare hand washing Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5
secondhand smoke secondhand smoke Danny Rivera is at risk for infection as evidenced by: his playing with a sick peer; how he touches his face often, especially his eyes/nose/mouth; how rarely he washes his hands; and his exposure to secondhand smoke. 0.5 out of 0.5

Signs & Symptoms

Student Response Model Answer Explanation Points Earned
N/A N/A Because the infection that Danny may develop hasn’t happened yet, he is not currently presenting with any signs or symptoms, so the correct answer here is “N/A.” 0.5 out of 0.5

 Self Assessment

 

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt Student Response Model Answer Explanation
Why would a nursing diagnosis of a cough be incorrect, compared to a risk for infection? Consider the difference between nursing and medical diagnoses. Whereas the cough can be unpleasant and a bother, it is a symptom of something more severe in the sense that it shows that the immune system could be at risk of getting an infection. The most effective nursing care you should prioritize is to educate the patient on avoiding the more serious outcome. While a cough can be unpleasant and frequent, it is actually a symptom of something more alarming: the immune system being at risk for an infection. The most effective nursing care you should prioritize is to educate your patient on avoiding this more serious outcome. Your nursing diagnosis should always take into account what condition is most serious, receiving the greatest benefit from your help. This diagnosis may not be the most obvious physical symptom to you or your patient, so always consider what is jeopardizing a patient’s health the most.

 Planning

3.5 out of 4

 

Short-Term Goal

Student Response Model Answer Explanation Points Earned
To have patient report decreased discomfort and coughing by end of clinic visit. To have the patient and his guardian verbalize and agree to their instructions on how to avoid infection & practice respiratory hygiene, by end of the healthcare visit. A risk-based diagnosis does not require medical interventions as the problem is hypothetical; the goal that does suit the diagnosis involves teaching the patient and his guardian about risk-reduction methods. 0 out of 0.5

Interventions

Student Response Model Answer Explanation Points Earned
Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Instruct family and patient on washing hands or using hand sanitizer before eating and after using the restroom Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family and patient that patient should increase fluid intake Instruct family and patient that patient should increase fluid intake Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Instruct family to keep their house smoke-free (reducing exposure to environmental pathogens) Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Instruct patient on washing hands or using hand sanitizer after coughing or being near someone sick Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient to avoid touching fingers to eyes, nose, or mouth Instruct patient to avoid touching fingers to eyes, nose, or mouth Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5
Instruct patient to cough into tissue, or sleeve if tissue is unavailable Instruct patient to cough into tissue, or sleeve if tissue is unavailable Many of these instructions work toward shrinking the patient’s likelihood of contact with harmful pathogens, which can lead to infection. Some instructions here also help prevent illness being spread to Danny’s environment and family members, which promotes community health and reduces the patient’s risk of becoming sick again. 0.5 out of 0.5

Intervention Rationale

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt Student Response Model Answer Explanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal. Ask patients and family memebers to verbalize and agree to their instructions on infection prevention and respiratory hygiene. These interventions will teach Danny and his guardian how to keep their hands and lungs clean in a variety of ways, so that Danny’s risk for infection is reduced as pathogens are eliminated. Infection can be caused by multiple culprits, so it’s important that your patient teaching covers a thorough and specific array of anti-infection habits.

Data Collections

Student Response Model Answer Explanation Points Earned
Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene Ask patient and family members to verbalize and agree to their instructions on infection prevention & respiratory hygiene It is important that your patient and his guardian agree to their instructions, as changing lifestyle habits can be intimidating but necessary for the patient’s health. Having Danny and his father verbalize back their instructions also assures they remember and understand the details. 0.5 out of 0.5

 Discussion Of Care

 

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt Student Response Model Answer Explanation
Explain the rationale behind your nursing diagnosis. Hello Danny, since you have been feeling unwell for the last three days, it is my responsibility to ensure that you get in the habit of practicing hand hygiene. Because you are at risk for developing an upper respiratory infection. My goal to you is to you and your family to avoid unnecessary infections by following these instructions. Some of the things that make you sicker are being near sick friend, being exposed to second hand smoke, washing your hands more, and touching your face with hands. I know it sounds like a lot of things but working together, we can reduce the infections in an effective manner. Danny, given that you aren’t feeling well, we want to make sure you don’t develop an infection, which for you just means getting even sicker. We’re going to talk about the ways we can work to prevent that, especially focusing on your risk factors, which are just things that give you a bigger chance of being sick. Some of your risk factors are that you were near a sick friend, have been exposed to cigar smoke, could stand to wash your hands more, and have touched your face with your fingers. I know that sounds like a lot, but if we work together, reducing your risk factors for infection can be easy and effective. A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement.
Explain your goal for Danny and the interventions and data collections through which you will achieve it. All right. In order to talk to you about how you are not going to get sicker, I will have a conversation with you and your father. Him, you and myself are going to work together to discuss and then have to agree to your goals. And then I am going to have you and your father repeat what you have learned so we can make sure that you have got it down pat. Let’s talk about how we’re going to help you not get sicker! So, I’m going to have a conversation with you and your father about things to do to ensure your health. You, he, and I will work together to discuss, and then have you agree to your goals. Then I’m going to have you and your father repeat what you’ve learned, so we can make extra sure you’ve got it down pat! You should communicate the Care Plan to the patient, allowing them to exercise involvement and agency in their own healthcare.
Explicitly ask for Danny’s consent to the Care Plan. Does this sound like a plan? Does this plan I just talked about sound good to you? A patient must consent to all interventions in their Care Plan. Disagreements are opportunities to provide further patient education and to consider alternative options.
Inform Danny you will now begin educating him and will then call to educate his guardian. Now, Danny, if you lack other questions, we can start now! Danny, if you don’t have any other questions, we can start our discussion now! It’s time to begin your education interventions, so let your patient know!

 Intervention & Evaluation

2.5 out of 2.5

 

Student Response Model Answer Explanation Points Earned
Partially Partially While Danny correctly verbalizes and agrees to his instructions for reducing infection risks, his father only agrees to some of his instructions, expressing apprehension toward not smoking inside the house. Your goal has been partially achieved. 2.5 out of 2.5

 Intervention & Evaluation Rationale

 

Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.

Prompt Student Response Model Answer Explanation
Did you achieve your goal for your patient and his guardian by the end of the visit, getting each of them to agree to and verbalize your instructions for avoiding infection and practicing respiratory hygiene? Whereas Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of his house. One of his instructions was to keep the house smoke free so as to reduce Danny’s risk of infection so this aspect of the goal has not been achieved. However, the paties verbally agree to most of the other interventions, which implies that the overall goal has been achieved partially. While Danny agrees to his instructions and has verbalized a complete and correct understanding of what to do, his father expresses reluctance about reducing his smoking inside of the house. One of his instructions was to keep the house smoke-free in order to reduce Danny’s risk of infection, so this aspect of your goal has not been achieved. However, both parties verbally agree to most of their other instructions, so your overall goal has been partially achieved. Even with progress being made in almost all aspects of your patient teaching, you must adhere to your goal and consider your work incomplete if certain agreements have not been reached.

Week 5               

Shadow Health Digital Clinical Experience Focused Exam: Cough Documentation

Patient Information

Initials: D.R

Age: 8-years old

Gender: Male

 SUBJECTIVE DATA:

Chief Complaint (CC): Patient reports of chronic coughing which makes him feel he is sick and needs immediate medical attention.

History of Present Illness (HPI): The patient’s condition Danny Riviera, an 8-year-old boy, arrives at the clinic complaining of a cough that has lasted four days. His cough is watery and clear, according to his description. It worsens at night, interfering with his sleep. As a result, he struggles to concentrate at school and suffers from fatigue. His right ear hurts. The mother chose over-the-counter cough medicine, which provided temporary relief. Dan claims to have a persistent runny nose, as well as a cold and sore throat.

Mr. Riviera, his father exposes him to secondhand smoke. He also had a bout of pneumonia last year. The patient does not report of feeling chills, fever or difficulty in breathing.

Medications: Danny acknowledges that he has been taking some medication at home. He takes a daily dose of vitamin and a cough syrup.

Allergies: The patient has no known drug allergy.

Past Medical History (PMH): Danny has no previous history of asthma however; he acknowledges his battle with pneumonia and coughs in the past.

Past Surgical History (PSH): He has no past history of nay surgical procedure.

Sexual/Reproductive History: There is no known history of reproductive diseases or disorders.

Personal/Social History: Danny acknowledges of a safe upbringing, with a safe home that is near a park where he visits frequently. There are no bets at home and he lives together with his parents and grandparents. His father, Mr. Riviera often smokes in the house.

Immunization History: His immunization record is up to date.

Significant Family History: The family is composed of a father, mother and both grandparents. He is the only child, and their family has no known history of allergies. Though his father battled with asthma attacks during his childhood.

Review of Systems:

General: While having the interview, the patient appears tired and coughs.

He also appears to be in good health. Fever, loss of appetite, weight loss, chills, or nocturnal sweats are all denied.

HEENT: The mucus membrane is wet, and the nasal discharge is clear, but the back of his neck is red and cobblestone. The conjunctiva of his eyes is pink, and his eyes are dull. The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarging and painful.

Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation.

When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.

Cardiovascular/Peripheral Vascular: Chest discomfort, tightness, palpitations, edema, cyanosis, and dyspnea are not present.

Psychiatric: There is no history of depression, anxiety, or psychotic problems.

Neurological: He experiences some headache but dizziness, loss of consciousness, or vision problems are denied.

Lymphatics: On palpation, the right cervical lymph nodes are tender.

OBJECTIVE DATA:

On physical examination, the following data was collected.

Vital signs:

Blood Pressure 120/76
O2 Sat 96%
Pulse 100
Resp. Rate 28
Temperature 37.2 c

 

General: During the interview, the patient appears tired and coughs. But appears to be in good health.

HEENT: The head is normocephalic and unaffected by trauma.

He has a moist mucus membrane, clear nasal discharge, and redness and cobblestone at the back of his throat. His eyes are dull, with a pink conjunctiva.

The right tympanic membrane is swollen and red. The lymph nodes in the patient’s right cervical region are enlarged and tender.

Respiratory: While the bronchoscopy is negative, there is no acute distress, an increased respiratory rate of 28 beats per minute, and clear breath sounds on auscultation.

When percussed, his chest wall resonated, yet his fremitus was normal and equal on both sides.

Cardiology: In both S1 and S2, there were no murmurs, gallops, or rubs.

Lymphatics: On palpation, the lymph nodes in the right cervical region are sensitive.

Psychiatric: There were no signs of mental illness.

Diagnostics/Labs: To assess any evidence of illness, routine lab tests were done, including a complete blood count and a white blood cell count. To assess the extent of the patient’s cough, spirometry and peak expiratory flow measures were taken. To rule out any other possibilities, bronchoprovocation testing was performed. Upper airway provocation studies, sinus imaging, CT scan of the thorax, and bronchoscopy are among the other tests used to detect cough and cold symptoms (Malesker et al., 2017). Nasal-laryngoscopy and a head-and-neck MRI were recommended for a more thorough examination of the ear pain.

ASSESSMENT:

Priority Diagnosis: Acute Viral Rhinitis, generally known as the common cold, is a viral infection that affects the nose and sinuses. As a result of a respiratory virus infection, it is linked to nasal mucosa lining inflammation. Sneezing, runny nose, congestion, cough, postnasal drip, sore throat, watery eyes, ear ache, swallowing difficulty, and exhaustion are some of the symptoms that youngsters experience (Malesker et al., 2017). Most of the symptoms listed above were present in the patient in the case study, indicating a common cold.

Differential Diagnosis:

  1. Acute sinusitis: This happens when the patient’s sinuses are infected by a cold virus.

Headache, fever, cough that worsens at night, excessively congested nose, green or thick yellow mucus, itchy and watery eyes, and ear pain are some of the symptoms that the patient may experience. Most of these symptoms were present in the case study patient (Shoukat et al., 2019).

He denied having a temperature, and the nasal discharge was clear and thin, therefore the diagnosis was ruled out.

  1. Influenza (flu) is a frequent respiratory viral infection in youngsters.

Fever, headache, runny nose, lethargy, cough, eye, and ear pain are all symptoms of this infection. Most of the aforesaid symptoms were present in the patient in the case study (Badyda et al., 2020). As a result, people with a history of pneumonia, such as those in the case study, are more likely to develop this illness.

  1. Ear Infection: Fluids can accumulate behind the eardrum due to sinus and cold infections.

Viruses and bacteria might proliferate as a result, resulting in ear infection. Ear pressure or fullness, ear pain, leakage, distorted hearing, and loss of balance are some of the symptoms that patients may experience (Badyda et al., 2020). Given that most children’s ear infections begin with a common cold, the patient’s right ear pain and concomitant upper respiratory symptoms could be due to an ear infection.

A Plan for the Treatment of the Patient

Previous Diagnosis: The patient’s previous bouts of pneumonia and cough were well treated.

Present Diagnosis: Acute Rhinitis which is a type of viral rhinitis.

Pharmacological Intervention: Cold medicines such as Dimetapp 10mL every 4 hours up to 6 doses every 24 hours are recommended (Malesker et al., 2017). Acetaminophen is used to relieve pain and fever. Drops containing dexamethasone and gentamicin for ear discomfort.

Non-pharmacological Intervention: The use of honey and saline nose spray can help with sore throats, coughs, and congested noses, respectively (Fernandez, & Olympia, 2017).

Extra fluids and a cool-mist humidifier are also required to help manage the patients’ cold symptoms.

Patient Education: Explain to Mrs. Riviera the importance of following the treatment plan. It’s also crucial to inform the patient’s parents about possible side effects and adverse responses that may necessitate medical intervention (Malesker et al., 2017).

Health Promotion: To emphasize to Mrs. Riviera the need to keep the son warm, eat a nutritious diet, and get enough sleep (Badyda et al., 2020).

Follow-up Plan: If the patient’s symptoms increase or if the prescribed drugs do not improve the patient’s symptoms within one week, the patient is advised to return to the clinic.

Reference

Badyda, A. J., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & D&# 261; browska, A. (2020). Influence of Particulate Matter on the Occurrence of Upper Respiratory Tract Symptoms in Children Aged 3-12 Years. In D24. LUNG INFECTION (pp. A6346-A6346). American Thoracic Society. DOI:10.1164/ajrccm-conference.2020.201.1_

Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., & Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed on different levels of ambient particulate matter. DOI: 10.1183/13993003.congress-2020.1303

Fernandez, F. G., & Olympia, R. P. (2017). Ear pain, nasal congestion, and sore throat. URGENT CARE MEDICINE, 77.

Malesker, M. A., Callahan-Lyon, P., Ireland, B., Irwin, R. S., Adams, T. M., Altman, K. W., … & Weir, K. (2017). Pharmacologic and nonpharmacologic treatment for acute cough associated with the common cold: CHEST Expert Panel Report. Chest152(5), 1021-1037. https://doi.org/10.1016/j.chest.2017.08.009

Shoukat, N., Kakar, A., Shah, S. A., & Sadiq, A. (2019). 10. Upper respiratory tract infections in children age 2 to 10 years in Quetta: A prevalence study. Pure and Applied Biology (PAB)8(2), 1084-1091. http://dx.doi.org/10.19045/bspab.2019.80050

Assignment 2: Digital Clinical Experience: Focused Exam: Cough

In this DCE Assignment, you will conduct a focused exam related to cough in your DCE using the simulation tool, Shadow Health. You will determine what history should be collected from the patient, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.

nurs 6512 week 5 assignment 2: digital clinical experience: focused exam: cough

To Prepare

  • Review this week’s Learning Resources and consider the insights they provide related to ears, nose, and throat.
  • Review the Shadow Health Resources provided in this week’s Learning Resources specifically the tutorial to guide you through the documentation and interpretation within the Shadow Health platform. Review the examples also provided.
  • Review the DCE (Shadow Health) Documentation Template for Focused Exam: Cough found in this week’s Learning Resources and use this template to complete your Documentation Notes for this DCE Assignment.
  • Access and login to Shadow Health using the link in the left-hand navigation of the Blackboard classroom.
  • Review the Week 5 Focused Exam: Cough Rubric provided in the Assignment submission area for details on completing the Assignment in Shadow Health.
  • Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?

Focused Exam: Cough Assignment:

Complete the following in Shadow Health:

  • Respiratory Concept Lab (Required)
  • Episodic/Focused Note for Focused Exam: Cough
  • HEENT (Recommended but not required)

Note: Each Shadow Health Assessment may be attempted and reopened as many times as necessary prior to the due date to achieve a total of 80% or better (this includes your DCE and your Documentation Notes), but you must take all attempts by the Week 5 Day 7 deadline.

Submission and Grading Information

By Day 7 of Week 5
  • Complete your Focused Exam: Cough DCE Assignment in Shadow Health via the Shadow Health link in Blackboard.
  • Once you complete your Assignment in Shadow Health, you will need to download your lab pass and upload it to the corresponding assignment in Blackboard for your faculty review.
  • (Note: Please save your lab pass as “LastName_FirstName_AssignmentName”.) You can find instructions for downloading your lab pass here: https://link.shadowhealth.com/download-lab-pass
  • Once you submit your Documentation Notes to Shadow Health, make sure to add your documentation to the Documentation Note Template and submit it into your Assignment submission link below.
  • Complete the Code of Conduct Acknowledgement.
Grading Criteria

To access your rubric:

Week 5 Assignment 2 DCE Rubric

  • Submit Your Assignment by Day 7 of Week 5

To submit your Lab Pass:

Week 5 Lab Pass

To participate in this Assignment:

Week 5 Documentation Notes for Assignment 2

To Submit your Student Acknowledgement:

Click here and follow the instructions to confirm you have complied with Walden University’s Code of Conduct including the expectations for academic integrity while completing the Shadow Health Assessment.

Chief Complaint (CC): “I guess I’m kind of sick. . . I’ve been coughing a lot

History of Present Illness (HPI): The affected person A young boy named Danny Riviera, who is only 8 years old, visits the medical center because he has been coughing for the past few days. According to what he says, the cough is very clear and has a watery quality to it. His cough is worse at night, which prevents him from getting adequate rest. As a consequence of this, he has trouble concentrating in class and often comes home exhausted. It’s painful in his right ear. The decision his mother made to use over-the-counter cough medicine, which only provided temporary relief, was made. Danny claims that he has a cold and that he suffers from a runny nose on a regular basis. Additionally, he inhales his father’s secondhand smoke on a regular basis. Within the past year, he has also been diagnosed with pneumonia. However, he does not have a fever, difficulty breathing, abdominal pain, chest tightness, or chills. He also does not have chest tightness.

Medications: The patient acknowledges that they do take their medications at home. In addition to that, he takes a vitamin every day. In addition to that, he takes a medication for coughing that is purple.

Allergies: NKDA

Past Medical History (PMH): Denies asthma diagnosis. Identifies immunizations as being up to date. Previous symptoms include chronic coughing and pneumonia.

Past Surgical History (PSH): None reported.

Sexual/Reproductive History:

Personal/Social History: Identifies himself as a member of a household that also includes his parents and grandparents. avers having a sense of well-being while at home. Describes a park with a playground in the neighborhood. It is reported that the father smokes in the house.

Immunization History: Immunizations are current.

Significant Family History: He is supported by his biological parents as well as both sets of grandparents.

 

Review of Systems:

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

                Cardiovascular/Peripheral Vascular:

               

                Psychiatric:

                Neurological:

                Lymphatics:

               

OBJECTIVE DATA:

Physical Exam:

Vital signs:

Blood Pressure 120/76
O2 Sat 96%
Pulse 100
Resp. Rate 28
Temperature 37.2 c

 

General: During the course of the interview, the patient appears exhausted and coughs several times. Additionally, he seems to be steady.

HEENT: The head is atraumatic and has a normocephalic shape. The mucus membrane is wet, and the discharge from the nose is clear. However, the back of his throat is red and clogged with mucus. His eyes are lifeless, and the conjunctiva around them is a pinkish hue. It seems as though the right tympanic membrane is inflamed and red. The lymph nodes in the patient’s right cervical region appear enlarged, and they have a certain degree of tenderness.

Respiratory: Lacks acute distress, has an increased respiratory rate at the age of 28, clear breath sounds on auscultation, and speaks in complete sentences; bronchoscopy is negative. When you percussed his chest wall, you could hear a resonant tone, and his fremitus was normal and bilaterally consistent.

Cardiology: In S1 and S2, there were no murmurs, gallops, or rubs.

Lymphatics: When palpated, the lymph nodes in the right cervical region are tender.

Psychiatric: No mental issues noted.

 

Diagnostics/Labs (Include any labs, x-rays, or other diagnostics that are needed to develop the                 differential diagnoses.)

ASSESSMENT:

 

Based on the findings of the completed physical examination and the observations that were made, the following possible diagnoses can be made.

  1. Common cold: The patient complains of having a stuffy nose and a sore throat, which are both symptoms of a common cold. This observation was also supported by the findings of a physical examination, which showed that the patient had swollen lymph nodes.
  2. Streptococcus throat infection: The patient’s complaint of a sore throat suggests that they may have strep throat. On the other hand, symptoms like nausea, vomiting, headaches, and fever did not present themselves at any point.

iii. Rhinitis is another condition that could have been causing the patient’s symptoms, as they included stuffy nose, sore throat, and drainage from the nose. In addition to this, the patient has a history of recurrent ear infections throughout their lifetime.

  1. Allergies and asthma: The patient does not have a history of allergic reactions. Nevertheless, it is possible that this condition will occur. This condition may have been the cause of the persistent cough. On the other hand, the patient does not exhibit any symptoms of wheezing, chest pain or tightness, or difficulty breathing.

Name: NURS_6512_Week_5_DCE_Assignment_2_Rubric

Description:

To complete the Shadow Health assignments, it is helpful to use the text and follow along with each chapter correlating to the area of assessment to assist in covering all the subjective questions and the physical assessment areas. Review the Advanced Health Assessment Nursing Documentation Tutorial located in the Weeks 1 and 4 Resources, the model documentation in Shadow Health, as well as sample documentation in the text to assist with narrative documentation of the assessments. Shadow Health exams may be added to or repeated as many times as necessary prior to the due date to assist in achieving the desired score.

Excellent Good Fair Poor
Student DCE score

(DCE percentages will be calculated automatically by Shadow Health after the assignment is completed.)

Note: DCE Score – Do not round up on the DCE score.

Points Range: 56 (56%) – 60 (60%)
DCE score>93
Points Range: 51 (51%) – 55 (55%)
DCE Score 86-92
Points Range: 46 (46%) – 50 (50%)
DCE Score 80-85
Points Range: 0 (0%) – 45 (45%)

DCE Score <79

No DCE completed.

Subjective Documentation in Provider Notes

Subjective narrative documentation in Provider Notes is detailed and organized and includes:

Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS)

ROS: covers all body systems that may help you formulate a list of differential diagnoses. You should list each system as follows:
General: Head: EENT: etc.

You should list these in bullet format and document the systems in order from head to toe.

Points Range: 16 (16%) – 20 (20%)

Documentation is detailed and organized with all pertinent information noted in professional language.

Documentation includes all pertinent documentation to include Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details, some organization and some pertinent information noted in professional language.

Documentation provides some of the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; and inadequate pertinent information noted in professional language.

Limited or/minimum documentation provided to analyze students critical thinking abilities for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

Points Range: 0 (0%) – 5 (5%)

Documentation lacks any details and/or organization; and does not provide pertinent information noted in professional language.

No information is provided for the Chief Complaint (CC), HPI, Current Medications, Allergies, Past Medical History, Family History, Social History and Review of Systems (ROS).

or

No documentation provided.

Objective Documentation in Provider Notes – this is to be completed in Shadow Health

Physical exam: Document in a systematic order starting from head-to-toe, include what you see, hear, and feel when doing your physical exam using medical terminology/jargon. Document all normal and abnormal exam findings. Do not use “WNL” or “normal”.

You only need to examine the systems that are pertinent to the CC, HPI, and History.

Diagnostic result – Include any pertinent labs, x-rays, or diagnostic test that would be appropriate to support the differential diagnoses mentioned

Differential Diagnoses (list a minimum of 3 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1).

Points Range: 16 (16%) – 20 (20%)

Documentation detailed and organized with all abnormal and pertinent normal assessment information described in professional language.

Each system assessed is clearly documented with measurable details of the exam.

Points Range: 11 (11%) – 15 (15%)

Documentation with sufficient details and some organization; some abnormal and some normal assessment information described in mostly professional language.

Each system assessed is somewhat clearly documented with measurable details of the exam.

Points Range: 6 (6%) – 10 (10%)

Documentation with inadequate details and/or organization; inadequate identification of abnormal and pertinent normal assessment information described; inadequate use of professional language.

Each system assessed is minimally or is not clearly documented with measurable details of the exam.

Points Range: 0 (0%) – 5 (5%)

Documentation with no details and/or organization; no identification of abnormal and pertinent normal assessment information described; no use of professional language.

None of the systems are assessed, no documentation of details of the exam.

or

No documentation provided.

Total Points: 100

Don’t wait until the last minute

Fill in your requirements and let our experts deliver your work asap.