Shadow Health COPD Debbie O’Connor -with 100% verified solutions | Exams Nursing | Docsity (2024)

Download Shadow Health COPD Debbie O’Connor -with 100% verified solutions and more Exams Nursing in PDF only on Docsity! Shadow Health COPD Debbie O’Connor -with 100% verified solutions Subjective Data Collection: 32 of 32 (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. 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.  Finding: Established chief complaint and reason for admittance Hover To Reveal...  Available: Indicates an item that is available to be found. Chief Complaint  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? 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  Finding: Reports sputum is mostly clear with occasional yellow, gray, or dark color (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: What does your sputum look like?  Finding: Reports wheezing (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: Are you wheezing?  Finding: Reports cough sounds like crackling (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: What does your cough sound like?  Finding: Asked about aggravating factors  Finding: Reports exertion worsens symptoms (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: Does exertion make your symptoms worse?  Finding: Reports coughing fits after smoking (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 do you have coughing fits?  Finding: Asked about treatment and relieving factors of respiratory symptoms  Finding: Reports trying to hold off on smoking cigarettes as long as possible Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What class of COPD were you diagnosed with?  Finding: Reports diagnosed after respiratory distress episode (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What was your respiratory episode?  Finding: Asked about ER visits or hospitalizations  Finding: Reports hospitalization after miscarriage at age 24 (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: When were you hospitalized?  Finding: Reports most recent hospitalization was two years ago (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: When was your most recent hospitalization?  Finding: Reports most recent hospitalization was for respiratory distress episode (Available) Pro Tip: Inquiring into the patient's relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient's existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: What was your recent hospitalization for?  Finding: Asked about home medications  Finding: Reports taking a long-acting beta-agonist (LABA) Home Medications (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you take a LABA?  Finding: Followed up on LABA  Finding: Reports the LABA is formoterol inhaler (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you use a LABA inhaler?  Finding: Reports formoterol dose of 12 micrograms (Available) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Asked about medication regimen adherence  Finding: Denies missing doses (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you miss doses of your medication?  Finding: Asked about spirometry  Finding: Reports sporadic spirometry readings at home (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you take spirometry readings at home?  Finding: Reports most recent FEV1 reading was 1.37 L, 49% of her predicted FEV1 (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: What is your most recent spirometry reading?  Finding: Asked about oxygen use  Finding: Denies oxygen therapy due to cigarette smoking (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you use oxygen even though you smoke?  Finding: Asked about allergies  Finding: Denies allergies (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Do you have any allergies?  Finding: Asked about vaccines  Finding: Denies recent influenza vaccine (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Have you had a flu shot?  Finding: Denies recent pneumococcal vaccines (Found) Pro Tip: A patient's home medications can provide insight into the patient's current treatment and its effacacy. Inquiring into medication history, dosage, and frequency will help you understand the patient's background and how it may affect their current situation. Example Question: Have you had a pneumonia vaccine? substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you drink alcohol?  Finding: Denies using illegal substances (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you use illegal drugs?  Finding: Followed up on current cigarette smoking  Finding: Reports three to five cigarettes a day for the past four months (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: How many cigarettes do you smoke a day?  Finding: Reports stressful situations trigger her smoking (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: What triggers your smoking?  Finding: Reports daughter convinced her to quit smoking because of declining health issues (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Why do you want to quit smoking?  Finding: Reports husband's death of lung cancer makes her want to quit (Available) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: What was your husband's cause of death?  Finding: Followed up on history of cigarette smoking  Finding: Reports started smoking at age 15 (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: When did you start smoking?  Finding: Reports quit smoking when her daughter was young but started smoking again in her 30s (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: What is the longest amount of time you quit smoking?  Finding: Asked about exercise  Finding: Denies exercise due to fatigue, exhaustion, exacerbated symptoms upon exertion (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Why don't you exercise?  Finding: Asked about diet  Finding: Reports eating mostly frozen meals when daughter is at work (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: What do you eat at home?  Finding: Reports her daughter cooks healthy meals for her (Found) Pro Tip: A patient's social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient's social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you cook?  Finding: Asked about relevant family history  Finding: Reports father, smoker, died of a heart attack (Found) Pro Tip: A patient's family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient's current complaint and how their family's health history might be influencing it. Example Question: Did your father smoke? Family Medical History  Finding: Reports mother died of smoking-related pneumonia (Found) Pro Tip: A patient's family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient's current complaint and how their family's health history might be influencing it. Example Question: Did your mother smoke?  Finding: Reports husband smoked and died of lung cancer (Available) Pro Tip: A patient's family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient's current complaint and how their family's health history might be influencing it. Example Question: Did your husband smoke?  Finding: Reports daughter is a "health nut" non-smoker (Available) Pro Tip: A patient's family medical history can indicate if the patient is at a higher risk for certain illnesses and disorders. Gathering this information can contextualize a patient's current complaint and how their family's health history might be influencing it. Example Question: Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Are your fingernails blue?  Finding: Asked about review of systems for genitourinary  Finding: Reports being postmenopausal (Available) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Are you postmenopausal?  Finding: Reports not sexually active (Found) Pro Tip: Understanding a patient's health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Are you sexually active? Activities of Daily Living  Finding: Asked about ADLs  Finding: Reports difficulty moving around home (Found) Pro Tip: Information about a patient's activities of daily living will help you determine if their wellbeing is at risk. Questions about your patient's ability to bathe themselves, feed themselves, or walk without assistance will help you determine whether the patient can care for themselves at home. Example Question: Do you have trouble moving around your home?  Finding: Reports difficulty with activities like dressing or cooking due to exhaustion COPD Medication(s) Selected tiotropium Points Earned ✓ + 9 points ✓ Rationale Congratulations! You have correctly prescribed Ms. O'Connor a tiotropium dry powder inhaler. As a LAMA, it has the highest level of evidence for effectiveness and safety for Ms. O'Connor's indication according to the latest GOLD prescription guidelines. You have COPD Exacerbations Medication(s) Selected albuterol / ipratropium Points Earned ✓ + 9 points ✓ Rationale Congratulations! You have correctly prescribed Ms. O'Connor a combination albuterol / ipratropium inhaler for her COPD Exacerbations. It will provide short term relief to Ms. O'Connor's symptoms and encourages medication compliance by reducing the number of inhalers she needs. Smoking Cessation Medication(s) Selected varenicline Points Earned ✓ + 9 points ✓ Rationale Congratulations! You have correctly prescribed Ms.O'Connor varenicline forsmoking cessation. Ms.O'Connor has failed to stop smoking using nicotine replacement in the past, and varenicline is easier to manage than bupropion in combination with nicotine received full credit for this answer. Field Student's Answer Is Correct? Route inhaled ✓ Quantity 30 (thirty) capsules ✓ Refills 1 (one) ✓ Indication COPD ✓ Additional Information This section covers the additional information and generic substitution fields for the prescription. These are not Health, but your instructor may choose to do so when inputting your grade. Field Student's Answer Dispense As Written? Required Additional Information please take with food or full glass of water Signature and Date: 1 out of 1 point This section covers the information identifying who wrote the prescription and when. Any errors in this section pharmacist not dispensing the medication to the patient, and therefore you will lose the point for this section. Field Student's Answer Is Correct? Signature ✓ Date ✓ Safe and Effective Dosage: 0 out of 7 point This section measures how well you put together a safe and effective dose for the patient's problems. Any incor lead to under or overdosing the patient, and therefore you will lose all of the points in this section. Field Student's Answer Is Corre Patient Information: 1 out of 1 point This section covers the information identifying the patient. Any incorrect answers here could result in the pharm medication to the patient, and therefore you will lose the point for this section. Field Student's Answer Is Correct? Patient Name Debbie O'Connor ✓ Date of Birth 10/05/1964 ✓ ipratropium bromide / albuterol md i 3 out of Medication Name ipratropium bromide / albuterol mdi Dosage 1 (one) actuation Strength 20 mcg / 100 mcg Frequency Wrong Answer: 3 (three) times daily (no more than six times daily) Correct answer: 4 times daily as needed Duration 30 (thirty) days Additional Fields: 1 out of 1 point This section covers the rest of the remaining fields for an accurate prescription. Any incorrect answers here cou prescription, and therefore you will lose the point for this sections. Field Student's Answer Is Correc Route inhaled Quantity 1 (one) canister, 120 (one hundred and twenty) metered doses Refills 3 (three) Field Student's Answer Is Correct? Patient Name Debbie O'Connor ✓ Date of Birth 10/05/1964 ✓ Safe and Effective Dosage: 7 out of 7 point This section measures how well you put together a safe and effective dose for the patient's problems. Any incor lead to under or overdosing the patient, and therefore you will lose all of the points in this section. Field Student's Answer Is Correc Medication Name varenicline starting convenience pack Dosage 1 (one) tablet Strength 0.5 mg for first 7 (seven) days / 1 mg thereafter Frequency once daily for first 3 (three) days / 2 (two) times daily thereafter Duration 1 (one) month Additional Fields: 1 out of 1 point This section covers the rest of the remaining fields for an accurate prescription. Any incorrect answers here cou prescription, and therefore you will lose the point for this sections. Field Student's Answer Is Correct? Route mouth ✓ Quantity 1 (one) starting package (one month supply) ✓ Refills 0 (zero) ✓ Indication Smoking Cessation ✓ Additional Information This section covers the additional information and generic substitution fields for the prescription. These are not Health, but your instructor may choose to do so when inputting your grade. Field Student's Answer Dispense As Written? Required Additional Information please do not take more than perscrribed