Mike is a 69-year-old man who presents to the outpatient office with a cough. Su
ID: 245684 • Letter: M
Question
Mike is a 69-year-old man who presents to the outpatient office with a cough.
Subjective Data
PMH: HTN, DM Cough is productive, bringing up green phlegm
Runny nose, sore throat
Denies fever
Sore throat pain when swallowing
No history of smoking or seasonal allergies
Objective Data
Vital signs: T 37, P 72, R 14, BP 134/64
Lungs: + Rhonchi bilateral upper lobes
O2 sat: 98%
Ears: TM bulging Nose: + erythema, yellow discharge
Throat: + erythema, pustules
Medications: metoprolol 12.5 mg/day, metformin (Glucophage) 500 mg twice a day
Answer these questions to help you think about how we would progress with our assessment as an RN:
1. What other questions should the nurse ask about the cough?
2. Develop a problem list from objective and subjective data.
3. What nursing diagnoses can be derived from the problems list?
4. What should be included in the plan of care?
5. What risk factors are associated with this age group?
6. Based on the readings, what is the most likely cause of cough for this patient?
Explanation / Answer
What other questions should the nurse ask about the cough?
-Find any history of imaginable contact to domestic aggravations like spray coal, asbestos, etc.?
-Does he partake high contact to faunas counting birds?
Develop a problem list from objective and subjective data.
Subjective Information: discomfort, temperature, anxieties, weakness.
Objective Information: Age, ethnicity, sex, over-all presence.
What nursing diagnoses can be derived from the problems list?
Strep throat is diagnosed based on symptoms. Strep throat indications are alike to those of sore esophagus related with cold nonetheless might also comprise no appetite, discomfort when swallowing, swollen tonsils with snowy spots and temperature.
What should be included in the plan of care?
-Lots of rest.
-Sufficient water intake.
-Consume calming foods.
-Mouthwash by warm and salt water.
-Humidifier usage.
What risk factors are associated with this age group?
Risk factors include infection spreading to:
-Tonsils
-Middle ear
-Sinuses
-Blood
Based on the readings, what is the most likely cause of cough for this patient?
-Streptococcal microorganisms are extremely transmissible.
-They can rampage established airborne precipitations when somebody with the contamination coughs or sneezes, or concluded communal nourishment or snacks.