Question

M.C. is a 69-year-old man who presents to the outpatient office with a hacking, raspy cough. Past Medical History: HTN (hypertension), DM (diabetes mellitus) Subjective Data Cough is productive, bringing up green sputum. Runny nose, sore throat Denies fever Sore throat pain when swallowing No history of smoking or seasonal allergies Complains of fatigue Objective Data Vital signs: T 37 P 72 R 14 BP 134/64 Lungs: + Rhonchi bilateral upper lobes, wheeze O2 Sat = 98% room air Ears = Tympanic membrane is bulging Nose = + erythema, yellow discharge Throat = + erythema, – pustules Medications: Metoprolol 12.5 mg per day, Glucophage 500 mg twice a day Questions What other questions should the nurse ask about the cough? Develop a problems list from the objective and subjective data. What nursing diagnoses can be derived from the problems list? What should be included in the plan of care? What risk factors are associated with this age group? Based on the readings, what is the most likely cause of this patient’s cough?

Answer 1

ANSWERS:-

1) What other questions should the nurse ask about the cough?

* Duration of cough- since how long? Days or months?

*Is the cough intermittent or continues?  

* When does the cough increase? During night, or morning ( any specific time? )

* Do you have chest pain while coughing?

* what was the color of sputum in the beginning? Whitish or greenish?

* Is there presence of blood with sputum?

2) Problem list based on subjective and objective data :-

a) Productive cough with greenish sputum.

b) Breathe sounds bilateral rhonchi and wheezes.

c)Runny nose with erythema and pustules.

d) Sore throat and pain and difficulty in swallowing.

e) Fatigue.

f) Bulging of tympanic membrane due to inflammation.

g) hypertensive and diabetic.

3) Nursing diagnosis :-

a) Ineffective airway clearance related to increased mucus production and ineffective clearence ( productive cough with green sputum and runny nose and rhonchi and wheezes)

b) Pain (acute) related to inflammation of upper airway. ( sore throat and pain while swallowing )

c) Activity intolerance related to fatigue.

d) Risk for imbalanced nutrition less than body requirements related to pain while swallowing.

4) What risk factors are associated with this age group?

* Immune system weakens and body's resistance decreases.

* This can lead to many other infections.

* Can lead to pneumonia and respiratory failure if not treated properly.

* His diabetes and hypertension also contribute to the risk of developing complications.

5) The most likely cause of cough is

* Bronchitis due to a bacterial or viral infection.