Question

In: Nursing

Part 1 M.C. is a 69-year-old man who presents to the outpatient office with a hacking,...

Part 1

M.C. is a 69-year-old man who presents to the outpatient office with a hacking, raspy 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
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%
Ears = TM 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?

Solutions

Expert Solution

• 1.The nurse should ask if the coughing increases at night or early in the morning.

2. If the cough causing shortness of breathing.

3.If chest pain and sweating are occured during coughing.

4. Is coughing induced vomiting occurs?

• Chief complain- Patient is suffering from runny nose, sore throat, bringing up green phlegm ,productive cough and suffering from pain and fatigue.

Past medical history- Hypertension and diabetes mellitus.

• Nursing diagnosis- Ineffective airway clearance related to runny nose as evidenced by chest auscultation.

• Plan of care-  

1. Breathing pattern is assed.

2. Vital signs should be assessed.

3. Steam inhalation is provided.

4. Comfortable position is given.

5. Chest auscultation is done.

6. Breathing coughing exercise is taught.

7. Nebulisation is provided as per doctor's order.

•Risk factors are-

1. Lower respiratory tract infections.

2. Covid - 19

3. Cardiovascular disorder.

4. Otitis media.

• Cause of Patient's cough may be sinusitis( Because in sinusitis TM bulging, green and yellow phlegm, low fever, erythema in nose and throat occurs).

Nightingale answered 2 years ago
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