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

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

The nurse should ask the following questions

1. What is the type of cough? Whether it is productive or non-productive cough?

2. What is the frequency of cough? What is duration of each cough? How longer one cough exist?

3. How many days before it occurred for first time?

What are the other problems that occurs while coughing?

The problem list that can be setup from objective and subjective data are

1. Acute otitis media can be seen due to bulging TM

2. Obstruction of air passage can be seen if crackels and wheezes occurs while breathing.

3. Phlegm may be the indicative of bacterial infection.

4. Yellow discharge from nose can be the symptoms of sinus infections.

Nursing diagnosis that can be abstracted from above problem list are

Ineffective airway clearance R/T inflammatory process AEB increases production of cough, AEB coloured sputum, Nasal damage, pustule in throat, bulging TM.

The plan of care should include other diagnosis like chronic emphysema or heavy smoking from past 35-40 years. This can be physically measured by anteroposterior and transverse diameter ratio of lung which normally occurs about 1:2 but the ratio of 1:1 may be tha indicative of chronic emphysema.

The risk factors that are related with this age group can be that the patient may suffer for lofelasting respiratory disease and infection. Even during any heavy work or walk he may suffer from lack of oxygen (Hypoxia).

The main reason as derived till now would be a bacterial infection.

Nightingale answered 1 year ago

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