Documentation in Community Health Nursing Essay
Review the case study highlighted below:
74-year-old Male presented to the clinic with the CC of “ dry cough†x 2 weeks. He confirms weight loss of 20 lbs in the last four months without trying to lose weight, intermittent hemoptysis in the morning, and night sweats. After obtaining a detailed history which includes an exposure to Asbestos and Mold during his time in the Military. He also report second hand smoking exposuire from his spouse of ten years. Documentation in Community Health Nursing Essay
The nurse practitioner reviews the vitals signs from the registered nurse that shows:
Temperature: 98.4
Respiratory Rate: 22
Pulse: 115
02 saturation: 93% on RA, baseline is 97% on RA Documentation in Community Health Nursing Essay
On examination, the nurse practitioner did not notice any swelling, discoloration, retractions, or deformity on the chest wall. No crepitus was palpated in the anterior or posterior chest wall. Auscultation revealed ” wheezing” on bilateral upper lung fields. The left lower lobe had diminshed breath sounds. Documentation in Community Health Nursing Essay
Guidelines
After reviewing the case study above, answer the following questions:
1. What are the pertinent subjective and objective findings that are concerning to the nurse practitioner from the case study? Analyze and discuss the relevance of each subjective and objective data from the case study and how it contributes to the nurse practitioner formulating an accurate diagnosis. Documentation in Community Health Nursing Essay
2. What are the likely differential diagnosis from this case study?
Submit a written report addressing the above questions. Your report should be at least 500 word APA formatted paper. Ensure you utilized schlorlary based research studies while discussing the above questions. Documentation in Community Health Nursing Essay