Focus Health History & Assessment Paper

Assignment 2 Assignment Instructions: Using shadow health: Danny For this 4-5 page assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Danny, a child who is complaining of a cough. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s). Introduction (including purpose statement) Focus of the assessment Describe the focus of this particular assessment on the patient complaining of a cough Subjective Component Describe the ROS, PMH, and other relevant data in this section. Objective Component Describe the physical examination findings including techniques of examination Documented evidence to support clinical reasoning Describe the list of differential diagnoses Plan of care Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment. Conclusion References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: Include a cover page and running head (this is not part of the 4-5 pages limit) Include transitions in your paper (i.e. headings or subheadings) Use in-text references throughout the paper Use double space, 12 point Times New Roman font Apply appropriate spelling, grammar, and organization Include a reference list (this is not part of the 4-5 pages limit) Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP) Competency 20 18 16 0 Points Earned Focus of the Assessment is identified with Special Considerations including Documented Focused Health History Documentation clearly shows student has completed a focused assessment with identified special considerations including a well-documented focused health history. Documentation supports the student has completed the focused assessment with minimal identification of special concerns. Focus Health History & Assessment Paper The focused health history is documented. Documentation supports the student has completed the focused assessment without identification of special concerns. The focused health history is documented and lacks depth and specificity of weekly topic. Documentation supports the student attempted to complete the focused assessment without identification of special concerns. The focused health history is briefly documented and lacks depth and specificity of weekly topic.

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/20 20 18 16 0 Documented Physical Examination Findings including Techniques of Examination Documentation clearly shows student has completed the physical examination and accurately describes the techniques of examination for the week. Documentation supports the student has completed the physical examination and describes the techniques of examination for the week. Documentation supports student completed some of the physical examination for the focused assessment of the week. Documentation is accurate but lacks depth. No evidence that the student is applying read concepts of advanced focused physical assessment. Documentation lacks depth and may lack coherence for understandability of tasks completed in this week. /20 20 18 16 0 Documented Evidence to Support Clinical Reasoning with External Course Resources Discourse clearly shows the student has studied the topic and has given thought to the focused assessed topic and documentation for the week. Discourse supports the student has studied the topic and has given thought to the focused assessment topic and documentation for the week. Discourse supports student studied some of the topic for the focused assessment topic this week. Discourse is accurate but lacks depth. No evidence that that student has read or studied the topic. Discourse lacks depth. May be presented in a rambling manner. Content is inaccurate &/or is unclear. /20 20 18 16 0 Individualized Plan of Care Based Upon Clinical Findings Accurately presents an individualized plan of care based upon clinical findings. Presents an individualized plan of care based upon clinical findings. Some minor omissions are noted. Presents a plan of care that is not individualized based upon the clinical findings. A plan of care is not presented or the plan of care presented lacks demonstration of competency or is irrelevant to the clinical findings. /20 5 4 3 0 Developmentally and Culturally Specific Accurately documents a developmentally and culturally specific assessment and plan of care for the selected patient. Documents a developmentally and culturally specific assessment and plan of care. Presents a developmentally and culturally specific assessment or plan of care and one or both are not based upon the selected patient. A developmentally and culturally specific assessment and plan of care are not presented or based upon the selected patient’s findings. /5 5 4 3 0 Demonstration of Compliance with Ethical and Legal Standards of Professional Nursing Practice Compliance with the ethical and legal standards of professional nursing practice is explicitly stated in the documentation of the focused physical assessment. Compliance with the ethical and legal standards of professional nursing practice is stated in the documentation. Compliance with the ethical and legal standards of professional nursing practice is briefly implied in the documentation of the focused physical assessment or inaccuracies are evidenced in the written assessment. Compliance with the ethical and legal standards of professional nursing practice is not included in the documentation of the focused physical assessment. /5 10 9 8 0 Grammar, Spelling, and Punctuation APA Format APA Format, grammar, punctuation and spelling is accurate with no errors. APA Format, grammar, punctuation and spelling is accurate with less than two types of errors. APA Format, grammar, punctuation and spelling is accurate with five or fewer types of errors. APA Format, grammar, punctuation and spelling is accurate with more than five types of errors.

Introduction

Cough is a common symptom in respiratory infections. The pediatric population often experiences episodes of coughing due to upper respiratory infections (Perotin et al., 2018). This paper will analyze and discuss the health information collected during the physical assessment and focus health history of Danny. Danny is an 8-year-old boy who presented in the clinic with complaints about cough and fatigue due to lack of enough sleep.

Subjective Component

Danny reports that he has been having a persistent cough for the last 5 days. He stated that the cough worsens at night and interferes with his ability to sleep. As a result, he wakes up tired due to coughing at night. Danny describes the cough as productive, clear, “gurgly” and watery. He reports that he was given a spoonful cough medication by the mother and he had temporary relief. Danny further reports having right ear pain, mild sore throat, clear sputum during coughing, and runny nose. According to Danny, he has a history of pneumonia from the previous year and he normally has regular ear infections. Danny denies having any fever, breathing problems, headache, chest pain, dizziness, or swallowing difficulties. Danny also denied any allergy, weight loss, nasal congestion, vision problems, or asthma incidence. He has also not had any weight loss or changes in appetite. Danny’s father has a history of asthma during childhood. He stays with his mother, father, and grandmother. Danny reports that both parents smoke and the father smokes cigarette while at home, and thus exposes him to secondary smoke. Danny does not have any pets at home.Focus Health History & Assessment Paper

Objective Component

Danny appears tired through the examination process. Danny was alone throughout the examination and thus his confidentiality and privacy were protected during the examination.

Examination of the eyes indicated normal sclera, lids, and conjunctive. However, both eyes have a dull appearance but the eyes do not appear sunken. Bilateral nares appear red with clear mucous and boggy turbinate. The left tympanic appears normal with a positive light reflex and translucent gray tympanic membrane. The right tympanic membrane appears opaque and red.

His neck is normal and both the posterior and anterior chest walls are symmetric without any lesion or deformity. Examination of the oral cavity indicates cobblestone at the back of the throat. The auscultation of the anterior and posterior chest wall indicates that all anterior regions are normal without any abnormal breathing sound. Percussion of posterior and anterior chest walls are resonant within all the areas. The patient did not manifest any pain or discomfort during the palpation of the maximally and frontal sinuses. The right supraclavicular lymph node is tender and appears enlarged. The vital signs of the patient were:

• Blood Pressure 120/76
• Respiratory Rate: 28
• Temperature: 37.2 c
• Pulse 100
• O2 Saturation: 96%
• Spirometry: FEV1 -3.15, FVC –3.91 = 80.5

Clinical Reasoning and Differential Diagnosis

Danny reported to have been coughing for approximately 5 days and thus the cough should be classified as an acute cough. The possible causes of the cough include bacteria, virus, or allergy. Notably, even though the vital signs of the patient are within the normal limits, the values are at the upper limit. The oxygen saturation is slightly reduced. The reduced oxygenation could also be a respiratory health problem (Lai et al, 2018). Since the expectorate and nasal mucous are clear and without any odor, allergies and virus are supported. Both parents of Danny smoke and the father smokes while indoors. Smoking is a major risk factor to respiratory infections and thus exposure of Danny to secondary smoking may be a contributing factor to the persistent cough (Jiang et al., 2020). Secondhand smoke predisposes an individual to various medical conditions that may exacerbate breathing problems, including coughing.

Based on these factors and the findings from the physical assessment of the patient, the differential diagnoses include strep throat, allergies, rhinitis, and a cold.

Plan of Care

The care plan for this patient will focus on identifying the cause of the symptoms and improving the symptoms. Therefore, a swab from the patient’s back throat will be taken and sent to the lab in order to confirm or exclude strep throat. Danny will also be referred to an allergist so that any allergy may be confirmed or ruled out.Focus Health History & Assessment Paper

An antitussive will be prescribed to Danny in order to relieve the cough (Cots et al., 2019). Danny will also be advised not to attend school for some days to ensure he gets enough rest while at home. Both parents are working and thus the grandmother is his caretake while at home. The parents will be educated about the prescribed medication and how to administer the medications. The parents will then be advised to ensure the grandmother understands how to administer the medication to Danny while under her care.

Moreover, since smoke is a major risk factor to respiratory infections, the parents will be educated about secondary smoking, the health benefits of smoke cessation, and the dangers associated with smoking indoors (Baskaran et al., 2019). Particularly, the father will be advised to stop smoking in the house because this exposes the occupants such as Danny to secondary smoke. Finally, Danny will be administered with a pneumonia vaccine in order to update his shots. Danny and the parents will be advised to visit the clinic for a review after one week.

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Conclusion

The paper discussed Danny, an 8-year-old patient who presented with a complaint about a cough, that worsens at night. The cough is productive and wet and the patient is unable to sleep well due to frequent coughing at night. The objective assessment indicates that Danny’s right tympanic membrane is opaque and red while the right supraclavicular lymph node is tender and appears enlarged. The differential diagnoses for the patient include strep throat, allergies, rhinitis, and a cold. Danny will be prescribed an antitussive to relieve the cough. Other tests will in order to rule out infections such as strep throat or allergy. Parents will be advised against smoking while in the house to reduce exposure to secondary smoke.Focus Health History & Assessment Paper

References

Baskaran, V., Murray, R. L., Hunter, A., Lim, W. S., & McKeever, T. M. (2019). Effect of tobacco smoking on the risk of developing community-acquired pneumonia: A systematic review and meta-analysis. PloS one, 14(7), e0220204. https://doi.org/10.1371/journal.pone.0220204

Cots, J. M., Moragas, A., García-Sangenís, A., Morros, R., Gomez-Lumbreras, A., Ouchi, D., Monfà, R., Pera, H., Pujol, J., Bayona, C., de la Poza-Abad, M., & Llor, C. (2019). Effectiveness of antitussives, anticholinergics, or honey versus usual care in adults with uncomplicated acute bronchitis: a study protocol of an open randomized clinical trial in primary care. BMJ Open, 9(5), e028159. https://doi.org/10.1136/bmjopen-2018-028159

Jiang, C., Chen, Q., & Xie, M. (2020). Smoking increases the risk of infectious diseases: A narrative review. Tobacco induced diseases, 18, 60. https://doi.org/10.18332/tid/123845

Lai, K., Shen, H., Zhou, X., Qiu, Z., Cai, S., Huang, K., Wang, Q., Wang, C., Lin, J., Hao, C., Kong, L., Zhang, S., Chen, Y., Luo, W., Jiang, M., Xie, J., & Zhong, N. (2018). Clinical Practice Guidelines for Diagnosis and Management of Cough-Chinese Thoracic Society (CTS) Asthma Consortium. Journal of thoracic disease, 10(11), 6314–6351. https://doi.org/10.21037/jtd.2018.09.153

Perotin, J. M., Launois, C., Dewolf, M., Dumazet, A., Dury, S., Lebargy, F., Dormoy, V., & Deslee, G. (2018). Managing patients with chronic cough: challenges and solutions. Therapeutics and clinical risk management, 14, 1041–1051. https://doi.org/10.2147/TCRM.S136036 Focus Health History & Assessment Paper