Develop problem list from the objective and subjective data

Reference no: EM133623195

Discussion Post

Select one of the following discussion questions below. Post a substantive initial response with references.

Option I

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

Task

Question A. What other questions should the nurse ask about the cough?
Question B. Develop a problem list from the objective and subjective data.
Question C. What nursing diagnoses can be derived from the problems list?
Question D. What should be included in the plan of care?
Question E. What risk factors are associated with this age group?
Question F. Based on the readings, what is the most likely cause of this patient's cough?

Option II

S.P. is a 75-year-old woman who presents to the provider's office with fatigue.

Subjective Data

PMH: HTN, hyperlipidemia, MI 3 years ago
Fatigue started about a month ago, getting worse
Relieved with rest, exacerbated with activity
Denies chest pain
Ankles swollen

Objective Data

Vital signs: T 37 P 112 R 18 BP 110/54
Lungs: bilateral lower lobe crackles
O2 Sat = 94%
Skin = cool to touch
CV = heart rate regular, positive peripheral pulses, ECG = no changes
+2 edema bilateral ankles
Medications: Metoprolol 20 mg per day, 325 mg of aspirin per day

Task

Question A. What other questions should the nurse ask about the fatigue?
Question B. What other assessments are necessary for this patient?
Question C. What are some causes of fatigue?
Question D. Develop a problem list from the objective and subjective data.
Question E. What should be included in the plan of care?
Question F. Based on the readings, what is this patient's most likely cause of fatigue?

Reference no: EM133623195

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