NURS 3120 Lecture Notes - Lecture 5: Passive Smoking, Chest Pain, Shortness Of Breath

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21 Feb 2017
School
Department
Course
Physical Assessment Respiratory System
Health History and Present Health
Chronic illnesses
Comorbidities
Medications/Allergies
Difficulty breathing with ADL (activities of daily living)
Difficulty breathing during sleep
How do you sleep sitting up, O2, sleep apnea (big comorbidity) machine
Are they compliant with their therapy?
Any medications.., nebulizers
How often how long
See a pulmonologist
Health History and Past Health
Diagnosed with any pulmonary conditions/diseases
Asthma
Bronchitis
Acute vs. Chronic
Emphysema
Lung cancer
TB/recurring infections
TB: on rise in certain areas of US, common on college campuses,
regionalization
Trauma to chest, pneumothorax
Smoking history (sensitive topic)
Past
Present
Cessation strategies
Chewing tobacco
o Oral cavity
o Lesions
Family h/o pulmonary diseases
General Health History
Home
Environmental factors
House/apartment
How many people live with you
Inner city pollution
Pets
Second hand smoke
Air/heating systems
Work/Travel
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Indoors/outdoors
Exposure to allergens, chemicals, radiation
Does employer monitor exposure
Well ventilated work areas, filtration systems
Travel out of US in recent weeks/months
Move Onto Problem Based History
Patients/clients will most commonly complain of cough, SOB (shortness of breath) and
chest pain with breathing
Our spto aalsis should ilude…
ONSET
LOCATION (have patient point) & DURATION
DESCRIPTION BY PATIENT/CLIENT
TRIGGERS/TREATMENTS
ANY OTHER SYMPTOMS NOTED
DEGREE OF SEVERITY OF EVENT
Your Patient Has a Cough…, With or Without Chest Pai
First notice of it
Intermittent or is it constant
Hae the desrie ough…, dr/hakig, produtie hat does sputu look like
Yellow, red, green
Odor
Only happen in morning?
Do they feel hoarse
Cough keep them up at night or wake them from a sleep
SOB with it
Chest pain, muscle strain
Have they tried any remedies, if yes did they work
Your Patiet/Cliet Coplais of “hortess of Breath…
How long has it been occurring
Persistent or occasional
Interferes with ADL
Notice any triggers
How many pillows for sleeping
Change of position help or treatments
Other problems when you are SOB do you feel weak or shaky
Let’s Begi Our Eaiatio
WASH HANDS
Look at our patiet hat is their geeral appearae…
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Document Summary

Health history and past health: diagnosed with any pulmonary conditions/diseases. Tb: on rise in certain areas of us, common on college campuses, regionalization: trauma to chest, pneumothorax, smoking history (sensitive topic) Cessation strategies: chewing tobacco, oral cavity, lesions, family h/o pulmonary diseases. Indoors/outdoors: exposure to allergens, chemicals, radiation, does employer monitor exposure, well ventilated work areas, filtration systems, travel out of us in recent weeks/months. Move onto problem based history: patients/clients will most commonly complain of cough, sob (shortness of breath) and chest pain with breathing. Your patient has a cough , with or without chest pai(cid:374: first notice of it, ha(cid:448)e the(cid:373) des(cid:272)ri(cid:271)e (cid:272)ough , dr(cid:455)/ha(cid:272)ki(cid:374)g, produ(cid:272)ti(cid:448)e (cid:894)(cid:449)hat does sputu(cid:373) look like(cid:895) Your patie(cid:374)t/clie(cid:374)t co(cid:373)plai(cid:374)s of hort(cid:374)ess of breath : how long has it been occurring, persistent or occasional. Interferes with adl: notice any triggers, how many pillows for sleeping, change of position help or treatments, other problems when you are sob do you feel weak or shaky.

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