Description
Shadow Health: Respiratory System Hourly Rounds Richard Trotier
Assignment Description: This assignment provides the opportunity to conduct a respiratory-related visit with a patient in a medical surgical setting. You will interview and examine the patient, document your findings, and complete nursing care activities.
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Estimated Time to Complete: 60 minutes
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Solution:Shadow Health: Respiratory System Hourly Rounds Richard Trotier
Category
Scored Items
Experts selected these topics as essential components of a strong, thorough interview with this patient.
Patient Data
Not Scored
A combination of open and closed questions will yield better patient data. The following details are facts of the patient’s case.
Patient Check In
Finding:
Established chief complaint
Finding:
Reports difficulty breathing
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Are you having trouble breathing?
Finding:
Reports rapid breathing
(Found)
Pro Tip: A patient’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:
Are you breathing more rapidly than usual?
Finding:
Asked about cultural or spiritual needs
Finding:
Reports wanting sage smudging ceremony to be performed
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Do you have any spiritual needs I can assist with?
Finding:
Reports wanting priest to perform communion
(Found)
Pro Tip: Asking a patient about their comfort level and current needs ensures a patient’s right to have their basic physical care and comfort needs met.Example Question:
Do you have any spiritual needs I can assist with?
History of Present Illness
Finding:
Asked about onset of symptoms
Finding:
Reports breathing problems began in the last few minutes
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
When did your breathing problems begin?
Finding:
Asked about cough
Finding:
Reports active cough
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Can you tell me about your cough?
Finding:
Reports cough has not worsened
(Available)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Has your cough worsened?
Finding:
Reports sputum
(Available)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Has your cough been productive?
Finding:
Denies increase in sputum
(Available)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Has there been an increase in sputum?
Finding:
Asked about chest pain
Finding:
Denies chest pain
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Are you having any pain in your chest?
Finding:
Reports heaviness in chest
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
How does your chest feel?
Review of Systems
Finding:
Asked about constitutional health
Finding:
Reports fatigue
(Available)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Are you feeling fatigued?
Finding:
Denies fever
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Do you have a fever?
Finding:
Denies chills
(Available)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Are you having any chills?
Finding:
Asked about cardiovascular system
Finding:
Reports rapid heartbeat
(Found)
Pro Tip: Asking about a patient’s different bodily systems and whether any symptoms are occurring allows you to understand how disease processes or other factors are affecting a patient’s health.Example Question:
Is your heart beating normally?
Finding:
Asked about neurological system
Finding:
Reports feeling lightheaded
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