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Focused Exam: COPD Results | Turned In
Differential Diagnosis & Primary Care Practicum - May 2020, NR511-April-2020
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Over view
Education & Empathy : 5 of 6 (83.3%)
Tr anscr ipt
Subjective Data Collection Durin g the patien t intervi e w , there are a numbe r of opportu n it i es to provid e patien t educati o n and emp at h y. The opportu ni ti e s listed below ar
those identified by nur sing ex per ts to be of par ticular impor tance to this patient. A M odel Statement is pr ovided as an ex ample of an
Objective Data Collection appr opr iate response to each oppor tunity.
Oppor tu n it i es mar ke d as N o t E nco unte r e d are opportu n it i es that were not elicite d in the intervi e w
Education & Em pathy Oppor tunities mar ked as Not Followed Up ar e missed oppor tunities that were present in the interview, but where no statements w ere
Documentation made
Oppor tunities mar ked as Followed Up w er e follow ed up by students, and include the dialogue betw een student and patient
Debr ief
Medication Selection
Patient Teaching 1 Anxiety Over Worsening Symptoms Fo llo we d Up
Pr escr iption Writing
Description : Ms. O'Connor reports anx iety and distress over her w orsening health.
Q uestio
w hat br ought you in today?
04:43 PM C
I'm having so much tr ouble just trying to br eathe. And I've had these terrible coughing fits. A few days
ago, a br onchospasm. My health is going dow nhill fast . . . I know it has to do with my smoking habit.
It's so hard to kick. I w as hoping I could get something to help me.
im sor r y to hear that you have been having such tr ouble br eathing. Im going to do w ahteer i can to help Empathiz
you today! 04:44 PM C
Thank you.
Q uestio
do you smoke cigar ettes?
05:02 PM C
I smoke cigarettes. I'm not proud of it. It's w hy I have this COPD. But it's hard to kick. I do try and hold
off betw een smokes w hen I can. Just -- the str ess fr om being sick makes me cr ave it even mor e.
Empathiz
im sor r y to hear that
05:03 PM C
Thanks.
, Q uestio
do you feel depr essed?
05:08 PM C
My body is such a w r eck that it makes me pr etty miser able. This COPD makes me -- I'm just so anx ious
and r eally need to get better .
Empathiz
im osr r y to hear that
05:08 PM C
Thank you.
Q uestio
do you have any str ess at home?
05:28 PM C
My daughter and I ar gue all the time. She's all about healthy living. It can be . . . anyw ay. She hates that I
smoke. Her dad died fr om lung cancer . She's got a point.
Empathiz
im sor r y to hear that
05:28 PM C
I appre ci at e it, darlin g.
Model Statem ent: "I'm sorry to hear that you are experi e n cin g anxie t y over your current health
conditions. Not being able to br eathe is a scar y condition. With the r ight ther apy, and if you quit
smoking, you'll begin to feel better soon."
2 Life Tragedy Fo llo we d Up
Description : Ms. O'Connor reports details of her difficult life, including the loss of her husband.
Q uestio
does anyone else in your house smoke? (Clarified to: Does anyone in your house smoke?)
04:46 PM C
Just me w ho smokes. My daughter hates it. Total health nut. She's alw ays nagging me to quit, and she's
right, but it's not that easy. But I get w hy she's so pushy. Her dad died from it, so did her grandparents.
(Clar ified to: if anyone at home smokes)
Empathiz
im so sor r y to hear that
04:46 PM C
I appre ci at e it, darlin g.
Q uestio
w hat kinds of gum have you tried before? (Clarified to: What treatments have you tried?)
05:03 PM C
I know the best treat me nt would be quittin g smoki n g . I feel like I've tried quittin g a hundred diffe re n t
w ays -- tried using nicotine replacement therapy. I've tried the gum, lozenges, patches . . . just couldn't
stick to it. Ultimately, the cr avings w on out. (Clar ified to: w hat tr eatments I have tried)
Q uestio
w hat do you do for a living?
05:04 PM C
I'm r etir ed. Used to be an office manager .
Q uestio
ar e you sex ually active?
05:04 PM C
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