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Mike is a 69-year-old man who presents to the outpatient office with a cough.

Mike is a 69-year-old man who presents to the outpatient office with a cough.

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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

Objective Data

Vital signs: T 37, P 72, R 14, BP 134/64

Lungs: + Rhonchi bilateral upper lobes

O2 sat: 98%

Ears: TM bulging Nose: + erythema, yellow discharge

Throat: + erythema, pustules

Medications: metoprolol 12.5 mg/day, metformin (Glucophage) 500 mg twice a day

Answer these questions to help you think about how we would progress with our assessment as an RN:

1. What other questions should the nurse ask about the cough?

2. Develop a problem list from objective and subjective data.

3. What nursing diagnoses can be derived from the problems list?

4. What should be included in the plan of care?

5. What risk factors are associated with this age group?

6. Based on the readings, what is the most likely cause of cough for this patient?

Solution Preview


What other questions should the nurse ask about the cough? -Find any history of imaginable contact to domestic aggravations like spray coal, asbestos, etc.? -Does he partake high contact to faunas counting birds? Develop a problem list from objective…

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