M.C. is a 69-year-old man who presents to the outpatient office with a hacking, raspy cough.

Option 1

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

Questions

1. What other questions should the nurse ask about the cough?
2. Develop a problem list from the 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 this patient’s cough?

(Image: Female Holding Head in Discomfort)

Option 2

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

Questions

1. What other questions should the nurse ask about the fatigue?
2. What other assessments are necessary for this patient?
3. What are some causes of fatigue?
4. Develop a problem list from the objective and subjective data.
5. What should be included in the plan of care?
6. Based on the readings, what is this patient’s most likely cause of fatigue?