Assessment of the respiratory status

Nelson Carson is a 62-year-old man who presents to his private practitioner’s office with a hacking, raspy cough.
Subjective Data
PMH: HTN, CAD
Cough is productive, bringing up green, thick phlegm
Runny nose, sore throat
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, wheezes
O2 Sat = 98%
Medications: Metoprolol 25 mg per day, ASA 325 mg/daily
What other questions should the nurse ask about the cough?
What nursing diagnoses can be derived from the data?
What should be included in the plan of care?
What risk factors are associated with this age group?
Based on the readings, what is the most likely cause of cough for this patient?
Apa format
ReferenceJarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.

Chapter 18: Thorax and Lungs
pp. 413–441 (Structure, Function, The Thoracic Cavity, Developmental Competence, Subjective Data, Objective Data)
Chapter 19: Heart and Neck Vessels
pp. 459–492 (Structure and Function, Heart Wall, Chambers, and Valves, Heart Sounds, Developmental Competence, Subjective Data, Objective Data )
Chapter 20: Peripheral Vascular System and Lymphatic System
pp. 509–529 (Structure and Function, Lymphatics, Developmental Competence, Subjective Data, Objective Data)

 

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