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