Help with nursing homework| Nursing homework help
Patient Information: Initials: J.D. Age: 7 Gender: Male
Subjective: CC Fever and Cough HPI: Dr. A 7 year old male presents with fever and cough that has been his chief complaint for three days. The boy has felt tired and weak with decreased appetite. J.D.’s mother reports that he has had a low-grade fever, ranging from 100-101°F, which has not responded to over-the-counter fever reducers. His persistent dry cough is also reported without mucus production. He denies having any travel or sick contact in recent times.
PMH: Allergies, Asthma
Objective: Vital Signs: Temp 100.2°F, HR 96 bpm, RR 20, BP 108/68 mmHg, O2 saturation 97% on room air. General: J.D. A weak and tired appearance with impaired eye contact, a dry cough and fatigue. Lungs: No crackles, wheezing or wheezing. The heart beats at a regular rate with no gallops or murmurs. Abdomen is soft and not tender, without hepatosplenomegaly. No lesions or rashes were noted on skin. Assessment: J.D. J.D. The patient presents with fever, cough and upper respiratory infection. His cough might be caused by asthma. However, his current condition is not one of wheezing and shortness.
Plan:
- As needed, recommend supportive care that includes plenty of fluids and rest as well as fever reducers.
- To prevent spreading of diseases, it is important to discuss the importance hand hygiene.
- For any symptoms of asthma, prescribe albuterol Inhaler.
- You can follow up within 3 days for further evaluation to determine if symptoms have improved or become worsened.
Education:
- To prevent spreading of diseases, it is important to discuss the importance hand hygiene.
- Teach J.D.’s mother how to use the albuterol inhaler properly and when to administer it.
- Advise J.D.’s mother to monitor his symptoms and bring him back to the clinic if he develops any shortness of breath or wheezing.