Case study

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?

Questions or assessments associated with cough include the following: OPQRSTU model

 How long have you have this cough?

 When did it start? Was it gradual or sudden?
 Is the cough constant, or does it come and go?
 Has the cough changed since you first noticed it?
 Describe your cough. Is it dry? Productive? Hacking? Hoarse?
 How often are you coughing up sputum (all of the time or periodically)?
 How much sputum do you cough up?
 What is the consistency of sputum (thick, thin, frothy)?
 Have you noticed whether sputum has an odour?
 Have you noticed any other symptoms along with the cough, such as shortness of breath,
chest pain or tightness with breathing, fever, stuffy nose, noisy respiration, hoarseness, or
gagging?
 Does the coughing tire you out?
 Does it keep you awake at night?
 Have you done anything to treat the cough yourself, such as medications, fluids, or a
vaporizer?
 Have these measures been effective?

2. Develop a problems list from the objective and subjective data.

Problems list from the objective and subjective data:

 Phlegm is green, could indicate a bacterial infection.

 Crackles and wheezes auscultated in lungs, could indicate restrictive or obstructive
disease or airway obstruction.
 red, sore throat with pustules
 bulging TM, may indicate acute otitis media
 yellow discharge from nose, again, could indicate sinus infection

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

The nursing diagnoses can be derived are:

  Ineffective airway clearance related to inflammatory process AEB increased production of
secretions, cough
 Acute Pain, related to sore throat and inflammation in ears AEB patient complain of sore
throat pain when swallowing.
 Actual or potential infectious process R/T ineffective airway clearance AEB colored
sputum and nasal drainage

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

The plan of care should include:

 Assess the respiratory rate, depth quality ,respiratory sound .

 Maintain a clear airway.
 Provide a comfortable upright position to improve the oxygenation.
 Administer supplemental oxygenation.
 Provide chest physiotherapy to the dependent lung lobes.
 Provide postural drainage to the patient.
 Send the sputum sample for culture and sensitivity.
 Provide steam inhalation to make the sputum thin
 Determining the cause of the cough and treating symptoms.
 Anti-inflammatories may be prescribed for pain management. In addition to antihistamines
as prescribed by physician
 Increasing fluid intake and monitoring for signs and symptoms of subsequent infections,
such as pneumonia or bronchitis, are recommended

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

Risk factors include low immunity as age increased with DM and HTN, pneumonia, bronchitis,
and dehydration.

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

The patient is having a serious upper respiratory tract infection. The symptoms are more likely
indicating a bacterial infection. Inflammation of the lung tissue is associated with
accumulation of sputum this can cause serious productive cough. So rhonchi in the upper
lobes are indicative of bronchitis. Rhonchi are heard in disorders causing obstruction of the
trachea or bronchus, such as chronic bronchitis.