Nursing case study

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 – give rationales, also.

1. What other questions should the nurse ask about the cough?
2. Develop a problems 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?

Sample Solution