Introduction- Symptom Analysis (COLDSPA) Performing a symptom analysis or expand

Introduction-
Symptom Analysis (COLDSPA)
Performing a symptom analysis or expanding on the “History of Present Health Concern” takes into account several aspects of the health problem and asks questions whose answers can provide a detailed description of the concern.
The student would address the onset, progression, and duration of the problem; signs and symptoms, related problems or concerns; what the patient believes is the cause of the problem, and their appraisal of the problem (minor, severe, etc.). Also adress if anything makes the problem better, worse, what treatments have been tried and the treatment’s effectiveness, and what how the problem has effected the patient’s daily life or lifestyle.The patient’s answers may provide the nurse with a beneficial information about the patient’s problem(s).
Performance Objective:
–Collect and analyze data regarding a symptom to obtain a history of present illness (symptom analysis) using the COLDSPA mnemonic by reviewing videos, chart and data provided.
–For the “A” element, address BOTH Associated Factors AND how the problem affects the patient
Evaluation:
Complete the symptom analysis template with the provided information and
utilize the collected information to formulate the symptom analysis reflection questions.
1. Review patient chart -upload today 10.45am
1b. Cardiac supplementary form– uploaded 10.48am
2. Watch Case Scenario video- Charles Jones –https://youtu.be/E48WWqqOoJA
3. completed focused assessment form–uploaded 10.52am
4. Completed assessment reflection.–uploade 10.54am
Comments made on the reflection
1. Q6 Name 2 nursing diagnosis, identify the priority diagnosis. Why do you think you chose that diagnosis?
—–Comments
Great! The priority diagnosis for this patient is Impaired gas exchange AEB O2 sat 93% on 2 L SOB without O2 cannula.; orthopnea and dyspnea on room air as well as increase respirations.
2. Q7 Possible interventions for this patient?
—-Comments
Good interventions! Other nursing interventions include:
Assess lung sounds and respiratory rate
Assess O2 sat with vital signs
Apply O2 via nasal cannula per Dr order
Teach patient about daily weights, managing fluids
Teach patient about managing energy by taking small breaks
Teach patient about IS