Question

Case Study: 52-Year-Old Female Presents with Chronic SOB, and Cough

History of Present Illness: Casey, who is 52-year-old female presents after admission to the San Francisco General 7E Medical/Surgical Hospital. Her chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office three months ago. At that time, she was diagnosed with acute bronchitis and treated with bronchodilators, empiric antibiotics, and a short course oral steroid taper. This management did not improve her symptoms, and she has gradually worsened over six months. She reports a 20-pound intentional weight loss over the past year. She denies camping, spelunking, or hunting activities. She denies any sick contacts. A brief review of systems is negative for fever, night sweats, palpitations, chest pain, nausea, vomiting, diarrhea, constipation, abdominal pain, neural sensation changes, muscular changes, and increased bruising or bleeding. She reported persistent cough and shortness of breath upon exertion.

Social History: Her tobacco use is 35 pack-years; however, she quit smoking shortly prior to the onset of symptoms, a year ago. She denies alcohol and illicit drug use. She is married, in a monogamous relationship, and has one adult daughter who leaves in Florida.

Allergies: NKDA

Past Medical History: HTN

Past Surgical History: Cholecystectomy

Medications: Lisinopril 10mg by mouth every day

Physical Exam:

Vitals: Temperature, 96.8 F; heart rate 86; respiratory rate, 20; blood pressure 142/82;

body mass index, 34

General: appears anxious, a pleasant female lying on a hospital stretcher. She is conversing freely, with respiratory distress causing her to stop mid-sentence.

Respiratory: She has diffused rales and mild wheezing; tachypneic.

Cardiovascular: She has a regular rate and rhythm with no murmurs, rubs, or gallops.

Gastrointestinal: Bowel sounds X4. No bruits or pulsatile mass. Reported last BM was 2 days ago.

Nursing Diagnosis	Patient Goals	Intervention	Rational	Evaluation
1.	1 2 3 4 5	1 2 3 4 5 6 7 8 9 10

Answer 1

Nursing Care plan for Patient , Mrs. Casey

Nursing Diagnosis:

* Ineffective breathing pattern related to infection / inflammatory process as evidenced by shortness of breath and tachypnoea.

(* Ineffective airway clearance related to tracheal bronchial inflammation as evidenced by dyspnoea and cough

* Impaired gas exchange related to inflammation of airways and alveoli as evidenced by tachypnoea and dyspnoea. )

Goals

* Patient maintains an effective breathing pattern as evidenced by relaxed breathing and absence of dyspnoea.

* Patient verbally indicates feeling comfortable when breathing.

* Patient respiratory rate remains within established limits

* Patient performs diapragmatic and pursed lip breathing.

* When patient carries out daily activities breathing pattern remains normal.

Interventions with Rationale :

* Assess the respiration, its characteristics, rate and depth:

to assess the base line data and to find out any abnormal respiratory pattern ( rationale)

* Auscultate for abnormal breath sounds

( Abnormal breath sounds may indicate any fluid collection or inflammatory process within lungs)

* Monitor Pulse oxymetry and ABG values

( pulse oximetry and Arterial blood gas analysis can reveal the oxygen saturation of blood)

* Assess for any changes in consciousness and mental status

( Any changes in consciousness and confusion are indicating the insufficient oxygen supply to brain)

* Provide a comfortable position, semi sitting position, for the patient.

(.to ease breathing by maximising the lung expansion)

* Encourage deep breathing exercises by demonstrating it.

( Deep breathing can increase oxygenation and prevents atelectasis)

* Encourage frequent rest periods and teach patient to take rest / pace in between the activity

( SOB can be worsened by continous activity)

* Provide proper Ventilation in the room by a fan with slow speed.

( Air movement in the room may improve dyspnoea)

* Maintain clear airway, encourage the patient to expectorate if any secretions while coughing.

( to facilitate clear airway for easy breathing)

* Assist the patient in ADL

( to avoid over exertion)

* Administer oxygen as pet physician's order:

to relieve from dyspnoea and to increase oxygen saturation.

* Administer medications , antitussives , as per physician's order.

( Antitussives for reducing the cough)

Evaluation:

* Patient maintains an effective breathing pattern as evidenced by patient's relaxed state.

* Patient's respiratory rate established within the limits as evidenced by Respiratory rate ( 16 - 24 bpm)

* Patient verbally indicates the feeling of comfortable while breathing.

* Patient performs diaphragmatic and pursed lip breathing.

* Patient's breathing pattern is normal when she carrying out the ADLs.