Question

CASE STUDY DETAILS

Case Scenario:

A 30-year-old female patient was brought by her husband to Accident & Emergency in Nizwa Hospital. Upon interview, the patient stated, “I am experiencing difficulty in breathing this past 2 days”. Upon assessment you noted the following: patient is restless with productive cough, crackles heard during auscultation, presence of nasal flaring and chest retractions with the following vital signs: BP 110/80, PR 110 bpm, RR 25 bpm, Temp. 37.1 ⁰C and SPO2 88.

1. Based from the above scenario identify ASSESSMENT DATA relevant to the care of the patient. Group the data gathered either subjective or objective data.
2. Applying the concepts learned about the nursing process and based on your assessment of the patient, what PRIORITY NURSING DIAGNOSIS?
3. Based on the given nursing diagnosis, identify the PLAN OF CARE applicable for the patient. Indicate the Goal and 3 outcome criteria.

Answer 1

1. Assessment data

Subjective data: patient complaint s of difficulty in breathing for last 2 days and cough production

Objective data: patient shows restless in behaviour and excessive sputum

Vital signs:    temperature: 37.1 F

                        Pulse rate: 110/beat per minute

                        Respiration: 25/breaths per minute

                          Blood pressure: 110/80 mm of HG

                          SPO2           : 88%

Respiratory assessment

Inspection: evidence of nasal flaring is present in nasal   chest wall retraction can be seen in chest

Auscultation: crackles heard in the lungs

2. PRIORITY NURSING DIAGNOSIS

1. Ineffective airway clearance related to obstruction of airway by mucus as evidenced by restlessness of patient, increased mucus production

2. Ineffective breathing pattern related to dyspnea, copious mucous production as evidenced by spo2 is 88%, presence of nasal flaring, chest wall retraction

3. Impaired gas exchange related to increased mucus production as evidenced by spo2 is 88%

4. imbalanced nutrition less than body requirement related to protein loss in sputum production as evidenced by increased mucus production

4. Activity intolerance related to breathing difficulty as evidenced by restless and spo2

5. Self care deficit related to breathing difficulty

3. Nursing care plan

Assessment	goals	Nursing diagnosis	intervention	Rationale	outcome
Subjective data: I have breathing difficulty for the past 2 days Objective data: Increased mucus production	To increase airway clearance	Ineffective Airway clearene related to obstruction of airway by mucus as evidenced by increased mucus production	· Assess vital signs · Make her fowler position · Educate diaphragmatic and pursed lip breathing · Calm and relax her · Encourage to remove sputum by coughing · Administer oxygen therapy · Administer medication as per order such as nebulizer with oxygen therapy	· To provide baseline data · To expanse the lungs · To slow the respiration · Anxiety increase s work of breathing · Removing sputum helps to clear passage · To increase spo2 · To clear mucus that obstructs airway passage	Her airway will be cleared
Subjective data: patient says I have breathing difficulty for the last 2 days Objective data : spo2 is 88%	To reduce breathing difficulty	Ineffective breathing pattern related to dyspnea, copious mucus production as evidenced by spo2 is 88%	· Check vital signs · Educate pursed lip breathing technique and diaphragmatic breathing technique · Advise her to limit exercise · Educate to avoid speaking continuously · Place her in a comfortable position	To provide baseline data It helps to reduce work of breathing To conserve energy for respiration Speaking increases work of breathing Such a comfortable makes her to breathe easy	Her breathing difficulty will be reduced
Subjective data : I have breathing difficulty for the last 2 days Objective data: Spo2 is 88%	To improve gas exchange	Impaired gas exchange related to increased mucus production as evidenced by spo2 is 88%	· Check vital signs · Check pulse oximetry for saturation · Check ABG analysis · Educate pursed lip breathing and diaphragmatic breathing techniques · To administer oxygen · To administer medication as per order	· To provide base line date · To check for increase or decrease of saturation · It provides data of respiratory oxygen, co2, hco3, ph · It improves gas exchange · To increase exchange · It helps to remove secretion and improve gas exchange	Gas exchange in the lungs will be improved