Read the following case study. Then, work through the steps of analyzing the case study data. First, identify abnormal data and strengths in what would be subjective and objective findings, make nursing and possible medical diagnoses, identify defining characteristics, confirm or rule out diagnoses, and document your conclusions. Identify collaborative problems, if any, for this client.
Theresa is a 55 year-old white woman. She is a part-time secretary for a local businessman and is very active in her community. She is married and has two children. She presents at the nursing clinic this morning with a complaint of extreme shortness of breath. When entering the exam room, she appears very anxious and states that she has experienced this problem since yesterday afternoon.
Theresa has no previous diagnosis of asthma, allergies, or respiratory problems, but brother and father have cases of mild asthma . The client has smoked for 35 years but reports limiting her smoking to a pack every 2-3 days for the past 10 years. Before that, she reports having smoked a pack every day. She worked in her office yesterday and reports having felt fine. She met friends at a local park for lunch but denies anything unusual about her daily activity. She states she has experienced “tightness in my chest” increasing in severity since about 5pm yesterday. She denies any other associated symptoms such as pain or cough. Her discomfort made sleeping difficult last night, and she states she has not eaten today because of her shortness of breath.
Theresa currently takes no medications. She reports having no regular exercise program but denies any intolerance to activity until the onset of dyspnea. She reports having tried only rest to alleviate the problem and knows “nothing else to do but go to the doctor.”
Theresa’s respiratory rate is 26 breaths/minute and appears somewhat labored. The client seems somewhat apprehensive and experiences obvious dyspnea on even mild exertion. Her anteroposterior diameter is within normal limits. The use of accessory muscles is noted, with respiration immediately after exertion. Expiration is somewhat labored and prolonged. Tactile fremitus is decreased, especially in lower lobes. Percussion tones are resonant over all lung fields. Breath sounds are decreased, with prolonged expiration. Voice sounds are also decreased. Expiratory wheeze is noted throughout the lung fields, especially bilaterally in the lower lobes.
INTRODUCTION:
The patient Mrs.Theresa a 55 year old white woman came with the complaint of extreme shortness of breath since about 5 pm yesterday.
Subjective data:
She states she has experienced "tightness in my chest". She denies any other associated symptoms such as pain or cough. Her discomfort made sleeping difficulty last night and she states she has not eaten today because of her shortness of breath.
Objective data:
Dyspnoea on even mild exertion.
The use of accessory muscles with respiration immediately after expiration
We can conclude her condition as asthma because all symptoms of asthma except coughing is present in her condition. And also there is family history of asthma. This patient also has a history of smoking. The use of accessory muscles are typically only used under conditions of high metabolic demand or respiratory dysfunction such as asthma.
ASTHMA is a chronic inflammatory disease that causes airway hyperresponsiveness, mucus production and mucosal edema resulting in reversible airflow obstruction.
Symptoms: include coughing, wheezing, shortness of breath and chest pressure.
Causes: Air pollutants and irritants such as smoke, respiratory infections, physical activity, cold air.
Medical diagnosis : Asthma
Diagnosing asthma includes a medical history, physical examination and lung tests.A detailed obtaining of medical history and a thorough physical examination should be maintained.
The lung tests include spirometry, peak flow, exhaled nitric oxide test, methacholine challenge.
Nursing diagnosis:
1. Ineffective breathing pattern may be related to swelling and spasm of the bronchial tubes in response to inhaled irritants possibly evidenced by use of accessory muscles.
2.Ineffective airway clearance may be related to bronchospasm possibly evidenced by chest tightness.
3. Imbalanced sleeping pattern may be related to breathing difficulty.
4. Anxiety may be related to respiratory distress possibly evidenced by dyspnoea.
On examination the findings reveals the characteristics of asthma so we can conclude it and confirm the rule out diagnosis.
Read the following case study. Then, work through the steps of analyzing the case study data....
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
Read the case study. Then answer the questions at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production but...
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Read the case study. Then answer the questions typed at the end of the case study. The patient is a 60-year-old Caucasian female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago requiring hospitalization. She uses BiPAP ventilatory support at night when sleeping. She denies fever, chills, cough, wheezing, and sputum production...