Question

CASE STUDY 1 March 19, 2020 Client History: A 26 year-old female from Lower East side comes to Bellevue ER with chief complaints of cough and shortness of breath for two days, unrelieved by the use of inhaler. The patient is warm to touch. 1. What questions will you ask in the history? 2. What body system(s) will you most thoroughly assess based on the patient's chief complaint? 3. Identify the vital signs you need to get & laboratory test that need to be requested. 4. List three nursing diagnosis. Explain why you consider such nursing diagnosis as 1", 2 and 3. Explain how you will rule out each diagnosis? 5. What are risk factors contributing to the client's condition? 6. Explain the pathophysiology of the condition. 7. What are appropriate interventions for the client? 8. What are therapeutic regimen? 9. What is the most likely worst complication to anticipate? 10. What nursing assessments will you need to monitor to identify that complication is developing? 11. What is the client likely to experience when complication starts to manifest? What labs you will monitor? 12. What will you advise the family? What precautionary measures to take? 13. What will you include in the discharge teaching/instruction? 14. What areas can be addressed to promote health promotion?

Answer 1

1) I may ask the questions like:

When did you experience first shortness of breath, during exercise or at rest?

How often you have this?

How long you have been short of breath? Is it getting worse?

How often and when do you cough?

Is there any sputum production while coughing?

Do you seen any blood while coughing?

2) Respiratory system is thoroughly assesse based on patient symptoms.

Inorder to get clues physical examination of patient body can be done.

Ears, eyes, nose and throat is examined to see signs of infection. Legs and feets are examined to see any edema is there. Abdominal palpitations is checked.

A careful examination of heart is done to exclude any heart disease that is associated with these respiratory symptoms.

3) Vital signs that needs to get are

Wheezing during normal breathing.

Taking longer time to exhale fully and an expanded chest

Breathing through pursed lips.

Bluish discolouration on finger tips due to cyanosis.

signs for blood backing up in neck vein.

Diagnosis test to be recommended are:

Excluding physical examination tests include spirometry, pulmonary lung test, FEV1/FVC ratio, vital capacity, chest radiography, CT, oxygen saturation etc

4) Hypoxemia is a primary nursing diagnosis. It is the deficiency of oxygen supply to blood. It may be the primary cause of shortness of breath. Administration of bronchodilators inhalation can help to overcome this.

Infection related to disordered lung function is the secondary diagnosis. The symptom that patient come up with is coughing. Infection may result from any disorder in the lung function and so considered as secondary to it. Postural drainage to clear sputum can be done and prescribed antibiotic can be administered.

Altered nutrition, loss of muscle mass, sticky sputum and potassium depletion are the tertiary nursing diagnosis of patient. Recommend supplemental oxygen and designed meal nutrition for patient.