Question

A 20-year old male came into the emergency room complaining of 10 lbs. weight loss x2 weeks and shortness of breath x1 week. Client recently was diagnosed with strep throat 2 weeks ago but didn’t finish his antibiotics. Vital signs: 100/50, HR 112, RR 28, T 98.9, 02 saturation 93% via room air. Blood glucose checked and the nurse is unable to get glucose result.

History:No prior medical history

Surgical History:None

Family History:Mother and Father (Diabetes & HTN), Paternal & Maternal Grandparents (DM Type 2)

Allergy:None

Case Study Questions:

1. What additional information do I need from this client?
2. What is my nursing diagnosis?
3. What is my priority nursing care?
4. What clinical manifestations will I see on physical examination?
5. What labs and diagnostic testing will be done? Give rationale for each lab & test.
6. What are my nursing interventions? Give rationale for each intervention.
7. What is the disposition?  

Answer 1

From following case study complaints I expect that these condition is COPD (chronic obstructive pulmonary disease.

Additional information I need was wether patient had chronic cough,sputum production ,dyspnea on exertion,and symptoms of respiratory insufficiency and infection. These may helps to diagnose perfectly

Nursing diagnosis : possible nursing diagnosis are .: 1.Ineffective breathing pattern related to shortness of breath. 2.pyrexia related to strep throat. 3.Imbalanced nutrition related to dyspnea. 4.self care deficit. 5.cardiac insufficiency related to tissue perfusion.

priority nursing care : Improvement of breathing pattern. Airway clearance ,relife from heart conditon (reducing heart rate.)

Clinical manifestations: Dyspnea, cough with sputum production present in COPD, from the assessment we came to know heart rate increased. O2 saturation 93% with room air .

Investigations : Arterial blood gas measurements to assess base line oxygenation.X- ray to exclude alternate diagnosis.Screening for alpha antitrypsin deficiency.

Nursing interventions.

"Ineffective breathing pattern related to shortness of breath" - Nursing diagnosis .

Goal-improvment in breathing pattern

Interventions with rationale:

Teach the patient diaphragmatic and pursed lip breathing , it helps patient prolong expiration time and decrease air trapping,with these techniques patient will breath more efficiently and effectively

Encourage use of an inspiratory muscle trainer if prescribed this strengthens and conditions the respiratory muscles.