Question

M.E., a 72-year-old white female presents to her local primary care office in January with c/o a worsening, productive cough and increased SOB. She describes the sputum as “a dime size amount that’s thick and yellow every time I cough.” Symptoms began 1 week ago after visiting her daughter in New Mexico and worsened three days ago. Denies sick exposure but did travel by air to visit daughter. She was seen at an urgent care clinic two days prior and treated for acute bronchitis. M.E. states she is no better after taking the antibiotic and cough medicine she received at the urgent care clinic. She reports some improvement in symptoms after using an Albuterol MDI, which she had left over from a hospitalization last year for “the same thing.” Associated symptoms include poor appetite, fatigue, anxiety and trouble sleeping. M.E. denies chest pain, peripheral edema, wheezing, and/or fever. Last spirometry at her pulmonologists’ office 6 months ago showed increased total lung capacity, and reduced FEV1/FVC.

What are the principal diagnoses and 2 additional diagnoses?

Answer 1

Assessment:

1.Productive cough

2.Shortness of breath

These are the two primary problem.

Nursing diagnosis:

1.Ineffective airway clearance related to increased production of sputum.

2.Ineffective breathing pattern related to sputum production in the respiratory tract.

Additional diagnosis:

1.Pain related to the presence of sputum in the chest.

2.Fluid volume excess related to the inflammatory process in the body.