Group 2

Theresa J. 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
examination room, she appears very anxious and states that she has experienced this problem since yesterday afternoon.
Theresa J. has no previous diagnosis of asthma, allergies, or respiratory problems, but her 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 to 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 the local park for lunch but
denies anything unusual about her daily activity.  She states she had 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 that
she has not eaten today because of her shortness of breath.
Theresa J. 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 to go to the doctor.”
Theresa J.’s respiratory rate is 26 breath/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.
Subjective Objective Assessment Planning Implementation Mini-Rationale (scratch) Evaluation
 Complains  Appears very Risk for After 10 minutes of Independent: Independent: After 15
of extreme anxious Ineffective nursing intervention, 1. Position the 1. To open for minutes of
shortness when Airway the patient will patient in airway in an at nursing
of breath entering the Clearance R/T report stability in fowler’s position rest or intervention,
since examination dyspnea AEB respiratory rate while resting on compromised the goal is met
yesterday room respiratory rate from 26 bpm to 20 bed. Regularly individual (poor and the patien
afternoon of 26 bpm and bpm, demonstrate check the ergonomic reports stabilit
 RR: 26bpm with prolonged comfortable patient’s position results in respiratory
 Father and and labored breathing with position to to more rate,
brother  Seems expiration minimal wheezing prevent sliding complication) demonstrated
have cases somewhat and prolonged down in bed. comfortable
of mild apprehensive labored breathing, 2. Lack of breathing with
asthma and and will maintain 2. Assess patient’s adequate minimal
experiences airway clearance/ or level of oxygen or wheezing and
 No obvious patency. consciousness. venous return showed
previous dyspnea on can lead to absence of
diagnosis even mild 3. Monitor oxygen complications to prolonged
of asthma, exertion. saturation brain. labored
allergies or breathing, and
respiratory  Anteroposter 4. Monitor 3. In case the maintains
problem ior diameter: adventitious patient cannot airway
within breath sounds. maintain her clearance/ or
 Has normal breathing we patency.
smoked for limits. 5. Encourage can use oxygen
35 years adequate period or ambu bag
but reports  Use of of rest.
limiting her accessory 4. To indicate if
smoking to muscles is 6. Keep there’s
a pack noted, with environment respiratory
every 2 to 3 respiration allergen free distress/ or
days for immediately accumulation of
the past 10 after 7. Educate and secretion.
years. exertion. encourage
Before patient on 5. To decrease
that, she  Expiration is performing deep dyspnea
 reports somewhat breathing occurrence
having labored and exercises or 6. To prevent
smoked a prolonged other theraphies further
pack every respiratory
day.  Tactile 8. Evaluate infection.
fremitus is sleeping 7. To help reduce
decreased, patterns, noting inflammation
 States she especially in insomnia due to and improve
had lower lobes breathing mind and body
experience discomfort. condition.
d  Percussion
“tightness tones are 9. Educate patient 8. To prevent
in my resonant about further nighttime
chest”, over all lung effects of airway
increasing fields smoking. incompetence
severity or sleep apnea
since 5 pm  Breath 10. Encourage
yesterday. sounds are verbalization of 9. To lessen the
decreased, feelings. frequency of
 No pain with smoking
and cough prolonged
expiration 10. To illicit
 Experience feedback from
d sleeping  Voice sounds the patient,
difficulty are also whether her
last night decreased condition is
due to her making her feel
discomfort.  Expiratory better or worse.
Collaborative:
wheeze is Collaborative:
1. Refer to other
 Not yet noted 1. To identify
medical
eaten throughout causative/preci
practitioners
anything the lung pitating factors
and assist with
due to her fields,
appropriate
shortness especially
testing of the
of breath. bilaterally in
patient’s
the lower
condition
 Takes no lobes
 medication (Tests may
include
 Has no pulmonary
regular function tests,
exercising chest X-ray,
program chest CT scans,
but denies blood tests,
any bronchoscopy,
intolerance laryngoscopy,
to activity tracheal
until the intubation or
onset of tracheostomy).
her
dyspnea
 Tried to
rest to
alleviate
the
problem
and knows
“nothing
else to do
but to go to
the doctor”