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This case study is based on shortness of breath. C.M. is a 69-year-old female who presents to the emergency department with shortness of breath.
Subjective Data:
PMH: HTN, hypothyroid
Sudden onset shortness of breath
Denies chest pain but reports chest tightness and cough
Current smoker, 1 pack a day for 50 years
Objective Data:
Vital signs: T 37 C, P 92, R 18, BP 144/64
Lungs: + inspirational wheeze upper and lower lobes, bilaterally
O2 sat = 90%
Skin cool to touch
CV = heart rate regular, positive peripheral pulses
Nose = + erythema, clear discharge
Throat = erythema
Medications:
Metoprolol, 12.5 mg per day
Synthroid, 0.50 mcg once per day
Answer the following 3 questions based on the case study data above
identify one nursing diagnosis. The nursing diagnoses must be properly formatted into 3 parts: the problem, the “related to”, and the “as evidenced by”.
Identify two nursing interventions related to the nursing diagnosis you selected.
Discuss assessment findings that led to the nursing diagnosis you selected.

 

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