Case Study: Shortness of Breath

Nurse Case Study: Shortness of Breath

Patient Profile:

• Name: Linda Stevens

• Age: 65 years

• Gender: Female

• Medical History: Hypertension, Type 2 Diabetes, Asthma

• Medications: Lisinopril, Metformin, Albuterol Inhaler

• Allergies: No known drug allergies

  
  

Chief Complaint: Linda presents to the emergency department with complaints of shortness of breath that began suddenly 2 hours prior to arrival. She describes it as a feeling of tightness in her chest and difficulty breathing.

Assessment:

• Vital Signs:

  • Blood Pressure: 150/90 mmHg

  • Heart Rate: 110 beats per minute

  • Respiratory Rate: 28 breaths per minute

  • Oxygen Saturation: 88% on room air

  • Temperature: 98.6°F (37°C)

• Physical Examination:

  • General: Patient appears anxious and in mild distress.

  • Respiratory: Use of accessory muscles, wheezing noted bilaterally, decreased breath sounds at the bases.

  • Cardiovascular: Tachycardic, regular rhythm, no murmurs.

  • Extremities: No cyanosis, capillary refill < 2 seconds, peripheral edema absent.

• Focused Assessment:

  • Lung auscultation reveals bilateral wheezing and rhonchi.

  • Patient reports history of asthma exacerbations and recent upper respiratory infection.

Diagnostic Tests to Consider:

• Chest X-ray: No acute infiltrates; mild hyperinflation noted.

• ECG: Sinus tachycardia, no ischemic changes.

• Blood tests: CBC, BMP, and D-dimer (pending).

• Arterial Blood Gas (ABG): pH 7.35, pCO2 50 mmHg, pO2 60 mmHg, HCO3 24 mEq/L (indicating respiratory acidosis).

Nursing Diagnosis

1. Impaired gas exchange related to bronchospasm and airway inflammation as evidenced by shortness of breath and low oxygen saturation.

   
   

2. Anxiety related to difficulty breathing as evidenced by patient’s verbalization of fear and observable distress.

Nursing Interventions:

1. Administer Oxygen: Start supplemental oxygen therapy via nasal cannula to maintain oxygen saturation above 92%.

2. Bronchodilator Therapy: Administer Albuterol via nebulizer as prescribed to relieve bronchospasm.

3. Positioning: Assist the patient to sit upright in high Fowler’s position to optimize lung expansion.

4. Monitor Vital Signs: Continuously monitor respiratory rate, heart rate, blood pressure, and oxygen saturation.

5. Patient Education: Teach the patient about the use of inhalers, recognizing early signs of exacerbation, and the importance of adhering to medication regimens.

6. Emotional Support: Provide reassurance and support to reduce anxiety and promote relaxation techniques.

Evaluation:

• After interventions, Linda's oxygen saturation increased to 94% on 2L nasal cannula.

• Wheezing decreased, and she reports feeling less anxious.

• Patient demonstrates understanding of her condition and the use of her inhaler.

Follow-up or Continued Needs:

• Linda will be discharged with a prescription for a short course of oral corticosteroids and a follow-up appointment with her primary care provider.

• Education on asthma management and an action plan will be provided to prevent future exacerbations.

Conclusion

This case study illustrates the nursing process in managing a patient with shortness of breath, emphasizing the importance of assessment, intervention, and patient education in promoting optimal health outcomes.