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

Nursing Interventions:

Evaluation:

Follow-up or Continued Needs:

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.