Health Assessment and Physical Examination
Case Study #1
Case
The patient, a 60-year-old male who works as a roofer, noted onset of shortness of breath, associated with more noticeable effort to breathe and rattling in chest, 6 months ago. SOB is aggravated when the patient is on the job, climbing ladders, carrying shingles, or walking around the job site picking up debris. Patient says he becomes fatigued easily and reports that if he does not sleep on two large pillows, he awakens somewhat short of breath. Patient reports coughing up a rusty brown mucoid sputum in the morning for approximately 5 years. Denies history of pneumonia, hemoptysis, tuberculosis, fever, night sweats, precordial pain or discomfort, heart murmurs, varicosities, phlebitis, or claudication. Vital signs: BP 150/84, T 37.1 C/98.8° F, P 86, R 28.
Physical Examination
General Appearance: Alert, responsive; appears older than stated age; lips dusky.
Heart: Rate 86, regular; heart sounds distant; no murmurs.
Lungs: Respirations 28/min; patient uses accessory muscles to facilitate respiration. Expiration prolonged; associated with lip pursing. AP diameter increased; patient has barrel-shaped chest. Auscultation yields distant lung sounds, with end-stage expiratory wheezes on forced expiration.
Nose: Within normal limits.
Throat: Within normal limits; jugular veins demonstrate some distension.
1) State the subjective data.
2) State the objective data and state whether each is normal or abnormal.
3) State at least two nursing diagnoses and choice rationale for choosing them
4) What information is need to make the diagnoses and generate a care plan for this patient?
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