Theresa J. is a 55-year-old Caucasian woman. She is a part-time secretary for a local businessman and is very active in her community.

Case Study

Theresa J. is a 55-year-old

Caucasian 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 exam room, she appears very anxious and states that

she has experienced this problem since yesterday afternoon.

Theresa J. does not have a previous

diagnosis of asthma, allergies, or respiratory problems, but her brother and

father have mild asthma. The client has smoked for 35 years but reports

limiting her smoking to a pack every 2-3 days for the past 10 years. Before

that she reports having smoked a pack per day. She worked in her office

yesterday and reports having felt fine. She met friends at a local park for

lunch but denies anything unusual about her daily activity. She states that she

has 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 does not take

any medications. She reports not having a regular exercise program and denies

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 go to

the doctor.”

Theresa J’s respiratory rate is 26

breaths/min and appears somewhat labored. The client seems somewhat

apprehensive and experiences obvious dyspnea on 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 the lower lobes,

Percussion tones are resonant over all lung fields. Breath sounds are

decreased, with prolonged expiration. Voice sounds are also decreased.

Expiratory wheezes are noted throughout the lung fields, especially bilaterally

in the lower lobes.

DIAGNOSTIC REASONING GUIDE

1.     Identify abnormal findings

Subjective:

Objective:

2.     Identify Cue Clusters

3.     Draw Inferences

4.     List Possible Nursing Diagnoses (Minimum of 4)

5.     Identify Defining Characteristics

6.     Confirm or Rule out Diagnoses (minimum of 3)

7.     Nursing Diagnoses that are Appropriate for the Client (Minimum of 2, cannot be a risk

for problem)

8.     Potential Collaborative Problems that May Require a Referral (minimum of 2)

9.     Potential Referral

10.  Identify One “Risk-For” Nursing Diagnosis