Read the following case study. Then, work through the steps of analyzing the case study data. First, identify abnormal data and strengths in what would be subjective and objective findings, make nursing and possible medical diagnoses, identify defining characteristics, confirm or rule out diagnoses, and document your conclusions. Identify collaborative problems, if any, for this client.
Theresa is a 55-year-old white 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 has no previous diagnosis of asthma, allergies, or respiratory problems, but the brother and father have cases of 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 every 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 she has experienced “tightness in my chest” increasing in severity since about 5 pm yesterday. She denies any other associated symptoms such as pain or cough. Her discomfort made sleeping difficult last night, and she states she has not eaten today because of her shortness of breath.
Theresa currently takes no medications. She reports having no regular exercise program but denies any 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’s respiratory rate is 26 breaths/minute and appears somewhat labored. The client seems somewhat apprehensive and experiences obvious dyspnea on even mild 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 lower lobes. Percussion tones are resonant over all lung fields. Breath sounds are decreased, with prolonged expiration. Voice sounds are also decreased. Expiratory wheeze is noted throughout the lung fields, especially bilaterally in the lower lobes.