Name: Charlynne G.

Araojo

Course/Year/Block: BSN – BLOCK 1D

Case Study:

Steve is a 32-year old man who presents to the emergency department with shortness of breath which he states has developed over the past 2
days. He has been feeling a bit dizzy this morning and thought he should see doctor as he developed what he describes as mild chest pain, mostly
on inspiration, this morning. He also reports his calves are sore and a little swollen. He initially called a medical advice line who suggested he
attended the emergency department rather than his general practitioner (GP) clinic. From your observations, it is clear Steve is using his accessory
muscles to breathe in and he reports that he has been using a lot of extra effort. Steve’s only past history involves sporting injuries. He is not taking
any regular medication. He travelled to Thailand on an end-of-season trip with his football team, returning the day before the symptoms appeared.

As the nurse in the emergency department, you conduct a full assessment of Steve. His vital signs are currently:

• BP – 104/74 mmHg

• HR – 105 beats/minute

• RR – 28 breaths per minute

• T – 37.2°C • SpO2 – 91% with no supplemental oxygen

NURSING CARE PLAN:

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: • Ineffective Short Term: • The nurse will → The semi-fowlers o Met
• Shortness of breath breathing • After 3 hours of position the position permits o Unmet
which developed over pattern related nursing patient into semi- maximum lung
the past 2 days to hypoxia AEB interventions the fowlers position. excursion and
according to the shortness of patient will chest expansion
patient. breath, use of demonstrate which helps to
• He has been feeling a accessory appropriate coping • The nurse will improve breathing.
bit dizzy this morning. muscles to behaviors and assess and record → Examining the o Met
• He developed what breathe in, methods to the patient’s vital patient's vital signs o Unmet
he describes as mild SpO2 of 91% signs every 4 hours will aid in
 chest pain, mostly on and a improve breathing monitoring when
inspiration this respiratory rate pattern. there is a change in
morning. of 28 breaths • The patient will the patient's
• The patient report per minute. demonstrate respiratory
that his calves are adequate condition and take
sore and a little oxygenation as immediate action
swollen. evidenced by an when there is an
oxygen saturation alteration of
Objective Data: of 92-98% after 3 breathing patterns.
• Using accessory hours.
muscles to breath in. • Observe and check → Taking a look at the
• Vital signs the oxygen patient's situation o Met
- BP-104/74mmHg saturation and RR oxygenation aids o Unmet
- HR-105 Long Term: of the patient in assessing the
beats/minute • After 1 week of every 30 min. efficiency of
- RR-28 breath per nursing oxygen therapy.
min. interventions the While assessing
- T- 37.2°C patient will be able the RR of a patient
- SpO2- 91% with to maintain an can be used to
no supplemented effective and determine
oxygen adequate whether or not the
breathing as patient's condition
shown by relaxed is improving.
breathing
characterized by a → Breathing
normal respiratory • The nurse will exercises methods
rate and free from provide and can be beneficial o Met
signs and demonstrate an encourage deep o Unmet
symptoms of essential breathing breathing, which
respiratory technique and promotes
distress. exercise to the oxygenation as
patient. well as preventing
atelectasis.