Case Study

AB is a 72-year-old female who the nurse is admitting to a telemetry hospital bed.  She stated: “I was feeling terrible—I had trouble breathing for a few days, but thought it would go away in awhile. But, I couldn’t sleep at night.   I haven’t eaten much of anything for days, but I gained 10 pounds! We were going to church this morning, but I just couldn’t catch my breath, so my husband brought me to the hospital to get help.”  
Physical assessment revealed an elderly woman with average body habitus, but an enlarged waist. She is alert, oriented x 4 and denies chest pain.  Her facial expression is slightly anxious and she is breathing with some difficulty, although she can finish a complete sentence in one breath. The telemetry monitor reveals sinus tachycardia with no ectopic beats.  The client is tachypneic. The nurse inspects the client’s chest, which reveals symmetric chest movement and  intact skin.  Lung sounds on the anterior chest reveal no adventitious sounds on the apices or the 2nd through 4th ICS on either sternal border. Abdomen is soft and slightly distended.  Radial, brachial, post tibial pulses are 2+.  Patient denies chest pain, but endorses feeling short of breath with a persistent nonproductive cough.
Assignment:

Organize the information by subjective and objective data.  (10%)
 
List five priority questions the nurse should ask to obtain a more complete history focused on this client’s thorax and lungs, heart and great vessels, peripheral vascular and lymphatic system, and abdomen.   (15%)
 
What additional assessments should the nurse do to complete a focused physical assessment of this client’s thorax and lungs, heart and great vessels, peripheral vascular and lymphatic system, and abdomen? (60%)
 
List three priority health problems the nurse should help this client with. (Use NANDA terminology)  (15%)
 

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