Health Assessment and Physical Examination
Case Study #1
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.
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?
Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.
You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.Read more
Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.Read more
Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.Read more
Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.Read more
By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.Read more