C.M. is a 69-year-old female who presents to the emergency department with shortness of breath.   Subjective data: PMH: HTN, hypothyroid Sudden onset shortness of breath Denies chest pain but reports chest tightness and cough Current smoker, 1 pack a day for 50 years   Objective data: Vital signs: T 37 C, P 92, R 18, BP 144/64 Lungs: + inspirational wheeze upper and lower lobes, bilaterally O2 sat = 90% Skin cool to touch CV = heart rate regular, positive peripheral pulses Nose = + erythema, clear discharge Throat = erythema   Medications: metoprolol 12.5 mg per day, Synthroid 0.50 mcg once per day   Questions What other questions should the nurse ask about the shortness of breath? What other assessments are necessary for this patient? What are some of the causes of shortness of breath?

Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
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C.M. is a 69-year-old female who presents to the emergency department with shortness of breath.

 

Subjective data:

  • PMH: HTN, hypothyroid
  • Sudden onset shortness of breath
  • Denies chest pain but reports chest tightness and cough
  • Current smoker, 1 pack a day for 50 years

 

Objective data:

  • Vital signs: T 37 C, P 92, R 18, BP 144/64
  • Lungs: + inspirational wheeze upper and lower lobes, bilaterally
  • O2 sat = 90%
  • Skin cool to touch
  • CV = heart rate regular, positive peripheral pulses
  • Nose = + erythema, clear discharge
  • Throat = erythema

 

Medications: metoprolol 12.5 mg per day, Synthroid 0.50 mcg once per day

 

Questions

  1. What other questions should the nurse ask about the shortness of breath?
  2. What other assessments are necessary for this patient?
  3. What are some of the causes of shortness of breath?
  4. Develop a problem list from objective and subjective data.
  5. What should be included in the plan of care?
  6. What risk factors are associated with this age group?
  7. Based on the readings, what is the most likely cause of shortness of breath for this patient?
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