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. : Alert, responsive; appears older than stated age; lips dusky. : Rate 86, regular; heart sounds distant; no murmurs. : 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. : Within normal limits. : 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?

1) The subjective data provided in the case are as follows:
– The patient, a 60-year-old male, experiences onset of shortness of breath.
– The shortness of breath is associated with more noticeable effort to breathe and rattling in the chest.
– The symptoms started 6 months ago.
– Shortness of breath is aggravated when the patient is on the job, climbing ladders, carrying shingles, or walking around the job site picking up debris.
– The patient becomes fatigued easily.
– The patient reports having to sleep on two large pillows to avoid waking up short of breath.
– The patient reports coughing up a rusty brown mucoid sputum in the morning for approximately 5 years.
– The patient denies any history of pneumonia, hemoptysis, tuberculosis, fever, night sweats, precordial pain or discomfort, heart murmurs, varicosities, phlebitis, or claudication.

2) The objective data provided, along with their classification as normal or abnormal, are as follows:
– Blood Pressure (BP): 150/84 – Abnormal (elevated).
– Temperature (T): 37.1 C/98.8° F – Normal.
– Pulse (P): 86 beats per minute – Normal.
– Respiratory Rate (R): 28 breaths per minute – Abnormal (elevated).
– General Appearance: The patient appears older than stated age and has dusky lips – Abnormal.
– Heart Sounds (H): Heart sounds are distant, with no murmurs – Abnormal (distant).
– Lung Sounds (L): Lung sounds are distant, with end-stage expiratory wheezes on forced expiration – Abnormal (end-stage expiratory wheezes).
– Oxygen Saturation (O2 Sat): Not provided – Unknown/Not given.
– Jugular Vein Distension (JVD): Some distension observed – Abnormal (distension).

3) Two nursing diagnoses that can be considered for this patient are:
– Impaired Gas Exchange: This diagnosis is appropriate based on the patient’s subjective data of shortness of breath, rattling in the chest, and coughing up mucoid sputum. The objective data of increased respiratory rate, barrel-shaped chest, prolonged expiration, and distant lung sounds further support this diagnosis. The rationale for choosing this diagnosis is that the patient’s respiratory function is impaired, leading to inadequate oxygenation and ventilation.
– Activity Intolerance: This diagnosis is appropriate based on the patient’s subjective data of becoming fatigued easily and experiencing aggravated shortness of breath during physical exertion. The patient’s job as a roofer involves activities that require physical effort, which exacerbate the symptoms. The patient also reports needing extra pillows to sleep comfortably, indicating decreased tolerance for exertion. The rationale for choosing this diagnosis is that the patient’s ability to perform physical activities is limited due to the respiratory symptoms.

4) To make the diagnoses and generate a care plan for this patient, additional information is needed. This may include:
– Further assessment of the patient’s respiratory function, such as obtaining specific oxygen saturation levels or performing pulmonary function tests.
– A detailed medical history, including any relevant conditions or exposures that may contribute to the symptoms.
– Identification of any risk factors or comorbidities that could be contributing to the respiratory symptoms.
– Assessment of the patient’s current medications and any potential side effects or interactions that may impact respiratory function.
– Collaboration with other healthcare professionals to obtain diagnostic tests or consultations, such as a chest x-ray or referral to a pulmonologist.

By gathering this information, a comprehensive care plan can be developed to address the patient’s specific needs and promote optimal respiratory function.