Subjective data includes the patient’s report of symptoms, sensations, and feelings. In this case, the patient reports a history of shortness of breath, increased effort to breathe, and rattling in the chest that started 6 months ago. The shortness of breath worsens when the patient is engaged in physical activity such as climbing ladders or carrying shingles. The patient also experiences fatigue easily and needs to sleep on two pillows to prevent waking up short of breath. Additionally, the patient reports coughing up rusty brown mucoid sputum in the morning for approximately 5 years. The patient denies a history of pneumonia, hemoptysis, tuberculosis, fever, night sweats, precordial pain or discomfort, heart murmurs, varicosities, phlebitis, or claudication.
Objective data refers to measurable information obtained through observation, examination, and testing. The objective data in this case includes vital signs, physical appearance, and physical examination findings. The patient’s vital signs are as follows: blood pressure is 150/84 mmHg, temperature is 37.1°C/98.8°F, pulse rate is 86 beats per minute, and respiratory rate is 28 breaths per minute. The patient appears older than stated age and has dusky lips. Upon auscultation of the heart, the sounds are distant and there are no murmurs. The patient’s respiratory rate is increased and the patient uses accessory muscles to facilitate respiration. The patient’s chest has an increased anteroposterior diameter, indicating a barrel-shaped chest. Auscultation of the lungs reveals distant lung sounds with end-stage expiratory wheezes on forced expiration. The jugular veins show some distension.
Based on the subjective and objective data, two nursing diagnoses that can be made for this patient are:
1) Impaired Gas Exchange related to obstructive lung disease secondary to chronic exposure to occupational and environmental irritants. The patient’s shortness of breath, increased effort to breathe, and the presence of wheezes on expiration indicate difficulty in exchanging gases effectively. The patient’s occupation as a roofer, which involves exposure to various irritants, may have contributed to the development of this condition.
2) Ineffective Breathing Pattern related to decreased lung compliance secondary to chronic obstructive pulmonary disease (COPD). The patient’s use of accessory muscles, lip pursing during expiration, and the presence of a barrel-shaped chest indicate altered breathing patterns. The decreased lung compliance associated with COPD affects the patient’s ability to breathe efficiently.
To make these diagnoses and generate a care plan for this patient, additional information is needed. This information includes a thorough medical history, including any previous diagnoses or treatments for respiratory conditions, smoking history, and history of exposure to occupational and environmental irritants. PFTs (Pulmonary Function Tests) may also be helpful in assessing lung function and determining the severity of the respiratory impairment. Chest X-rays or CT scans may provide information about the structural changes in the lungs. Arterial blood gas (ABG) analysis can help evaluate the patient’s ability to oxygenate and eliminate carbon dioxide. It would also be important to assess the patient’s current medications, including any inhalers or respiratory treatments.
