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BREATHING
SUB GROUP 4 :
CELESTE , HIDAYAH , KELLY , NABILAH , SASI , XIAO HUI , YU XING
CASE STUDY
Mr Yusof, a 66 year old retiree, is admitted to your
medical ward from the emergency department. The
provisional diagnosis is pneumonia. He complains of
breathlessness and has a productive cough. He appears to be
anxious and tired. He is unable to provide his medical history.
His wife answers for him instead while he sits, leaning over
the bedside table. She says that he has been coughing out
greenish sputum over the past 3 days.
Assessment
Temperature: 38.3 C
Blood Pressure: 140/80mmHg
Pulse Rate: 108 beats per minute
Respiration: 28 breaths per minutes, with the use of
accessory muscles
SpO2: 92%
Pain Score: 4/10, complained of chest tightness from
frequent coughs
Mr Yusof
Gender
Male
Address
Birthdate
1949
Place of birth
Singapore
Race
Malay
Age
66 years old
Marital status
Married
Primary caregiver
Wife
Provider of history
Wife
Admission date
23 July 2015
Renovation supervisor
Chief complaints
Productive cough
Diagnosis
Pneumonia
Location
Duration
Three days
Relieving
factors
Treatment
Current Medication
(medication that the ED
has given before
admitting to our ward)
Past medical/surgical
history
Family History
Social History
Oral antibiotics
Erythromycin
Oral Paracetamol
None
NIL
Worked as a renovation
supervisor
Lives with wife, no
children
Smokes cigarettes since
age of 16 years, smokes
10-15 sticks per day
What is
Breathlessness?
Shortness of breath
(SOB)
It is a feeling of difficult or laboured breathing that can be
caused by certain acute or sudden onset conditions.
It is a sensation of difficulty or uncomfortable breathing
Normal breathing
Spo2: 95 100%
Objective data
Subjective data
Sleeping
Objective data
Subjective data
Date identified
Ineffective
Breathing Pattern
(Actual Problem)
23 July 2015
23 July 2015
Fever
23 July 2015
Date resolved
Mr Yusof will be
able to breath
normally with
the use of less
accessory
muscles.
To facilitate better
lung expansion
and improves gas
exchange.
Mr Yusofs
respiratory rate
will be 12-20
breaths per
minute
throughout
hospitalization.
Assess Mr Yusofs
respiratory rate every 30
minutes within thefirst 8
hours and then every 4
hourly parameters if RR
has returned to normal
range.
To ensure that
patient is
breathing
normally.
Auscultate Mr Yusofs
breathing sounds.
Abnormal
breathing sounds
may indicate
inadequate
ventilation.
Goal &
Expected
Outcome (E0)
Interventions
Rationale
Subjective Data:
Mr Yusof complains
of breathlessness.
Mr Yusofs wife
mention he has
been coughing out
greenish sputum.
His wife answered
his medical history
for him.
Mr Yusof will be
able to breath
normally with
the use of less
accessory
muscles.
Assist patient to a
position of comfort
around 45 degrees in
semi-fowler position).
To facilitate lung
expansion and
sputum
expulsion.
Auscultate Mr Yusofs
breathing sound.
Patients airway
may be block by
mucous plug,
affecting his
breathing.
Increase Mr Yusofs
fluid intake.
Increasing fluid
intake can help to
loosen the thick
sputum secretion.
Allows better
Objective Data:
Effective airway
Use of accessory
clearance.
muscles
RR 28 bpm(Normal
range is 12-20
bpm)
Resolve Mr
Evaluati
on
Goal &
expected
outcome (E0)
Interventions
Rationale
Subjective
Data:
Smoking
since age of
16
10-15 sticks
per day
To
reduce/eliminat
e knowledge
deficit.
Educate Mr
Yusof how bad
smoking is to
his health and
regarding his
illness.
Educate Mr
Yusof what is
pneumonia and
how is it
affecting his
health and
work.
To ensure the
Ask patients
treatment given relative to
is accurate
perform return
demo or
Evaluat
ion
References
Vera, M. (2012). 5 Pneumonia Nursing Care Plans.
Retrieved from
http://nurseslabs.com/pneumonia-nursing-care-plans/
Vera, M. (2013). 5 Chronic Obstructive Pulmonary
Disease (COPD) Nursing Care Plans. Retrieved from
http://nurseslabs.com/5-chronic-obstructive-pulmonarydisease-copd-nursing-care-plans/
Sabtu. (2013) Ineffective Airway Clearance. Retrieved
from
http://nursinginterventionsrationales.blogspot.sg/2013/
07/ineffective-airway-clearance.html