What would be the Subjective or Objective Data if the Nursing Diagnosis is Impaired Comfort related to episodic shortness of breath? Scenario: Patient X, a 79-year-old male and retired construction worker from Cebu, was taken to the hospital on September 3 due to a two-week progression of episodic shortness of breath. The patient was in good health until two weeks ago, when he discovered he was having trouble catching his breath while walking. He was used to walking 3 kilometers without stopping, but now he was out of breath after only 100 meters. The patient's symptoms were worsening, and he had been complaining of shortness of breath while lying down for the past three days. He had always slept with one pillow, but now he needed two. In addition, the patient reported an 8 to 10 pound weight gain in the previous 6 weeks. He had pitting edema from the feet to the knees on both sides. The patient was diagnosed with Class III Heart Failure by the doctor. The patient had been referred to Hospital two years prior with a history of worsening dyspnea prompted by less than normal activity, lower-extremity edema, and belly enlargement. He sought medical attention because of belly swelling, which was identified as ascites. The patient was a former smoker who had quit smoking at the age of 37. He was also an alcoholic who had last consumed alcohol three years prior. In 1990, he was also diagnosed with Diabetes Mellitus, Hypertension, and Dyslipidemia. There are no documented sensitivities to foods, medications, or the environment. Physical Exam Initial physical exam reveals temperature 36.2 degrees centigrade, heart rate 74 bpm, respiratory rate 28, BP 104/54 and O2 saturation 90% on room air. HEENT: Head: Normocephalic Mouth: Moist mucous membranes Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light. No scleral icterus. Neck: Neck supple. No JVD present. No masses or surgical scarring. Throat: Patent and moist Cardiovascular: (+) S4 sounds, bilateral pitting edema 2+ lower extremities Pulmonary/Chest: Tachypnea present, Crackles at the base of the lungs. Patient barely able to finish a full sentence due to shortness of breath. Abdominal: feeling of fullness, ballooning belly, weight gain Skin: Skin is very dry Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No sensation losses
Q: What would be the Subjective or Objective Data if the Nursing Diagnosis is Impaired Comfort related to episodic shortness of breath?
Scenario:
Patient X, a 79-year-old male and retired construction worker from Cebu, was taken to the hospital
on September 3 due to a two-week progression of episodic shortness of breath.
The patient was in good health until two weeks ago, when he discovered he was having trouble catching his breath while walking. He was used to walking 3 kilometers without stopping, but now he was out of breath after only 100 meters. The patient's symptoms were worsening, and he had been complaining of shortness of breath while lying down for the past three days. He had always slept with one pillow, but now he needed two. In addition, the patient reported an 8 to 10 pound weight gain in the previous 6 weeks. He had pitting edema from the feet to the knees on both sides. The patient was diagnosed with Class III Heart Failure by the doctor.
The patient had been referred to Hospital two years prior with a history of worsening dyspnea prompted by less than normal activity, lower-extremity edema, and belly enlargement. He sought medical attention because of belly swelling, which was identified as ascites.
The patient was a former smoker who had quit smoking at the age of 37. He was also an alcoholic who had last consumed alcohol three years prior. In 1990, he was also diagnosed with Diabetes Mellitus, Hypertension, and Dyslipidemia. There are no documented sensitivities to foods, medications, or the environment.
Physical Exam
Initial physical exam reveals temperature 36.2 degrees centigrade, heart rate 74 bpm, respiratory rate 28, BP 104/54 and O2 saturation 90% on room air.
HEENT:
Head: Normocephalic
Mouth: Moist mucous membranes
Eyes: Conjunctiva and EOM are normal. Pupils are equal, round, and reactive to light.
No scleral icterus.
Neck: Neck supple. No JVD present. No masses or surgical scarring.
Throat: Patent and moist
Cardiovascular: (+) S4 sounds, bilateral pitting edema 2+ lower extremities
Pulmonary/Chest: Tachypnea present, Crackles at the base of the lungs. Patient
barely able to finish a full sentence due to shortness of breath.
Abdominal: feeling of fullness, ballooning belly, weight gain
Skin: Skin is very dry
Neurologic: Alert, awake, able to protect her airway. Moving all extremities. No
sensation losses
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