ICA CASE STUDY 1

BREATHING

SUB GROUP 4 :
CELESTE , HIDAYAH , KELLY , NABILAH , SASI , XIAO HUI , YU XING

 Define and Explain Breathlessness

Identify Objective and Subjective data related to
breathlessness
List of Other History
Analyse the data given and list down the potential
nursing problems associated to breathlessness
Identify Expected Outcomes to evaluate effectiveness of
nursing interventions
Describe appropriate nursing care for Mr Yusof and
explain the rationales behind it.

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

CASE STUDY (CONTINUED)

Treatment as ordered by the doctor at the emergency department includes:

Oxygen 28% via a face mask

Oral antibiotics Erythromycin 500mg every 6 hours (to treat pneumonia)
Oral Paracetamol 1 gram every 6 hours (to reduce fever)
Bed rest
Nil by mouth

Client/Patient demographic data

Name

Mr Yusof

Gender

Male

Address

Jurong West Street 91

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

Highest educational Unknown

level
Occupation

Renovation supervisor

Reasons of Seeking Health

Care
Breathlessness
Reasons for
coming to hospital

Chief complaints

Productive cough

Diagnosis

Pneumonia

Exploring Chief Complaint using OLDCART

Onset

Breathlessness , productive cough , greenish

sputum

Location

Chest tightness from the frequent cough

Duration

Three days

Characteristic Patient has been coughing out greenish sputum for

, severity
the past 3 days
Aggravating
factors

Smoking 10 15 sticks per day since 16 years old

Relieving
factors

Sits , lean over table

Treatment

Oxygen 28% via a face mask

Oral antibiotics erythromycin 500gram every 6
hours (to treat pneumonia)
Oral paracetamol 1gram every 6 hours (to reduce
fever)
Bed rest

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%

Other History ( What other ALs are affected as

well?)
Controlling Body Temperature

Objective data

Subjective data

Mr Yusof is having a fever of 38.3 C. How long has Mr Yusof been

having the fever?
Did Mr Yusof take any medication
to reduce his fever?

Sleeping
Objective data

Subjective data

Pain score of 4/10

Complained of chest tightness

Does Mr Yusof still feel pain even
when coughing fits have stop?

Master problem list

Problem

Date identified

Ineffective
Breathing Pattern
(Actual Problem)

23 July 2015

Ineffective Airway 23 July 2015

Clearance
(Potential Problem)
Knowledge Deficit
(Actual Problem)

23 July 2015

Fever

23 July 2015

Date resolved

Patient problem 1: Ineffective Breathing

Assessment
Goal &
Interventions
Rationale
Evaluat
Pattern
expected
ion
outcome (E0)
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.
Objective Data:
Use of accessory
muscles
RR 28 bpm(Normal
range is 12-20 bpm)
HR is 108
bpm(Normal Range
is 60-100 bpm)

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 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.

Patient problem 2 : Ineffective Airway Clearance

Assessment

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.

Send sputum specimen

Allows better

Objective Data:
Effective airway
Use of accessory
clearance.
muscles
RR 28 bpm(Normal
range is 12-20
bpm)
Resolve Mr

Evaluati
on

Patient Problem 3 :Knowledge Deficit

Assessment

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.

Mr Yusof knows about

the seriousness of his
smoking attitude and
how it will affect his
health.

Educate Mr
Yusof what is
pneumonia and
how is it
affecting his
health and
work.

Mr Yusof knows what

pneumonia is and how
to prevent lungs
irritation when working.

To ensure the
Ask patients
treatment given relative to
is accurate
perform return
demo or

Mr Yusofs relatives can

help to understand of
his illness, condition,
and treatment

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