Case Study Theresa J. is a 55-year-old Caucasian woman. She is a… Case StudyTheresa J. is a 55-year-oldCaucasian woman. She is a part-time secretary for a local businessman and isvery active in her community. She is married and has two children. She presentsat the nursing clinic this morning with a complaint of extreme shortness ofbreath. When entering the exam room, she appears very anxious and states thatshe has experienced this problem since yesterday afternoon. Theresa J. does not have a previousdiagnosis of asthma, allergies, or respiratory problems, but her brother andfather have mild asthma. The client has smoked for 35 years but reportslimiting her smoking to a pack every 2-3 days for the past 10 years. Beforethat she reports having smoked a pack per day. She worked in her officeyesterday and reports having felt fine. She met friends at a local park forlunch but denies anything unusual about her daily activity. She states that shehas experienced “tightness in my chest” increasing in severity sinceabout 5pm yesterday. She denies any other associated symptoms such as pain orcough. Her discomfort made sleeping difficult last night, and she states thatshe has not eaten today because of her shortness of breath. Theresa J. currently does not takeany medications. She reports not having a regular exercise program and deniesintolerance to activity until the onset of dyspnea. She reports having triedonly rest to alleviate the problem and knows “nothing else to do but go tothe doctor.” Theresa J’s respiratory rate is 26breaths/min and appears somewhat labored. The client seems somewhatapprehensive and experiences obvious dyspnea on exertion. Her anteroposteriordiameter is within normal limits. The use of accessory muscles is noted, withrespiration immediately after exertion. Expiration is somewhat labored andprolonged. Tactile fremitus is decreased, especially in the lower lobes,Percussion tones are resonant over all lung fields. Breath sounds aredecreased, with prolonged expiration. Voice sounds are also decreased.Expiratory wheezes are noted throughout the lung fields, especially bilaterallyin the lower lobes. DIAGNOSTIC REASONING GUIDE1.     Identify abnormal findings  Subjective:     Objective:2.     Identify Cue Clusters3.     Draw Inferences4.     List Possible Nursing Diagnoses (Minimum of 4)5.     Identify Defining Characteristics 6.     Confirm or Rule out Diagnoses (minimum of 3)7.     Nursing Diagnoses that are Appropriate for the Client (Minimum of 2, cannot be a riskfor problem)8.     Potential Collaborative Problems that May Require a Referral (minimum of 2)9.     Potential Referral10.  Identify One “Risk-For” Nursing Diagnosis Health ScienceScienceNursing

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