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Case Study 10- REspiratoryAcute Respiatory Distress L.A. is a 32-year-old man who presents to the emergency department with shortness of breath that he states has developed over the past 2 days. He has been feeling a bit dizzy this morning and thought he should see a doctor as he developed what he describes as very mild chest pain, mostly on inspiration, this morning. He also reports his calves are sore and a little swollen. He initially called a medical advice line who suggested he attend the emergency department rather than his general practitioner (GP) clinic. From your observations, it is clear LA is using accessory muscles to breathe in and he reports that he has been using a lot of extra effort. As the nurse in the emergency department, you conduct a full assessment of Steve. His vital signs are currently:. BP – 104/74 mmHg.HR – 105 beats/minute. RR – 28 breaths/minute.T-37.2°C. SpO2 – 91% with no supplemental oxygen TASK Write care plan about this case including subjective and objective data following the guidelines. You must include 2 Nursing Diagnosis. Student ID Student ID PLANNING RATIONALE Patient Care Plan Template Case 2 Nursing Diagnosis ASESSMENT NIRSING PATIENT DIAGNOSIS CENTERED GOALS (in priority order) Subjective data: Problem NURSING INTERVENTIO EVALUATIO N Met: Etiology Partially Met: Objective data: Signs and Symptoms
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