Mrs. S, a 78-year-old female, presents to the clinic
complaining of difficulty catching her breath and persistent
indigestion. She is a well-established patient at the clinic. With
the exception of today’s visit, she describes her overall health as
good. Her medical history includes hypertension, dyslipidemia (both
well controlled with medications and lifestyle management), and
osteoarthritis. Her surgical history consists of a Cesarean section
40 years ago and a total right knee replacement 5 years ago without
complications. She is recently widowed and lives alone within a
retirement community complex. She has 2 daughters and 5
grandchildren who live in different states. She is a nonsmoker and
drinks 2–3 glasses of wine per month. Her physical activity is
limited secondary to osteoarthritis of her knees and hips; but she
participates in aquatic aerobics every Monday and Wednesday morning
although, since her husband’s death 6 months ago, she has not been
going regularly. She is actively involved in the retirement
community, where she serves as a board member and is one of the
social chairs for the clubhouse. Her mother, a lifelong smoker,
died at age 65 from lung cancer; her father had a history of
hypertension and died at age 80 from pneumonia. Her sister is a
breast cancer survivor. There is no other significant family
history. Upon review of systems, she reports fatigue, general
weakness, and indigestion discomfort on and off for 2 weeks. Her
indigestion typically lasts for 5–20 minutes. She has had bouts of
heartburn that typically resolve with over-the-counter (OTC)
antacids, but these have not helped lately. Within the past few
days, she’s noticed shortness of breath (SOB), activity intolerance
related to dyspnea on exertion (DOE), nausea, a nonproductive
cough, and an epigastric/reflux burning sensation. Her chief
complaints today are shortness of breath (SOB) and indigestion pain
that does not radiate. She denies palpitations, headache, fever,
chills, vomiting, and diarrhea. Her medications include losartan,
50 mg daily; lovastatin, 10 mg daily; naproxen, 250 mg twice daily
as needed for pain. She is allergic to penicillin.
OBJECTIVE: Mrs. S is ambulatory, awake, alert and oriented x4.
She is noticeably short of breath and appears anxious. Weight: 150
lb; height: 5 ft 4 inches; BP: 80/60; P: 106; T: 98.6; RR: 24.
Chest/lungs: Diminished at bases although difficult to assess
related to patient’s inability to take a deep breath due to
discomfort. No chest tenderness on palpation. Cardiac: Rate
irregular, tachycardic; S1, S2, and S4 sounds noted. Skin:
Diaphoretic, cool.
DIAGNOSTICS: EKG reveals some ST depression in leads V1 and V2
suggestive of posterior heart ischemia. Cardiac enzymes and CXR
should be deferred to emergency department. Write a care plan in
RAM format with three diagnosis, three intervention for each
nursing diagnosis.