Question

Patient Profile:

Gladys Young is a 68 year old female that resides in an Independent Living facility with her husband. She presents to her primary care physicians office with complaints of fever, chills, nausea and vomiting. She also states that she has had some mild hemoptysis occasionally with her persistent coughing. She has recently completed treatment with Chemotherapy for Breast cancer and is concerned that she may have an infection. You are the nurse caring for her.

You complete the following assessment:

Subjective Data:

She is able to complete a sentence in its entirety, but she is persistently coughing during the history. She is a former smoker, she smoked ½ pack of cigarettes per day for 30 years and quit when she was diagnosed with breast cancer 6 months ago. She denies shortness of breath or chest tightness. She has not yet gotten her influenza vaccine, but did receive the Pneumovax vaccine last year. She has had problems with persistent coughing at night which has prevented her from getting a good night’s sleep for the past two weeks. She also states that she has been waking up soaked in sweat in the morning.

Objective Data:

• Temp – 38.6 C; HR – 132 beats/min; RR—28; BP – 168/87; O2 sat – 90% on Room Air
• Auscultation: Lungs with faint crackles at bases bilaterally. No wheezing present.
• Patient is flushed and warm to touch.

Answer the following questions:

1. What additional questions would you like to ask this patient?
2. What do you think the patient’s diagnosis is and why?

Answer 1

Nurse can ask if the patient has sputum while coughing ,the color of the sputum.Did the patient experience any pain while coughing.Is the patient feeling weak ?Is there is any difficulty in breathing? How long is the cough and is there any breath sounds while breathing.Did the patient experience fever ?Did she has appetite?

This patient is suffering from pneumonia.A variety of symptoms like low oxygen saturation (90), persistent coughing,fever,chills, vomiting,crackles, decreased breath sounds,increased respiration rate ,increased heartbeat suggest pneumonia.This patient also has blood in the coughed up mucus.She has fever and chills.She also has persistent cough,with rapid shallow breathing.All this suggest she has pneumonia.A chest radiograph can confirm the diagnosis.