Nursing Case Study: Plan of Care for J. D.

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Patient Initials: J. D.

Subjective Data: The patient reports having severe wheezing and shortness of breath, combined with at least one instance of coughing on a daily basis. Having taken albuterol once on the day of the visit, the patient experiences trouble speaking without being interrupted by the shortness of breath.

Chief complaint: severe wheezing, shortness of breath and coughing at least once daily. She can barely get her words out without taking breaks to catch her breath and states she has taken albuterol once today.

History of Present Illness: Frequent asthma attacks for the past 2 months (more than 4 times per week on average), serious MVA 10 weeks ago; post-traumatic seizure 2 weeks after the accident; anticonvulsant phenytoin started – no seizure activity since initiation of therapy.

PMH/Medical/Surgical History: History of periodic asthma attacks since early 20s; mild congestive heart failure diagnosed three years ago; placed on sodium restrictive diet and hydrochlorothiazide; last year placed on enalapril due to worsening CHF; symptoms well controlled the last year. No surgical history was confirmed or reported.

Social History: The patient’s father died of kidney failure at the age of 59; the patient’s mother died of CHF at the age of 62. The patient does not smoke and does not consume alcohol. She has an average daily intake of four cups of coffee and four diet cola cans per day.

Review of Symptoms: Positive for Respiratory: Shortness of breath, coughing, wheezing; and General: exercise intolerance. Denies headache, swelling in the extremities, and seizures.

Objective Data

Vital Signs: BP – 171/94, P – 122, R – 31, T – 96.7, Wt – 145, Ht – 5’3’’, BMI – 25.7

Physical Assessment Findings

HEENT: PERRLA, oral cavity without lesions, TM without signs of inflammation, no nystagmus noted.

Cardio: Regular rate and rhythm normal S1 and S2.

Chest: Bilateral expiratory wheezes.

Abdomen: soft, non-tender, non-distended no masses.

GU: Unremarkable.

Rectal: Guaiac negative.

EXT: +1 ankle edema, on right, no bruising, normal pulses.

NEURO: A&O X3, cranial nerves intact.

Laboratory and Diagnostic Testing Results

  • Na – 134
  • K – 4.9
  • Cl – 100
  • BUN – 21
  • Cr – 1.2
  • Glu – 110
  • ALT – 24
  • AST – 27
  • Total Chol – 190
  • CBC – WNL
  • Theophylline – 6.2
  • Phenytoin – 17
  • Chest Xray – Blunting of the right and left costophrenic angles.
  • Peak Flow – 75/min; after albuterol – 102/min
  • FEV1 – 1.8 L; FVC 3.0 L, FEV1/FVC 60%

The level of glucose in the lab test results is above the normal range, which may be characteristic of the patient’s age. The most concerning feature of these results is the blunting identified through the radiological examination of the patient’s chest. In light of the presenting symptoms, these findings are directly related to the reported condition and require further attention on behalf of the medical unit.


The presence of bilateral blunting of the costophrenic angles implies that this may be a case of pleural effusion. In this case, the liquid is accumulated within the tissue of the lungs, causing severe breathing difficulties, coughing, and wheezing. The patient reports these particular symptoms that have been aggravated in the aftermath of her car accident. This condition may be caused by a variety of illnesses within the chest cavity and other parts of the body. For example, it is one of the common features of lung cancer, including its metastatic varieties (Jany & Welte, 2020). However, as the symptoms became prevalent after physical injuries, this suggests a different nature of this condition. Although post-traumatic pleural effusion is not common, circumstances suggest that the patient may have developed this particular condition. De Azevedo Pereira et al. (2008) report several cases in which chest wall traumas ultimately caused similar scenarios, even though pleuritis was not diagnosed nor observed until 10 days to several months after discharge. Therefore, it is highly likely that subsequent examinations will confirm that this is a case of recurrent post-traumatic non-eosinophilic pleural effusion.

The observed blunting on the X-Ray can also imply a case of pleural thickening. In this scenario, the pleura of the lung thickens as a result of scar tissue developing, showing abnormalities during radiological examinations. While the presenting symptoms can be associated with smoking, the patient denies any intake of nicotine or smoke, thus eliminating emphysema and other smoking-related conditions. On the other hand, pleural thickening is a fairly common sign of hemothorax (Zeiler et al., 2020). In other words, blunting and corresponding respiratory symptoms can be caused by the accumulation of blood in the pleura as a result of the preceding chest injury. If the damage was not too serious at the moment of the accident, it could have gone unnoticed during the patient’s prior stay. The history of medicine has seen cases in which initially minor damage to the chest wall resulted in more frequent and intense asthma attacks in the future. Over the next 10 weeks after J. D. was discharged, the damage to smaller blood vessels caused them to fill the pleura with blood, and hemothorax aggravated her asthma.

Finally, there is a possibility that a hospital-acquired infection is involved in this condition. More specifically, the initial damage to the patient’s body reduces the immune response to external threats, making them susceptible to infectious diseases that are present at the hospital. In this particular scenario, the patient may have been exposed to hospital-acquired COVID-19. Marago and Minen (2020) report that hospital-acquired infections account for 16.2% of the novel coronavirus cases (para. 2). If this particular patient contracted COVID-19 during her initial stay at the facility, the disease may have passed in a light form. However, even though the infection does not yield major symptoms, patients are often left with long-term complications that emerge after several months. Therefore, although it is less likely than the previous diagnoses, the presenting symptoms may imply a case of COVID-19 complications.

Plan of Care

In light of the collected data, the patient requires immediate measures that will help the medical team understand the exact nature of the condition. In this regard, computer tomography of the lungs and chest wall is to be prescribed in order to identify possible damage to blood vessels or pleural tissues. If pleural effusion is confirmed, the patient is to undergo a biopsy to determine the nature of the liquid that is accumulated in the lungs. A malignant effusion is unlikely, but the patient may require therapeutic thoracentesis (Jany & Welte, 2020). For pleural thickening, there is no effective pharmacological treatment since most cases do not pose severe symptoms.

However, this patient reports serious breathing difficulties, which may be alleviated via surgery if pharmacological options fail to provide improvements. For both cases, a pharmacological therapy based on diuretics is to be prescribed (Zeiler et al., 2020). If COVID-19 is involved, it is vital to ensure that the infection is no longer in its active stage, especially if it is recent and not hospital-acquired. Ultimately, the patient is to proceed with her asthma medication, namely albuterol and anticonvulsant phenytoin, possibly increasing the dosage until the improvements are sustained. Outside of the pharmacological and therapeutic options, the patient is to remain physically active as much as the symptoms allow it. This includes daily walks with a slow tempo, preferably in an environment with cleaner air. Smoking and alcohol should remain out of the question. Following the initial treatment, pulmonologist and cardiologist consultation will be needed regularly to track the patient’s condition, especially in relation to the family’s CHF history.


De Azevedo Pereira, A. E., Terra, R. M., Teixeira, L. R., Pego-Fernandes, P. M., & Jatene, F. B. (2008). Recurrent post-traumatic non-eosinophilic pleural effusion: Report of three cases. Clinics, 63(3), 414-415. Web.

Jany, B., & Welte, T. (2019). Pleural effusion in adults—Etiology, diagnosis, and treatment. Deutsches Ärzteblatt International, 116(21), 377-386. Web.

Marago, I., & Minen, I. (2020). Hospital-acquired COVID-19 infection – The magnitude of the problem. The Lancet. Web.

Zeiler, J., Idell, S., Norwood, S., & Cook, A. (2020). Hemothorax: A Review of the literature. Clinical Pulmonary Medicine, 27(1), 1-12. Web.

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