Matutina, a 55-year-old black woman, presents with extreme shortness of breath. Her respiratory rate is 26 breaths per minute and she appears anxious. She reports tightness in her chest and difficulty sleeping and eating due to shortness of breath. Her family history includes mild asthma in her brother and father. On examination, her breath sounds are decreased with prolonged expiration and expiratory wheezing is noted. She is diagnosed with asthma. Nursing diagnoses include ineffective breathing pattern and ineffective airway clearance related to her dyspnea and tightness in chest. Short and long-term goals are made to improve her breathing and ability to clear her airways.

1. St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur
DEPARTMENT OF NURSING
MIDTERMS EXAMINATION
NCM 101: Health Assessment
Second Semester A.Y. 2021-20202
(RLE/LEC)
SECTION C
Melanio P. Rojas Jr. MAN
(Clinical Instructor)
Name: Tanya L. Rillera Score: ___________________
Course/Year: BSN 1 – C Date: 5/28/2022
Case Study
Matutina is a 55 years old black woman. She is a part-time secretary for a local
businessman and is very active in her community. She is married and has two children. She
presents at the nursing clinic this morning with a complaint of extreme shortness of breath.
When entering the examination room, she appears very anxious and states that she has
experienced this problem since yesterday afternoon.
Matutina has no previous diagnosis of asthma, allergies, or respiratory problems, but her
brother and father have cases of mild asthma. The client has smoked for 35 years but reports
limiting her smoking to a pack every 2 to 3 days for the past 10 years. Before that, she reports
having smoked a pack every day. She worked in her office yesterday and reports having felt
fine. She met friends at a local part for lunch but denies anything unusual about her daily
activitity. She states she has experienced “ tightness in my chest” increasing in severity since
about 5 pm yesterday. She denies any other associated symptoms such as pain or cough. Her
discomfort made sleeping difficult last night and she states has not eaten today because of her
SOB.
Matutina currently takes no medications. She reports having no regular exercise
program but denies any intolerance to activity until the onset of dyspnea. She reports having
tried only rest to alleviate the problem and knows nothing else to do but go to the doctor.
Matutina respiratory rate us 26 BPM and appears somewhat labored. The client seems
somewhat apprehensive and experiences obvious dyspnea on even mild exertion. Her anterior
diameter is within normal limits. The use of accessory muscle is noted, with respiration
immediately after exertion. Expiration is somewhat prolonged and labored. Tactile fremitus is
decreased, especially in lower lobes. Percussion tones are resonant over all lung fields. Breath
sounds are decreased, with prolonged expiration. Voice sounds are also decreased. Expiratory
wheeze is noted throughout the lung fields, especially in the lower lobes.

2. Medical diagnosis: ASTHMA
Biographic Data:
Matutina is a 55 years old black woman. She is a part-time secretary for a local businessman
and is very active in her community. She is married and has two children
General Survey
 Age: 55 years old
 Respiratory Rate: 26 breaths/minute
 Appearance: Black old woman
Chief Complaints
She presents at the nursing clinic this morning with a complaint of extreme shortness of breath.
When entering the examination room, she appears very anxious and states that she has
experienced this problem since yesterday afternoon.
Present Health History
She states she has experienced “ tightness in my chest” increasing in severity since about 5
pm yesterday. She denies any other associated symptoms such as pain or cough. Her
discomfort made sleeping difficult last night and she states has not eaten today because of
her SOB. She reports having no regular exercise program but denies any intolerance to
activity until the onset of dyspnea. She reports having tried only rest to alleviate the problem
and knows nothing else to do but go to the doctor.

3. Family Health History
Matutina has no previous diagnosis of asthma, allergies, or respiratory problems, but her
brother and father have cases of mild asthma. The client has smoked for 35 years but
reports limiting her smoking to a pack every 2 to 3 days for the past 10 years. Before that,
she reports having smoked a pack every day.
Past Health History
Matutina has no previous diagnosis of asthma, allergies, or respiratory problems, but her
brother and father have cases of mild asthma.
Physical Examination Findings
 Respiratory rate is 26 BPM.
 Anterior diameter is within limit.
 Expiration is somewhat prolonged and labored
 Tactile fremitus is decreased, especially in lower lobes.
 Percussion tones are resonant over all lung fields.
 Voice sounds are also decreased.
 Breath sounds are decreased.

4. ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“ It’s like I’m running
out of breath since
yesterday.” As
verbalized by the
patient.
Objective:
RR: 26 BPM
Shortness of breath
Appears anxious
Ineffective Breathing pattern
related to dyspnea (shortness
of breath).
Short-term goal:
After 10 hours of
nursing intervention the
patient will be relieved
without the feeling of
discomfort.
Long-term goal:
After 2 weeks or nursing
intervention, the patient
will be able to maintain
effective breathing
pattern by relaxed
breathing at normal rate
and depth and absence
of dyspnea.
Independent
1. Monitor the patient’s
breathing patterns.
2. Encourage the patient to
have frequent rest periods.
Dependent
3. Administer respiratory
medications and oxygen as
prescribed by the doctor.
Interdependent
4. Refer the patient for an
exercise evaluation and the
formulation of a personalised
exercise regimen.
1. Breathing patterns that
are unusual might
indicate an illness or
malfunction.
2. Shortness of breath
might be exacerbated by
increased exercise.
3. Beta-adrenergic
agonists open airways by
relaxing airway smooth
muscles and causing
bronchodilation.
4. Exercise helps
patients feel better by
training their respiratory
muscles.
Short-term
goal:
After 10 hours
of nursing
intervention
the patient was
able to relieved
without the
feeling of
discomfort.
The goal was
completely
met.
Long-term
goal:
After 2 weeks
or nursing
intervention,
the patient was
able to
maintain
effective
breathing
pattern by
relaxed
breathing at
normal rate
and depth and
absence of
dyspnea.
The goal was
completely
met.

5. ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“ I feel tightness in
my chest and I
struggle to sleep last
night. I haven’t eaten
today because I’m
having difficulties to
breath.” As
verbalized by the
patient.
Objective:
RR: 26 BPM
Shortness of breath
Ineffective Airway Clearance
related to dyspnea (shortness
of breath) and tightness in
chest.
Short-term goal:
After 8 hours of nursing
intervention, the patient
will be able to maintain
patent airway with
sounds clearing and
absence of dyspnea.
Long-term goal:
After 2 weeks of nursing
intervention, the patient
will be able to identify
the behaviors to achieve
airway clearance.
Independent:
1. Assess the patient’s vial
signs of respiration at least
every 4 hours.
2. Encourage deep breathing
exercises.
3. Demonstrate proper
splinting of the chest and
effective coughing while in an
upright position.
Dependent
4. Administer medications
such as bronchodilators, as
prescribed by the doctor.
Interdependent:
5. The patient should use
humidified oxygen or
humidifier.
1. To monitor the
effectiveness of medical
treatment.
2. To facilitate the
expansion of the lungs
and smaller airways.
3. To reduce chest
discomfort.
4. To facilitate respiration
by dilating the airways.
5. To avoid bacterial
growth.
Short-term
goal:
After 8 hours
of nursing
intervention,
the patient was
able to
maintain
patent airway
with sounds
clearing and
absence of
dyspnea.
The goal was
completely
met.
Long-term
goal:
After 2 weeks
of nursing
intervention,
the patient was
able to identify
the behaviors
to achieve
airway
clearance.
The goal was
completely
met.

6. ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Hindi po ako nag
gagamot at hindi po
ako nag e-exercis.
Kapag napapagod po
ako nagpapahinga
lang ako.” As
verbalized by the
patient.
Objective:
RR: 26 BPM
AP diameter: normal
Dyspnea
Use of accessory
muscle
Tactile fremitus is
decreased, especially
in lower lobes.
Percussion tones are
resonant over all lung
fields.
Breath sounds are
decreased, with
prolonged expiration.
Impaired gas exchange related
to dyspnea and use of
accessory muscle.
Short-term goal:
After 10 hours of
nursing intervention, the
patient will be able to
verbalizes
understanding of
oxygen and other
therapeutic
interventions.
Long-term goal:
After 2 weeks of nursing
intervention, the patient
will be able to maintains
clear lung fields or
manifest resolution and
remains free of signs of
respiratory distress.
Independent:
1. Assess for vital signs and
symptoms.
2. Position patient with head of
the bed elevated, in a semi-
fowlers position
3. Turn the patient every 2
hours.
Dependent:
4. Provide humidified oxygen
as prescribed.
5. Encourage or assist with
ambulation as per the
physician’s order.
Interdependent:
6. Refer the patient to a chest
physiotherapist.
1. To monitor any
changes in vital signs as
the patient receives
medical treatment.
2. To increase lung
expansion.
3. To prevent
complications of
immobility.
4. To reduce drying out
the lungs.
5. Ambulation facilitates
lung expansion,
secretion clearance and
stimulates deep
breathing.
6. To enable to patient to
receive more information
and enabling of improved
gas exchange.
Short-term
goal:
After 10 hours
of nursing
intervention,
the patient was
able to
verbalizes
understanding
of oxygen and
other
therapeutic
interventions.
The goal was
completely
met.
Long-term
goal:
After 2 weeks
of nursing
intervention,
the patient was
able to
maintain clear
lung fields or
manifest
resolution and
remains free of
signs of
respiratory
distress.
The goal was
completely
met.

7. Voice sounds are
decreased.
Expiratory
wheeze throughout
the lung fields,
especially in the
lower lobes.

8. Please create a FDAR based on the given case study below.
Focus
Subjective:
“ I feel tightness in my chest and I struggle to sleep last night. I haven’t eaten today because
I’m having difficulties to breath.” As verbalized by the patient.
Objective:
RR: 26 BPM
Shortness of breath
Data
Ineffective Airway Clearance related to dyspnea (shortness of breath) and tightness in chest.
Action
Short-term goal:
After 8 hours of nursing intervention, the patient will be able to maintain patent airway with
sounds clearing and absence of dyspnea.
Long-term goal:
After 2 weeks of nursing intervention, the patient will be able to identify the behaviors to
achieve airway clearance.
Response
Short-term goal:
After 8 hours of nursing intervention, the patient was able to maintain patent airway with
sounds clearing and absence of dyspnea.
The goal was completely met.
Long-term goal:
After 2 weeks of nursing intervention, the patient was able to identify the behaviors to achieve
airway clearance.
The goal was completely met.

9. Please create a FDAR based on the given case study below.
Focus
Subjective:
“ It’s like I’m running out of breath since yesterday.” As verbalized by the patient.
Objective:
RR: 26 BPM
Shortness of breath
Appears anxious
Data
Ineffective Breathing pattern related to dyspnea (shortness of breath).
Action
Short-term goal:
After 10 hours of nursing intervention the patient will be relieved without the feeling of
discomfort.
Long-term goal:
After 2 weeks or nursing intervention, the patient will be able to maintain effective breathing
pattern by relaxed breathing at normal rate and depth and absence of dyspnea.
Response
Short-term goal:
After 10 hours of nursing intervention the patient was able to relieved without the feeling of
discomfort.
The goal was completely met.
Long-term goal:
After 2 weeks or nursing intervention, the patient was able to maintain effective breathing
pattern by relaxed breathing at normal rate and depth and absence of dyspnea.
The goal was completely met.