This paper presents a comprehensive advanced practice nursing case study of a 65-year-old retired female patient with a history of childhood asthma, long-term cigarette smoking, and recurring respiratory distress. The paper covers subjective and objective assessment data, physical examination findings, laboratory results, and ICD-9 diagnoses including emphysema, pneumonia, oral candidiasis, and tobacco use disorder. It concludes with a detailed advanced practice nursing intervention plan addressing smoking cessation, pulmonary function testing, inhaler therapy, social support services, and treatment of oral candidiasis. The case illustrates multifaceted clinical reasoning in managing a patient with overlapping chronic and acute respiratory conditions.
The paper demonstrates evidence-based clinical reasoning by connecting physical assessment findings (e.g., dull percussion, expiratory wheeze, elevated WBC with left shift) directly to differential diagnoses and then to targeted interventions. This chain of evidence-to-action is the defining feature of competent advanced practice clinical writing.
The paper opens with a brief theoretical framing of respiratory physiology, then presents the full patient case in standard SOAP-adjacent format: subjective data (complaints, history, social context), objective data (vitals, physical exam, labs), formal ICD-9 diagnoses, and a multi-pronged intervention plan. References are cited in APA style throughout.
In order to sustain life, the human body must have oxygen. When a person cannot breathe, or when insufficient oxygen enters the body through respiration, life cannot continue. The respiratory system provides the person with the ability to breathe and take in oxygen, while also expelling carbon dioxide. If oxygen is not received, brain cells begin to die, followed by other cells, organs, and tissues. Addressed here is a case study dealing with the respiratory system, conditions it may face, and how those issues can be treated.
Patient Initials: Unknown Age: 65 Sex: Female
The patient complains of a dry cough that is rarely productive. She has had the cough for two weeks, and for the last two days has also been running a low-grade fever (up to 101°F when taken orally). Her appetite is decreased, but without nausea or vomiting. When coughing occurs during the night, the patient must sit up in a chair in order to make breathing easier. She also has shortness of breath after activity, and her throat is slightly sore — most often in the morning.
The patient has experienced similar difficulties in the past. The most recent episode was three months ago. The hospital informed her that she should be admitted to treat her condition, but she refused. Before she was discharged, she was provided with an inhaler and an antibiotic. While she did feel better with that treatment, it took a significant amount of time to do so.
The patient takes no prescription medications for her breathing condition. For pain, she takes Tylenol PRN, and has taken antibiotics and used an inhaler in the past. She is allergic to sulfa drugs, which cause her to break out into a rash. She has never been hospitalized for breathing problems, and states that she did have emphysema. When she was treated for this problem during a prior episode, she declined a pulmonary function test. She has a history of childhood asthma and smokes cigarettes. In the 1970s, she had a hysterectomy.
The patient has two siblings. One is a 75-year-old sister who was diagnosed with osteoporosis at age 55. The other sister is 72 years of age and was diagnosed with breast cancer at age 60.
The patient is retired from hairdressing. She attends church and occasionally participates in church functions. She also enjoys sewing and does not leave her home very often. Stress levels are very low due to her retired status and a low-stress home environment. She eats healthily but does not exercise due to the shortness of breath she experiences during activity. She sees her primary care provider three to four times per year for physical examinations. She smokes one pack of cigarettes per day and has done so for the last 40 years, but does not use alcohol or drugs. She has a high school diploma, owns her home, and receives an annual pension. Her finances are stable, but she does rely on medication samples, as her insurance does not cover all of the prescriptions she needs.
The patient has two grown daughters whom she sees at least once every month. She also has contacts and acquaintances at her church, but there is no one she can talk to on a regular basis. The patient has indicated that she would like her daughters to get more involved in her life, but does not know how to talk to them about this. Her daughters and church contacts are the only support system available to her.
The patient feels she may be depressed, since she spends most of her time at home alone. She notes that the depressive feelings are getting worse as she ages and seem to worsen each year. Her sense of self-efficacy has been declining over the last decade. Community resources are available to her, but she is unaware of them. She enjoys visiting with her physician during checkups but finds that her physician is very busy and does not spend much time with her.
The patient is concerned about her shortness of breath and cough. She fears that something could be wrong with her heart, or that she may have lung cancer. She is also worried about pneumonia that might require hospitalization. Due to the prolonged cough and fever, she is seeking medical attention. However, she has previously declined both hospitalization and diagnostic testing for this condition. She knows she should do more to maintain a healthy lifestyle and recognizes that depression may be contributing to some of her physical symptoms.
BP = 130/70, Temp = 101°F (oral), P = 100 and regular, R = 20 and non-labored, Wt = 130 lbs, Ht = 5'5", BMI = 21.63.
HEENT: There is white material on the buccal mucosa that does not wipe off with a tongue blade. These findings are consistent with oral candidiasis.
Lymph Nodes: None noted.
Lungs: Decreased breath sounds and dull percussion in the right lower lobe. There is also an end-expiratory wheeze in the right lower lobe. No rales or rhonchi are present. Increased anterior-posterior diameter of the chest wall is observed. Hyperinflation is a common finding in asthma, chronic bronchitis, and emphysema — all of which present as COPD. Dullness on percussion implies consolidation, pleural fluid, or pleural scarring. Expiratory wheezing is generally associated with asthma, chronic bronchitis, COPD, or pulmonary edema. Decreased breath sounds are also heard in ARDS, asthma, emphysema, and pleural effusion.
Heart: Regular rate and rhythm without murmur.
Carotids: No bruits.
Abdomen: Benign.
Rectum and Genital/Pelvic: Not examined.
Extremities, Including Pulses: 2+ pulses throughout; no edema.
Neurologic: Not examined.
WBC = 15,000 with a positive left shift (normal WBC range: 4,500–10,000). The patient's elevated level is termed leukocytosis (Wijkstrom-Frei et al., 2003). A "shift to the left" indicates that an inflammatory or infectious process is underway, meaning that bands or stabs have increased (Wijkstrom-Frei et al., 2003).
SaO₂ = 98%
Chest X-ray: Hyperinflation of both lungs with increased AP diameter; evidence of emphysema.
EKG: Normal sinus rhythm.
Client's Support System: Church contacts and daughters are the only support system available.
Client's Locus of Control and Readiness to Learn: Positive health beliefs are present, and the patient acknowledges that she should do more to maintain a healthy lifestyle.
This case illustrates the complex, overlapping nature of chronic respiratory conditions and the importance of a comprehensive, patient-centered nursing approach. The patient's long history of smoking, recurrent respiratory illness, social isolation, and reluctance to undergo diagnostic testing all require coordinated clinical and psychosocial intervention. Addressing her physical diagnoses alongside her emotional and social needs represents best practice in advanced nursing care.
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Mayo Clinic Staff. (2014). Oral thrush. Retrieved from http://www.mayoclinic.org/diseases-conditions/oral-thrush/basics/basics/definition/con-20022381
Travis, S. M., Conway, B. A., Zabner, J., et al. (1999). Activity of abundant antimicrobials of the human airway. American Journal of Respiratory Cell and Molecular Biology, 20(5), 872–879.
Wijkstrom-Frei, C., El-Chemaly, S., Ali-Rachedi, R., et al. (2003). Lactoperoxidase and human airway host defense. American Journal of Respiratory Cell and Molecular Biology, 29(2), 206–212.
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