COMPREHENSIVE I-HUMAN CASE STUDY: JAMES
TAYLOR – 39-YEAR-OLD MALE WITH SHORTNESS OF
BREATH (CHAMBERLAIN UNIVERSITY) | ADVANCED
DDX CASE PLAY SETUP & FULL CASE ANALYSIS
INCLUDING HPI, ROS, PE, DIAGNOSTICS
(2025/2026 UPDATE)
Full Name: James Taylor
Age: 39 years
Date of Birth: August 14, 1986
Sex: Male
Race/Ethnicity: Caucasian
Marital Status: Married
Occupation: Warehouse Supervisor
Education Level: High school graduate
,Address: 1247 Brookside Lane, Springfield, IL
Living Situation: Lives with spouse and two children
Insurance: Employer-sponsored PPO medical plan
Emergency Contact:
• Name: Emily Taylor (spouse)
• Phone: (555) 294-8002
⬛ ICD-10 CODES
Primary Diagnosis
• J18.G – Community-acquired pneumonia, unspecified organism
Secondary / Related Codes
• R06.02 – Shortness of breath
• R05.1 – Acute cough
• R07.8G – Other chest tightness
• Z87.8G1 – Personal history of nicotine dependence
• Z77.0G0 – Exposure to environmental tobacco smoke / dust
(workplace exposure)
⬛ NANDA-BASED NURSING CARE PLAN
1. Nursing Diagnosis (NANDA)
Ineffective Breathing Pattern (00032)
Related to:
• Infection/inflammation of lung tissue
• Increased work of breathing
• Hypoxemia
, Evidenced by:
• Respiratory rate 22
• SpO₂ 93% on room air
• Patient reports dyspnea
• Use of accessory muscles (mild)
Desired Outcomes (NOC)
Respiratory Status: Gas Exchange (0402)
Target outcomes:
• SpO₂ ≥ 95% on room air
• RR within normal range
• Improved breath sounds
• Patient reports decreased shortness of breath
Nursing Interventions (NIC)
Respiratory Monitoring (3350)
• Monitor RR, SpO₂, breath sounds every visit
• Assess for increased work of breathing or cyanosis
Oxygen Therapy (3320) (if indicated)
• Administer O₂ to maintain SpO₂ > 94%
Airway Management (3140)
• Encourage coughing and deep breathing exercises
• Teach use of incentive spirometer
TAYLOR – 39-YEAR-OLD MALE WITH SHORTNESS OF
BREATH (CHAMBERLAIN UNIVERSITY) | ADVANCED
DDX CASE PLAY SETUP & FULL CASE ANALYSIS
INCLUDING HPI, ROS, PE, DIAGNOSTICS
(2025/2026 UPDATE)
Full Name: James Taylor
Age: 39 years
Date of Birth: August 14, 1986
Sex: Male
Race/Ethnicity: Caucasian
Marital Status: Married
Occupation: Warehouse Supervisor
Education Level: High school graduate
,Address: 1247 Brookside Lane, Springfield, IL
Living Situation: Lives with spouse and two children
Insurance: Employer-sponsored PPO medical plan
Emergency Contact:
• Name: Emily Taylor (spouse)
• Phone: (555) 294-8002
⬛ ICD-10 CODES
Primary Diagnosis
• J18.G – Community-acquired pneumonia, unspecified organism
Secondary / Related Codes
• R06.02 – Shortness of breath
• R05.1 – Acute cough
• R07.8G – Other chest tightness
• Z87.8G1 – Personal history of nicotine dependence
• Z77.0G0 – Exposure to environmental tobacco smoke / dust
(workplace exposure)
⬛ NANDA-BASED NURSING CARE PLAN
1. Nursing Diagnosis (NANDA)
Ineffective Breathing Pattern (00032)
Related to:
• Infection/inflammation of lung tissue
• Increased work of breathing
• Hypoxemia
, Evidenced by:
• Respiratory rate 22
• SpO₂ 93% on room air
• Patient reports dyspnea
• Use of accessory muscles (mild)
Desired Outcomes (NOC)
Respiratory Status: Gas Exchange (0402)
Target outcomes:
• SpO₂ ≥ 95% on room air
• RR within normal range
• Improved breath sounds
• Patient reports decreased shortness of breath
Nursing Interventions (NIC)
Respiratory Monitoring (3350)
• Monitor RR, SpO₂, breath sounds every visit
• Assess for increased work of breathing or cyanosis
Oxygen Therapy (3320) (if indicated)
• Administer O₂ to maintain SpO₂ > 94%
Airway Management (3140)
• Encourage coughing and deep breathing exercises
• Teach use of incentive spirometer
