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Transcript of Asthma Baiae
8/13/2019 Asthma Baiae
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PHYSICAL EXAMINATION
Patient’s Name: Kristoff Panganiban
Age: 2 years old and three months
Address: San Juan City
Sex: Male
Birth date: April 6, 2007
Place of birth: Bulacan
Ethnic group: None
Dialect: Tagalog
Marital Status: N/A
Religion: Roman Catholic
Monthly Income: 10,000
Chief Complaint: Nose Bleeding
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GENERAL ASSESSMENT
Temperature 37.3
Pulse Rate 82
Respiratory Rate 25
Blood Pressure 110/80
AREAS TO BE ASSESSED FINDINGS NORMS ANALYSIS
Anthropometric
Height 78cm
Weight 11kg
General Appearance and MentalStatus
Body build The client’s height isproportional to the
client’s weight
Proportionate, Relaxed anderect posture, coordinated
body movements
Normal or no deviationfound
Overall hygiene and grooming The client is wellgroomed and neat.
Clean and neat Normal or no deviationfound
Signs of health illness/stress The client is restless Healthy Normal or no deviation
found
Attitude, Speech Quantity, andorganization
The client iscooperative, moderate
pace andunderstandable.
Cooperative, able to followinstructions
Normal or no deviationfound
Skin
Skin color The client has light brownskin color, generally uniformexcept areas exposed to the
sun.
Light brown to dark, ruddypink to light pink: from yellow
overtones to olive
Normal or no deviationfound
Skin lesions Absence of Edema, somefreckles, some birthmarks,
some flat and raised nevi; noabrasions or other lesions
Freckles some birthmarks,some flat and raised nevi; no
abrasion or other lesion
Normal or no deviationfound
Skin moisture Moisture in the skin foldsand the axillae (varies withenvironmental temperature
and humidity, bodytemperature, and activity)
Moisture in skin folds andthe axillae
Normal or no deviationfound
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Skin temperature The client has uniform bodytemperature.
Uniform; within normal range Normal or no deviationfound
Skin turgor The skin of the client Skin springs back whenpinched
Normal or no deviationfound
Nails
Curvature and angle The client has a normalcurvature and angle of nail
160 degree angle concave,and spoon shape in all nails.
Normal or no deviationfound
Fingernail and toenail bedcolor
Pinkish in color Pinkish in color Normal or no deviationfound
Blanch test of capillary refill Returns in 2secs pinkish incolor
Prompt or return in pinkishor usual color (4secs.)
Normal or no deviationfound
AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Head
Skull
Shape, size and symmetry Symmetrical in shape,
normocephalic, smooth skullcontour, equal.
Rounded; smooth skull
contour
Normal or no deviation
found
Depression, masses,nodules
No depression, nodules,masses found
No depression, masses,nodules felt
Normal or no deviationfound
Symmetry of facialmovements
The client has symmetricalfacial movements
Symmetric facial movements Normal or no deviationfound
Scalp
Color and appearance The client’s scalp has auniform color, shiny andsmooth, no masses and
nodules felt.
The scalp should be shinyand smooth without lesions,
lumps, or massesNormal or no deviation
found
Hair
Evenness of growth over the
scalp
The client has evenly
distributed hair
Evenly distributed hair Normal or no deviation
found
Texture, Thickness orthinness
The client has a oily, thickcurly hair
Thick Normal or no deviationfound
Infestations and infections Absence of infestation andinfections
No infestations andinfections present
Normal or no deviationfound
AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Eyes
(Visual Acuity)
Test near visionThe client can read
nearly the sentence/s inthe newspaper while she
is in a sitting position.
Able to read Normal or no deviationfound
Test distance visionThe client’s distance
vision is 20/20 in botheyes (Left and Right)
At a distance of 20ft. thenormal eye can read the chart
Normal or no deviationfound
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Eyebrows
The client has evenlydistributed hair and has
equal movement
Even distribution of hair, hasequal movement
Normal or no deviationfound
EyelashesThe client has equal
distribution of hair andequal movements, curled
slightly outward
Even distribution of hair, hasequal movements: curled
slightly outward
Normal or no deviationfound
Eyelids No discharge, nodiscoloration
Skin intact; no discharge: nodiscoloration
Normal or no deviationfound
Consensual and directresponse
Both eye constricts,PERRLA
Both illuminated and non-illuminated eye constricts
Normal or no deviationfound
Accommodation PERRLA Pupils constrict when lookingat near; pupils dilate whenlooking at far object; pupilconverge when near object ismoved toward nose
Normal or no deviationfound
Ear
Auricles Symmetric in shape andhas fair in color.
Same color as to the facialcolor, auricle aligned in theother canthus, 10degrees
from vertical
Normal or no deviationfound
Hearing Acuity Can hear normal voicetones Normal voice tone can beheard Normal or no deviationfound
Watch tick test Identified ticking of awatch
Able to hear ticking on bothears
Normal or no deviationfound
Nose
External nose Symmetric, uniform incolor, no discharge and
lesions
Symmetric, straight, nodischarge or flaring, uniform in
color, no tenderness, nolesion
Normal or no deviationfound
Patency Air movement isrestricted on the right andleft nose, no undeniable
sound heard.
Air moves freely as the clientbreaths on one nose
Normal or no deviationfound
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Mouth and orapharnyx
Outer lips Pinkish, soft smooth andable to purse
Pink, soft, moist, smooth,able to purse
Normal or no deviationfound
Inner lips and buccalmucosa
The client’s inner lips andbuccal mucosa is pink in
color, moist, soft, glisteningand elastic
Pink, moist, soft, glistening,elastic
Normal or no deviationfound
Teeth and gums The client only have 8 teeth. 30teeth, no retractions,smooth, white, glistening,shiny enamel, moist, firm
texture of the gums
Normal or no deviationfound
Tongue movement The client’s tongue is freelymoves
Freely moves Normal or no deviationfound
Salivary glands palates anduvula
The client’s salivary glands,palates and uvula are samein color as buccal, soft ,pinkirregular texture of the hard
palate and positioned inmidline
Same color as buccalpositioned in mid line, soft,pink, irregular texture of the
hard palate
Normal or no deviationfound
Orapharynx and tonsils The client’s orapharynx andtonsils are smooth and pink
in color
Pink and smooth Normal or no deviationfound
AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Neck muscles
Neck muscles Equal in symmetry andcentered Equal in size and centered Normal or no deviationfound
Head movement and Musclestrengths
The client has a equalmuscle strength Muscle
strength: 5 – activemovements against full
resistance without fatigue.
Equal muscle strength Normal or no deviationfound
Lymph nodes Not palpable Not palpableNormal or no deviation
found
AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Thorax
Posterior thorax
Spinal alignment The client’s spinal column isaligned straight.
Spined aligned vertically.Spinal column is straight,
right and left shoulders andhips are at the same height
Normal or no deviation found
Temperature, tenderness Skin intact; uniformtemperature; chest wall
Uniform temperature; no Normal or no deviation found
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and masses intact; no masses tenderness; no masses
Respiratory excursion Not symmetric Full and symmetric hestexpansion when the clientstake a deep breath, apart an
equal distance and at thesame time
Percussion of posteriorthorax
Percussion notes resonate
except over scapula; Lowestpoint of resonance is at thediaphragm; percussion on arib normally elicits dullness
Symmetric in percussion:
Clearly on the apex of thelungs
Normal or no deviation found
Auscultation of posteriorthorax
Wheezing sounds Resonated sound exceptover scapula
Vesicular sound on base oflungs;
Brochovesicular sound on2nd intercostals spaces
Anterior thorax
Breathing patterns Distant breath sounds, Quiet, rhythmic, andeffortless respiration
Temperature, tendernessand masses
Uniform in temperature; notenderness and nodules,
masses felt
Uniform temperature; notenderness and masses
Normal or no deviation found
Respiration excursion Full symmetrically chestexpansion
Full symmetric chestexpansion
Normal or no deviation found
Percussion of anterior thorax Flat on heavy muscles andbones, resonates to the 6th
intercostals space
Resonates to the 6th intercostals spaces; flat onheavy muscles and bones;
dull over the heart; tympanicover stomach
Normal or no deviation found
Auscultation of trachea Distant breath sounds Brachial and breath sound Normal or no deviation found
Auscultation of anteriorthorax
Percussion notes resonatedown to the sixth rib at thelevel of the diaphragm butare flat over the areas of
heavy muscle and bone, dullon areas over the heart andliver, and tympanic over the
underlying stomach
Brochovesicular andvesicular breath sound
Normal or no deviation found
AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Cardiovascular
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Aortic and pulmonary areas Absence of pulsation No pulsation Normal or no deviation found
Tricuspid areas
No pulsation found; no liftand heaves
No pulsation
No lift and heaves
Normal or no deviation found
Apical areas No lift or heaves No lift or heaves
Normal or no deviation found
Auscultation of the aortic,pulmonary, tricuspid, apical
valves.
Aortic valve heard at the 2nd ICS right sternal border.
Pulmonic valve heard at the2nd ICS left sternal border.
Tricuspid valve heard at the5th intercostals space (ICS)left sternal border. Apical
valves heard at left 5th ICS,(midclavicular line)
S1: Usually heard at all sites
Usually louder at the apicalarea
S2: Usually heard at all sites
Usually louder at the base ofthe heart
Systole: silent interval;slightly shorter duration thandiastole at normal heat rate(60 to 90 beats/min)
Diastole: silent interval;slightly longer duration thansystole at normal heart rates
S3: in children and youngadults
S4: in many older adults
Normal or no deviation found
Carotid arteries Normal or no deviation found
Palpation of carotid Symmetric pulse volumes;full pulsations, thrustingquality; quality remainssame when the client
breathes, turns head, andchanges from sitting tosurpine position; elastic
arterial wall
Symmetric pulse volumesfull pulsation, thrusting
quality
Normal or no deviation found
Auscultation of carotid artery No sound heard onauscultation
No sound heard onauscultation
Normal or no deviation found
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AREAS TO BE ASSESSED ACTUAL FINDINGS NORMAL FINDINGS ANALYSIS
Abdomen
Skin integrity Uniform in color no surgicalscars
Unblemished skin; uniform incolor; silver-white striae or
surgical scars
Normal or no deviationfound
Abdominal movements Symmetric movementscaused by respiration;
visible peristalsis in verylean people; aortic
pulsations in thin persons atepigastric area
Symmetric movementscaused by respirations; visibleperistalsis in very lean people;
aortic pulsations in thin at
epigastric area
Normal or no deviationfound
Bowels sounds, andperitoneal friction rubs
Absence of arterial bruitsand friction rub
Audible bowel sounds;absence of arterial bruits; No
friction rub
Normal or no deviationfound
Percussion of the severalareas of four quadrants
Tympanic over the stomachand gas-filled bowels;
dullness esp. over the liverand spleen or a full bladder.
Tympany over the stomach;dullness over the spleen or
liver
Normal or no deviationfound
Light palpation followed byDeep palpation
Absence of tenderness;relaxed abdomen w/ smoothconsistent tension
No tenderness relaxedabdomen with smooth
consistent tension
Normal or no deviationfound
Musculoskeletal SystemMuscle, Joints
Muscle and contractures,
tremors
No contractures and tremors No contractures Normal or no deviation
found
Strength of neck or jaws
Strength of upperextremities
Strength of lower extremities
Temporomandibular: 5-100% normalMuskuloskeletal upperextremities: 5-100%normalMuskuloskeletal upperextremities: 5-100% normal
0-0% normal strength1-10%2-25%3-50%4-70%5-100%
Normal or no deviationfound
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HEALTH CARE PLAN
Ineffective airway clearance related to increased
production of secretions.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION
PLAN
RATIONALE EVALUATIO
Subjective:
“Nahihirapan
ako huminga” as
verbalized bythe patient.
Objective:
•
Use of
accessory
muscle.
•
Abnormal
breath sounds.
•
V/S taken as
follows: T: 37.3
P: 82 R: 25 BP:
110/80
Ineffective
airway
clearance
related toincreased
production of
secretions.
.
Bronchial
asthma is a
chronic
inflammatorydisease of the
airways,
associated with
recurrent,
reversible
airway
obstruction
with
intermittent
episodes ofwheezing and
dyspnea.
Bronchial
hypersensitivity
is caused by
various stimuli,
which
innervate the
vagus nerve
and betaadrenergic
receptor cells
of the airways,
leading to
bronchial
smooth muscle
After 3 days
of nursing
interventions,
the patientwill
demonstrate
behaviors to
improve
airway
clearance.
Independent:
•
Auscultatebreath sounds.
Note adventitious
breath sounds
like wheezes,
crackles and
rhonchi.
•
Elevate head of
the bed, have
patient lean on
overbed table or
sit on edge of the
bed.
•
Keep
environmental
pollution to aminimum like
dust, smoke and
feather pillows,
according to
individual
situation.
Some degree
of
bronchospasm
is present withobstructions in
airway and
may or may
not be
manifested in
adventitious
breath sounds.
•
Elevation ofthe bed
facilitates
respiratory
function by use
of gravity.
•
Precipitators
of allergic type
of respiratory
reactions that
can trigger or
exacerbate
onset of acute
episode.
After 3 days
nursing
intervention
the patient wable to
demonstrat
behaviors to
improve airw
clearance
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constriction,
hypersecretion
of mucus, and
mucosal
edema.
.
•
Encourage or
assist with
abdominal or
pursed lip
breathingexercises.
•
Assist with
measures to
improve
effectiveness of
cough effort.
• Increased fluid
intake to 3000
ml/ day. Provide
warm or tepid
liquids.
Collaborative:
•
Administer
bronchodilators
as prescribed.
•
Provides
patient with
some means to
cope with or
controldyspnea and
reduce air
tapping.
•
Coughing is
most effective
in an upright
position after
chest
percussion.
. •
Hydration
helps decrease
the viscosity of
secretions,
facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.
•
To reduce the
viscosity of
secretions.
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INTRODUCTION:
Asthma is a chronic, reversible, obstructive airway disease, characterized by wheezing. It iscaused by a spasm of the bronchial tubes, or the swelling of the bronchial mucosa, after exposureto various stimuli.
Asthma is the most common chronic disease in childhood. Most childrenexperience their first symptoms by 5 years of age.
ETIOLOGY:
Asthma commonly results from hyperresponsiveness of the trachea and bronchi to
irritants. Allergy influences both the persistence and the severity of asthma, and
atopy or the genetic predisposition for the development of an IgE-mediated response to common
airborne allergens is the most predisposing factor for the development of asthma.
CLASSIFICATION:
1. Extrinsic Asthma – called Atopic/allergic asthma. An
“allergen” or an “antigen” is a foreign particle which enters the body. Our immune system over -
reacts to these often harmless items, forming “antibodies” which are normally used to attackviruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body.
Common irritants:
Cockroach particles Cat hair and saliva
Dog hair and saliva
House dust mites
Mold or yeast spores
Metabisulfite, used as a preservative in many beverages and some foods
Pollen
2. Intrinsic asthma – called non-allergic asthma, is not allergy-related, in fact it is caused by anything except an allergy. It may be caused by inhalation of
chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress,
laughter, exercise, cold air, food preservatives or a myriad of other factors.
Smoke
Exercise
Gas, wood, coal, and kerosene heating units
Natural gas, propane, or kerosene used as cooking fuel
Fumes
Smog
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Viral respiratory infections
Wood smoke
Weather changes
ANATOMY AND PHYSIOLOGY:
The upper respiratory tract consists of the nose, sinuses, pharynx, larynx, trachea, andepiglottis.
The lower respiratory tract consist of the bronchi, bronchioles and the lungs.
The major function of the respiratory system is to deliver oxygen to arterial blood and remove
carbon dioxide from venous blood, a process known as gas exchange.
The normal gas exchange depends on three process:
Ventilation – is movement of gases from the atmosphere into and out of the lungs. This is
accomplished through the mechanical acts of inspiration and expiration.
Diffusion – is a movement of inhaled gases in the alveoli and across the alveolar capillary
membrane
Perfusion – is movement of oxygenated blood from the lungs to the tissues.
Control of gas exchange – involves neural and chemical process
The neural system, composed of three parts located in the pons, medulla and spinal cord,
coordinates respiratory rhythm and regulates the depth of respirations
The chemical processes perform several vital functions such as:
regulating alveolar ventilation by maintaining normal blood gas tension
guarding against hypercapnia (excessive CO2 in the blood) as well as hypoxia (reduced tissue
oxygenation caused by decreased arterial oxygen [PaO2]. An increase in arterial CO2 (PaCO2)
stimulates ventilation; conversely, a decrease in PaCO2 inhibits ventilation.
helping to maintain respirations (through peripheral chemoreceptors) when hypoxia occurs.
The normal functions of respiration O2 and CO2 tension and chemoreceptors are similar in
children and adults. however, children respond differently than adults to respiratory disturbances;
major areas of difference include:
Poor tolerance of nasal congestion, especially in infants who are obligatory nose breathers up to
4 months of age
Increased susceptibility to ear infection due to shorter, broader, and more horizontally
positioned eustachian tubes.
Increased severity or respiratory symptoms due to smaller airway diameters
A total body response to respiratory infection, with such symptoms as fever, vomiting and
diarrhea.
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SIGNS AND SYMPTOMS:
1. Non Productive to Productive Cough
2. Dyspnea
3. Wheezing on expiration
4. Cyanosis
5. Mild apprehension and restlessness
6. Tachycardia and palpitation 7. Diaphoresis
PATHOPHYSIOLOGY:
CLINICAL MANIFESTATIONS:
1. Increased respiratory rate
2. Wheezing (intensifies as attack progresses)
3. Cough (productive)
4. Use of accessory muscles
5. Distant breath sounds6. Fatigue
7. Moist skin
8. Anxiety and apprehension
9. Dyspnea
Steps of Clinical and Diagnostic as per National Asthma Education and
Prevention Program
Mild Intermittent Asthma
Symptoms ? 2 times per week
Brief exacerbations
Nighttime symptoms ? 2 times a month
Asymptomatic and normal PEF (peak expiratory flow) between exacerbations
PEF or FEV, (forced expiratory volume in 1 second) ? 80% of predicted value
PEF variability < 20%
Mild Persistent Asthma
Symptoms > 2 times/week, but less than once a day
Exacerbations may affect activity Nighttimes symptoms > 2 times a month
PEF/FEV ? 80% of predicted value
PEF variability 20%-30%
Moderate Persistent Asthma
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Daily Symptoms
Daily use of inhaled short-acting ?2 - agonists
Exacerbations affect activity
Exacerbations ? 2 times a week
Exacerbations may last days
Nighttime symptoms > once a week
PEF/FEV > 60%-<80% of predicted value
PEF variability > 30%
Severe Persistent Asthma
Continual symptoms
Frequent exacerbations
Frequent nighttime symptoms
Limited physical activity
PEF or FEV ? 60% of predicted value
PEF variability > 30 %
LABORATORY AND DIAGNOSTIC FINDINGS:
Spirometry will detect:
a. Decreased for expiratory volume (FEV)
b. Decreased peak expiratory flow rate (PEFR)
c. Diminished forced vital capacity (FVC)
d. Diminished inspiratory capacity (IC)
NURSING MANAGEMENT:
1. Assess respiratory status by closely evaluating breathing patterns and monitoring vital signs
2. Administer prescribed medications, such as bronchodilators, anti-inflammatories, and
antibiotics
3. Promote adequate oxygenation and a normal breathing pattern
4. Explain the possible use of hyposensitization therapy
5. Help the child cope with poor self-esteem by encouraging him to ventilate feelings andconcerns. Listen actively as the child speaks, focus on the child’s strengths, and help him to
identify the positive and negative aspects of his situation.
6. Discuss the need for periodic PFTs to evaluate and guide therapy and to monitor the course of
the illness.
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7. Provide child and family teaching. Assist the child and family to name signs
and symptoms of an acute attack and appropriate treatment measures
8. Refer the family to appropriate community agencies for assistance.