difficulty of breathing – bronchial asthma

8/7/2019 Difficulty of breathing bronchial asthma

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DIFFICULTY OF

BREATHING BRONCHIAL ASTHMA


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NURSINGHISTORY


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A. BIOGRAPHIC DATA

Name: Pt. K.CGender: Male

Age: 25 y/o

Address: 166-B Mandave St. Valenzuela

City

Religion: Born Again Christian

Occupation: Call Center Agent

Date of Admission: July 19, 2010

Attending Physician: Dr. Wake


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B. REASON FOR SEEKING

CONSULTATION (Chief Complaint)Difficulty of breathing for 5 days

C. HISTORY OF PRESENT ILLNESS:

5 days prior to admission, the patientstarted experiencing difficulty of breathing

which subsides whenever he uses a

nebulizer but recurred after few hours but

afterwards worsened which made himsought a physician who recommended

admission.


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D. PAST MEDICAL/SURGICALHISTORY:

Past medical history reveals that the

patient has ad recurrent upper respiratory

infection and had bronchitis 2 yrs. ago. Thept. has had no hospitalizations or

emergency department visits. Current

medications include diphenhydramine for

his intermittent runny nose and an

occasional puff of albuterols inhaler which

only borrowed from his cousin.


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E. SOCIAL HISTORY:

The patient has been working as a callcenter agent for more than 4 years already;

He has been working late night due to his

graveyard shift of 10pm-6am Monday to

Friday. The patient graduated as a B.SAccountancy. He has a lived in partner in

which he has already 2 children ages 4 and 2

yrs. Old. His lived in partner is a currently a

college student that is why they are gettingtheir additional financial support from their

parents.


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The couple rent in a single storey

apartment which is near to a factory. Thepatient is a heavy drinker consuming 4

bottles of beer a day and 12 bottles of beer

when there is an occasion. He also admits

that he is a chain smoker consuming 1 packs per day for almost 7 yrs or 10.5

packyear. The patient also admits that he

takes marijuana occasionally.


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F. FAMILY HISTORY:

Family history reveals that the

patients father had a history of seasonal

hay fever as a child. Both parents are

indoor and outdoor smokers. The motherreports that her husband has had some

difficulties with episodic cough and

shortness of breaths, but has not seen a

physician.


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On the other hand the mother saidthat she also had asthma during childhood

but eventually fades and has not recurred

since then but the mother has a current

medical condition of hypertension. He has2 siblings which his mother claimed never

had a serious medical condition aside from

fever and cough & colds.


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PHYSICALASSESSMENT


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General Appearance:

Seen lying on bed with 565 cc D5NM + Aminophylline 250 mg regulated @

10-15gtts/min, intact and infusing well.

The patient was observed to be weak. Upon

interview the patient was conscious andcoherent.

Initial Vital Signs:

Temp: 36.3 C

PR: 76 bpm

RR: 24 cpm

BP: 110/70


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Area to be

Examine

Normal

findings

Findings Analysis

a. Scalp No lesions, scar

and nits.No

masses and

tenderness

Scalp has no

scars or lesions

without nits.

a. Hair No presence of

alopecia, well

deistributed,

shiny

Hair is fine and

well distributed

a. Face Symmetrical,

no lesions and

wrinkles

Symmetrically

when showing

face expression


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EYES Parallel;

non-

protruding ,symmetrical

ly, PERRLA

Pupils are

responsive

and reactiveto light and

have an

equal size.

a. Eyelashe

s

black in

color , well

distributed

Eyelashes

evenly

distributed.

a. eyelidsand

Eyebrow

s

Intact,symmetricall

y distributed

on both eyes

Symmetricaand intact

eyelids and

eyebrows.


14/21

EAR

a. pinna Symmetrical,

bean shaped

and no

tenderness,lesions or scar.

Properly

aligned, soft,

and non tender

pinna. Levelsat the outer

canthus of the

eye.

a. ear canal No discharge,

present of

small amount

of cerumen.

Ear canal has

some cerumen

and no pus

discharged.


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MOUTH

a. lips Pink in color ,

moist and

symmetrical

Lips are

pinkish in

color, moist,

symmetrical

and smooth.

a. gums and

tongue

Pink in color ,

moist

Gums and

buccal mucosa

are pinkish in

color, smoothand moist.

Tongue moves

freely.


16/21

NECK Movable from

left to right,

No palpablelymph node,

symmetrical,

no lesions and

scars

moves freely,

trachea is in

the midline,No palpable

nodules,

Thyroid is nt

palpable

UPPER

EXTREMITI

ES

Can move

freely

symmetrical

Can move

freely and

symmetrical


17/21

Chest Bronchial

sounds without

wheezing orronchi, no

tenderness

upon palpation,

no presence of

skin lesion and

scars.

Bronchial

sounds

Breathing isirregular with

wheezing to

ronchi

Sound upon

auscultation.

Ribs are

prominent due

to thin body.


18/21

ABDOMEN Symmetrical,

no tenderness

and skin

lesion, scars

Appears

slightly

protuberant

and

normoactive

sounds upon

auscultation.

Symmetrical

movementscaused by

respiration

Back and

EXTREMITI

ES

Can move

freely

Symmetricaland no lesions

and scars.

Midline spine

.Peripheral

pulses are

symmetricaland Extremities

symmetrical in

size.Spine is in

the midline.


19/21

Nails Pinkish,

symmetrical

and Capillaryrefill back

within

2-3seconds

Nails and nail

beds are

pinkish incolor.

Capillary

refill:2-

3seconds

Skin Skin is smooth,

warm and no

presence of

lesions, scars.

Patient skin

color is fair,

smooth texture,

dry

and warm to

touch.


20/21

NAME OF TEST Normal

Values

Abnor

mal

Findings

Analysis

Complete Blood

Count

(July 12,2009- 6:59

am)

Purpose: CBC is

ordered to aid

in the detection

of anemias;

RBC: 4-6 x

10/L

Hct: 0.37-

0.47

Hgb: 110-

160 gm/L

4.28

0.36

111

Increased

segmenters

(mature

neutrophils)

reflect abacterial

infection since

thisare the

bodys first

bacterial

infectionsbut continue to

function during

the chronic

phase.


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NAME OF TEST Normal

Values

Abnor

mal

Findings

Analysis

hydration status;

and as part

of routine hospital

admission test. The

differential WBC isnecessary

For determining

the type of

infection.

WBC: 5-10 x

10 /L

Lymphocyte

s:0.25-0.35

Segmenters:

0.50-0.65

Eosinophil:

0.01-0.06

11.3

0.25

0.74

0.01

bacterial

invasion.

Lymphocytes are

decreased during

early acutebacterial

infection and

only increase late

in bacterial

infections but

continue tofunction during

the chronic

phase.

difficulty of breathing – bronchial asthma

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