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



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


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


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


Skin moisture Moisture in the skin foldsand the axillae (varies withenvironmental temperature

and humidity, bodytemperature, and activity)

Moisture in skin folds andthe axillae




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


Nails

Curvature and angle The client has a normalcurvature and angle of nail

160 degree angle concave,and spoon shape in all nails.


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.)


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


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



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




Eyebrows

The client has evenlydistributed hair and has

equal movement

Even distribution of hair, hasequal movement


EyelashesThe client has equal

distribution of hair andequal movements, curled

slightly outward

Even distribution of hair, hasequal movements: curled

slightly outward


Eyelids No discharge, nodiscoloration

Skin intact; no discharge: nodiscoloration


Consensual and directresponse

Both eye constricts,PERRLA

Both illuminated and non-illuminated eye constricts


Accommodation PERRLA Pupils constrict when lookingat near; pupils dilate whenlooking at far object; pupilconverge when near object ismoved toward nose


Ear

Auricles Symmetric in shape andhas fair in color.

Same color as to the facialcolor, auricle aligned in theother canthus, 10degrees

from vertical


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


Nose

External nose Symmetric, uniform incolor, no discharge and

lesions

Symmetric, straight, nodischarge or flaring, uniform in

color, no tenderness, nolesion


Patency Air movement isrestricted on the right andleft nose, no undeniable

sound heard.

Air moves freely as the clientbreaths on one nose




Mouth and orapharnyx

Outer lips Pinkish, soft smooth andable to purse

Pink, soft, moist, smooth,able to purse


Inner lips and buccalmucosa

The client’s inner lips andbuccal mucosa is pink in

color, moist, soft, glisteningand elastic

Pink, moist, soft, glistening,elastic


Teeth and gums The client only have 8 teeth. 30teeth, no retractions,smooth, white, glistening,shiny enamel, moist, firm

texture of the gums


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


Orapharynx and tonsils The client’s orapharynx andtonsils are smooth and pink

in color

Pink and smooth Normal or no deviationfound


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


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



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


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


Respiration excursion Full symmetrically chestexpansion

Full symmetric chestexpansion


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


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



Cardiovascular



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


Apical areas No lift or heaves No lift or heaves


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


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


Auscultation of carotid artery No sound heard onauscultation

No sound heard onauscultation





Abdomen

Skin integrity Uniform in color no surgicalscars

Unblemished skin; uniform incolor; silver-white striae or

surgical scars


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


Bowels sounds, andperitoneal friction rubs

Absence of arterial bruitsand friction rub

Audible bowel sounds;absence of arterial bruits; No

friction rub


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


Light palpation followed byDeep palpation

Absence of tenderness;relaxed abdomen w/ smoothconsistent tension

No tenderness relaxedabdomen with smooth

consistent tension


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%




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



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.





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



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.

http://nursingcrib.com/wp-content/uploads/upper-respiratory-system.jpg



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

http://nursingcrib.com/pathophysiology-of-asthma/





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.



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.

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Asthma Baiae