PHYSICAL EXAMINATION

Patients 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 Pulse Rate Respiratory Rate Blood Pressure 37.3 82 25 110/80

AREAS TO BE ASSESSED
Anthropometric Height Weight General Appearance and Mental Status Body build

FINDINGS
78cm 11kg

NORMS

ANALYSIS

Overall hygiene and grooming

The clients height is proportional to the clients weight The client is well groomed and neat. The client is restless

Proportionate, Relaxed and erect posture, coordinated body movements Clean and neat

Normal or no deviation found Normal or no deviation found Normal or no deviation found Normal or no deviation found

Signs of health illness/stress

Healthy

Attitude, Speech Quantity, and organization

The client is cooperative, moderate pace and understandable.

Cooperative, able to follow instructions

Skin Skin color

The client has light brown skin color, generally uniform except areas exposed to the sun.

Light brown to dark, ruddy pink to light pink: from yellow overtones to olive

Normal or no deviation found

Skin lesions

Absence of Edema, some freckles, some birthmarks, some flat and raised nevi; no abrasions or other lesions Moisture in the skin folds and the axillae (varies with environmental temperature and humidity, body temperature, and activity)

Freckles some birthmarks, some flat and raised nevi; no abrasion or other lesion

Normal or no deviation found

Skin moisture

Moisture in skin folds and the axillae

Normal or no deviation found

Skin temperature

The client has uniform body temperature.

Uniform; within normal range

Normal or no deviation found

Skin turgor

The skin of the client

Skin springs back when pinched

Normal or no deviation found

Nails Curvature and angle The client has a normal curvature and angle of nail Pinkish in color 160 degree angle concave, and spoon shape in all nails. Pinkish in color Normal or no deviation found Normal or no deviation found Normal or no deviation found

Fingernail and toenail bed color Blanch test of capillary refill

Returns in 2secs pinkish in color

Prompt or return in pinkish or usual color (4secs.)

AREAS TO BE ASSESSED Head Skull Shape, size and symmetry

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Depression, masses, nodules Symmetry of facial movements Scalp Color and appearance

Symmetrical in shape, normocephalic, smooth skull contour, equal. No depression, nodules, masses found The client has symmetrical facial movements The clients scalp has a uniform color, shiny and smooth, no masses and nodules felt. The client has evenly distributed hair The client has a oily, thick curly hair Absence of infestation and infections

Rounded; smooth skull contour No depression, masses, nodules felt Symmetric facial movements

Normal or no deviation found Normal or no deviation found Normal or no deviation found

The scalp should be shiny and smooth without lesions, lumps, or masses

Normal or no deviation found

Hair Evenness of growth over the scalp Texture, Thickness or thinness Infestations and infections

Evenly distributed hair

Normal or no deviation found Normal or no deviation found Normal or no deviation found

Thick

No infestations and infections present

AREAS TO BE ASSESSED Eyes (Visual Acuity) Test near vision

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Test distance vision

The client can read nearly the sentence/s in the newspaper while she is in a sitting position. The clients distance vision is 20/20 in both eyes (Left and Right)

Able to read

Normal or no deviation found

At a distance of 20ft. the normal eye can read the chart

Normal or no deviation found

Eyebrows

The client has evenly distributed hair and has equal movement

Even distribution of hair, has equal movement

Normal or no deviation found

Eyelashes

The client has equal distribution of hair and equal movements, curled slightly outward

Even distribution of hair, has equal movements: curled slightly outward

Normal or no deviation found

Eyelids

No discharge, no discoloration

Skin intact; no discharge: no discoloration

Normal or no deviation found

Consensual and direct response Accommodation

Both eye constricts, PERRLA PERRLA

Both illuminated and nonilluminated eye constricts Pupils constrict when looking at near; pupils dilate when looking at far object; pupil converge when near object is moved toward nose

Normal or no deviation found Normal or no deviation found

Ear

Auricles

Symmetric in shape and has fair in color.

Same color as to the facial color, auricle aligned in the other canthus, 10degrees from vertical

Normal or no deviation found

Hearing Acuity

Can hear normal voice tones

Normal voice tone can be heard

Normal or no deviation found

Watch tick test

Identified ticking of a watch

Able to hear ticking on both ears

Normal or no deviation found

Nose External nose Symmetric, uniform in color, no discharge and lesions Symmetric, straight, no discharge or flaring, uniform in color, no tenderness, no lesion Normal or no deviation found

Patency

Air movement is restricted on the right and left nose, no undeniable sound heard.

Air moves freely as the client breaths on one nose

Normal or no deviation found

Mouth and orapharnyx Outer lips Pinkish, soft smooth and able to purse Pink, soft, moist, smooth, able to purse Normal or no deviation found

Inner lips and buccal mucosa

The clients inner lips and buccal mucosa is pink in color, moist, soft, glistening and elastic The client only have 8 teeth.

Pink, moist, soft, glistening, elastic

Normal or no deviation found

Teeth and gums

30teeth, no retractions, smooth, white, glistening, shiny enamel, moist, firm texture of the gums Freely moves

Normal or no deviation found

Tongue movement

The clients tongue is freely moves The clients salivary glands, palates and uvula are same in color as buccal, soft ,pink irregular texture of the hard palate and positioned in midline The clients orapharynx and tonsils are smooth and pink in color

Normal or no deviation found Normal or no deviation found

Salivary glands palates and uvula

Same color as buccal positioned in mid line, soft, pink, irregular texture of the hard palate

Orapharynx and tonsils

Pink and smooth

Normal or no deviation found

AREAS TO BE ASSESSED

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Neck muscles Neck muscles Equal in symmetry and centered Equal in size and centered Normal or no deviation found

Head movement and Muscle strengths

The client has a equal muscle strength Muscle strength: 5 active movements against full resistance without fatigue. Not palpable

Equal muscle strength

Normal or no deviation found

Lymph nodes

Not palpable

Normal or no deviation found

AREAS TO BE ASSESSED Thorax Posterior thorax Spinal alignment

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

The clients spinal column is aligned straight.

Spined aligned vertically. Spinal column is straight, right and left shoulders and hips are at the same height Uniform temperature; no

Normal or no deviation found

Temperature, tenderness

Skin intact; uniform temperature; chest wall

Normal or no deviation found

and masses Respiratory excursion

intact; no masses Not symmetric

tenderness; no masses Full and symmetric hest expansion when the clients take a deep breath, apart an equal distance and at the same time Symmetric in percussion: Clearly on the apex of the lungs Normal or no deviation found

Percussion of posterior thorax

Percussion notes resonate except over scapula; Lowest point of resonance is at the diaphragm; percussion on a rib normally elicits dullness Wheezing sounds

Auscultation of posterior thorax

Resonated sound except over scapula Vesicular sound on base of lungs; Brochovesicular sound on 2nd intercostals spaces

Anterior thorax Breathing patterns Distant breath sounds, Quiet, rhythmic, and effortless respiration Uniform temperature; no tenderness and masses Normal or no deviation found

Temperature, tenderness and masses

Uniform in temperature; no tenderness and nodules, masses felt Full symmetrically chest expansion Flat on heavy muscles and bones, resonates to the 6th intercostals space

Respiration excursion

Full symmetric chest expansion Resonates to the 6th intercostals spaces; flat on heavy muscles and bones; dull over the heart; tympanic over stomach

Normal or no deviation found

Percussion of anterior thorax

Normal or no deviation found

Auscultation of trachea Auscultation of anterior thorax

Distant breath sounds Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over the areas of heavy muscle and bone, dull on areas over the heart and liver, and tympanic over the underlying stomach

Brachial and breath sound Brochovesicular and vesicular breath sound

Normal or no deviation found Normal or no deviation found

AREAS TO BE ASSESSED Cardiovascular

ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Aortic and pulmonary areas

Absence of pulsation No pulsation found; no lift and heaves

No pulsation No pulsation No lift and heaves

Normal or no deviation found Normal or no deviation found

Tricuspid areas

Normal or no deviation found Apical areas Auscultation of the aortic, pulmonary, tricuspid, apical valves. No lift or heaves Aortic valve heard at the 2nd ICS right sternal border. Pulmonic valve heard at the 2nd ICS left sternal border. Tricuspid valve heard at the 5th intercostals space (ICS) left sternal border. Apical valves heard at left 5th ICS, (midclavicular line) No lift or heaves S1: Usually heard at all sites Usually louder at the apical area S2: Usually heard at all sites Usually louder at the base of the heart Systole: silent interval; slightly shorter duration than diastole at normal heat rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S3: in children and young adults S4: in many older adults Carotid arteries Palpation of carotid Symmetric pulse volumes; full pulsations, thrusting quality; quality remains same when the client breathes, turns head, and changes from sitting to surpine position; elastic arterial wall No sound heard on auscultation Symmetric pulse volumes full pulsation, thrusting quality Normal or no deviation found Normal or no deviation found Normal or no deviation found

Auscultation of carotid artery

No sound heard on auscultation

Normal or no deviation found

AREAS TO BE ASSESSED Abdomen Skin integrity

ACTUAL FINDINGS Uniform in color no surgical scars Symmetric movements caused by respiration; visible peristalsis in very lean people; aortic pulsations in thin persons at epigastric area Absence of arterial bruits and friction rub Tympanic over the stomach and gas-filled bowels; dullness esp. over the liver and spleen or a full bladder. Absence of tenderness; relaxed abdomen w/ smooth consistent tension

NORMAL FINDINGS Unblemished skin; uniform in color; silver-white striae or surgical scars Symmetric movements caused by respirations; visible peristalsis in very lean people; aortic pulsations in thin at epigastric area Audible bowel sounds; absence of arterial bruits; No friction rub Tympany over the stomach; dullness over the spleen or liver No tenderness relaxed abdomen with smooth consistent tension

ANALYSIS Normal or no deviation found Normal or no deviation found

Abdominal movements

Bowels sounds, and peritoneal friction rubs Percussion of the several areas of four quadrants

Normal or no deviation found Normal or no deviation found

Light palpation followed by Deep palpation

Normal or no deviation found

Musculoskeletal System Muscle, Joints Muscle and contractures, tremors Strength of neck or jaws Strength of upper extremities Strength of lower extremities

No contractures and tremors

No contractures

Normal or no deviation found Normal or no deviation found

Temporomandibular: 5100% normal Muskuloskeletal upper extremities: 5-100%normal Muskuloskeletal upper extremities: 5-100% normal

0-0% normal strength 1-10% 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 EVALUATION

Subjective: Nahihirapan ako huminga as verbalized by the 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 to increased production of secretions. .

Bronchial asthma is a chronic inflammatory disease of the airways, associated with recurrent, reversible airway obstruction with intermittent episodes of wheezing and dyspnea. Bronchial hypersensitivity is caused by various stimuli, which innervate the vagus nerve and beta adrenergic receptor cells of the airways, leading to bronchial smooth muscle

After 3 days of nursing interventions, the patient will demonstrate behaviors to improve airway clearance.

Independent: Auscultate breath 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 a minimum like dust, smoke and feather pillows, according to individual situation.

Some degree of bronchospasm is present with obstructions in airway and may or may not be manifested in adventitious breath sounds. Elevation of the 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 of nursing interventions, the patient was able to demonstrate behaviors to improve airway clearance

constriction, hypersecretion of mucus, and mucosal edema. .

Encourage or assist with abdominal or pursed lip breathing exercises. Assist with measures to improve effectiveness of cough effort.

Provides patient with some means to cope with or control dyspnea 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.

Increased fluid intake to 3000 ml/ day. Provide warm or tepid liquids. Collaborative: Administer bronchodilators as prescribed.

INTRODUCTION: Asthma is a chronic, reversible, obstructive airway disease, characterized by wheezing. It is caused by a spasm of the bronchial tubes, or the swelling of the bronchial mucosa, after exposure to various stimuli. Asthma is the most common chronic disease in childhood. Most children experience 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 CLASSIFICATION: 1. Extrinsic Asthma called Atopic/allergic asthma. An allergen or an antigen is a foreign particle which enters the body. Our immune system overreacts to these often harmless items, forming antibodies which are normally used to attack viruses or bacteria. Mast cells release these antibodies as well as other chemicals to defend the body. Common irritants:

asthma.

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 allergyrelated, 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, and epiglottis. 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.

SIGNS AND SYMPTOMS:

1. 2. 3. 4. 5. 6. 7. Non Productive to Productive Cough Dyspnea Wheezing on expiration Cyanosis Mild apprehension and restlessness Tachycardia and palpitation Diaphoresis

PATHOPHYSIOLOGY: CLINICAL MANIFESTATIONS:

1. 2. 3. 4. 5. 6. 7. 8. 9. Increased respiratory rate Wheezing (intensifies as attack progresses) Cough (productive) Use of accessory muscles Distant breath sounds Fatigue Moist skin Anxiety and apprehension Dyspnea

Steps of Clinical and Diagnostic as per National Prevention Program Mild Intermittent

Asthma Education and

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

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 and concerns. Listen actively as the child speaks, focus on the childs 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 and symptoms of an acute attack and appropriate treatment measures 8. Refer the family to appropriate community agencies for assistance.

signs