PHYSICAL EXAMINATION

Patients Name: Kristoff Panganiban Age: 2 ears o!" an" t#ree mont#s A""ress: 2$% &i'toria St( San )*an Cit Se+: Ma!e ,irt# "ate: A-ri! ./ 2%%0 P!a'e of birt#: ,*!a'an Et#ni' gro*-: None 1ia!e't: Taga!og Marita! Stat*s: Sing!e 2e!igion: 2oman Cat#o!i' Mont#! In'ome: 3%/%%% C#ief Com-!aint: Nose ,!ee"ing

4ENE2AL ASSESSMENT Temperature Pulse Rate Respiratory Rate Blood Pressure 50(5 62 2$ 110/80

A2EAS TO ,E ASSESSE1

7IN1IN4S

NO2MS

ANALYSIS

Ant#ro-ometri' Height Weight 4enera! A--earan'e an" Menta! Stat*s Body build

78cm 11kg

'$erall hygiene and grooming *igns o& health illness/stress +ttitude" *peech ,uantity" and organi-ation

The client s height is proportional to the client s !eight The client is !ell groomed and neat( The client is restless The client is cooperati$e" moderate pace and understandable(

Proportionate" Rela#ed and erect posture" coordinated body mo$ements )lean and neat Healthy )ooperati$e" able to &ollo! instructions

%ormal or no de$iation &ound

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

S8in *kin color

The client has light bro!n skin color" generally uni&orm e#cept areas e#posed to the sun( +bsence o& 0dema" no &reckles and no birthmarks 3oisture in the skin &olds and the a#illae 4$aries !ith en$ironmental temperature and humidity" body temperature" and acti$ity5 The client has uni&orm body

.ight bro!n to dark" ruddy pink to light pink/ &rom yello! o$ertones to oli$e

%ormal or no de$iation &ound

*kin lesions

*kin moisture

1reckles some birthmarks" some &lat and raised ne$i2 no abrasion or other lesion 3oisture in skin &olds and the a#illae

%ormal or no de$iation &ound

%ormal or no de$iation &ound

*kin temperature

6ni&orm2 !ithin normal range

%ormal or no de$iation &ound

temperature( *kin turgor Nai!s )ur$ature and angle 1ingernail and toenail bed color Blanch test o& capillary re&ill The client has a normal cur$ature and angle o& nail Pinkish in color Returns in 8secs pinkish in color 170 degree angle conca$e" and spoon shape in all nails( Pinkish in color Prompt or return in pinkish or usual color 49secs(5 NO2MAL 7IN1IN4S Rounded2 smooth skull contour %o depression" masses" nodules &elt *ymmetric &acial mo$ements The scalp should be shiny and smooth !ithout lesions" lumps" or masses 0$enly distributed hair Thick %o in&estations and in&ections present %ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound The skin o& the client *kin springs back !hen pinched %ormal or no de$iation &ound

A2EAS TO ,E ASSESSE1 Head S8*!! *hape" si-e and symmetry ;epression" masses" nodules *ymmetry o& &acial mo$ements S'a!)olor and appearance

ACT9AL 7IN1IN4S *ymmetrical in shape" normocephalic" smooth skull contour" e:ual( %o depression" nodules" masses &ound The client has symmetrical &acial mo$ements The client s scalp has a uni&orm color" shiny and smooth" no masses and nodules &elt( The client has e$enly distributed hair The client has a oily" thick curly hair +bsence o& in&estation and in&ections

ANALYSIS

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

%ormal or no de$iation &ound

Hair 0$enness o& gro!th o$er the scalp Te#ture" Thickness or thinness <n&estations and in&ections

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

A2EAS TO ,E ASSESSE1 Eyes (Visual Acuity) Test near $ision

ACT9AL 7IN1IN4S

NO2MAL 7IN1IN4S

ANALYSIS

Test distance $ision

0yebro!s

0yelashes

0yelids

The client can read +ble to read nearly the sentence/s in the ne!spaper !hile she is in a sitting position( The client s +t a distance o& 80&t( distance $ision is the normal eye can read 80/80 in both eyes the chart 4.e&t and Right5 The client has 0$en distribution o& e$enly distributed hair" has e:ual hair and has e:ual mo$ement mo$ement The client has e:ual 0$en distribution o& distribution o& hair hair" has e:ual and e:ual mo$ements/ curled mo$ements" curled slightly out!ard slightly out!ard %o discharge" no *kin intact2 no discoloration discharge/ no discoloration Both eye constricts" P0RR.+ P0RR.+ Both illuminated and non= illuminated eye constricts Pupils constrict !hen looking at near2 pupils dilate !hen looking at &ar ob>ect2 pupil con$erge !hen near ob>ect is mo$ed to!ard nose

%ormal or no de$iation &ound

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

)onsensual and direct response +ccommodation

Ear +uricles *ymmetric in shape and has &air in color( *ame color as to the &acial color" auricle aligned in the other canthus" 10degrees &rom $ertical %ormal or no de$iation &ound

Hearing +cuity

)an hear normal $oice tones <denti&ied ticking o& a !atch

%ormal $oice tone can be heard +ble to hear ticking on both ears

%ormal or no de$iation &ound %ormal or no de$iation &ound

Watch tick test

Nose 0#ternal nose *ymmetric" uni&orm in color" !ith discharge and lesions +ir canty mo$e &reely because o& some discharge *ymmetric" straight" no discharge or &laring" uni&orm in color" no tenderness" no lesion +ir mo$es &reely as the client breaths on one nose %ormal or no de$iation &ound

Patency

%ormal or no de$iation &ound

Mo*t# an" ora-#arn + 'uter lips Pinkish" so&t smooth and able to purse The client s inner lips and buccal mucosa is pink in color" moist" so&t" glistening and elastic The client only ha$e 8 teeth( Pink" so&t" moist" smooth" able to purse Pink" moist" so&t" glistening" elastic %ormal or no de$iation &ound %ormal or no de$iation &ound

<nner lips and buccal mucosa

Teeth and gums

?0teeth" no retractions" smooth" !hite" glistening" shiny enamel" moist" &irm te#ture o& the gums 1reely mo$es *ame color as buccal positioned in mid line" so&t" pink" irregular te#ture o& the hard palate

%ormal or no de$iation &ound

Tongue mo$ement *ali$ary glands palates and u$ula

The client s tongue is &reely mo$es The client s sali$ary glands" palates and u$ula are same in color as buccal" so&t "pink irregular te#ture

%ormal or no de$iation &ound %ormal or no de$iation &ound

o& the hard palate and positioned in midline 'rapharyn# and tonsils The client s orapharyn# and tonsils are smooth and pink in color Pink and smooth %ormal or no de$iation &ound

A2EAS TO ,E ASSESSE1 Ne'8 m*s'!es %eck muscles

ACT9AL 7IN1IN4S 0:ual in symmetry and centered The client has a e:ual muscle strength 3uscle strength/ @ A acti$e mo$ements against &ull resistance !ithout &atigue( %ot palpable

NO2MAL 7IN1IN4S 0:ual in si-e and centered 0:ual muscle strength

ANALYSIS

%ormal or no de$iation &ound %ormal or no de$iation &ound

Head mo$ement and 3uscle strengths

.ymph nodes

%ot palpable

%ormal or no de$iation &ound

A2EAS TO ,E ASSESSE1 T#ora+ Posterior t#ora+ *pinal alignment

ACT9AL 7IN1IN4S

NO2MAL 7IN1IN4S

ANALYSIS

The client s spinal column is aligned straight(

*pined aligned $ertically( *pinal column is straight" right and le&t shoulders and hips are at the same height 6ni&orm temperature2 no tenderness2 no masses 1ull and symmetric hest e#pansion !hen the clients take a deep breath" apart an e:ual

%ormal or no de$iation &ound

Temperature" tenderness and masses Respiratory e#cursion

*kin intact2 uni&orm temperature2 chest !all intact2 no masses %ot symmetric

%ormal or no de$iation &ound

distance and at the same time Percussion notes resonate e#cept o$er scapula2 .o!est point o& resonance is at the diaphragm2 percussion on a rib normally elicits dullness Whee-ing sounds *ymmetric in percussion/ )learly on the ape# o& the lungs %ormal or no de$iation &ound

Percussion o& posterior thora#

+uscultation o& posterior thora#

Resonated sound e#cept o$er scapula Besicular sound on base o& lungs2 Brocho$esicular sound on 8nd intercostals spaces

Anterior t#ora+ Breathing patterns Temperature" tenderness and masses ;istant breath sounds" 6ni&orm in temperature2 no tenderness and nodules" masses &elt 1ull symmetrically chest e#pansion 1lat on hea$y muscles and bones" resonates to the 7th intercostals space ,uiet" rhythmic" and e&&ortless respiration 6ni&orm temperature2 no tenderness and masses 1ull symmetric chest e#pansion Resonates to the 7th intercostals spaces2 &lat on hea$y muscles and bones2 dull o$er the heart2 tympanic o$er stomach Brachial and breath sound %ormal or no de$iation &ound

Respiration e#cursion Percussion o& anterior thora#

%ormal or no de$iation &ound %ormal or no de$iation &ound

+uscultation o& trachea +uscultation o& anterior thora#

;istant breath sounds

%ormal or no de$iation &ound

Percussion notes Brocho$esicular and %ormal or no de$iation resonate do!n to the $esicular breath sound &ound si#th rib at the le$el o& the diaphragm but are &lat o$er the areas o&

hea$y muscle and bone" dull on areas o$er the heart and li$er" and tympanic o$er the underlying stomach

A2EAS TO ,E ASSESSE1 Car"io:as'*!ar +ortic and pulmonary areas

ACT9AL 7IN1IN4S +bsence o& pulsation %o pulsation &ound2 no li&t and hea$es

NO2MAL 7IN1IN4S %o pulsation %o pulsation %o li&t and hea$es

ANALYSIS

%ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound %ormal or no de$iation &ound

Tricuspid areas

+pical areas +uscultation o& the aortic" pulmonary" tricuspid" apical $al$es(

%o li&t or hea$es +ortic $al$e heard at the 8nd <)* right sternal border( Pulmonic $al$e heard at the 8nd <)* le&t sternal border( Tricuspid $al$e heard at the @th intercostals space 4<)*5 le&t sternal border( +pical $al$es heard at le&t @th <)*" 4midcla$icular line5

%o li&t or hea$es *1/ 6sually heard at all sites 6sually louder at the apical area *8/ 6sually heard at all sites 6sually louder at the base o& the heart *ystole/ silent inter$al2 slightly shorter duration than diastole at normal heat rate 470 to C0 beats/min5 ;iastole/ silent

inter$al2 slightly longer duration than systole at normal heart rates *?/ in children and young adults *9/ in many older adults Caroti" arteries Palpation o& carotid *ymmetric pulse $olumes2 &ull pulsations" thrusting :uality2 :uality remains same !hen the client breathes" turns head" and changes &rom sitting to surpine position2 elastic arterial !all %o sound heard on auscultation *ymmetric pulse $olumes &ull pulsation" thrusting :uality %ormal or no de$iation &ound %ormal or no de$iation &ound

+uscultation o& carotid artery

%o sound heard on auscultation

%ormal or no de$iation &ound

A2EAS TO ,E ASSESSE1 Ab"omen *kin integrity

ACT9AL 7IN1IN4S 6ni&orm in color no surgical scars

NO2MAL 7IN1IN4S 6nblemished skin2 uni&orm in color2 sil$er=!hite striae or surgical scars

ANALYSIS %ormal or no de$iation &ound

+bdominal mo$ements

Bo!els sounds" and peritoneal &riction rubs Percussion o& the se$eral areas o& &our :uadrants

*ymmetric mo$ements caused by respiration2 $isible peristalsis in $ery lean people2 aortic pulsations in thin persons at epigastric area +bsence o& arterial bruits and &riction rub Tympanic o$er the stomach and gas=&illed bo!els2 dullness esp( o$er the li$er and spleen or a &ull bladder( +bsence o& tenderness2 rela#ed abdomen !/ smooth consistent tension

*ymmetric mo$ements caused by respirations2 $isible peristalsis in $ery lean people2 aortic pulsations in thin at epigastric area +udible bo!el sounds2 absence o& arterial bruits2 %o &riction rub Tympany o$er the stomach2 dullness o$er the spleen or li$er

%ormal or no de$iation &ound

%ormal or no de$iation &ound %ormal or no de$iation &ound

.ight palpation &ollo!ed by ;eep palpation M*s'*!os8e!eta! S stem M*s'!e/ )oints 3uscle and contractures" tremors *trength o& neck or >a!s *trength o& upper e#tremities *trength o& lo!er e#tremities

%o tenderness rela#ed abdomen !ith smooth consistent tension

%ormal or no de$iation &ound

%o contractures and tremors Temporomandibular/ @=100D normal 3uskuloskeletal upper e#tremities/ @= 100Dnormal 3uskuloskeletal upper e#tremities/ @= 100D normal

%o contractures 0=0D normal strength 1=10D 8=8@D ?=@0D 9=70D @=100D

%ormal or no de$iation &ound %ormal or no de$iation &ound

HEALTH CA2E PLAN

<ne&&ecti$e air!ay clearance related to increased production o& secretions(

(

ASSESSMENT 1IA4NOSIS IN7E2ENCE

PLANNIN4

INTE2&ENTION 2ATIONALE E&AL9ATION PLAN

*ub>ecti$e/ E%ahihirapan ako humingaF as $erbali-ed by the patient( 'b>ecti$e/ G 6se o& accessory muscle( G +bnormal breath sounds( G B/* taken as &ollo!s/ T/ ?7(? P/ 88 R/ 8@ BP/ 110/80

<ne&&ecti$e air!ay clearance related to increased production o& secretions( (

Bronchial asthma is a chronic in&lammatory disease o& the air!ays" associated !ith recurrent" re$ersible air!ay obstruction !ith intermittent episodes o& !hee-ing and dyspnea( Bronchial hypersensiti$ity is caused by $arious stimuli" !hich inner$ate the $agus ner$e and beta adrenergic receptor cells o& the air!ays" leading to bronchial smooth muscle constriction" hypersecretion o& mucus" and mucosal edema( (

+&ter ? days o& nursing inter$entions" the patient !ill demonstrate beha$iors to impro$e air!ay clearance(

<ndependent/ G +uscultate breath sounds( %ote ad$entitious breath sounds like !hee-es" crackles and rhonchi( G 0le$ate head o& the bed" ha$e patient lean on o$erbed table or sit on edge o& the bed( G Heep en$ironmental pollution to a minimum like dust" smoke and &eather pillo!s" according to indi$idual situation( G 0ncourage or assist !ith abdominal or pursed lip breathing e#ercises( G +ssist !ith measures to impro$e e&&ecti$eness o& cough e&&ort(

*ome degree o& bronchospasm is present !ith obstructions in air!ay and may or may not be mani&ested in ad$entitious breath sounds( G 0le$ation o& the bed &acilitates respiratory &unction by use o& gra$ity( G Precipitators o& allergic type o& respiratory reactions that can trigger or e#acerbate onset o& acute episode( G Pro$ides patient !ith some means to cope !ith or control dyspnea and reduce air tapping( G )oughing is most e&&ecti$e

+&ter ? days o& nursing inter$entions" the patient !as able to demonstrate beha$iors to impro$e air!ay clearance

INT2O19CTION: +sthma is a chronic" re$ersible" obstructi$e air!ay disease" characteri-ed by !hee-ing( <t is caused by a spasm o& the bronchial tubes" or the s!elling o& the bronchial mucosa" a&ter e#posure to $arious stimuli( +sthma is the most common chronic disease in childhood( 3ost children e#perience their &irst symptoms by @ years o& age( ETIOLO4Y: +sthma commonly results &rom hyperresponsi$eness o& the trachea and bronchi to irritants( +llergy in&luences both the persistence and the se$erity o& asthma" and atopy or the genetic predisposition &or the de$elopment o& an <g0=mediated response to common airborne allergens is the most predisposing &actor &or the de$elopment o& asthma( CLASSI7ICATION: 3( E+trinsi' Ast#ma ; 'a!!e" Ato-i'<a!!ergi' ast#ma( +n EallergenF or an EantigenF is a &oreign particle !hich enters the body( 'ur immune system o$er=reacts to these o&ten harmless items" &orming EantibodiesF !hich are normally used to attack $iruses or bacteria( 3ast cells release these antibodies as !ell as other chemicals to de&end the body( )ommon irritants/

)ockroach particles )at hair and sali$a ;og hair and sali$a House dust mites 3old or yeast spores 3etabisul&ite" used as a preser$ati$e in many be$erages and some &oods Pollen

2( Intrinsi' ast#ma A 'a!!e" non=a!!ergi' ast#ma" is not allergy=related" in &act it is caused by anything e#cept an allergy( <t may be caused by inhalation o& chemicals such as cigarette smoke or cleaning agents" taking aspirin" a chest in&ection" stress" laughter" e#ercise" cold air" &ood preser$ati$es or a myriad o& other &actors(

*moke 0#ercise

Ias" !ood" coal" and kerosene heating units %atural gas" propane" or kerosene used as cooking &uel

1umes *mog Biral respiratory in&ections Wood smoke Weather changes

ANATOMY AN1 PHYSIOLO4Y:

The upper respiratory tract consists o& the nose" sinuses" pharyn#" laryn#" trachea" and epiglottis( The lo!er respiratory tract consist o& the bronchi" bronchioles and the lungs( The ma>or &unction o& the respiratory system is to deli$er o#ygen to arterial blood and remo$e carbon dio#ide &rom $enous blood" a process kno!n as gas e+'#ange( The normal gas exchange depends on three process:

&enti!ation A is mo$ement o& gases &rom the atmosphere into and out o& the lungs( This is accomplished through the mechanical acts o& ins-iration an" e+-iration( 1iff*sion A is a mo$ement o& inhaled gases in the al$eoli and across the al$eolar capillary membrane Perf*sion A is mo$ement o& o#ygenated blood &rom the lungs to the tissues(

Control of gas exchange involves neural and chemical process The neural system" composed o& three parts located in the pons" medulla and spinal cord" coordinates respiratory rhythm and regulates the depth o& respirations The chemical processes per&orm se$eral $ital &unctions such as/

regulating al$eolar $entilation by maintaining normal blood gas tension guarding against hypercapnia 4e#cessi$e )'8 in the blood5 as !ell as hypo#ia 4reduced tissue o#ygenation caused by decreased arterial o#ygen JPa'8K( +n increase in arterial )'8 4Pa)'85 stimulates $entilation2 con$ersely" a decrease in Pa)'8 inhibits $entilation( helping to maintain respirations 4through peripheral chemoreceptors5 !hen hypo#ia occurs(

The normal &unctions o& respiration '8 and )'8 tension and chemoreceptors are similar in children and adults( ho!e$er" children respond di&&erently than adults to respiratory disturbances2 ma>or areas o& di&&erence include/

Poor tolerance o& nasal congestion" especially in in&ants !ho are obligatory nose breathers up to 9 months o& age <ncreased susceptibility to ear in&ection due to shorter" broader" and more hori-ontally positioned eustachian tubes( <ncreased se$erity or respiratory symptoms due to smaller air!ay diameters + total body response to respiratory in&ection" !ith such symptoms as &e$er" $omiting and diarrhea(

SI4NS AN1 SYMPTOMS:

1. Non Pro"*'ti:e to Pro"*'ti:e Co*g# 2. 1 s-nea 3. >#ee?ing on e+-iration 4. C anosis 5. Mi!" a--re#ension an" rest!essness 6. Ta'# 'ar"ia an" -a!-itation 7. 1ia-#oresis

PATHOPHYSIOLO4Y: CLINICAL MANI7ESTATIONS: 1( <ncreased respiratory rate 8( Whee-ing 4intensi&ies as attack progresses5 ?( )ough 4producti$e5 9( 6se o& accessory muscles @( ;istant breath sounds 7( 1atigue 7( 3oist skin 8( +n#iety and apprehension C( ;yspnea

Ste-s of C!ini'a! an" 1iagnosti' as -er Nationa! Ast#ma E"*'ation an" Pre:ention Program Mild Intermittent Asthma

*ymptoms L 8 times per !eek Brie& e#acerbations %ighttime symptoms L 8 times a month +symptomatic and normal P01 4peak e#piratory &lo!5 bet!een e#acerbations P01 or 10B" 4&orced e#piratory $olume in 1 second5 L 80D o& predicted $alue P01 $ariability M 80D

Mild Persistent Asthma

*ymptoms N 8 times/!eek" but less than once a day 0#acerbations may a&&ect acti$ity %ighttimes symptoms N 8 times a month P01/10B L 80D o& predicted $alue P01 $ariability 80D=?0D

Moderate Persistent Asthma

;aily *ymptoms ;aily use o& inhaled short=acting L8 = agonists 0#acerbations a&&ect acti$ity 0#acerbations L 8 times a !eek 0#acerbations may last days %ighttime symptoms N once a !eek P01/10B N 70D=M80D o& predicted $alue P01 $ariability N ?0D

Severe Persistent Asthma

)ontinual symptoms 1re:uent e#acerbations 1re:uent nighttime symptoms

.imited physical acti$ity P01 or 10B L 70D o& predicted $alue P01 $ariability N ?0 D

LA,O2ATO2Y AN1 1IA4NOSTIC 7IN1IN4S: *pirometry !ill detect/ a( ;ecreased &or e#piratory $olume 410B5 b( ;ecreased peak e#piratory &lo! rate 4P01R5 c( ;iminished &orced $ital capacity 41B)5 d( ;iminished inspiratory capacity 4<)5 N92SIN4 MANA4EMENT: 1( +ssess respiratory status by closely e$aluating breathing patterns and monitoring $ital signs 8( +dminister prescribed medications" such as bronchodilators" anti=in&lammatories" and antibiotics ?( Promote ade:uate o#ygenation and a normal breathing pattern 9( 0#plain the possible use o& hyposensiti-ation therapy @( Help the child cope !ith poor sel&=esteem by encouraging him to $entilate &eelings and concerns( .isten acti$ely as the child speaks" &ocus on the child s strengths" and help him to identi&y the positi$e and negati$e aspects o& his situation( 7( ;iscuss the need &or periodic P1Ts to e$aluate and guide therapy and to monitor the course o& the illness( 7( Pro$ide child and &amily teaching( +ssist the child and &amily to name signs and symptoms o& an acute attack and appropriate treatment measures 8( Re&er the &amily to appropriate community agencies &or assistance(

PROBLEM PRIORITIZATION
Ineffective airway

CRITERIA 1. Nature of the Problem

COMPUTATION 3/3 x 1

ACTUAL SCORE 1

JUSTIFICATION It is a health deficit

2. Modifiability of the Problem

2/2 x 2

The resources are available and interventions are feasible.

3. Preventive Potential

3/3 x 1

This can be prevented because the client is a are of his situation and ta!e his medicine to prevent asthma attac!

". #alience of the Problem

1/2 x 1

1/2

The family $ive importance to the child%s situation

TOTAL

41!