Assessment

ASSESSMENT 1. Patient’s Profile Name: Romeo Bitanggol Age: 20 Address: Purok 25, Gumamela Street, Sanito, Ipil Zamboanga Sibugay Province Gender: Male Civil Status: Married Religion: Roman Catholic Date Admitted: May 4, 2008 Diagnosis: Bronchial Asthma

2. Nursing History The patient experienced intermittent acute asthmatic attack when he was 8 years old with complaints of difficulty in breathing, tightness in chest and slight fever and he was admitted in the hospital for 2 weeks for treatment then after, he was discharged at home for follow up medications. But due to poor compliance of medications and sudden exposure to pollutants from a company where he is currently working, recurrent attack of his asthma becomes prolonged and prompt admission to the hospital for further treatment. His grandmother suffers the same disease as well as his aunt.

3. Physical Examination Area of assessment 1. Head, Skin and Nails

Findings Skin is pale in color, head is normocephalic, frequent sweating is noted, nailbeds are cyanotic and capillary refill is poor. Temperature is 37.5 degree celcius.

2. Eyes & vision

Conjuntiva is pale in color, vision is 20 / 20 upon snellen chart test and he does not wear any reading glasses.

3. Ears & Hearing

He suffers ringing of both ears, his pinna is pale in color but no discharges noted.

4. Nose & Sinuses

Nasal flaring is seen with labored respiration, Sinuses are painless and discharges are noted.

5. Mouth & Neck

Bad breath odor, oral mucosa, lips & tongue are dry and pale in color. Tonsils are swelling.

6. Thorax & Lungs

Tenderness & pain over intercoastal spaces, unequal fremitus and unequal chest expansion. Uneven excursion & dullness is noted upon percussion. Wheezing is noted upon auscultation. Respiratory rate is 30 breaths per minute. He complaints of difficulty of breathing.

7. Heart & Breast

Slow rapid radial and apical pulse for about 60 beats per minute. Blood pressure is 110 / 80 mmHg. Breast shape is equally symmetrical In size & shape.

8. Abdomen

Bowel sound is heard for about 2 – 3

per minute. He loss his appetite in eating. 9. Male genitalia

He urinate twice a day and no discharges noted.

10.Rectum & Anus

He defecate once in 2 days with smushy fowl odored feces. No hemorrhoids noted.

11.Musculoskeletal System

He cannot move rapidly or bend over. His muscle is weak and needs support from his significant others or caregiver in maintaining his activity daily living.

12.Neurological System

He is tired and weak looking & unable to talk thoroughly due to his coughing. Guarded behavior is noted and he is anxious.