case pres2

8/13/2019 Case Pres2

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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'anEt#ni' gro*-: None

1ia!e't: Taga!og

Marita! Stat*s: Sing!e

e!igion: oman Cat#o!i'

Mont#! In'ome: 3%/%%%

C#ief Com-!aint: Nose ,!ee"ing

4ENE AL ASSESSMENT

Temperature 50(5

Pulse Rate 62

Respiratory Rate 2$

Blood Pressure 110/80

A EAS TO ,EASSESSE1 7IN1IN4S NO MS ANALYSIS


2/20


3/20

temperature(

*kin turgor The skin o& the client *kin springs back!hen pinched

%ormal or node$iation &ound

Nai!s

)ur$ature and angle The client has anormal cur$ature and

angle o& nail

1 0 degree angleconca$e" and spoon

shape in all nails(


ingernail and toenail bed color

Pinkish in color Pinkish in color %ormal or node$iation &ound

Blanch test o&capillary re&ill

Returns in secs pinkish in color

Prompt or return in pinkish or usual color

49secs(5


A EAS TO ,EASSESSE1

ACT9AL7IN1IN4S

NO MAL7IN1IN4S ANALYSIS

Head S8*!!

*hape" si-e andsymmetry

*ymmetrical in shape"normocephalic"

smooth skull contour"e:ual(

Rounded2 smoothskull contour


;epression" masses"nodules

%o depression"nodules" masses &ound

%o depression"masses" nodules &elt


*ymmetry o& &acialmo$ements

The client hassymmetrical &acial

mo$ements

*ymmetric &acialmo$ements


S'a!-)olor and appearance The client s scalp has

a uni&orm color" shinyand smooth" no

masses and nodules&elt(

The scalp should beshiny and smooth!ithout lesions"

lumps" or masses


Hair$enness o& gro!th

o$er the scalpThe client has e$enly

distributed hair $enly distributed

hair %ormal or node$iation &ound

Te#ture" Thickness orthinness

The client has a oily"thick curly hair

Thick %ormal or node$iation &ound


4/20

A EAS TO ,EASSESSE1

ACT9AL7IN1IN4S


Eyes(Visual Acuity)

Test near $ision The client can readnearly thesentence/s in thene!spaper !hileshe is in a sitting

position(

+ble to read %ormal or node$iation &ound

Test distance $isionThe client s

distance $ision is0/ 0 in both eyes4.e&t and Right5

+t a distance o& 0&t(the normal eye can read

the chart


yebro!s

The client has

e$enly distributedhair and has e:ualmo$ement

$en distribution o&

hair" has e:ualmo$ement

%ormal or no

de$iation &ound

yelashesThe client has e:ualdistribution o& hair

and e:ualmo$ements" curled

slightly out!ard

$en distribution o&hair" has e:ual

mo$ements curledslightly out!ard


yelids %o discharge" nodiscoloration

*kin intact2 nodischarge nodiscoloration


)onsensual and directresponse

Both eye constricts"P RR.+

Both illuminated andnon= illuminated eye

constricts


+ccommodation P RR.+ Pupils constrict !henlooking at near2 pupilsdilate !hen looking at&ar ob>ect2 pupilcon$erge !hen nearob>ect is mo$ed to!ardnose


Ear

+uricles *ymmetric in shapeand has &air in

color(

*ame color as to the&acial color" auriclealigned in the othercanthus" 10degrees

&rom $ertical



5/20

Hearing +cuity )an hear normal$oice tones

%ormal $oice tone can be heard


Watch tick test


6/20

o& the hard palate and positioned in midline

'rapharyn# andtonsils

The client sorapharyn# and

tonsils are smooth and pink in color

Pink and smooth %ormal or node$iation &ound

A EAS TO ,EASSESSE1

ACT9AL7IN1IN4S


Ne'8 m*s'!es

%eck muscles :ual in symmetryand centered

:ual in si-e andcentered


Head mo$ement and3uscle strengths

The client has a e:ualmuscle strength

3uscle strength @ Aacti$e mo$ements

against &ull resistance!ithout &atigue(

:ual muscle strength %ormal or node$iation &ound

.ymph nodes %ot palpable %ot palpable %ormal or node$iation &ound

A EAS TO ,E

ASSESSE1

ACT9AL

7IN1IN4S

NO MAL

7IN1IN4SANALYSIS

T#ora+

Posterior t#ora+

*pinal alignment The client s spinalcolumn is aligned

straight(

*pined aligned$ertically( *pinal

column is straight"right and le&t

shoulders and hips areat the same height

%ormal or no de$iation&ound

Temperature"tenderness and masses

*kin intact2 uni&ormtemperature2 chest

!all intact2 no masses

6ni&orm temperature2no tenderness2 no

masses


Respiratory e#cursion %ot symmetric ull and symmetrichest e#pansion !hen

the clients take a deep breath" apart an e:ual


7/20

distance and at thesame time

Percussion o& posterior thora#

Percussion notesresonate e#cept o$er

scapula2 .o!est pointo& resonance is at the

diaphragm2 percussion on a rib

normally elicitsdullness

*ymmetric in percussion

)learly on the ape# o&

the lungs


+uscultation o& posterior thora#

Whee-ing sounds Resonated sounde#cept o$er scapula

esicular sound on base o& lungs2

Brocho$esicularsound on nd

intercostals spaces

Anterior t#ora+

Breathing patterns ;istant breath sounds" ,uiet" rhythmic" ande&&ortless respiration

Temperature"tenderness and masses

6ni&orm intemperature2 notenderness and

nodules" masses &elt

6ni&orm temperature2no tenderness and

masses


Respiration e#cursion ull symmetricallychest e#pansion

ull symmetric cheste#pansion


Percussion o& anteriorthora#

lat on hea$y musclesand bones" resonatesto the th intercostals

space

Resonates to the th

intercostals spaces2&lat on hea$y musclesand bones2 dull o$erthe heart2 tympanic

o$er stomach


+uscultation o&trachea ;istant breath sounds Brachial and breathsound %ormal or no de$iation&ound

+uscultation o&anterior thora#

Percussion notesresonate do!n to the

si#th rib at the le$el o&the diaphragm but are&lat o$er the areas o&

Brocho$esicular and$esicular breath sound



8/20

hea$y muscle and bone" dull on areaso$er the heart and

li$er" and tympanico$er the underlying

stomach

A EAS TO ,EASSESSE1

ACT9AL7IN1IN4S


Car"io as'*!ar+ortic and pulmonary

areas+bsence o& pulsation %o pulsation %ormal or no

de$iation &ound

Tricuspid areas

%o pulsation &ound2no li&t and hea$es

%o pulsation

%o li&t and hea$es


+pical areas %o li&t or hea$es %o li&t or hea$es


+uscultation o& theaortic" pulmonary"

tricuspid" apical$al$es(

+ortic $al$e heard atthe nd


9/20

inter$al2 slightlylonger duration thansystole at normal heartrates

*? in children andyoung adults

*9 in many olderadults

Caroti" arteries %ormal or node$iation &ound

Palpation o& carotid *ymmetric pulse$olumes2 &ull

pulsations" thrusting:uality2 :uality

remains same !henthe client breathes"

turns head" andchanges &rom sittingto surpine position2elastic arterial !all

*ymmetric pulse$olumes &ull

pulsation" thrusting:uality


+uscultation o&carotid artery

%o sound heard onauscultation

%o sound heard onauscultation


A EAS TO ,EASSESSE1

ACT9AL7IN1IN4S

NO MAL7IN1IN4S

ANALYSIS

Ab"omen*kin integrity 6ni&orm in color no

surgical scars6nblemished skin2uni&orm in color2

sil$er=!hite striae orsurgical scars



10/20

+bdominalmo$ements

*ymmetricmo$ements caused by

respiration2 $isible peristalsis in $ery lean

people2 aortic pulsations in thin

persons at epigastricarea

*ymmetric mo$ementscaused by respirations2

$isible peristalsis in$ery lean people2 aortic pulsations in thin at

epigastric area


Bo!els sounds" and peritoneal &riction

rubs

+bsence o& arterial bruits and &riction rub

+udible bo!el sounds2absence o& arterial

bruits2 %o &riction rub


Percussion o& these$eral areas o& &our

:uadrants

Tympanic o$er thestomach and gas=&illed bo!els2 dullness esp(

o$er the li$er andspleen or a &ull

bladder(

Tympany o$er thestomach2 dullness o$er

the spleen or li$er


.ight palpation&ollo!ed by ;eep

palpation

+bsence o&tenderness2 rela#edabdomen !/ smoothconsistent tension

%o tenderness rela#edabdomen !ith smooth

consistent tension


M*s'*!os8e!eta!S stem M*s'!e/

)oints3uscle and

contractures" tremors %o contractures and

tremors %o contractures %ormal or no

de$iation &ound

*trength o& neck or >a!s

*trength o& uppere#tremities

*trength o& lo!ere#tremities

Temporomandibular@=100D normal3uskuloskeletalupper e#tremities @=100Dnormal3uskuloskeletalupper e#tremities @=100D normal

0=0D normal strength1=10D= @D?=@0D9=70D

@=100D



11/20

HEALTH CA E PLAN


12/20

SESSMENT 1IA4NOSIS IN7E ENCE PLANNIN4 INTE &ENTIONPLAN

ATIONALE E&AL9ATION

>ecti$eahihirapanhumingaFerbali-ed bypatient(ecti$e

o&essoryscle(

normalath sounds(

taken aslo!s T

? P 8 R @110/80


13/20


14/20

INT O19CTION:

+sthma is a chronic" re$ersible" obstructi$e air!ay disease" characteri-ed by !hee-ing(


15/20

Ias" !ood" coal" and kerosene heating units

%atural gas" propane" or kerosene used as cooking &uel

umes

*mog

iral 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$er o#ygen to arterial blood and remo$ecarbon 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( Thisis 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 )' in the blood5 as !ell as hypo#ia 4reducedtissue o#ygenation caused by decreased arterial o#ygen JPa' K( +n increase in arterial)' 4Pa)' 5 stimulates $entilation2 con$ersely" a decrease in Pa)' inhibits $entilation(

helping to maintain respirations 4through peripheral chemoreceptors5 !hen hypo#iaoccurs(


16/20

The normal &unctions o& respiration ' and )' tension and chemoreceptors are similar inchildren and adults( ho!e$er" children respond di&&erently than adults to respiratory disturbances2ma>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


17/20

Ste-s of C!ini'a! an" 1iagnosti' as -er Nationa! Ast#ma E"*'ation an" Pre entionProgram

Mild Intermittent Asthma

*ymptoms L times per !eek Brie& e#acerbations

%ighttime symptoms L times a month

+symptomatic and normal P 4peak e#piratory &lo!5 bet!een e#acerbations

P or " 4&orced e#piratory $olume in 1 second5 L 80D o& predicted $alue

P $ariability M 0D

Mild Persistent Asthma

*ymptoms N times/!eek" but less than once a day #acerbations may a&&ect acti$ity

%ighttimes symptoms N times a month

P / L 80D o& predicted $alue

P $ariability 0D=?0D

Moderate Persistent Asthma

;aily *ymptoms

;aily use o& inhaled short=acting L = agonists #acerbations a&&ect acti$ity

#acerbations L times a !eek

#acerbations may last days

%ighttime symptoms N once a !eek

P / N 0D=M80D o& predicted $alue

P $ariability N ?0D

Severe Persistent Asthma

)ontinual symptoms re:uent e#acerbations

re:uent nighttime symptoms


18/20


19/20

PROBLEM PRIORITIZATION

Ineffective airway


20/20

CRITERIA COMPUTATION ACTUAL SCORE JUSTIFICATION

1. Nature of theProblem 3/3 x 1 1 It is a health deficit

2. Modifiability of theProblem 2/2 x 2 2

The resources areavailable and

interventions arefeasible.

3. PreventivePotential 3/3 x 1 1

This can be preventedbecause the client isa are of his situationand ta!e his medicine toprevent asthma attac!

". #alience of theProblem 1/2 x 1 1/2

The family $iveimportance to the child%ssituation

TOTAL 4 1 !

case pres2

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