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 Findings

1. Head, Skin and Nails 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.