HISTORY COLLECTIO

• IDENTIFICATION DATA
• Name : Arvind
• Age : 24yr
• Sex : Male
• Qualification : B.ed
• Occupation : Student
• Marital status : Unmarried
• Religion : Hindu
• Immunization : Vaccinated
• Income :-
• Address : Piplod surat
• Name of hospital : Civil hospital
• Ward : Male medical ward
• Bed no : 10
• Diagnosis : Asthma

HISTORY OF THE PATIENT

CHIEF COMPLAIN:
The patient come the hospital with complain of the chief complain:
➢ Severe vertigo from 1 week
➢ Vomiting from 1 week
➢ Chest pain from 1 week
➢ Dyspnea from 1 week
HISTORY OF PRESENT ILLNES
The patient was not feeling well from chest pain, vomiting, obstruction.
HISTORY OF PAST MEDICAL HISTORY
• PAST MEDICAL HISTORY-NOT YET
• PAST SURGICAL HISTORY- NOT YET
PRESENT MEDICAL HISTORY
• PRESENT MEDICAL HISTORY- Respiratory problem, asthma
• PRESENT SURGICAL HISTORY- -
 • PRESENT CHIEF COMPLAIN
Cough (all night and early in morning)
Dyspnoea, hypoxia, prolong expiration

FAMILY HISTORY
No of family member :4
Family status : Nucleus
H/O communicable chronic illness: Not present
H/O Congenital / Hereditory diseas- Not prese

FAMILY CHART
NAME AG SEX RELATIONSHI EDUCATIO OCCUPATIO HEALT
OF THE E P WITH N N H
FAMILY PATIENT STATU
MEMBE S
R
1.Naren 48 Male Father 12th Farmer Health
y
2.Seema 45 Femal Mother 8th Housewife Health
e y
3.Arvind 24 Male Patient B.ed Student ILL
4. Ravi 19 Male Brother 12th Student Health
y

FAMILY TREE

Father Mothe
MARITAL STATUS
Year of marriage :-
Marital relationship :-
ENVIRONMENTAL STATUS
House : Pakka/ own
Locality : Urban
Kitchen : Common
Light facility : Natural light adequate
Ventilation : Adequate
Bathroom : Common
Latrine : Common
Water supply : Tap water
Drainage : Close
Cleanliness : Adequate

SOCIOECONOMIC HISTORY
Income per month – 20,000/month
Earning member -- 2

NUTRITIONAL HISTORY
Vegetarian/Non-vegetarian: Vegetarian
No. of meal per day :3
No. of glass water of day : 7-8 glass
Tea/ coffee : Tea
Fruit /Juice : Fruit
PERSONAL HISTORY
Oral care frequency /day : Once
Bath frequency / day : Once
Bowel habit : Normal
HEALTH HABIT
Sleep pattern : Normal
Duration of sleep : 6-7 Hours
Duration of rest in a day : 2 Hours
Any sleep disorder : Not present
ELIMINATION HABIT
Bladder: frequency – 4 to 5 time per day
Characteristic- Normal
Bowel : frequency - Once
Characteristic – Normal
OTHER HABIT
Smoking : Present
Alcohol : Absent
Tobacco : Not present

PHYSICAL EXAMINATION:
• GENERAL APPEARANCE:
Sensorium : Conscious
Orientation : Normal
Activity : Normal
Body build : Medium
ANTHROMETRIC MEASURMENT:
Height : 5.4 feet
Weight : 52kg

VITAL SIGNS:
Temperature : 37.5C
Pulse : 74beat/min
Respiration : 17breath/min
Blood pressure : 120/80mmhg
HEAD:
Hair : Normal
Color of hair : Black
Scalp : Normal
pediculosis : Not present
EYE:
Eye brows : Normal
Eye lid/lashes : Normal
Eye ball : Normal
Conjunctiva : Normal
Eye discharge : Not present
Use of glasses : Absent
Pupil : Normal
NOSE:
Nasal septum : Normal
Nasal discharge : Not present
Allergies : Present
Bleeding : Not present
Sinusitis : Absent
MOUTH
Dental : Normal
Dental caries : Not present
Gums : Normal
Odor of mouth : Normal
LIPS:
Lips cracked/
healthy: Healthy
Cleft lips : Absent
Stomatitis : Not present
EARS:
Position and alignment: Symmetrical
Use of hearing aid : Not present
Ear discharge : Absent
Hearing activity : Normal
RASPIRATORY SYSTEM:
Cough : Present
Sputum : Present
Dyspnea : Present
Activity intolerance: Present
CARDIOVASCULAR SYSYTEM
Chest pain : Mild
Palpitation : Not present
Edema : not present
Numbness : absent
Dizziness : not present
Heart sound : wheezing
Dyspnea : present
DIGESTIVE SYSTEM:
Abdominal girth : Normal
Diarrhea/ constipation: Absent
• Abdominal inspection :
Size : -
Symmetry:-
• Palpation:
Tenderness : Absent
Fluid collection : Absent
• Percussion :
Ascites/peritonitis: Absent
Bowel sound : Normal
GENITOURINARY SYSTEM:
Frequency of urination: Normal
Color : Normal/pale
Catheter present : Not present
Normal /hematuria /Anuria:Normal
INTEGUMENTARY SYSTEM:
Skin color/texture : Normal
Allergy/dermatitis : Not present
Abnormal growth : Not present
Skin turgidity : Normal
MUSCULOSKELETAL SYSTEM:
Range of motion : Normal/proper
Joint swelling /pain : Not present
Change in ADL : Present
weakness/paralysis : Weakness
Joint movement : Normal
Gait : Normal
NEUROLOGICAL SYSTEM
Orientation : Normal
Convulsion : Absent
Paralysis : Not present
Change in sensation : Not present
Memory impairment: Not present
Thinking : Normal
Judgement : Normal
Consciousness : Conscious

VITAL SIGNS:
VITAL SIGN PATIENT VALUE NORMAL VALUE REMAKERS
1.Temperature 99f 98.6f Hyperthermia
2.pulse 98b/m 72-84b/m Tachycardia
3.Respiration 10/m 16-24b/m Bradycardia
4.Blood pressure 130/90mmhg 120/80mmhg Normal

LAB INVESTIGATION

INVESTIGAION PATIENT VALUE NORMAL VALUE REMARL

HB 12.1GM/DL 11.- 16.5GM/DL NORMAL

TOTAL COUNT 18,200MM 4,000-11,000 NORMAL

NEUTROPHIL 88% 40-73% NORMAL

LYMPHOCYTES 20% 20-45% NORMAL

ESINOPHILS 0.2% 1-6% NORMAL

MONOCYTES 0.3% 2-10% NORMAL

ESR 14MM/HR 10-15MM/HR NORMAL

RBC 4.11MILL/CUMM 4.5- NORMAL

6.5MILL/CUMM
PLATELET COUNT 1.22 1.5-4.5 NORMAL

PCV 34.2% 37-47% LOW

TREATMENT CHART

NAME OF THE DRUG DOS ROUT FREQUENC ACTION SIDE

E E Y EFFECT
1. TAB.AMINOPHYLLINE 100MH ORAL BD TO RELIEV CHEST PAIN
COUGH, OR
WHEEZING, DISCOMFORT
SHOTNESS OF , FATINTING,
BREATH IRREGULAR
HEARTBEAT,
INCREASE IN
URINE
VOLUME.

2. TAB.DOXOPHYLLINE 400MG ORAL OD RELAXING THE HEADACHE,

MUSCLES OF NAUSEA,
THE AIRWAYS VOMITTING,
AND WIDENS STOMACH
AIRWAY PAIN,
INSOMNIA

3. TAB. ASTHALIN 4MG ORAL BD RELAXING AND NAUSEA,

WIDENING THE VOMITTING,
LUNGS’AIEWAY DIZZIBESS,
, MAKING IT INCREASE
EASIER TO HEART RATE,
BREATH HEADACHE,
TREMOR
 4. TAB.SINGULAIR 5MG ORAL OD IT REDUCE DIARRHOEA,
INFLAMMATIO HEADACHE,
N IN THE STOMAC
AIRWAYS AND PAIN
MAKES
BREATHING
EASIER.

ASTHMA
Asthma is a chronic lung disease affecting people of all ages. It is caused by
inflammation and muscle tightening around the airways, which makes it harder
to breathe. Symptoms can include coughing, wheezing, shortness of breath
and chest tightness. These symptoms can be mild or severe and can come and
go over time
LIST OF THE THEORY APPLICATION CONDITION
Specific theories discussed include: (I) the health belief model, (2) models of
health, illness, and sick- role behavior, (3) social learning theory, (4) models of
physician-patient relationships, (5) self- regulation model, (6) communication
theory, (7) attribution, control, and decision-making
The health belief model of asthma
The individual's asthma control will increase when the individual has a good
perception. Therefore, the individual perceptions are important to prevent
their asthma from incurring uncontrolled asthma as their health problem.
PLAN THE CARE OF PATIENT WITH THEORY
Quick-acting medications relieve airflow obstruction, while systemic
corticosteroids reduce airway inflammation. Oxygen supplementation may be
required for severe cases. Monitoring lung function helps assess treatment
response.
NURSING ASSESSMENT
• Assess the general condition of the patient
• Assess the vital signs of the patient
• Assess the nutritional status of the patient
• Assess the breathing pattern of the patient
 • Assess the knowledge level of the patient

SHORT TERM GOAL

• To improve breathing pattern of the patient
• To clear the airway of the patient
• To reduce anxiety of the patient
• To make the patient able to eat & drink
• To improve the physical activity of the patient
LONG TERM GOAL
• To prevent further complication
• To provide rehabilitation care to patient
• To encourage the patient timely follow up
• To maintain the airway clean
NURSING DIAGNOSIS
• Infective breathing pattern related to narrowing of bronchi as evidenced
as evidenced by cough and dyspnea
• Infective airway clearance related to pulmonary secretion as evidenced
by wheezing sound
• Fatigue related to respiration efforts for breathing as evidence by
exhaustion and lethargy
• Anxiety related to hospitalization as evidenced by facial expression of
the patient.
• Imbalance nutrition related to loss of appetite as evidenced by aging.
DIET PLAN
NAME OF THE TIME INGREDENTS AMOUNT CALORIES
DIET
Breakfast: 9 AM Oats 1 bowel 380
Oats Muesli ½ bowel 270
milk Nuts
Lunch: 1:00PM Rice 1 plate 160
Rice Moong dal 1 bowel 198
Dal Mix veg 1 bowel 170
Mix veg
Snacks: 4:00PM Tea 1 cup 90
Tea Biscuit 2 pes 80
Biscuits
Dinner: 9:00PM Chapati 3pcs 170
Chapati egg 2pcs 220
Egg curry

HEALTH EDUCATION
DIET:
Patient was encouraged to include following ingredients in diet:
• Intake of low fat or fat free food
• Intake of fresh fruit and vegetables
• Avoid spicy and fried food
• Intake of high protein diet
EXERCISE:
• Educate the patient for doing passive chest exercises to promote lung
expansion
• Educate the patient not to lift heavy things and not to do heavy exercise
MEDICATION:
• To educate the patient about the medication
 • To provide knowledge about how to take the medicine and take the
proper time medicine

PERSONAL HYGIENE:
• Asked the patient to maintain proper and normal hygiene
• Told the patient to take daily bath
• To given education about hand hygiene and hand washing
• Advised the patient to adopt proper life style and maintain good life
FOLLOW UP CARE:
• Ask the patient to took the medicines at proper time
• Ask the patient to consult the doctor as per given time
CONCLUSION
during my clinical posting I have look after Mr. Arvind for my
care plan he got admitted in civil hospital with chief complain
of sever vertigo, vomiting, chest pain started giving care and
the patient relative are cooperatively. And I have got idea
about how to give care the patient with diagnosis of asthma.
BIBLIOGRAPHY
• Brunners and Suddarth’s text book of medical-surgical
nursing volume 1, south Asian edition. (Page no:453)
• SEA Edition:
Suresh k. Sharma, S. Madhvi
International editors: Janice L. Hinkle, Kerry H. Cheever