IDENTIFICATION DATA:-
Name:-Rajesh makwana
Age:-44 years
Sex :-male
Marrital status:-Married
Ward name:-medical ward
Bed no:-10
Religion:-Hindu
Education:-10th pass
Occupation:-farmer
Diagnosis:-asthma
*chief complain:-
-Mr.rajeh makwana was admitted in the civil hospital ,Mehsana for last 5 days
with the chief complain of fver,cough and dyspnea.
*past medical history:-
-Mr.rajesh makwana has no evidence of any past medical history.
*present medical history:-
-Mr.rajesh makwana is suffering from cough,fever and dyspnea last few days.
*past surgical history:-
-Mr.rajrsh makwana has no evidence of present surgical history.
*socio-economic status:-
-Mr.rajesh makwna belongs to middle class family.he is a farmer .his monthly
income is about 8000 .he is the only person who work in his family.
*personal history :-
Habits:- no any bad habits
Exercise:-morning work
Activity pattern:-moderate
Sleep pattern:-insomnia
Diet:-vegetarian
Key word:-
SR NO. FAMILY AGE SEX RELATION HEALTH
MEMBER WITH PT STATUS
1. Rajesh 44 yr male patient unhealthy
makwna
2. gitaben 42 yr female wife healthy
3. vijay 18 yr male son healthy
4. nikita 14 yr female daughter healthy
5. kavita 12 yr female daughter healthy
PHYSICAL EXAMINATION_______
*General appearance:-
-leval of consciousness:-conscious
-Nourishment:-well nourishment
-Body build:-moderate
-Activity:-active
-Posture:-straight
-Weight:-60 kg
*vital signs:-
-Tempertaure:-99 F
-pulse:-92 beats/min
-Respiration:-32 breath/min
-nlood pressure:-130/90 mmhg
*skin:-
-colour:-pallor
-Temperature:-warm
-Texturw:-dry
Lession:-No
Head:-
-scalp:-normal
-shape:-symmetry
-Texture:-dryness
-hair color:-black
Eye:-
-eye ball:-normal
-eye lid:-normal
-eye brows:-normal
-visual activity:-reactive to the light
Mouth:-
-lips:-pink in color
-teeth:-normal
-gums:-pale
-tounge:-norma
-larynx:-normal
Ear:-
-external ear:-both are symmetrical in shape
-hearing:-normal
Neck:-
-movement:-NORMAL
-ROM:-normal
-thyroid gland:-palpable
Lymph node:-normal
Chest:-
-Inspection :-normal &symmetrical
-auscualtaion:-crackles amd wheeze sound present
-Palpation:-normal
Percussion:-normal
Abdomen:-
-Inspection:-normal
-auscultaion:-bowel sound present
-palpation:-normal
-percussion:-normal
Extremities :-
-upper extremitis:-both are syemmetrical
-lower extrimites:-both are normal
INVESTIGATION
TEST NAME PATIENT VALUE NORMAL VALUE REMARKS
Hb 10.5 mg/dl 12-14 gm/dl decreased
Wbc 13.4/ml 4.5 *10 Increased
Platelets 6.2 lakh 4 lakh Decreased
Rbc 85mg /dl <140mg/dl Normal
Na 138 md/dl 135-145 md/dl Normal
cl- 48 mg/dl 98-107 mg/dl decresed
MEDICATION
SR NO. DRUG DOSE ROUTE FREQUENCY ACTION
NAME
1. salbutamol 5 mg oral B.D Relief in
broncospasm
2. terbutaline 5 Mg oral B.D Prevent
bronchospasm
3. albuterol 5 mg oral B.D Relaxing air
passages
NURSING DIAGNOSIS
1)Ineffective breathing pattern related to narrow of bronchi as evidenced by
dyspnea.
2)ineffective airway clearance related to pulmonary secretion as evidenced by
the wheezing sound.
3)impaired gas exchange related to altered delivery of O2.
4)anxiety related to fear of suffocation as evidenced by facial expression of the
patient.
5)knowledge deficit related to the disease condition as evidenced by frequently
asked question.
6)insomnia related to ineffective breathing pattern.
Health education
Diet:-
-Advice the patient not to take oily diet or spicy food.
Exercise:-
- Educate the patient for doing passive chest exercise to promote lung
expansion.
- To teach the patient’s family regarding medication and action of
medication.
- Provide counseling to the family members and patient to reduce the stress
level.
*medication:-
-advice the patient to take the medication at properly.
-advie the patient to take the medication at proper time
*follow-up:-
-advice the patient to come to hospital for weekly checkup.
*Rest and sleep:-
-provide education to the patient for rest and edequate sleep properly.
-Take a sleep minimum 7 to 8 hours.
-take propere rest.
