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    Health Assessment

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    The patient presented with shortness of breath that worsened with activity and improved with rest. Symptoms had been ongoing for one week and were worsening. On examination, the patient had wheezing in all lung lobes, an oxygen saturation of 89% on room air, and a peak flow of 50% of personal best. The patient has a history of childhood asthma but it had been well controlled for the past few months until the current symptoms began. Current medications include an inhaled corticosteroid, long-acting beta agonist, and albuterol rescue inhaler.

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    Health Assessment

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    api-277534147
    14 views2 pages
    The patient presented with shortness of breath that worsened with activity and improved with rest. Symptoms had been ongoing for one week and were worsening. On examination, the patient had wheezing in all lung lobes, an oxygen saturation of 89% on room air, and a peak flow of 50% of personal best. The patient has a history of childhood asthma but it had been well controlled for the past few months until the current symptoms began. Current medications include an inhaled corticosteroid, long-acting beta agonist, and albuterol rescue inhaler.

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    The patient presented with shortness of breath that worsened with activity and improved with rest. Symptoms had been ongoing for one week and were worsening. On examination, the patient had wheezing in all lung lobes, an oxygen saturation of 89% on room air, and a peak flow of 50% of personal best. The patient has a history of childhood asthma but it had been well controlled for the past few months until the current symptoms began. Current medications include an inhaled corticosteroid, long-acting beta agonist, and albuterol rescue inhaler.

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    14 views2 pages

    Health Assessment

    Uploaded by

    api-277534147
    The patient presented with shortness of breath that worsened with activity and improved with rest. Symptoms had been ongoing for one week and were worsening. On examination, the patient had wheezing in all lung lobes, an oxygen saturation of 89% on room air, and a peak flow of 50% of personal best. The patient has a history of childhood asthma but it had been well controlled for the past few months until the current symptoms began. Current medications include an inhaled corticosteroid, long-acting beta agonist, and albuterol rescue inhaler.

    Copyright:

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    of 2

    Samantha LaClair

    Nursing Health Assessment Documentation Record

    System Being Assessed: Respiratory


    CC (Chief Complaint): I am short of breath

    O: Started about one week ago-not really sudden


    L: SOB- no location
    D: All the time- Worse today 3/14/15
    C: Really tight in the chest area. C/O not being able to get enough air in
    A: Worse during activity- nothing alleviates it
    R: Nonproductive cough- peak flow level is 50% at personal best
    T: Tried puffer no respiratory meds helped
    S: 9 out of 10 when moving. Sleeping in lounge chair because of this problem. 5 out
    of 10 with no exertion.

    HPI (history of present illness) includes How have you been lately?-overall last six
    month : Pt states they have asthma and that it was under control for past couple
    of months. Generally does not have issues with breathing except during very humid
    weather.

    Medications (prescribed, OTC, Herbals): Denies O2 at home, uses a puffer. No


    respiratory meds have helped. Denies herbal meds. At 0900 used 2 puffs of
    Beclovent , Serevent 1 puff BID, Proventil rescue inhaler at 1000 q 4hrs, motrin at
    1000 2 pills 400mg.

    Allergies: NKA to food or drugs. Denies environmental allergies.

    PMH: Asthma as a child. Denies injury or surgery to chest. Denies TB, cancer, cystic
    fibrosis, bronchitis, emphysema. Denies hx of cardiac history. Denies hx of
    pneumonia. Has not received flu shot. Last time hospitalized as a child with asthma.

    PSH: Denies surgery to neck and lungs. Denies chest and heart surgery.

    FH: Mother had TB, father had asthma. Parents did not have allergies. No siblings.
    Grandparents alive and well.

    Social History: Denies smoking. Denies drinking. Reports that husband smokes
    outside. Admits to using a can of snuff every couple of days.

    General Survey: T 98.6F, R 22 labored, O2 sat 89% room air, AP 98 reg rate/rhythm,
    BP 140/90, cap refill < 3 sec. No edema noted, post tibia and pedal pulses 2+, LS
    wheezes heard in all lobes and diminished. PERRLA 2+. Skin turgor non-tenting, skin
    warm and dry. Pt appears anxious and slightly disoriented. Often losing thought
    process.

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