Hizon, Dan Melton Anthony A.

BSN-3B

Instructions
CASE SCENARIO FOR CASE STUDY:
A 36 year old client who has a history of asthma arrives in the emergency room with
complaint of difficulty breathing. She tells the nurse that she developed a cold about
three days ago and now it has settled in her lungs. She has been coughing all through
the night but has been unable to cough up any sputum. She has not had a respiratory
problem for over a year and did not have her prescribed Alupent inhaler available.
The nurse performs an assessment. Vital signs: T 38.1 C, P 132 R 28, BP 140/86 O2
sat 94% The nurse auscultates the breath sounds and assesses the client for signs of
respiratory distress and dehydration.
The nurse listen to the client’s anterior and posterior chest and hears expiratory and
inspiratory wheezes with diminished breath sounds. The client is sitting up forward and
using her abdominal muscles to breathe. She is able to speak quietly between breaths
and states she knows she will get better. Capillary refill is within 2 seconds. Her oral
mucous membranes and tongue are dry. The veins in her hand and forearm are flat
when her intravenous line is started
The emergency room physician examines the client and orders a stat aerosol treatment
with albuterol. Additional orders are initiated:
IV of 1000 ml 5% dextrose Lactated Ringers at rate 150 ml/hr
Aminophylline 250 mg in 50 ml 5% dextrose over 20 minutes
Levofloxacin 500 mg IVP now
In an hour the client is reassessed. Vital signs have improved, oxygen saturation is 98%
and breath sounds are improved with less wheezing and better air exchange. The client
is observed in the emergency room for another hour and is discharged with a
prescription for levofloxacin 500mg PO qd X 9 doses and an albuterol inhaler 2 puff qid.
The client is to see her primary care provider in a week.

Prepare 5 priority NCP for this patient suffering from asthma

Make a comprehesnive drug study of the medications ordered by the doctor
Perform a thorough assessment by Imagining your patient based on the manifestations
presented
Physical Assessment:
Integumentary
Skin: Skin is uniform in color, unblemished and no foul odor
Hair: Hair is straight, clean, black, supple I texture. No scalp lesions or flacking.
No hair noted on axilla or chest, back or face
Nails: fingernails short in length and thickness, clear, No clubbing o beau’s lines
Head and Neck
Head: Head is symmetrically rounded
Neck: Neck is non-tender with full of ROM
Eyes
Eyebrow: Eyebrow is evenly distributed hair, symmetrically aligned
Eyelashes: eyelashes is equally distributed and curled slightly outward
Eyelids: no discoloration, lid close symmetrically
Ears
Auricles with deformity, lumps or lesions. Auricles and mastoid process non-
tender. Bilateral auditory canal clear. Tympanic membrane pearly gray bilaterally
with visible land-marks. Hearing with Whisper test bilaterally
Mouth, Throat, Nose and Sinuses
Mouth and throat: Lips dry, no lesions and ulcerations. Buccal is dry. No ulcer or
nodules. Gums pink and moist without inflammation, bleeding or discoloration.
Hard and soft palate smooth without lesions or masses. Tongue midline when
protrudes, no lesions or masses. Uvula in midline and elevates on phonation.
Nose: external structure of nose without deformity, asymmetry, or inflammation,
nares patent. Turbinates and middle meatus pale pink, without swelling, exudate,
lesions or bleeding. Nasal septum midline without bleeding, perforation or
deviation.
Sinus: Frontal and maxillary sinuses non-tender
Thorax and lungs
Thorax: skin light brown without scars, pulsations or lesions. No hair noted.
Thorax expand evenly bilaterally without retractions or bulging. Difficulty in
 Respiration labored and noisy. No tenderness, crepitus or masses. Use
accessory muscle such as abdominal muscle to breathe, wheezes with
diminished sounds
Abdomen
Abdomen rounded, symmetrical without masses, lesion, pulsations, or peristalsis
noted. Abdomen free of hair, bruising and increased vasculature. Umbilicus in
mid-line, without herniation, swelling or discoloration. Tympany percussed
throughout. No tenderness or masses noted with light and deep palpation. Liver
and spleen non-palpable
Peripheral Vascular
Upper extremities: Equal in size and symmetry bilaterally; light brown; warm and
dry to touch without edema, bruising, or lesions. Radial pulse = in rate and 2+
bilaterally. Brachial pulses equal and 2+ bilaterally
Low extremities: legs symmetric. Skin intact, light brown; warm and dry to touch
without edema, bruising, lesions or increased vascularity. Femoral pulse 2+ and
equal without bruits. Dorsalis pedal and posterior tibial pulses 1+ and equal. No
edema palpable
Musculoskeletal
Posture erect. Gait steady and coordinated with even base. Full ROM of cervical
and lumbar spine. Full ROM of cervical and lumbar spine. Full ROM of upper and
lower extremities. Strength 5/5 of upper and lower extremities