Physical Assessment Report for an 18-Years-Old Asthma Patient

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Table of Contents

Health History
Physical Examination
Needs Assessment
Reflection
References

An 18-years-old adolescent boy was diagnosed with Asthma, which in the recent past has been controlled using a rescue inhaler at a local health facility. The medical team decided that before any nursing plan is put in place for the patient, there must be a comprehensive examination of the boy involving the collection of his subjective and objective data (Kamangar, 2021). To determine the interrelationships of subjective data and objective data, synthesize the data, and identify health priorities for the patient.

Health History

The patient is a Hispanic adolescent boy aged 18 years, weighing 70 kg, 1.76 meters tall, and is a strong member of Jehovah’s witness church. The boy was brought to the hospital because he is asthmatic and the disease keeps on recurring. The patient was looking tired, restless and he was aggravated. The airways were swollen, with contracting muscles. Both the boy and father looked worried about his situation and they seemed to be losing hope in managing the disease. The patients’ father explained that the disease had been controlled in the recent past through the use of an inhaler which has not been effective. The boy and his family suspect that he is suffering frequent asthma attacks due to allergies to cold and dust, however none of his members of the family suffer from asthma. The patient was vaccinated and immunized against polio when he was below 5 years old, and last year against COVID-19. The patient’s skin color was normal, no lesions, no bruises, and no allergic reactions; his hair and nails were in good conditions.

The boy is in the fifth stage of psychological development where he is looking for an identity and sense of being himself. Throughout the interview and from observation, the boy looked sharp, focused, and independent based on some of his responses. He only requires a lot of encouragement and reinforcements from the family and those around him to boost his confidence. Chances are that his disease condition may affect his sense of self-belief because of continuous experience of pain and distress. This may create uncertainty in him, make him feel insecure, confused, and hinder his full development of identity and independence. His family strongly believe in God’s intervention in everything including spiritual healing, and they were not sold to the idea of any man-made or traditional medicine. The boy requires collaborative support, empathy, and counseling from the medics and family members. His family and the community around him including school teachers must take the active role of being his caregivers while at home or in school.

Physical Examination

The patient had ineffective breathing patterns; wheezing sound when breathing out; shortness of breath; and the airway clearance was poor due to bronchospasms, increased pulmonary secretions, or ineffective cough. Inspections of the head, eyes, ears, and the throat showed no problems; thyroid gland and lymph nodes normal. Temperature, pulse rate and blood pressure were normal, mental condition was good, his abdomen was soft, the patient could walk with ease; arteries and veins were functioning normally.

Needs Assessment

Firstly, the patient needs education and counseling on how to keep himself away from asthma triggers. He must be sensitized that asthma is very sensitive and is easily triggered by exposure to cold things, tobacco smoke, dry air, vigorous exercises, upper respiratory infections, and allergens like pollen grain, mold, and dust. Therefore, he should self-manage to always keep far away from these triggers. This is supported by Miller (2020), who said finding out factors that trigger attacks, and avoiding them are important parts of good asthma management. Both the boy and family need psychological therapies to help them moderate their religious beliefs about spiritual healing, which impedes the medication procedures and preventive measures required to manage asthma. Just like Swihart, et al., (2021), observed that the diversity of religion in the world creates challenges for medics to deliver competent medical care.

Continuous exposure to the triggers of asthma, combined with lack of support from both the family, friends, and teachers in school, loneliness, and strong spiritual beliefs, may create doubts in the patient about his condition. This could make him lose hope about managing asthma completely. On the other hand, putting the triggers under control, getting full support and encouragement from the family and school teachers, and incorporating best spiritual practices in his health education will raise his self-belief. It will boost his sense of identity and confidence in the education and management of asthma including following the prescribed medication. The patient will then be assured and positive about the teaching.

Reflection

I introduced myself and had a cordial chat with the patient; this helped to reduce the tension in the room due to worries he had, and build his trust in the process. The interview lasted for 35 minutes; it went on well; the boy was cooperative and independent-minded. There were no communication barriers, or any challenges; nothing went wrong with the approach and the interview; the patient gave out all the information which the interview intended to extract.

References

Kamangar, N. (2021). Health assessment.Health Science Journal. Web.

Miller, R. L. (2020). Patient education: Trigger avoidance in asthma.UpToDate. Web.

Swirhart, D. L., Yarrarapu, N. S., and Martin, R. L. (2021). Cultural religious Competence in clinical practice.NCBI. Web.

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Physical Assessment Report for an 18-Years-Old Asthma Patient

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