Mr James Saunders a 36-year-old man has been admitted in the ward with his exacerbation of asthma. The subjective data (data collected by communicating) presented are Mr Saunders say that he is not feeling too bad and has no chest pain. He also says that he has been struggling from this disease since his childhood and it is more frequent in the early spring and it is even worst in the windy days. The objective data (data obtained from observing) are he has his hearing aid on the both ears, shortness of breath, on taking vital signs he has Blood pressure of 140/70, his respiration rate is 28/mins, oxygen saturation in room air is 90% Mr Saunders appears to be flushed, and is speaking in short sentences. He has a moderate use of accessory muscle while breathing and in auscultation he has wide spread of wheeze. There are four main ways for the respiratory assessment, which are inspection, palpation, percussion and auscultation.
Obtaining a detailed history from the patient is one of the essential parts in assessment of the patient. Detailed history includes asking past and present history (medical history, surgical history, allergies, medications, injuries, accidents, immunizations’ and childhood illness), family health
References: Eisner, Mark D., et al. "Risk factors for hospitalization among adults with asthma: the influence of sociodemographic factors and asthma severity." Respiratory research 2.1 (2000): 53. Estes, M., Calleja, P., Theobald, K., and Harvey, T. (2013). Health assessment and physical examination. (ANZ ed.) Melbourne: Cengage Learning Australia. Guthrie, C., & Tingen, M. (2002). Continuing education. Asthma: a case study, review of pathophysiology, and management strategies. Journal Of The American Academy Of Nurse Practitioners, 14(10), 457-464. Holgate ST, Douglass J (2010) Fast Facts: Asthma. Third edition. Health Press Limited, Oxford. Kaufman, G. (2011). Asthma: pathophysiology, diagnosis and management. Nursing Standard, 26(5), 48-56. Kennedy, S. (2006). Assessment of a patient with an acute exacerbation of asthma. Nursing Standard, 21(4), 35-38. Killeen, K., & Skora, E. (2013). Pathophysiology, diagnosis, and clinical assessment of asthma in the adult. Nursing Clinics Of North America, 48(1), 11-23. doi:10.1016/j.cnur.2012.11.001 Rees J (2010) Asthma in adults.In Rees J, Kanabar D, Pattani S (Eds) ABC of Asthma. Sixth Edition, John Wiley & Sons, Chichester, 1-54.