Republic of the Philippines

EASTERN SAMAR STATE UNIVERSITY

COLLEGE OF NURSING

Related Learning Experience (RLE)

A Case Study of Asthma

Submitted by:

Chloie Marie C. Rosalejos

BSN 2-A

Submitted to:

Mrs. Natividad Baldono

Clinical Instructor
 I. Patient’s Demographic Profile
Name: Dominga Gecomo
Age: 62 years old
Sex: Female
DOB: August 29, 1938
Address: Brgy. Lumotad, Taft, Eastern Samar
Nationality: Filipino
Religion: Roman Catholic
Occupation: None
Civil Status: Married
Date of Admission: December 12, 2018
Time of Admission: 6:00am
Chief Complaint: Difficulty in breathing
Source of Information: Patient, SO, and patient chart
Admitting Diagnosis: Asthma

II. Nursing History

Present History

Two days prior to admission, the patient is having difficulty breathing as

evidenced by long deep breaths upon inhalation and exhalation making the client
uncomfortable enough to have a sleep. In addition, due to distance from their
 residence to Eastern Samar Provincial Hospital, the client and SO decided to travel
at dawn, making the client restless upon admission.

Past Medical History

According to SO, client had been hospitalized often and is admitted twice at
Eastern Visayas Regional Medical Center (EVRMC). She doesn’t know if she had a
complete vaccination during her childhood years. She goes on outpatient basis when
she experiences alteration in her health. She has experience cough, colds, mumps,
and chickenpox during her early years. She has no allergies to food and drugs and
has not taken food supplements in the past.

Family history
According to the client there is no familial disease she can trace in their
family history.

III. Gordon’s Typology of 11 Functional Health Patterns

1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

Before hospitalization, the client’s description about her health is a situation

wherein she is unable to do tasks and activities because of her lost eyesight last May
2019 due to gluacoma. She rates her health 7 on a health scale, 10 as the highest
and 1 as the lowest. Every time she feels bad about her health, she increases her
fluid intake, she rests and she sleeps as management. According to her, she seeks
medical advice whenever she feels something bad in her health. However because
of her lost of faith with physicians as they are unable to treat her impaired vision, she
is deciding to seek for the assistance of albolaryos. The client also believes in
healing powers of superstitious beliefs such as shedding the back skin of a lizard and
eating it as an aid to asthma.

During hospitalization, the client said that it seems she is imprisoned with the
consequences of being unhealthy that she cannot function well and cannot longer
perform her ADL’s due to her present condition. She describes her current health
problem as something which down casted her from the normal ways of running her
life which made her rate her health status as 5 in the above mentioned health scale.
Though at some intonations of her voice, she wants to insist that she’s okay.

2. NUTRITION-METABOLIC PATTERN

Before hospitalization, the patient weighs 45 kilograms and he has a height of

4’7”. She eats three times a day, according to her she eats foods that are being
prepared; she is not choosy in terms of eating but their usual menu according to his
SO are vegetables. In a day, she takes approximately 4 liters of water. According to
her, she don’t take any supplemental vitamins.

During hospitalization, the patient said that she doesn’t have the appetite to
eat, but, still her drinking habits and behaviors don’t changed. According to her,
though she has loss of appetite, she still needs to eat. She needs to follow the diet
given by the attending physician which is DAT and she eats foods given by the
hospital.
 Edible
Food Items Approximate Portion Calories Total
Measurement (weight in Calories
grams)
Bread (Pan de 2 pieces (5x5cm 40 100 200
Sal ) each)
Rice, cooked ½ cup 80 100 300

Squash ½ cup cooked 45 16 35

Scrambled egg 2 serving 365.2 730.40

String beans pod ½ cup cooked 45 15 35

Canned goods 2 pieces 30 30 60

Banana cue 1 ½ 0f 9 1/2 x 1 20 40 85

Total calories 1 445.4

Total calories needed (Age: 48 years old, 4’7” inch and 45 kg) 2,000

Difference 554.6

3. ELIMINATION PATTERN

Before hospitalization,the client did not specified how many times a day she
urinates but she made mentioned that she urinates frequently a day which measures
approximately ½ cup every urination. Her urine is yellow amber in color. She
mentioned that whenever she feels that she wants to urinate, she still has to seek
assistance with her SO before urinating.Client has no pain when voiding. She
defecates 1-2 times a day with brown stool. She feels no discomfort during
defecation.

4. ACTIVITY-EXERCISE PATTERN

Before hospitalization, she considers her work being a farmer as a form of her
exercise. According to her, she do farming every day like planting camotes and
vegetables. This is their form of living. Though she finds this work tiring, she don’t
have any choice but to do it since she serve as the breadwinner in their family. Taking
rest particularly lying on bed is her way to overcome his tiredness and stress.

Functional Level Classification Findings / Assessment

1. Perceived ability for bed mobility 0

2. Perceived ability for general mobility 2

 3. Perceived ability for dressing 2

4. Perceived ability for bathing 2

5. Perceived ability for grooming 0

6. Perceived ability for toileting 3

7. Perceived ability for home maintenance 1

8. Perceived ability for shopping 4

9. Perceived ability for cooking 0

10. Perceived ability for feeding 0

11. Perceived ability for use of telephone 0

12. Perceived ability for going to places out of 0

walking distance

Legends:

0 = complete independent
1 = requires use of equipment or device
2 = requires help from another person for assistance, supervision, or teaching
3 = requires help from another person and equipment or device
4 = complete dependence

Because of her unwanted health problem, Mrs. AB’s ability to work and to do
activities and exercises is so much affected. She is thinking on how to continue their
living if she’s in hospital suffering a disease. With his present condition, she needs
assistance in performing hygiene practices such as dressing, bathing, etc. She also
needs some support and assistance in going to the CR.

5. SEXUALITY-REPRODUCTIVE PATTERN

According to Mrs. AB, she is not sexually active, but in the time that she is
sexually active, she and her husband engaged into sexual intercourse twice a week.
The couple doesn’t use any methods to prevent pregnancy. Mrs. AB hasn’t yet
contracted a sexuality transmitted infection. She described her level of satisfaction in
her sexual relationship as 8 in a scale 10 as the highest and 1 as the lowest. And she
has three children.

6. SLEEP-REST PATTERN

Before hospitalization, Mrs. AB sleeps at night at around 7pm and wakes up

at around 1am. He has 1hour nap during the day usually 12noon up to 1pm in the
break of his work as a carpenter. According to him, he doesn’t have difficulty falling
asleep but he wakes up very early and cannot fall asleep again.
 During hospitalization, she can’t easily fall asleep in the hospital because she
is used to sleep in their house and not on other houses or even hospitals as stated
by the client. She doesn’t also have continuous sleeping patterns (she sleeps then
after few hours or minutes, she wakes up) because of responding in her urge to
urinate. But according to her, she’s okay because she does nothing in the hospital
but to sleep, sit and lay down. The client doesn’t take any sleep-inducing drugs.

7. COGNITIVE-PERCEPTUAL PATTERN

All of her senses are all functioning. She is aware of her environment. She
has the ability to understand, communicate, write, remember and make decisions.

8. ROLE RELATIONSHIP PATTERN

Before hospitalization, Mrs. AB has a good relationship in her family and her
friends. She is not involved in any organizations in their place but she has good
relationship with the people around them.

During hospitalization, the relationship and intimacy of the patient to her roles and
responsibilities is lessened and decreased due to a great situation which trapped her
to continue it.

9. SELF-PERCEPTION – SELF-CONCEPT PATTERN

Before hospitalization, “He ako itun tao nga hihimuon itun tanan nga ak
kakayahan, guminhawa lait kinamumutngan hit ak pamilya.” as verbalized by Mrs.
AB. According to her, she is healthy and she described herself as strong and well-
rounded mother to her family as well as in her society.

During hospitalization, “Pareho man ak hin yana hin tanaman nga waray
kabibis-igi ” was the verbalization of the client. She wants to go home but she can’t
let herself stay no longer in the hospital.

10. COPING STRESS TOLERANCE PATTERN

Before hospitalization, whenever the client feels stressed or tired, she

increases her fluid intake and she takes rest and sleep. She also prays for spiritual
support. According to her, the most stressful thing in her life is when problems come
in one time. She is also being stressed with her works and being worried about their
financial problems.

During hospitalization, if she feels stressed, she just sleep, rest and relax.
Sometimes, she cries her problems and she prays for God’s protection and
guidance.

11. VALUE-BELIEF PATTERN

Before hospitalization, the client believes in God and she knows that she is
the main source of her strength and hope. And she is Roman Catholic.

During hospitalization, the client’s relationship to God became closer despite

of her condition. She believes that God has a great contribution in his recovery.

PHYSICAL ASSESSMENT:
General appearance:
Mrs. AB is awake and coherent; she has a good posture and gait. She appears calm
and properly groomed. She is oriented to time, place and person.

AREA TECHNIQUES USED NORMAL ACTUAL ANALYSIS

ASSESSED FINDINGS FINDINGS

SKIN:

Color inspection light to deep Light to deep Normal

brown brown

Texture palpation smooth, presence Smooth, normal

of hair presence of hair

Skin turgor palpation skin springs back Skin springs back Abnormal
immediately when slowly when due to some
pinched pinched- about 4 dehydration
seconds

Temperature palpation uniform within Uniform within Normal

normal range normal range

presence of palpation no edema no edema Normal

edema

presence of skin palpation some birth marks, no lesion, with flat Normal
lesion some flat and mole
raised moles

HAIR:

Color inspection brown or black Black Normal

distribution inspection evenly distributed evenly distributed Normal

hair thickness inspection either very little or Great number of Normal

and thinness great deal of body body and scalp
and scalp hair hair

thick or thin hair

texture and palpation smooth and silky Rough and dry Due to poor
oiliness hygienic
measures
and some
dehydration

presence of lice inspection without lice without lice Normal

NAIL:

Color Inspection Pinkish Pinkish Normal

Shape and Inspection and Smooth, convex in Smooth, convex Normal
texture palpation curvature, long in curvature, long

Thickness Inspection Extremely thin Extremely thin Normal

Capillary refill Performed blanched Prompt return of Returns Normal

test pink or usual color immediately

HEAD:

Size, shape and Inspection Rounded Rounded Normal

symmetry (normocephalic)sy (normocephalic)
mmetric, with symmetric with
frontal, parietal frontal, parietal
and occipital and occipital
prominences prominences

Head Inspection and 35-45 cm 38 cm Normal

circumference palpation

Presence of Inspection Smooth, uniform Smooth, uniform Normal

mass or nodules in consistency, in consistency,
absence of absence of
nodules and nodules and
mass. mass.

Head movement inspection Can lift head Can lift head Normal
slightly and turn slightly and turn
them from side to them from side to
side side

EYES:

Eyebrows: hair Inspection Hair evenly Hair evenly Normal

distribution and distributed, skin distributed, skin
alignment intact, eyebrows intact, eyebrows
symmetrically symmetrically
aligned aligned

Eyelashes: inspection Equally Equally Normal

evenness of distributed, curled distributed, curled
distribution and slightly outward. slightly outward.
direction of curl

Conjuctiva and Inspection Bulbar Bulbar Normal

sclera Conjunctiva is conjunctiva is
clear with tiny clear with tiny
capillaries visible, capillaries visible,
Palpebral Palpebral
 conjunctiva is conjunctiva is
pink, no pink, no
discharge, sclera discharge, sclera
is white is white

Response to Inspection Illuminated pupils Illuminated pupils normal

light constrict constrict

Ability to read inspection Able to read news Cannot able to Abnormal

newsprint print read newsprint due to aging
materials

NOSE:

Symmetry, Inspection Symmetrical, Symmetrical and normal

shape and color straight and uniform in color
uniform in color

Occurrence of Inspection Pink mucosa, no Pink mucosa, no normal

redness, discharge and discharge and
swelling and swelling free of swelling free of
discharge lesion lesion

Facial sinus Palpation No tenderness No tenderness Normal

MOUTH:

Lips:
Symmetry, color, Inspection and Symmetry of Symmetry of Normal
tenderness palpation contour uniform contour uniform
pink color, soft, pink color, soft,
moist, smooth moist, smooth
texture texture

Gums:
Color and Inspection Pink, moist and Pink, and moist normal
moisture firm

Teeth:

Number Inspection Complete teeth- Incomplete- 17 Abnormal

32 number of number of teeth due to aging
teeth

Position and Inspection Central position, Central position, Normal

color pink in color, pink in color,
slightly round slightly round
Smell Inspection No foul odor Mild foul odor Abnormal
due to poor
hygienic
measures

EARS:

Auricles: Inspection Color is same as Color is same as Normal

Color, symmetry the color of the the color of the
of size and face, symmetrical face, symmetrical
position auricles align in auricles align in
the outer canthus the outer canthus
of the eyes of the eyes

Texture, Palpation Mobile, firm, no Mobile, firm, no Normal

elasticity and tenderness, pinna tenderness, pinna
areas of recoils after it is recoils after it is
tenderness folded folded

NECK:

Appearance and inspection Short and mobile Short and mobile Normal
movement

THORAX:

Color Inspection Light to deep Brown Normal

brown

Chest shape Inspection Rounded Rounded Normal

Respiratory Inspection 16-20cpm 15cpm Normal

pattern

Breath sound Auscultation Vesicular, Clear breath Normal

broncho-vesicular sounds
and bronchial

HEART:

Cardiac rate and auscultation 60-100 bpm 84 bpm Normal

rhythm

Apical pulse auscultation Left 5th ICS, lateral Left 5th ICS, Normal
to midclavicular lateral to
line midclavicular line
ABDOMEN:

Contour Inspection Rounded Rounded Normal

Bowel sound auscultation High pitched High pitched Normal

irregular gurgles, irregular gurgles,
hyperactive hyperactive

UPPER &
LOWER
EXTREMITIES:

size inspection Equal in size Equal in size Normal

Strength and inspection Can flex and Can flex and Normal
tone extend arms and extend arms and
legs legs

Mobility Inspection mobile Mobile Normal