Gordon’s Functional Health Pattern (Teen)

Adolescent Summary – Gordon’s Functional Health Pattern

Biographical Data

Date of Visit: 8/31/2012, 10:30am.

Age

DOB: 3/2/1999

Race/Gender Hispanic, Female

Weight: 34 kg.

Height: 4ft. 7 inches

BMI: Normal Range 16.6 kg/m2

Phone [HIDDEN]

Reason for Visit: Evidence of exasperated asthmatic conditions. (Not an acute asthma attack). Became overexerted at school, 8/30/12. Restless night and complaints of tightness in chest and inability to catch breath. Slight wheezing can be heard during exhales. Potential asthma complications; albuterol has proven slightly ineffective in easing symptoms and discomfort.

Financial History: Patient is fully covered under parent’s insurance. Mother works; serving as informant and escort to physician. Single parent household.

Past Health History: Patient is fully immunized and receives all routine health and wellness physicals and exams as appropriate. Last physical exam 5/30/2011, prior to beginning of summer camp. History includes struggle with exercise-induced asthma (albuterol use via bronchodilator). Describes an allergy to pineapple (reaction includes appearance of red, rash like spots on face). Mother provides multi-vitamin supplements. No reported childhood illness. No chronic illness.

Wellness Young Adult Behavior Assessment History Screening: In good, general health and physical condition. Mother indicates normal, full term pregnancy, although patient did have jaundice during first two weeks of life. Otherwise healthy infancy and early childhood. Patient is active in school activities (participates in physical education and cheerleading). Enjoys swimming and bike riding, helps with household chores. Lives in middle class community and walks/plays with two younger female siblings and peers within subdivision. No depression. Normal menstruation began age 11. Last menstrual period began 8/17/12. Becomes winded in prolonged activities. Describes normal eliminations and voids. No history of hospitalizations, serious accidents or injuries.

Nutrition: Mother emphasizes healthy eating habits and fresh fruits and vegetables. Junk and processed food consumption is limited. Water consumed daily. 3-4 meals eaten per day with snacks allowed in between. No underage tobacco, drug or alcohol usage known or suspected.

Family History: Mother has Type 2 diabetes mellitus (T2DM), which she has been living with for 7 years. Father has hypertension and is overweight. Family history indicates susceptibility to T2DM with the disease occurring in both the maternal and paternal families. History of high blood pressure and depression on material side of family. Youngest sibling also has asthma. No other instances of asthma in family.

Review of Systems (as applicable)

General Health State: Facial expression and demeanor appropriate to situation. Speech is clear. Being monitored by mother. Withheld from school due to labored breathing. Self-medicating with albuterol and light pain medication as needed.

Skin: Mostly dry, warm. No excessive sweating.

Hair: Normal texture. No loss reported.

Nails: Normal color. No abnormalities reported.

Head: Aspirin taken at 9:10 AM for “slight head-ache.” No dizziness reported.

Eyes: No change in vision reported. Patient wears eyeglasses.

Ears: Examination reveals no discharge, fluid or infection. Past history of infections in left ear — typically in conjunction with cold/flu.

Nose/Sinuses: No change in sense of smell. Examination reveals no concerns.

Mouth/Throat: Recent tooth filling in back molar. No current toothache, alteration in taste or hoarseness. No throat irritation and normal coloring and appearance. Reports daily dental care.

Neck: Normal range of motion. No tenderness in lymph nodes. Strep throat at age 8.

Neurological System: Normal and well-oriented. Grips and flexion strong.

C-V: Temperature normal. Heartbeat regular. Pulse rate 70. S1, S2 auscultated over aortic, pulmonic, erb’s point, tricuspid and mitral areas. No edema.

Respiratory System: Describes slight tightness in chest. Labored, shallow breathing with intercostals retractions and wheezes throughout. Intermittent cough.

Musculosketal System: Describes a slight fatigue due to poor rest the night prior. Accessory muscle employed to complete breathing function.

GI and G-U Systems: Abdomen normal is appearance, size and shape. No BM reported for day. Voids described as normal. No bladder pain, urgency, distention or tenderness.

Pain: Only a slight discomfort from continued labored breathing.

Primary Nursing diagnosis:

Ineffective breathing pattern related to inflammation of airway, bronchospasm. Impaired gas exchange of alveoli and excess secretions secondary to asthma manifested by low oxygen saturation. Ordered oxygen therapy (breathing treatment). Monitor O2 saturation and assess respiratory functioning regularly throughout day of care. Goal that patient will tolerate a wean off of O2 by 1830 as demonstrated by an O2 saturation of 92% or better on room air.

Rationale:

Asthma is an inflammatory disease characterized by mucosal edema, increased viscid secretions, and smooth muscle contraction which result in wheezing, dyspnea, and cough (Hull et al., 2009). The increased secretions can lead to airway obstruction which will cause O2 saturation to drop. Regular monitoring of oxygen saturation for early detection of abnormalities is required. Conducting a complete respiratory assessment allows accurate ratings of patient status and evaluation of treatment options.

Wellness nursing diagnosis:

Instruct Melissa to notify parents or school administrators immediately if there are any changes in respiratory status. Provide instruction for proper use of metered dose inhaler; not use more than 4 puffs/day or risk an increase in asthma symptoms. Instruction to increase water intake (add O2 to body) during physical activity and avoid overexertion.

Rationale:

Melissa needs improved education in pre-empting asthmatic symptoms.

“Risk For” nursing diagnosis:

Ensure that patient is aware that Albuterol inhaler is not to be used for an acute asthma attack. Medication should be used 30 to 60 minutes prior to physical activity.

Rationale:

Risk for activity intolerance related to potential for breathing difficulties. Melissa needs improved education in identifying symptoms of an asthma episode. Requires demonstration of proper use of her peak flow meter and interpretation of the identified result. Medication protocols should be discussed with school staff as needed to support Melissa at school. Must stress that Melissa’s asthma may cause current or unknown allergic reactions to be more severe. Collaborate with physical education and recess staff to highlight Melissa’s need for medication as well as limited physical activity during periods of asthma exacerbations.

Reference

Hull, J., Hull, P., Parsons, J., Dickinson, J., & Ansley, L. (2009). Approach to the diagnosis and management of suspected exercise-induced bronchoconstriction by primary care physicians. BMC Pulmonary Medicine, 929.