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Nursing Processes Patient with Left Shoulder Pain Case Study

Nursing Processes Patient with Left Shoulder Pain Case Study

Question Description
I’m trying to learn for my Nursing class and I’m stuck. Can you help?

patient………… please fill out attached document file,,, “nursing process worksheet”

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Demographic Data

Patient:

HB is an 84-year-old female.
DOB: 10/25/1936.
Full code
DPOA: Daughter
Living Will: None
CC: Left Shoulder pain for 2 days

HPI: Patient complins of left shoulder pain (location) for past two days (Duration) after fell while climbing staircase at home. Sudden pain started after fall (Onset). Patient stated is experiencing difficulty moving left arm, lifting light subjects, limited ROM at adduction and adduction. Pain radiates to arm and neck (Radiation). Nursing Processes Patient with Left Shoulder Pain Case Study. Pain rate 9/10 (Severity), worsening with movements and liftings (Aggravating factors). Patient report nothing make is better (Alleviating factors) Takes Motrin for pain which is not effective.

PMH: left total knee surgery in 2015. Gastritis, Right knee pain, HTN, CAD, hypothyroidism.

Allergies: Denies allergy to medication, food, and seasonal allergy.

Medication:

Levothyroxine 50 mcg orally daily on empty stomach.
Protonix 40 mg orally daily.
Toprol XL 50 mg orally daily
Gabapentin 300 mg po qhs.
Motrin 400 mg orally qid prn pain
Influenza vaccine and pneumonia 13 and 23 up to date.
Family Hx: Mother deceased at age 69 secondary to cardiac arrest, father deceased at 65, due to stroke. Son at age 64 (+) HTN. Daughter 55 is healthy.

Social Hx: Home maker, lives with disabled husband. providing care for husband with dementia. Smokes 1 pack a day. Drinks occasionally 2-3 times per months, last drink a week ago. Denies drugs. Does not drive. Daughter takes her to church every Sunday.

Vital signs:

BP= 119/75
P= 83 beats/ min (Radial)
RR=18 RR/min
T= 96.8 F Oral
O2 sat= 98 % Room Air
H=66 Inches
W= 174 Ibs
BMI=28.1
Physical assessment and ROS:

Appearance: Patient is hard of Hearing, denies weight changes, denies fever, reports sleep 6-7 hours of night, reports appetite as good. Dress appropriately to weather, makes eye contact.

Skin: No visible rash, hematoma, inflammation. No open wound, bruises, hematoma noted at left shoulder.

CV: Denies chest pain. S1, S2 WNL, no murmur

Respiratory: Denies Shortness of Breath, Chest wall pain,

GI: Denies Diarrhea, constipation, abdominal pain, and melena. Abdomen is flat, soft, Bowel sound present in all 4 quadrants. No abdominal tenderness.

MS: Reports inability to move left shoulder. Rates left shoulder pain rate 9/10. Decreased left should ROM. Unable to abduct or adduct the left farm. Holding the left arm at side. Right arm has full range of motion, able to abduct and adduct more than 90 degrees. Strength is decreased in left hand.

GU: Denies urinary frequency, urgency, pain and burning with urination. Urine as yellow and clear. Nursing Processes Patient with Left Shoulder Pain Case Study.

Neurology: Denies bilateral upper and lower numbness and tingling.

Left hand has less strength compared to right hand; Left shoulder has limited ROM compared to right shoulder. Left should is positive for swelling and hematoma, and inflammation.

Diagnostic Procedure: Left shoulder x-ray is positive for fracture, Reports shows a Left Humeral Fracture

Laboratory Results:

Hgb: 11.1
HCT: 33.4
Platelet: 200,000
Na:136
K: 2.8
Bun: 18
Cr: 0.9
ALT: 50
AST: 15
UA: Within normal range
Assessment/ Diagnosis: Left shoulder Fracture

MD orders:

Regular Diet
CBC, CMP, LFT, UA
EKG
Left shoulder x-ray
Physical therapy evaluation and treatment
Ibuprofen 400 mg po q 6 hours PRN pain for pain rate 1-5
Norco 5/325 mg po q 8 hours PRN pain rate of 6-10.
Potassium Chloride 40 meq po x 1.
Ice pack to left shoulder 4 times a day.
Immobilize the left arm with Should sling for until next visit in 2 weeks.
Refer to physical therapy for pain management and maintain mobility, and gait assessment.
Report Fever more than 100.4
Report constipation
Smoking cessation education
Nursing diagnosis Format:

Nursing diagnosis —- Related to —- Contributing factors —- As Evidence by —— sign/ symptoms

nurs_121l_a___nursing_process

You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.

Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.

Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.

The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink.Nursing Processes Patient with Left Shoulder Pain Case Study.  If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS

Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation

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Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. Nursing Processes Patient with Left Shoulder Pain Case Study.
It is best to paraphrase content and cite your source.
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For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication

Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. Nursing Processes Patient with Left Shoulder Pain Case Study.

 

 

 

 

 

 

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