Case Study: Patient with Left Shoulder Pain
Case Study: Patient with Left Shoulder Pain
patient………… please fill out attached document file,,, “nursing process worksheet”
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
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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). 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.
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