Functional Assessment In Nursing

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RK is a 26 year old married Caucasian female working as a waitress while attending nursing school.

Source: RK, reliable.

Chief Complaint: “My right shoulder hurts”

HPI: Noticed shoulder pain while working 3 days ago, lifts heavy trays, pain hasn’t resolved with rest. Doesn’t recall a specific injury/incident. Describes anterolateral shoulder pain and burning sensation that worsens when lifting arm over head or lifting trays at work.

Past Health: Depression

Childhood Illnesses: Pt has been generally healthy. Had Chickenpox as a child. Received all recommended childhood vaccines. Denies having Measles, Mumps, Rubella, Pertussis, Croup, or Rheumatic Fever.

Accidents: States fractured both wrists as a child, one Fx r/t Trampoline,
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No change in appetite, weight, hair or skin.

Functional Assessment

Self Concept: Graduated from community college and is presently in nursing school. Works part-time on weekends as a waitress. Is married and has one child at home. Financial status is stable and adequate to meet needs. Believes in God, attends church occasionally. Sees self as independent, dependable & honest.

Activity-Exercise: Activities change daily due to college schedule. Jogs twice weekly. Works weekends. Independent with all ADL’s. No assistive devices needed. Has no specific hobby but enjoys outings and activities with her daughter.

Sleep-Rest: Sleeps well, 8-9 hours per night, no sleep aids.

Nutrition: 24 recall: Breakfast- Cereal with banana & milk, & a cup of coffee. Lunch-Chicken sandwich, waffle fries, Dr. Pepper. Dinner-Spaghetti with meatballs, garlic toast, salad & iced tea. Snacks- fruit, granola bars. Drinks water between meals ~ 1 liter/day. No food intolerances.

Alcohol: Has a rare to occasional glass of wine, no cigarette use. CAGE ‘no’ to all
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Will continue with current lifestyle and exercise pattern.

Measurement: Height: 64.5 inches (5’4.5”) Weight: 129lbs BMI: 23-24. BP 126/82 Rt arm sitting, P86 regular, R16 unlabored, T 98.0 oral

General Survey: RK is a 26 yo Caucasian female with complaints of right shoulder pain with overhead arm movement. No pain at this time. Alert, pleasant, relaxed, sitting in chair. Vital signs as noted above. Ht appears within normal range for age and genetic heritage, body build is proportional. Well nourished, well groomed and appropriately dressed in no acute distress. Ambulates with a steady, even, gait with normal arm swing.

Head to Toe Examination

Skin: Unblemished, color is uniform, light skin tone, no foul odor. Skin is W&D, smooth & intact, turgor is good. No edema, birthmarks, bruises or lesions. Hair: Color brown, even distribution, no scalp lesions or infestations noted. Nails: Clean, smooth edges, slightly curved, no ridges or discoloration. Nail beds pink and firm, lanula present.

Head: Round, normocephalic and symmetrical. No lumps, lesions or tenderness. No facial weakness or involuntary

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