Problem-Focused Assessment: BREAST Instruction: Based on the case study assessment information, write a focused health assessment following the components of health history taking and make poss
Problem-Focused Assessment: BREAST
Instruction: Based on the case study assessment information, write a focused health assessment following the components of health history taking and make possible nursing care plan (SOAP).
Scenario
a Female patient aged 58-years old working as a grade school teacher, came to the hospital complaining of shoulder pain. The patient reports the insidious onset of right shoulder pain that began approximately 3 months ago. She reports pain is at worse 6/10, best 3/10. She describes the pain as a deep ache that wakes her up at night at least three times a week. The patient reports difficulty with self-care activities such as bathing, hair care, and dressing due to shoulder pain. The patient reports that she has lost weight unintentionally over the past month and attributes it to increased stress at work. She has a Family history of High blood pressure, diabetes, and her mother passed away from breast cancer, and hypothyroidism.
Problem-Focused Assessment Write-up
I – Focus Assessment
Biographic Data
Chief complaint
History of Present Illness
Location
Onset
Intensity
Quality
Previous episode
Alleviating factor
Aggravating factor
Associated symptoms
Past Medical History
Family History
Social History
II. PHYSICAL ASSESSMENT based on the case presented
Inspection
Palpation
I – NURSING CARE PLAN (SOAP)
SUBJECTIVE
The patient complaint of shoulder pain and she report the insidious onset of right shoulder pain that began approximately 3 months ago. She reports pain is at worse 6/10, best 3/10. She describes the pain as a deep ache that wakes her up at night at least three times a week. The patient reports difficulty with self-care activities such as bathing, hair care, and dressing due to shoulder pain. The patient reports that she has lost weight unintentionally over the past month and attributes it to increased stress at work. She has a Family history of High blood pressure, diabetes, and her mother passed away from breast cancer, and hypothyroidism.
OBJECTIVE
ASSESSMENT
PLAN
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