Anabela Santos, RN
Pacific College of Oriental Medicine
Class: NR 302 The Nurse as Facilitator of Healing II: Modalities
Instructor: David Rabinowitsch, DNP RN CHTP/I CNE
Subject presented on 10/11/2014 with the complaint that she is experiencing bilateral shoulder pain at bedtime. She states pain is only present when she is lying down in bed. Describes the pain as a hybrid of soreness and achiness. Rates pain at a “6”on scale of 0-10 (0 is no pain and 10 is severe pain). No medications or interventions have been taken/pursued, and she has no evidence of what may diminish the acute pain. She feels better in the daytime when she is mobile, however pain presents upon immobility in bed. No further actions exacerbate pain besides nighttime immobility. Subject states that she is mostly able to fall asleep without incident. However, there are times when she is not able to fall asleep due to the pain. Furthermore, when she is awakened by the pain, she is unable to return to sleep. Total loss of up to one hour of sleep minimum per day. Subject expresses desire to improve her comfort level and sleep quality. Comprehensive holistic nursing assessment completed.
BACKGROUND AND HISTORY
Subject is a 43 years old, married, female with 2 children. She is a court recorder and full time homemaker. Highest level of formal education completed is a Bachelor of Science in Business. She is an only child who was raised in Barra de Mira, Portugal, by her parents and extended family. Her parents immigrated to New Jersey, USA with the subject at the age of 8 years old.
Subject has been diagnosed with Sarcoidosis (no flare ups in last 2-3years), Chronic Fatigue Syndrome, Kerataconus, and history of hypercholesterolemia. Hospitalizations include a Pilonidal cyst removal in 1987, vaginal delivery in 2001, and Emergent Cesarean section in 2004. She denies any known drug allergies. States sensitivity to wine, with end result of hives. Cheese is the only dairy product that makes her feel bloated. She is not on any current medications, supplements, and/or herbs. Furthermore, she is in the process of changing her health care provider (HCP).
Subject is alert and oriented x 3 with clear speech. She has full ROM to BUE and BLE with steady gait noted upon ambulation. No redness, edema, or ecchymosis noted to bilateral shoulder area. Skin is pink, warm, and dry to touch. B/P: 129/96 HR: 82 R: 18 Pain level: 6 on a scale of 0-10. Heart rate regular with no adventitious sounds. Capillary refill less than 3 seconds. Lung sounds clear bilaterally. Abdomen soft and non-distended. Bowel sounds + to all four quadrants. Voiding and evacuating without difficulty. Pedal pulses + bilaterally. No edema noted. Surgical scars are noted and healed.
Subject reports desire to incorporate more physical activity into her daily routine. She is currently walking 2 miles on average per day. She is comfortable and highly knowledgeable regarding nutrition. She is committed to buying clean, organic foods. Furthermore, she actively pursues all natural products for the home.
Subject reports well-being in her mental, emotional, and spiritual dimensions. Most assessment scores ranged from 7-10 (on 1-10 scale). She is religious but feels more connected when she is teaching and doing rather than sitting and listening. Does not perform any self-care for relaxation. Expresses interest in integrating her health with complementary and alternative modalities. “Good health and peace of mind” rate high for subject’s values.
PLAN OF CARE: Nursing Diagnosis:
-Impaired Comfort related to acute pain to bilateral shoulders.
-Disturbed sleep pattern related to discomfort while lying supine.
-Readiness for enhanced self-management
Subject will effectively use holistic modality safely at home to decrease pain to bilateral shoulders as evidenced by drop in pain