Head. Client has symmetrical structure without deformities or lesions. Her hair is wavy and thick. Client’s scalp is without tenderness, lesions, pests, or flaking. Her facial movements are strong, appropriate, and symmetrical. The client is able to detect sharp and dull sensations on her forehead, cheek, and chin.
Eyes. The client’s vision is 20/30 in her left eye and 20/200 in her right eye with the Snellen chart. Her gaze is steady and fixed without nystagmus. The client’s conjunctiva is moist and pink, and the sclera is white and clear. Her eyes are in parallel alignment with evenly distributed color. The client’s vision field is less than the examiner’s field. Her left pupil is equal, round, and reactive to light and show accommodation whereas the right eye is unresponsive.
Ears. The client’s ears are properly aligned, symmetrical, and equal in size with no swelling or thickening. The ears are without lumps, lesions, …show more content…
My client’s overall health is reasonable; however, she does have some swelling, redness, and tenderness in her left shoulder from a possible torn rotator cuff. This inflammation causes my client to experience acute pain, and she does have difficulty performing complete range of motion in her left shoulder. The main nursing diagnosis that I selected for my client is impaired physical mobility related to pain and musculoskeletal impairment as evidenced by swelling in the left shoulder, tenderness upon palpation, and limited range of motion of the left shoulder (Carpenito, 2013, p. 389). I selected this diagnosis because my client’s overall well-being would improve if she was not experiencing pain and discomfort throughout the entire day. My second diagnosis for my client would be fatigue related to sleep disturbance and inflammation as evidenced by reports of feeling tired from lack of sleep from the pain (Carpenito, 2013, p. 238-239). The client states she gets little or no sleep due to the pain in her left
Eyes. The client’s vision is 20/30 in her left eye and 20/200 in her right eye with the Snellen chart. Her gaze is steady and fixed without nystagmus. The client’s conjunctiva is moist and pink, and the sclera is white and clear. Her eyes are in parallel alignment with evenly distributed color. The client’s vision field is less than the examiner’s field. Her left pupil is equal, round, and reactive to light and show accommodation whereas the right eye is unresponsive.
Ears. The client’s ears are properly aligned, symmetrical, and equal in size with no swelling or thickening. The ears are without lumps, lesions, …show more content…
My client’s overall health is reasonable; however, she does have some swelling, redness, and tenderness in her left shoulder from a possible torn rotator cuff. This inflammation causes my client to experience acute pain, and she does have difficulty performing complete range of motion in her left shoulder. The main nursing diagnosis that I selected for my client is impaired physical mobility related to pain and musculoskeletal impairment as evidenced by swelling in the left shoulder, tenderness upon palpation, and limited range of motion of the left shoulder (Carpenito, 2013, p. 389). I selected this diagnosis because my client’s overall well-being would improve if she was not experiencing pain and discomfort throughout the entire day. My second diagnosis for my client would be fatigue related to sleep disturbance and inflammation as evidenced by reports of feeling tired from lack of sleep from the pain (Carpenito, 2013, p. 238-239). The client states she gets little or no sleep due to the pain in her left