![]() ![]() (Impaired physical mobility SOAP NOTE Assessment) S1, S2 are normal with regular heart rhythm and heart rate. Neck: ROM is full,no masses on palpation.Ĭardiovascular: no murmurs, clicks hear on auscultation. ![]() The tongue is red with no cracks or sores. Mouth: lips are pink, the oral cavity is moist with no phlegm, the gums are pink and moist, and the patient has all teeth. Nose: There is no drainage present, and patency is adequate. No drainage was noted, and both years can hear. Ear: External year position and shape is normal on inspection. Eyes: has high eye acuity, pupils react to light, they are equal and round. The scalp has no lesions and no tenderness noted on palpation. HEENT: Head: size and symmetry are normal on inspection, and hair is clean and fine. Her speech is soft with a clear tone.(Impaired physical mobility care plan) General: The patient appears distressed but alert and oriented to place and time. Neurological: The patient reports stooped posture and deny memory loss, tremors, severe headaches, and loss of consciousness.Endocrine: The patient denies swollen glands, excessive sweating, thyroid problems, and reports weight loss. Musculoskeletal: The patient denies back tenderness, stiffness, and joint swelling but reports back pain, limited ROM due to swelling at the hip area, and inability to bear weights.(Impaired physical mobility care plan) Gastrointestinal: The patient denies constipation, abdominal pain/discomfort, heartburn, nausea,bowel movement changes, guarding and tenderness, and distension. Skin: The patient denies discoloration, bruising, lumps, and open wounds Respiratory: The patient denies chest tightness, wheezing, pain, consistent coughs, and breathing difficulties. The patient reports swelling of the lower limb. Throat: patient denies sore throat, erythema(Impaired physical mobility care plan)Ĭardiovascular: the patient denies chest pains or discomforts, fast/slow heart rates, and cold feet/hands. Neck: the patient denies swelling and enlarged lymph nodes, pain or difficulty swallowing, and stiffness. Mouth: The patient denies bleeding gums, decayed or missing teeth, odors, and dryness. Nose-the patient denies congestion, nose bleeds, and dryness. Eyes: The patient denies blurry vision but uses eyeglasses for reading. Ears- the patient reports no changes in hearing, ear discharge, or ringing in years. HEENT: Head- the patient, denies headaches, hair loss, or notable masses. General: The patient denies headache, bruises, and chills but reports fever and is concerned about weight loss Review of Systems: Subjective (Impaired physical mobility SOAP NOTE Assessment ) The patient denies smoking or alcohol use.įamily History: Father (deceased) had diabetes and hypertension. Personal History: Married with two children and live together in their apartment. Surgical History: myomectomy six years agoAllergy: No known allergiesImmunizations: The patient took a flu shot in 2019. PMH: Pneumonia during childhood, bone fractures Impaired physical mobility SOAP NOTE Assessment(Impaired physical mobility care plan) She is also not on medication but took Tylenol for pain before she decided to come for help. However, the patient denies loss of height, chills, headache, and tingling of feet. ![]() The patient reports that she cannot perform some ADLs due to pain and limited mobility. She reports that she has also lost significant weight despite eating the same food without engaging in physical activity. She says that the pain is aggravated by minimal activities such as walking short distances, bending, and carrying out daily house chores with no relieving factors. The patient also reports that she had fractured two times last year, and mild traumas caused all. She expected the pain and swelling to go away, but it persisted, hence seeking medical care. Her upper leg was hit by a chair one day ago, causing swelling. She reports that mild pain started three months ago but became more severe in two weeks. The Caucasian female visits the office with concerns over prolonged back pain, significant weight loss, and stopped posture. Patient: The patient is a 49 years old woman who presents with back pain and swollen upper thigh/hip.ĬC: The patient complains of back pain, swollen hip, and significant weight loss in the last two and a half months. All you need to do is place an order with us Impaired physical mobility Head to Toe Assessment (SOAP NOTE Assessment for a patient with Impaired physical mobility) For a more detailed analysis, you can also read Osteoporosis Nursing Diagnosis, Nursing Care Plan and Nursing InterventionsĪs you read, keep in mind that our professional nursing writers are ready to help with your assignment if you get stuck. ![]()
0 Comments
Leave a Reply.AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |