Case Study/ Care Plan Activity
Instructions: Create a care plan based off the information provided. Use your nursing diagnosis
handbook and your textbook for reference. Submit your care plan
Client Scenario: J.R. is a 66-year-old Caucasian male. He lives alone on a small rural farm. His wife died
two months ago. His three children live out of state. J.R. spends his days working to keep his small farm
running. J.R. was admitted for surgical repair for a torn rotator cuff of his right shoulder.
Patient: J.R.
Age: 66
Gender: Male
Height/Weight: 5’9”/ 200 pounds
Allergies: NKDA (no known drug allergies)
Code status: Full Code
Privacy Code: none
Time: 0700
Attending Physician: Dr. Moss
Patient Chief Complaint: Right shoulder pain 6/10 (10 being the worst pain)
Current History: J.R.’s right shoulder had been causing him pain for a few days. He went to see is primary
care doctor who referred him to a surgeon. He is a scheduled admission for surgery.
B/P HR RR TEMP SP02 PAIN
155/90 90 16 98.8 95% 6/10
History of skin cancer to nose which was removed by a dermatologist 3 years ago. Additional history
includes hypertension, kidney stones, spontaneous pneumothorax, and sleep apnea. States he does not
use his C-PAP machine for his sleep apnea because he “does not like the way it feels on his face”. Last
admission 8 years ago for hernia repair. Patient has smoked one pack a day since the age of 16. He
reports that he now drinks 3-4 beers a day since his wife died. He wants to try to “stop his bad habits”
but does not know they best way how.
HEENT Head normocephalic. 20/30 vision bilaterally. Slightly hard of hearing. Nares patent. Mucosa pink,
with no lesions. Tonsils present.
RESPIRATORY Reports chronic, nonproductive cough.
, CARDIOVASCULAR Denies chest pain, palpitations, or shortness of breath. No syncope or pre-syncope
episodes.
NEUROLOGICAL Complains of weakness and pain to right arm. Denies numbness.
HEENT Slightly hard of hearing. Wears glasses when reading. No complaints of headaches change in
vision, nasal problems, or sore throat.
DIETARY HISTORY: Reports decreased appetite. Reports that his wife used to go grocery shopping and
cook meals. Since her death he has mainly ordered in or has gotten fast food.
I & O No complaints of nausea, vomiting, or change in stool pattern, consistency, or color. Patient
complains of occasional hesitancy with urination. Denies pyuria or hematuria.
INTEGUMENTARY Complains of dry, scaly skin. Worries about his increased risk of skin cancer since he is
outside working on the farm. States he “uses sunscreen when he remembers to put it on”.
LYMPHATIC: No palpable nodes. Denies problems with lymphatic.
ENDOCRINE Reports increase in fatigue over the past few months.
MUSCULOSKELETAL Patient complains of right shoulder pain that is stabbing and aching. He has been
taking extra strength ibuprofen which helps bring his pain down to a 5/10. Gait is coordinated. Does not
use any assistive devices.
PSYCHOLOGICAL/FAMILY - SUPPORT
Wife died two months ago. Lives alone on his farm. He is worried about he will be able to take care of his
farm with his injury. Three adult children live out of state and patient only sees them on special
occasions.
Care Plan
Subjective assessment data:
Weakness and pain in the right arm.
Decreased appetite
Occasional hesitancy with urination
Uses sun cream when he remembers
Increase in fatigue over the past few months
Stabbing and aching right shoulder pain
Anxiety with activity competency
Complaints of dry, scaly skin.
Instructions: Create a care plan based off the information provided. Use your nursing diagnosis
handbook and your textbook for reference. Submit your care plan
Client Scenario: J.R. is a 66-year-old Caucasian male. He lives alone on a small rural farm. His wife died
two months ago. His three children live out of state. J.R. spends his days working to keep his small farm
running. J.R. was admitted for surgical repair for a torn rotator cuff of his right shoulder.
Patient: J.R.
Age: 66
Gender: Male
Height/Weight: 5’9”/ 200 pounds
Allergies: NKDA (no known drug allergies)
Code status: Full Code
Privacy Code: none
Time: 0700
Attending Physician: Dr. Moss
Patient Chief Complaint: Right shoulder pain 6/10 (10 being the worst pain)
Current History: J.R.’s right shoulder had been causing him pain for a few days. He went to see is primary
care doctor who referred him to a surgeon. He is a scheduled admission for surgery.
B/P HR RR TEMP SP02 PAIN
155/90 90 16 98.8 95% 6/10
History of skin cancer to nose which was removed by a dermatologist 3 years ago. Additional history
includes hypertension, kidney stones, spontaneous pneumothorax, and sleep apnea. States he does not
use his C-PAP machine for his sleep apnea because he “does not like the way it feels on his face”. Last
admission 8 years ago for hernia repair. Patient has smoked one pack a day since the age of 16. He
reports that he now drinks 3-4 beers a day since his wife died. He wants to try to “stop his bad habits”
but does not know they best way how.
HEENT Head normocephalic. 20/30 vision bilaterally. Slightly hard of hearing. Nares patent. Mucosa pink,
with no lesions. Tonsils present.
RESPIRATORY Reports chronic, nonproductive cough.
, CARDIOVASCULAR Denies chest pain, palpitations, or shortness of breath. No syncope or pre-syncope
episodes.
NEUROLOGICAL Complains of weakness and pain to right arm. Denies numbness.
HEENT Slightly hard of hearing. Wears glasses when reading. No complaints of headaches change in
vision, nasal problems, or sore throat.
DIETARY HISTORY: Reports decreased appetite. Reports that his wife used to go grocery shopping and
cook meals. Since her death he has mainly ordered in or has gotten fast food.
I & O No complaints of nausea, vomiting, or change in stool pattern, consistency, or color. Patient
complains of occasional hesitancy with urination. Denies pyuria or hematuria.
INTEGUMENTARY Complains of dry, scaly skin. Worries about his increased risk of skin cancer since he is
outside working on the farm. States he “uses sunscreen when he remembers to put it on”.
LYMPHATIC: No palpable nodes. Denies problems with lymphatic.
ENDOCRINE Reports increase in fatigue over the past few months.
MUSCULOSKELETAL Patient complains of right shoulder pain that is stabbing and aching. He has been
taking extra strength ibuprofen which helps bring his pain down to a 5/10. Gait is coordinated. Does not
use any assistive devices.
PSYCHOLOGICAL/FAMILY - SUPPORT
Wife died two months ago. Lives alone on his farm. He is worried about he will be able to take care of his
farm with his injury. Three adult children live out of state and patient only sees them on special
occasions.
Care Plan
Subjective assessment data:
Weakness and pain in the right arm.
Decreased appetite
Occasional hesitancy with urination
Uses sun cream when he remembers
Increase in fatigue over the past few months
Stabbing and aching right shoulder pain
Anxiety with activity competency
Complaints of dry, scaly skin.
