“I just transferred to the Medical Oncology floor this morning.
They want to get me up but it is hard to move due to pain 6/10 on my left side.”
Blood pressure (mmHg)
Heart rate (beats/min)
Electrocardiography during activity
Respiratory rate (breath/min)
Pulse oximetry on 2 L NC (SpO2)
Borg rate of perceived exertion (RPE) scale
Patient found supine in bed with head of bed (HOB) elevated 45 degrees and arms resting on a pillow in her lap.
No apparent distress or difficulty breathing.
Bandage in place over left thorax with minimal serosanguineous drainage from incision.
Lines/equipment notable for telemetry, right upper extremity (RUE) peripheral IV, 4L O2 by NC.
Cardiovascular and pulmonary
Inspection: no accessory muscle use, left lateral trunk lean with decreased left thoracic expansion.
Palpation: reduced expansion left upper lobe (L UL). 2 + pedal pulses bilateral lower extremity (BLE).
Auscultation: diminished breath sounds L UL, no adventitious sounds.
Range of motion (ROM)
Left shoulder: flexion and abduction (ABD): 120 degrees
Left elbow, wrist, and hand: within functional limit (WFL)
Right upper extremity (RUE): WFL throughout
BLE: WFL throughout
Left shoulder flexion and ABD: 3–/5 and limited by pain
Left elbow, wrist, and hand: 3 + /5
RUE: 3 + /5 throughout
BLE: > 3 + /5 throughout as demonstrated through functional mobility