Presumptive Nursing Diagnosis
The accuracy of diagnosis is dependent on various factors. Subjective and objective assessments assist in acquiring the information about the patient’s condition (Rosdalh & Kwalski, 2008). In the context of the presented case, the presumptive nursing diagnosis is Cutaneous Lupus Erythematosus. This autoimmune disease has a special set of symptoms such as rash, fatigue, fever, and shallow oral ulcers (Kuhn, Lehmann, & Ruzicka, 2005). Nonetheless, the rationale for the chosen diagnosis will be presented with the help of subjective and objective assessments.
As for the evaluation of patient’s health and social background, it could be said that there are several factors, which can contribute to the development of Cutaneous Lupus Erythematosus. Her medical record does not portray any recent chronical diseases and illnesses while tonsillectomy was present at the age of nine. In turn, she has never been hospitalized previously. Moreover, the information about her parents does not offer any reasoning for any chronical diseases. A combination of these factors indicates no possibility of the chronical illness as a potential diagnosis.
Sequentially, the physical examination supports the presumptive diagnosis. As it was mentioned earlier, the primary symptoms of Cutaneous Lupus Erythematosus are rash (focused on the face), fatigue, and the unreasonable rise in temperature (Kuhn et al., 2005). The examination of the patient revealed the similar symptoms. To support the initial hypothesis, Mary has rash erythematous plaques on her cheeks and nose, shallow ulcers in the mucosa and complains about fatigue (BP 112/62 mm Hg) and fever (100.3 F). At the same time, a high reaction to sun and pains in muscles underline the reasoning for the preliminary diagnosis. In the end, it could be said that both objective and subjective evaluation emphasize that the possibility of Cutaneous Lupus Erythematosus as a presumptive diagnosis.
Teaching and Nursing Care Plan on This Case
Increasing awareness of the patient and providing information about his/her medical condition is critical in the first place. In this case, initially, one has to pay attention to patient’s learning style by making observations and having a conversation (Bastable, 2016). Based on the findings, written, oral, or visual presentation will be conducted to deliver the information about the disease to the patient. General facts about Cutaneous Lupus Erythematosus will be provided with the assistance of the commonly accepted language. Thus, the medical terms have to be avoided. Meanwhile, particular attention has to be paid to the treatment of the disease, as the patient has to be prepared for challenges and be optimistic about the outcomes of the medical intervention.
Speaking of the nursing care plan, the first step is to conduct another examination to determine the nature of the rash in more details. Blood testing will help see any changes in the percentage of leukocytes and ANA (American Skin Association, 2016). The next step is to reveal whether any internal organs are affected by the disease. MRI scanning can be used to disclose the existence of any abnormalities. Based on the assessments performed previously, it will be possible to prescribe suitable medications such as corticosteroid creams to treat the skin lesions and oral drugs including methotrexate and azathioprine (American Skin Association, 2016). At the same time, the patient will be asked to apply sunscreen creams before going outdoors and avoid sunlight (American Skin Association, 2016). The second appointment will be scheduled within a week to check the progress of the interventions.
References
American Skin Association. (2016). Cutaneous Lupus Erythematosus. Web.
Bastable, S. (2016). Essentials of patient education. Burlington, MA: Jones & Bartlett Learning.
Kuhn, A., Lehmann, P., & Ruzicka, T. (2005). Cutaneous Lupus Erythematosus. Dusseldorf, Germany: Springer.
Rosdalh, C., & Kwalski, M. (2008). Textbook of basis nursing. New York, NY: Wolters Kluwer Health.