History of Present Illness
Mary, 35 years old, is an electrical engineer. She showed up at the nurse’s office because she has a rash on her face and across the bridge of her nose for one week. Mary noticed it after returning from a hiking and camping trip to the Appalachians. She has not used any new cosmetics, detergents, or medications and did not try any new or unfamiliar food. She denies using medications or lotions to make the situation better. Mary says that it becomes worse when she is outdoors, and the lesions are painful and itchy. Mary says that it is the first time in her life that she has such a rash and denies its spread to other areas of her body.
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As for other symptoms, she noticed weight loss, fever, increased fatigue, muscle aches, especially in wrist and hand, and mouth soreness. However, the patient denies cough, ear pain, headache, diarrhea, chest pain, sore throat, temperature intolerance, pain with urination, abdominal pain or pain with urination, nasal or sinus congestion, and shortness of breath, etc. No sign of joint stiffness in the morning.
Past Medical History
At age 9, Mary had a tonsillectomy because of chronic strep throat infections. Except for that, no other stories of hospitalization because she was always healthy. Mary has never had children.
Mary lives with her boyfriend. She has a master’s degree in engineering. Nearly every evening the patient has a glass of wine with her meal, denies illicit drugs, does not smoke. Mary’s mother has rheumatoid arthritis. Except for that, no other stories of health concerns in her family because her father is absolutely healthy.
Physical Examination: Review of Symptoms
General Constitutional systems: Alert young woman. BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F. Experiences fever, weakness, and fatigue. Full range of motion; no swelling or deformity; muscles with normal bulk and tone; no exudates.
Head: Normocephalic head bone, atraumatic.
Eyes: Sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm, equal, round, and reactive to light and accommodation.
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Ears, Nose, Mouth, Sinuses: shallow ulcers in the buccal mucosa bilaterally; Oropharynx moist and erythema in the posterior pharyngeal wall.
Skin: Several erythematous plaques scattered over the cheeks and the bridge of the nose, sparing the nasolabial folds.
Chest/lungs: No cough or shortness of breath.
Cardiovascular: No information provided.
Lymph nodes: Neck supple, no cervical lymphadenopathy or thyromegaly.
Focused Physical Examination: HEENT, Cardiac, Respiratory, Lymphatic systems and focus on skin.
Presumptive Nursing Diagnosis
A nursing diagnosis is a clinical judgment about a patient, his or her family, environment, and reactions to health conditions. In Mary’s case, the most likely presumptive nursing diagnosis is the risk for impaired skin integrity. The motivation for this decision is that the patient is at risk for alteration in the epidermis and/or dermis (Herdman& Kamitsuru, 2014). In Mary’s case, it is the risk for further damage to skin layers. There are both internal and external risk factors involved. As for internal risk factors, this group might include drinking alcohol nearly every night. Change of environment because of a hiking trip to the Appalachians is a potential external risk factor.
There will be several dimensions of a teaching plan. First of all, Mary will be informed about possible consequences of skin integrity. This step would help her take the situation seriously and follow other nurse’s recommendations. Next, the patient will be educated on the importance of proper diet, i.e. excluding alcohol from dinners. Moreover, she will be taught about the necessity to keep her skin dry and clean, and use only warm water while washing instead of hot (LeMone et al., 2014). Finally, Mary will be educated to avoid touching or scratching the affected areas because it might worsen the situation and to apply prescribed lotions as required.
In the case of Mary, a care plan will involve several steps. First, it is necessary to assess the level of skin integrity noting any signs of redness (Gulanick & Myers, 2013). For this reason, it is recommended to examine other body parts, even though the patient claims that the rash has not spread, especially bony areas such as knees and elbows. This step will be taken again by a nurse later to find out whether the problem is solved. Nevertheless, Mary will be asked to conduct self-examinations every day to control the further spread of the rash. She will have to focus on possible skin color changes, pain, swellings, etc., and take notes that she will show next time Mary comes to the nurse’s office. Next, lesions and areas of dry skin will be anointed with lotion or ointment to provide enough moisture (Swearingen, 2016). It is significant to note that lotions and ointments should be alcohol-free. In addition to the initial procedure in the nurse’s office, the patient will be prescribed a lotion and asked to apply it several times a day. If prescribed medication solves the problem and the skin condition is back to normal, treatment can be stopped.
Gulanick, M., & Myers, J. L. (2013). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.). Maryland Heights, MS: Mosby.
Herdman, H.T., & Kamitsuru, S. (Eds.). (2014). NANDA International, Inc. nursing diagnoses: Definitions & Classifications, 2015-2017. Oxford, UK: Wiley Blackwell.
LeMone, P., Burke, K., Levett-Jones, T., Dwyer, T., Moxham, L., Reid-Searl, K., … Debra Raymond. (2014). Medical-surgical nursing: Critical thinking for person-centred care. (2nd ed.). Frenchs Forest, NSW: Pearson Australia.
Swearingen, P. L. (2016). All-in-one nursing care planning resource: Medical-surgical, pediatric, maternity, and psychiatric-mental health. (4th ed.). St. Louis, MO: Elsevier.