Patient's Medical History and Nursing Care Plan | Free Essay Example

Patient’s Medical History and Nursing Care Plan

Words: 1173
Topic: Health & Medicine
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Patient History and Physical Examination

Patient Name: Mary

Chief Complaint: The client complained about having a rash on her face.

History of Present Illness: The patient said that the rash appeared on her skin after the holiday she spent hiking and doing various outdoor activities in the Appalachians.

Past Medical History

Family History: Mary’s mother had a diagnosis of rheumatoid arthritis. Nevertheless, the client’s father does not have any health issues.

Personal and Social History

Mary is thirty-five years old. She occupies the position of an electrical engineer. At the age of nine, the client underwent the tonsillectomy procedure due to multiple issues and infections that bothered her throat. However, Mary did not have any illnesses or health problems after the case described above as she maintained a healthy lifestyle. It would be proper to mention that the client has never given birth to a child and has not been hospitalized in her entire life due to the absence of complaints. The patient does not consume tobacco products and drugs. However, she prefers to drink a glass of wine every night at dinner. The client has got a master’s degree in engineering. It would be proper to mention that Mary has been living with her boyfriend within the past five years.

Review of Systems

General: Mary lost weight. Also, she has a high fever and fatigue.

Skin: The medical examination showed that the patient’s face was covered with a rash.

Head and Neck: The client has no health problems with her head and neck.

Eyes, Ears, Nose, Throat, and Mouth: Mary said that she felt mouth soreness.

Lymphatic System: The client has no health problems in her lymphatic system.

Chest and Lungs: The client has no health problems in her chest and lungs.

Heart and Blood Vessels: The results of the blood pressure measurement procedure are the following: BP one hundred and twelve/sixty-six mm Hg; HR sixty-two BPM and regular.

Gastrointestinal System: The client has no health problems in her gastrointestinal system.

Genitourinary System: The client has no health problems in her genitourinary system.

Musculoskeletal System: Mary said that she felt some pain and ache in her muscles. Perhaps, this is a consequence of intensive outdoor activities. When a person is not used to an active lifestyle, his or her muscles are likely to be sore after a set of physical exercises (Pinto, Berenguer, & Martins, 2015). The most painful zones were the patient’s hands and wrists.

Nervous System: The client has no health problems with her nervous system.

Physical Examination

General: As it is mentioned above, the examination showed that Mary lost her weight and had an increased fever and fatigue.

Mental Status: Also, the woman does not have any psychological issues. Therefore, she can be claimed mentally healthy.

Skin: A plethora of red boils emerged on Mary’s facial skin. However, the rest of the body does not seem to have the same issue. It would be proper to mention that the densest concentration of the rash can be observed on the client’s cheeks and nose.

Head: The client has no health problems with her head.

Eyes: The color of the patient’s sclera was white, and the woman’s conjunctivae were clear. Moreover, her pupils constrict from four mm to two mm equal and round. The eyes demonstrated a decent reaction to bright light. Therefore, the patient does not have any visual challenges.

Ears: The client has no health problems with her ears.

Nose: The client has no health problems with her nose.

Throat and Mouth: The medical examination showed that Mary had shallow ulcers in the buccal mucosa bilaterally.

Neck: As it is mentioned above, Mary’s neck supples without cervical lymphadenopathy or thyromegaly.

Chest & Lungs: The respiratory rate amounts to twelve breaths per one minute.

Breast: The client has no health problems in her breast.

Heart: The patient’s blood pressure is HR sixty-two BPM and regular.

Abdomen: The client has no health problems in her abdomen.

Musculoskeletal System: The medical examination did not detect any issues in Mary’s musculoskeletal system. Moreover, she has a full range of motion, no deformity or swelling. Muscles work appropriately (with normal bulk and tone).

Neurologic System: The client has no health problems in her neurologic system.

Nursing Care Plan

Assessment

It is necessary to make regular medical examinations to collect appropriate data as to the patient’s health. All the acquired information must be structured and recorded at the end. It would be proper to mention that interviewing is one of the most efficient data collection methods in the given case. It is advantageous to interview Mary, her boyfriend, and people who surround her on a daily basis to have a precise understanding of her behavior.

Subjective

Mary said that she did not consume any medical products or food that could have led to the rash on her face, which always itched and ached. Moreover, the client feels even worse when she goes outside and remains under the sun rays for an extended period. The woman faced the health problem for the first time when she returned from her vacation in the Appalachians. Although the patient complained about the pain in her muscles near hands and wrists, the examination did not detect any issues there. The client is concerned about her weight loss, high fever, and fatigue. It would be proper to mention that Mary’s mother had rheumatoid arthritis, which might have an impact on the patient’s health as well.

Objective

According to the acquired examination results, Mary’s blood pressure is one hundred and twelve/sixty-six mm Hg. Moreover, the heart rate of sixty-two BPM is considered to be normal. The respiratory test showed that the client makes twelve breaths per minute. Unfortunately, the patient’s temperature is higher than it should be (one hundred degrees Fahrenheit). The woman has a rash all over her face.

Nursing Diagnosis

Although this information has to be approved, the client is thought to have such diagnoses as a risk for impaired skin integrity, fatigue, allergy to some medicaments, and impaired comfort (NANDA International, 2017).

Planning

The patient’s condition must be discovered. Nurses will be allowed to develop an appropriate intervention and treatment plan once they receive a precise medical diagnosis.

Intervention

It is necessary to undergo various tests and examinations to prove the considered diagnosis. The following list will enumerate the number of sound event in the given case:

  • Fatigue – nutrition and mood management
  • Impaired skin integrity – skincare and infection control (Pezzi, Rabelo-Silva, Paganin, & Souza, 2016)
  • Allergy – medical administration and allergy treatment
  • Impaired comfort – anxiety and pain elimination, along with the use of appropriate medicaments

Patient Teaching

The patient must be informed about possible by-effects and unfortunate consequences that might be caused by the violation of the developed care plan. Also, it is necessary to consult Mary as to her new regime and appropriate prescription drugs. Also, it would be advantageous to create a plan for regular doctor visits. The client’s boyfriend should be aware of the intervention plan as his partner requires a healthy atmosphere.

References

NANDA International. (2017). NANDA nursing diagnosis list for 2015-2017. Web.

Pezzi, M. V., Rabelo-Silva, E. R., Paganin, A., & Souza, E. N. (2016). Nursing interventions and outcomes for the diagnosis of impaired tissue integrity in patients after cardiac catheterization: Survey. International Journal of Nursing Knowledge, 27(4), 215-219. Web.

Pinto, S. M., Berenguer, S. M., & Martins, J. C. (2015). Is impaired comfort a nursing diagnosis? International Journal of Nursing Knowledge, 27(4), 205-209. Web.