Asiel Case Study
Introduction
The patient, Mary, has presented the list of complaints that allowed me to suspect Lyme disease, discoid lupus erythematosus, and systemic lupus erythematosus in her. The last diagnosis was confirmed by physical examination. I have developed a nursing care plan to address Mary’s problems and a teaching care plan to help her learn about the necessity of nursing interventions and their impact on her health.
History and Physical Examination
The patient has presented the following complaints: itching rash on the face and nose bridge, symptoms worsening while outdoors, fever, fatigue, weight loss, mouth soreness, and muscle and joint aches. I have performed a general survey: the patient looked like she was suffering from fever, had a malar rash. Her heath history includes chronic strep throat infections. The patient has denied any influence of cosmetics, medication, smoking, and food. She also denies such symptoms as spreading of rash, temperature intolerance, constipation, painful urination, polyuria, polyphagia, diarrhea, polydipsia, headache, nasal or sinus congestion, eat pain, morning joint stiffness, sore throat, cough, chest pain, abdominal pain, and shortness of breath.
The examination of vital signs did not reveal any problematic issues. Skin examination revealed some erythematous plaques on her cheeks and nose bridge. During the musculoskeletal examination, arthralgia was revealed, but the muscles were in normal shape. Some ulcers were discovered in buccal mucosa on both sides. Oropharynx moist with erythema was discovered in her posterior pharyngeal wall. Neck examination did not reveal any problems.
Nursing Diagnosis
After performing a general survey, I had three possible diagnoses in mind. These diagnoses should be evaluated to identify the most appropriate one.
- Lyme disease. Having traveled to the Appalachians, Mary was most likely exposed to ticks that can transmit Lyme disease. Fever is also a symptom of Lyme disease, as well as joint and muscular pain. According to the patient, the rash appeared in a week after the vacation, which is consistent with what is known about the passing of Lyme disease. However, in this case, the rash would not be itching. Also, the Lyme rash does not typically appear only on the face and nose bridge; it starts from the place of a tick bite (most likely arms or legs but not face) and spreads over the body (Cameron, Johnson, & Maloney, 2014), which the patient denies. Therefore, it is not Lyme disease.
- Discoid lupus erythematosus. The way of rash spreading (face and nose bridge) is similar to what happens in the case of discoid lupus erythematosus. However, the patient experiences weight loss, muscular and joint pain, and fever, which is unlikely for discoid lupus erythematosus (Drucker et al., 2016). Therefore, this diagnosis is not correct.
- Systemic lupus erythematosus. The patient has a malar rash, which is typical for this disease. She belongs to the age group that is usually affected by it. The presence of fever, weight loss, joint pain, sensitivity to the sun (the condition of the rash worsens when Mary is outdoors), and oral ulcers also confirm that it may be systemic lupus erythematosus. According to the guidelines developed by the American College of Rheumatology, the presence of 4 out of 11 signs confirms that a patient has systemic lupus erythematosus (American College of Rheumatology, n.d.). Mary has 4 signs; therefore, she should be diagnosed with systemic lupus erythematosus.
Teaching Care Plan
The time frame for the teaching plan is two weeks. The teaching methodology will include nurse instruction. The general learning outcome is making the patient understand the necessity of nursing intervention and their impact on her body.
- Meeting 1: hygiene and sleep. Learning outcomes: the patient understands the importance of stable sleep habits, knows how to maintain specific oral hygiene, is aware of the necessity to cover herself from sunlight.
- Meeting 2: exercise and relaxation. Learning outcomes: the patient knows basic techniques of muscle exercise and relaxation and is aware of their positive impact.
- Meeting 3: weight and nutrition. Learning outcomes: the patient is aware of the specifics of her diet and nutrition regime.
- Meeting 4: medicine. Learning outcomes: the patient understands the reason for taking analgesics and can explain how they work.
Nursing Care Plan
The nursing diagnosis is systemic lupus erythematosus. The patient’s problem list includes:
- malar rash;
- joint pain;
- fever;
- fatigue;
- weight loss;
- sun sensitivity;
- oral ulcers.
The following interventions are recommended:
- learning exercise and muscle relaxation techniques;
- establishing stable sleeping habits;
- maintaining good nutrition;
- maintaining sufficient oral hygiene;
- avoid sunlight, cover skin as much as possible;
- delay possible plans for pregnancy;
- take the analgesics prescribed by the doctor (Gurevitz, Snyder, Wessel, Frey, & Williamson, 2013).
The nursing goals are:
- minimizing and preventing the rash;
- making the patient feel less fatigued;
- providing relief for joint pain;
- stopping weight loss and gaining the lost weight back;
- making the patient insensitive to sun exposure;
- curing and preventing oral ulcers.
Evaluation: within a week since the start of the treatment, the rash was minimized, as well as the oral ulcers.
Conclusion
Having analyzed the history and performed a physical examination, I diagnosed the patient with systemic lupus erythematosus. Teaching and nursing care plans were composed accordingly.
References
American College of Rheumatology. (n.d.). 1997 Update of the 1982 American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Web.
Cameron, D.J., Johnson, L.B., & Maloney, E.L. (2014). Evidence assessments and guideline recommendations in Lyme disease: the clinical management of known tick bites, erythema migrans rashes and persistent disease. Expert Review of Anti-infective Therapy, 12(9), 1103-1135.
Drucker, A.M., Su, J., Mussani, F., Siddha, S.K., Gladman, D.D., & Uriwitz, M.B. (2016). Prognostic implications of active discoid lupus erythematosus and malar rash at the time of diagnosis of systemic lupus erythematosus: Results from a prospective cohort study. Lupus, 25(4), 376-381.
Gurevitz, S.L., Snyder, J.A., Wessel, E.K., Frey, J., & Williamson, B.A. (2013). Systemic lupus erythematosus: A review of the disease and treatment options. The Consultant Pharmacist, 28(2), 110- 121.