Physical Assessment In Health Care
Physical Assessment in Health Care
Carlos Arteta
Florida National University
Professor: Angel Cano
April 2, 2016
Case Study # 1
A 35 years old electrical engineer presented to the office for a clinical evaluation. Her name is Mary. She is complaining of a face rash that has been present for one week. The rash is across her face and the bridge of her nose. The rash appeared after one week of hiking and camping in the Appalachians. Mary denies new soap, detergent, lotions, environmental exposures, medications and foods. She notices that going outdoors makes the rash worse, and it has not spread to other areas of her body. She has never had this rash before.
The lesions itch and are painful. She has noticed some increase fatigue, …show more content…
She is alert and oriented to time, place and person. Her vital signs are as follow: BP 112/66 mmHg, HR 62 BPM, RR 12 breaths/min, temperature 100.3° F. Several erythematous plaques scattered over the cheeks and the bridge of nose, sparing the nasolabial folds. She is normocephalic, atraumatic, with white sclera and clear conjunctivae. Her pupils constrict from 4 mm to 2 mm and equally round reactive to light and accommodation. Her oropharynx is moist with erythema in the posterior pharyngeal wall. No exudates are noted. She presents shallow ulcers in the buccal mucosa bilaterally. There is no indication of cervical lymphadenopathy or thyromegaly. She has full range of motion, no presence of swelling of deformity and her muscles have normal tone and bulk.
Based on this information, my presumptive nursing diagnosis is impaired skin integrity related to skin rash. The nursing plan for Mary should be based on skin protection. Patient must avoid prolonged exposure to sunlight and other forms of ultraviolet lighting, including certain types of fluorescent light. Mary needs to wear long sleeves and a large-brimmed hat when outdoors. She should use sun blocking agents with sun protection factor of 30 or higher on exposed skin …show more content…
As a non-drug treatment sun exposure must be minimized by avoiding going out in bright sun as much as possible, and use of protective clothing and high factor sunscreens must be a must. As a drug treatment corticosteroids may be used topically or intralesionally. Very potent forms are necessary for hypertrophic lesions. Fluocinonide cream may be more effective than hydrocortisone in treating people with discoid lupus erythematosus (DLE). Systemic steroids do not seem to be effective. When systemic treatment is required, hydroxychloroquine is the first-line agent. Hydroxychloroquine and acitretin (an oral retinoid) appear to be of equal efficacy, although adverse effects are more frequent and more severe with acitretin. Other possible treatments include topical retinoid and immunosuppressive agents (e.g. azathioprine or
Carlos Arteta
Florida National University
Professor: Angel Cano
April 2, 2016
Case Study # 1
A 35 years old electrical engineer presented to the office for a clinical evaluation. Her name is Mary. She is complaining of a face rash that has been present for one week. The rash is across her face and the bridge of her nose. The rash appeared after one week of hiking and camping in the Appalachians. Mary denies new soap, detergent, lotions, environmental exposures, medications and foods. She notices that going outdoors makes the rash worse, and it has not spread to other areas of her body. She has never had this rash before.
The lesions itch and are painful. She has noticed some increase fatigue, …show more content…
She is alert and oriented to time, place and person. Her vital signs are as follow: BP 112/66 mmHg, HR 62 BPM, RR 12 breaths/min, temperature 100.3° F. Several erythematous plaques scattered over the cheeks and the bridge of nose, sparing the nasolabial folds. She is normocephalic, atraumatic, with white sclera and clear conjunctivae. Her pupils constrict from 4 mm to 2 mm and equally round reactive to light and accommodation. Her oropharynx is moist with erythema in the posterior pharyngeal wall. No exudates are noted. She presents shallow ulcers in the buccal mucosa bilaterally. There is no indication of cervical lymphadenopathy or thyromegaly. She has full range of motion, no presence of swelling of deformity and her muscles have normal tone and bulk.
Based on this information, my presumptive nursing diagnosis is impaired skin integrity related to skin rash. The nursing plan for Mary should be based on skin protection. Patient must avoid prolonged exposure to sunlight and other forms of ultraviolet lighting, including certain types of fluorescent light. Mary needs to wear long sleeves and a large-brimmed hat when outdoors. She should use sun blocking agents with sun protection factor of 30 or higher on exposed skin …show more content…
As a non-drug treatment sun exposure must be minimized by avoiding going out in bright sun as much as possible, and use of protective clothing and high factor sunscreens must be a must. As a drug treatment corticosteroids may be used topically or intralesionally. Very potent forms are necessary for hypertrophic lesions. Fluocinonide cream may be more effective than hydrocortisone in treating people with discoid lupus erythematosus (DLE). Systemic steroids do not seem to be effective. When systemic treatment is required, hydroxychloroquine is the first-line agent. Hydroxychloroquine and acitretin (an oral retinoid) appear to be of equal efficacy, although adverse effects are more frequent and more severe with acitretin. Other possible treatments include topical retinoid and immunosuppressive agents (e.g. azathioprine or