Diagnosis and Nursing Plan

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As a nurse, it is imperative to understand that all kind of people will come in with all kinds of medical problems and issues. Nurses are required to care for these patients and, in some cases, to also diagnose them.  In order to demonstrate this responsibility and its fulfillment, I will provide a medical history and physical examination information for a particular patient, which will then be used to determine an appropriate diagnosis and formulate a nursing plan for this patient.

The patient in this particular case is a 35-year-old woman named Mary. She came into the office because she had developed a rash on her face that had remained there for a week. She claimed not to have tried any new soaps, detergents, or other products or had any exposures that could have caused the rash. The rash is present on her face and the bridge of her nose, and she said it developed after a hiking and camping trip in the Appalachian Mountains. The rash contains itching, painful lesions, and, while Mary has not made any attempts to get rid of the rash, thinking it would go away on its own, she has said that the rash becomes worse when she spends time outdoors.

Fortunately for Mary, who has never had this rash before, the rash has not spread to other areas. Aside from the rash itself, other symptoms she has noticed include increased fatigue, weight loss, mouth soreness, and fever, as well as increased muscle aches and pains, which are particularly bad in the hand and wrist. Symptoms that she was asked about but that were not present include a headache, sore throat, ear pain, nasal congestion, sinus congestion, chest pain, shortness of breath, cough, stomach pain, pain upon urination, constipation, diarrhea, temperature intolerance, polyuria, polydipsia, and polyphagia.

Mary was able to provide a full and detailed medical history, which will be helpful in properly diagnosing her and ensuring that she gets the correct treatment for her ailments. She reports having had a tonsillectomy at the age of nine due to chronic strep throat infections. Aside from this, however, she has been mostly healthy and has never been hospitalized. Mary does not have any children. She does not smoke, has a glass of wine almost every evening, and does not use illicit drugs. Finally, in terms of her family history, her father reports no health issues while her mother does suffer from rheumatoid arthritis.

Obviously, given this information, there are many health issues that Mary could be experiencing. A good first step is to rule out smaller, less serious ailments. One of these smaller, less serious ailments that Mary could be experiencing is a severe sunburn that has led to sun poisoning, which is often coupled with a painful sun rash.

HeatRash.Org (2017) explains that, “Sun rash usually occurs when one is exposed to the sun…It starts off as sunburn and the skin starts peeling after 24 hours” (para. 5). It is very possible that Mary was badly sunburned on her mountain trip the week prior to coming into the office. This could have easily led to a sun rash, which, in turn, could have been irritated by scratching and touching, causing the lesions and making the rash persistent. Furthermore, she could be worsening the sunburn and rash by going outside, which would explain her rash getting and feeling worse when she does so.

HeatRash.Org (2017) lists the symptoms of a sun rash as severe sunburn; itching blisters; and dry, flaky, peeling skin (para. 6). Based on this information, it is likely that Mary is suffering from a sun rash. If further testing shows that she is, prescription creams to relieve pain and itching and close monitoring, as well as keeping the area clean to prevent infection, would all be necessary.

Of course, sunburn with sun rash present is not the only possibility for Mary. There is also a good chance that she could be suffering from poison ivy, poison sumac, or poison oak, common rash-causing ailments she easily could have contracted while hiking in the mountains. Coulter (2017) explains that, in those who have contracted one of these conditions, “The rash is painful, and it starts after you’ve brushed against any part of these plants. The leaves, vines, and even the roots contain a natural oil called urushiol that causes allergic reactions in most people” (para. 2). Coulter (2017) goes on to explain that the rash can be quite difficult to get rid of, especially if one is only trying over the counter treatment. Fortunately, however, health care professionals are skilled in testing for these rashes, so if further testing of Mary’s rash was performed and it did, ultimately, turn out to be caused by poison ivy, poison oak, or poison sumac, treatment would be relatively easy. Typical treatments simply involve prescription creams and ointments to help rid the body of the rash and the associated pain, itching, and discomfort.

If it does ultimately turn out that, unfortunately for Mary, her condition is not caused by something as simple as sunburn/sun rash or exposure to a poison plant, then nurses would have no choice but to look to other potential causes that are more serious. One such potential cause would be lupus, which can cause a facial rash of the type that Mary is experiencing.

Dr. Richard D. Sontheimer (2017) says that “Approximately two-thirds of people with lupus will observe some type of effect on their skin” (para. 1). He (2017) goes on to say that, “in fact, 40-70 percent of people with lupus will find that their disease is made worse by exposure to ultraviolet (UV) rays from sunlight or artificial light” (para. 1). Given this information, it is very possible that Mary’s sun exposure has led to a lupus-related rash, which could be an indicator that she is suffering from undiagnosed lupus.

Obviously, in this case, the first step would be to test for lupus as well as for cutaneous lupus, a skin disease. As Sontheimer (2017) explains, “Skin disease in lupus can cause rashes or sores (lesions), most of which will appear on sun-exposed areas such as the face, ears, neck, arms, and legs” (para. 2). Given this information, such testing is definitely not out of line.

If it does turn out that Mary has lupus and a related skin rash, she would need general treatment for the rash itself, for which Sontheimer (2017) advises special skin care and biopsy treatments to ensure that the lesion is not cancerous (para. 3). Aside from that and more importantly, however, she would need to begin getting on medications and developing a treatment plan to help her manage and control her lupus as fully as possible. However, lupus is not the only “more serious” possibility in terms of what Mary may be experiencing.

Given the fact that Mary does have a close family history of rheumatoid arthritis, this cannot be overlooked as a possible cause for her current complaints. While many people are not aware of this information, it is true that rheumatoid arthritis sometimes causes rashes and skin complaints of the type that Mary is experiencing. WebMD (2017) notes that while the condition mainly affects the joints, it can also have effects on the skin (para. 1), which may be what is happening here.

WebMD (2017) states that “If [rheumatoid vasculitis] happens in larger blood vessels, it can cause a painful rash. In serious cases, ulcers can form, and there’s a chance they could become infected” (para. 7). Given Mary’s family history, this could be what’s at play here, which is why further testing for rheumatoid arthritis is necessary. If the condition is found to be present, attempts should be made to help manage it and any related skin problems.

Obviously, there are a great many possibilities in terms of Mary’s diagnosis. Through testing and ruling out of other possibilities, a correct diagnosis can be arrived at. What that diagnosis is will determine what type of treatments need to be offered out of those suggested.

References

Coulter, L. (2017). “Poison Plants: Identifying Poison Ivy, Poison Oak, and Poison Sumac.” Retrieved from http://www.hgtv.com/outdoors/flowers-and-plants/poison-plants-identifying-poison-ivy-poison-oak-and-poison-sumac

HeatRash.Org. (2017). “Heat Rash Vs. Sun Rash: Know the Difference.” Retrieved from http://www.heatrash.org/heat-rash-vs-sun-rash-know-difference/

Sontheimer, R.D. (2017). “How Lupus Affects the Skin.” Retrieved from http://www.resources.lupus.org/entry/skin

WebMD. (2017). “When Rheumatoid Arthritis Causes Skin Problems.” Retrieved from http://www.webmd.com/rheumatoid-arthritis/guide/rheumatoid-arthritis-skin-problems#1