Patient History and Physical Examination
Patient Name: Mary
Chief Complaint: Rash across the face and the bridge of the nose.
History of present illness: never occurred before. Does have mouth soreness. The patient has noticed some increased muscle aches and pains, which are worse in the hand and wrist.
Past Medical History
Tonsillectomy at age 9 for chronic strep throat infections. Mary has been as healthy as an adult. She has never had children. She has never been hospitalized for any reason.
Family History: a mother with rheumatoid arthritis. Her father is healthy.
Personal and Social History
Mary is a 35 years old electrical engineer. She does not smoke; she drinks a glass of wine nearly every night with her dinner; she denies illicit drug use. She completed a master’s degree in engineering. She has lived with her boyfriend for the past 5 years.
Review of Systems
- General: rash on her face that has been present for 1 week. Denies new soaps, detergents, lotions, environmental exposures, medications, and foods. The rash is across her face and the bridge of her nose. She states that she first noticed it after spending a week hiking and camping in the Appalachians. The lesions itch and are painful. Denies any spread of the rash to other areas; has never had this rash before.
- Skin: rash across the face and the bridge of the nose.
- Head and Neck: denies headache
- Eyes, Ears, Nose, Throat, and Mouth: ear pain, nasal or sinus congestion; mouth soreness.
- Lymphatic System: weight loss.
- Chest and Lungs deny chest pain, shortness of breath, cough.
- Heart and Blood vessels: no complaints.
- Gastrointestinal System: no abdominal pain. Denies polydipsia, or polyphagia.
- Genitourinary System denies pain with urination, constipation, or diarrhea. Denies polyuria.
- Musculoskeletal System: some increased muscle aches and pains, which are worse in the hand and wrist. Denies early morning joint stiffness or difficulty with being able to move in the morning.
- Nervous System: fever; increased fatigue.
- General: BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F.
- Mental Status: alert young woman, no issues identified.
- Skin: Several erythematous plaques scattered over the cheeks and the bridge of the nose, sparing the nasolabial folds.
- Head: Head is normocephalic, atraumatic, and without lesions; hair evenly distributed.
- Eyes: Sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm and equal, round, and reactive to light and accommodation.
- Ears: Canals patent. Bilateral TMs pearly gray with positive light reflex; landmarks easily visualized.
- Nose: Nasal mucosa pink; normal turbinates. No septal deviation
- Throat and Mouth: Oropharynx moist with erythema in the posterior pharyngeal wall; no exudates; shallow ulcers in the buccal mucosa bilaterally.
- Neck: Neck supple without cervical lymphadenopathy or thyromegaly.
- Chest & Lungs: no issues.
- Breast: Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
- Heart: regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. No edema.
- Abdomen: Abdomen soft, non-tender. No hepatosplenomegaly.
- Musculoskeletal System: Full range of motion; no swelling or deformity; muscles with normal bulk and tone.
- Neurologic System: alert young woman, sitting comfortably on the examination table.
Nursing Care Plan
Subjective: “rash appeared after a week of hiking and camping in the Appalachians.”
Objective: The patient experiences an uncomfortable face rash accompanied by the symptoms of fatigue, fever, and body soreness.
Nursing Diagnosis: skin rash related to possible contact with an allergen or bacteria; severely limits the patient’s quality of life due to accompanying symptoms that the patient-reported.
- The patient will experience a relief in the reported symptoms;
- The patient will be able to eliminate the rash;
- The patient will be able to make lifestyle changes to prevent the symptoms from reoccurring.
- Assess skin (including color, texture, temperature, and moisture level), note tenderness, erythema, and edema in order to determine the specific type of dermatitis (different types have different characteristic patterns);
- Systematic assessment of the skin on the face to look for possible areas of allergic contact (Vera, 2012).
- Identification of aggravating factors: since the patient denies new soaps, detergents, lotions, medications, foods, and environmental exposures, it is likely that bacteria encountered during the 1-week hike is the cause of the rash and its accompanying symptoms.
- Identification of scratching and itching signs: there can be a risk of infection in the case of scratching. Characteristic patterns linked to scratching include reddened papules, lichenification, and erythema.
- Identification of any scarring due to itchiness, which can result in unwanted body image issues.
- Encourage the patient to implement a skincare routine to decrease skin irritation and promote healing (mild soap, letting skin air dry, application of topical creams and ointments).
- Encourage the patient to avoid possible aggravators (skincare products, irritant foods, and drinks, stress, etc.).
- Manage the fever and fatigue by drinking plenty of fluids, eating healthy foods, and having as much rest as possible (Mayo Clinic Staff, 2015).
Patient education in this nursing care plan will be centered on three key recommendations: good nutrition, prevention, and management. As to proper nutrition, the patient will be educated on the importance of eating a well-balanced diet that includes protein, vegetables, fruit, and liquids. The reported glass of wine every day with dinner can be reduced to two glasses a week to determine whether skin condition improves with the decreased use of alcohol.
With regards to prevention, it is worth to advise the patient to restrain from hiking activities until the rash disappears completely. If the patient decides to make such trips, it is important to take preventative measures in the form of anti-allergic prescription medication and wear protective clothing, glasses, and headwear. Lastly, the third section on patient education should focus on teaching the patient how to manage the rash and its accompanying symptoms in the case of its recurrence. The intervention steps presented above can serve as a guideline for the patient.
Mayo Clinic Staff. (2015). Fever treatment: Quick guide to treating a fever. Web.
Vera, M. (2012). 4 dermatitis nursing care plans. Web.