Case Summary
The patient is a 35-year old woman. She has been suffering from rash for a week. The rash is constituted by erythematous plaques scattered across the cheeks and the bridge of the nose. The lesions are itchy and painful. The patient has noted fatigue, fever, and weight loss. The physical examination has shown heightened body temperature at 100.3F. No swelling in lymph nodes was observed. She also experiences muscle pains, especially in her hands and wrists. The patient also experiences mouth soreness. The examination showed shallow ulcers in buccal mucosa bilaterally and the erythema in the back of the throat. The symptoms first started after her return from the Appalachians where she was hiking and camping. The patient claims that rash gets worse when she goes outdoors. She denies the use of any new body care substances, detergents, or foods. The patient also denies the spread of rash to other areas. She has undergone the tonsillectomy at the age of 9 for chronic strep throat infections. The patient has been healthy as an adult. She did not have this rash before.
Nursing Diagnosis
The results of the assessment indicate several problems according to the NANDA nursing diagnosis list (NANDA, 2014). Fever and fatigue indicate the risk of infection. Most likely, the patient has contracted an infectious disease with an incubation period of about a week. The care needs to taken before the clinical diagnosis is complete. The redness of the patient’s throat, ulcers, and the perceived soreness indicate the impaired integrity of the oral mucous. Those symptoms also indicate the possibility of infection. Another concern is the impaired skin integrity with the rash. There is no immediate evidence that the patient’s life or safety might be in danger. However, all of the listed factors threaten the patient’s comfort and health prospects.
Care and Education Plan
Until the medical diagnosis is reached the patient needs to exercise caution. While there is no indication that the disease is highly infectious, the patient will need to limit contact with the public. Taking an ill leave from the job is advisable since it will help with the fatigue management. Treating the impaired oral mucous integrity and skin integrity should be the focus of the plan. The ulcers in the patient’s mouth seem to be the secondary effect of the disease. They do not greatly discomfort her or cause any significant pain. It is important to educate the patient on the proper dietary habits and oral care while the ulcers remain. The advice would include avoiding spicy and hot food which can cause damage to the damaged mucous, as well as the use of a softer toothbrush.
She should also monitor the condition of the ulcers and be instructed to inform the doctor in case there is any change (Doenges, Moorhouse, & Murr, 2013) Taking care of the damaged skin is also important. The patient should be reminded to avoid aggravating factors which in her case, besides scratching the irritated areas, includes being outdoors (Gulanick & Myers, 2014). That coincides with the precautionary measures to avoid the possible spread of infection and treat the fatigue. Applying some medication to lessen the discomfort from the rash is also advisable. Using over-the-counter inflammation solutions can help. Aloe-based herbal remedies are often considered an effective way to alleviate the discomfort (Vallerand, Sanoski, & Deglin 2014).
The patient should be instructed to carefully monitor the state of the skin rash and promptly report any changes. Most of the evidence indicate the contrary, but the rash can be a result of an allergy, so she should also be advised to stop applying any other solutions to the skin of the face. For the mouth soreness, the patient should be advised to take some over-the-counter medication, in case the discomfort starts to bother her. It is advisable to avoid unnecessary medication if possible. Recommending a wide range of symptomatic pharmacological treatments can make an accurate clinical diagnosis more difficult. However, as a complex measure to combat the symptoms, the patient can be prompted to take paracetamol pills. That should be reserved as a measure in case she has to take part in strenuous activities. She should be educated on the possible side effects of the paracetamol and advised to limit its use since the drug can damage the liver if used continuously.
Conclusion
The case study presents a yet unidentified disease and a patient in need of symptomatic treatment. Since no definite diagnosis is present, the caution should be the number one priority. Avoiding unnecessary medication and educating the patient on the proper health monitoring are the essential part of effective treatment. However, most of the diagnosed problems can be treated without the use of pharmacology. With proper nursing practices, the patient’s comfort can be restored and the health prognosis improved.
References
Doenges, M., Moorhouse, M., & Murr, A. (2013). Nursing diagnosis manual. Philadelphia, PA: F.A. Davis.
Gulanick, M., & Myers, J. (2014). Nursing care plans. Philadelphia, PA: Elsevier/Mosby.
NANDA. (2014). The Complete list of NANDA Nursing Diagnosis for 2012-2014, with 16 new diagnoses. Web.
Vallerand, A., Sanoski, C., & Deglin, J. (2014). Davis’s drug guide for nurses. Philadelphia, PA: F.A. Davis.