Physical Assesment Case Study - Research Paper Example

Client was awake, alert and coherent. Physical assessment revealed erythematous plaques covering both cheeks, and at the bridge of her nose, without affecting the nasolabial folds or any other part of her body. Aside from that, her head was found to be normocephalic with no signs of trauma or other deformities. She had clear white sclera and clear conjunctiva; her pupils were reactive to both light and accommodation. Erythema was noted on the posterior wall of her pharynx, and ulcers were found on both of her buccal mucosa.

Her neck showed no swelling or bumps, and no traces of lymphadenopathy or thyromegaly. Patient had no trouble achieving full range of motion in her joints with no obvious swelling or deformities. Patient’s vital signs showed a normal heart rate at 62 beats per minute, normal respiratory rate at 12 breaths per minute, a normal blood pressure of 112/66 mmHg, and an elevated temperature of 100.3 degrees Fahrenheit. Interview and Health History Patient reported that the rash was first noticed after a week outdoor hiking and camping in the Appalachians.

She denies exposure to any new skin products, usage of medications, environmental exposure, and food allergies. She has not taken any medication for the rash. She denies experiencing headache, sore throat, ear pain, nasal congestion, chest pain, shortness of breath, cough, pain during urination, urination and diarrhea. She reports no stiffness in the joints or difficulty in getting up in the morning. The only surgical procedure that the patient has undergone was a tonsillectomy at age 9 due to her chronic strep throat infection.

Other than that, she has not had any other diseases needing hospitalizations as an adult. An investigation into her family history revealed that her mother had rheumatoid arthritis She does not engage in smoking or recreational drug use, but admits to taking a glass of wine almost every night with dinner. Nursing Care Plan Based on the information, the patient’s main concern is the rash on her face and what it means. Considering the location, the shape, and the other symptoms, it could be a malar rash pointing to Systemic Lupus Erythematosus, but since it is yet to be diagnosed, the more pressing concern is her fatigue.

This can be caused by not enough energy being produced to cope with the inflammation going on with her rash, the erythematous posterior wall of her pharynx, and her fever. Her weight loss could also be an effect of this. Fatigue is defined as “an overwhelming sense of exhaustion and decreased capacity for physical and mental work at the usual level” (Doenges, Moorhouse, & Murr, 2010). The patient verbally reports feeling fatigue after the rash appeared (Sommers, Johnson, & Beery, 2010; Smeltzer & Bare, 2011; WebMD, 2011).

In a nursing care plan to take care of the client’s fatigue, the desired outcomes would be that the client will: - Report improved sense of energy - Identify the basis of fatigue and individual areas of control - Perform ADLs and participate in desired activities at level of ability - Participate in recommended treatment program with sufficient energy (Source: Doenges, Moorhouse, & Murr, 2010; Sommers, Johnson, & Beery, 2010) Nursing interventions to help with the patients fatigue are: Intervention: Identify the presence of physical and/or psychological conditions (e.g. infection, nutritional deficiency, depression, trauma, autoimmune disorders, substance use/abuse,