Nursing Health Assessment Case Study

Case Study

Margrite is a 34 year old European American who was admitted for an emergency appendectomy yesterday.  She is 24 hours postop. Vital signs are stable. Lungs are clear. She is voiding and has normoactive bowel sounds.  Her pain is controlled with 2 Vicodin every 6 hours and she has been up walking around her room.  She asked you for a new Tegaderm for the two red, scaly lesions on her left hand.  

She said 2 months ago, she had what appeared to be poison ivy on the back of her hand. But, when the vesicles cleared, the itching and scaling remained.  She has been covering the lesions on her hand with tegaderm  because it relieves the itching.  Additional lesions have appeared over her left eyebrow, her right eye, and a small patch of it above her right upper lip.  She has tried multiple over the counter medications:  hydrocortisone, antibacterial cream and an antifungal.  Nothing has helped.

These are the questions that will be need to be answered

1. Is there additional subjective data to obtain? Explain. (10%)

2. What are the expected findings (“normal”) of a skin assessment? (20%)

3. Using these four characteristics, describe the skin lesions: color, surface characteristics, pattern, distribution and region. (If any are not applicable, explain why)  (40%)

4. What information is missing to give a complete “clinical description” (p. 66) of these lesions?  (10%)

5. Using NANDA language, name two diagnoses that are a priority for this patient.  Give rationale.  (20%)

Case Studies

This assignment is graded in the same manner as a quiz, thus a rubric is not

associated with the case studies. However, points are assigned to each question and the percentage of points earned for that assignment constitutes the grade for a case study. Rationales are required in order to adequately answer the assigned questions. APA, grammar and spelling are considered an essential component of communicating or documenting the correct information, and points may be deducted from an answer for errors