Case Study Patient Introduction
Ms. Danielle Arquee is a 74-year-old woman who comes to her primary care clinic with concerns related to various “spots” on her face. She says they have been there for a while, and she thought they were just “age spots” but got concerned after her friend was diagnosed with a malignant melanoma.
Critical Thinking The following questions should be kept in mind while studying this assessment chapter:
1. What are the possible causes of Ms. Arquee's facial lesions?
2. What questions should the patient be asked to determine the possible causes?
3. What should be included in the physical assessment? What specific characteristics of the skin lesions should the nurse look for?
4. What diagnostic studies might be ordered?
Subjective Data Past Medical History.
Past medical history (PMH) reveals previous trauma, surgery, or disease that involves the skin. Many diseases have dermatological manifestations. The nurse needs to determine if the patient has noticed any problems such as jaundice, delayed wound healing, cyanosis, or pallor. It is important to obtain specific information related to sensitivities, allergies, and skin reactions to insect bites and stings. Any history of chronic or unprotected exposure to UV light should be noted.
Medications. Many vitamins, hormones, antibiotics, corticosteroids, and antimetabolites have adverse effects that are manifested in the skin, so the patient should be asked about any skin-related changes that occurred after taking medications. Additionally, it is important to document the use of medications (i.e., drug's name, length of use, method of application, and effectiveness) to treat a primary or secondary skin problem.
Surgery or Other Treatments. The nurse should determine if any surgical procedures, including cosmetic surgery, were done on the skin. Any previous biopsy results should be recorded, as should any treatments done specifically for a skin problem or for another health problem. Any treatments undergone for cosmetic purposes should also be documented.
Family History. The nurse should obtain information about any family history of skin diseases or systemic diseases with dermatological manifestations. Any family or personal history of skin cancer, particularly melanoma, must also be noted.
Self-Care History. The patient should be questioned about health and hygiene practices related to the integumentary system, including the brand name, quantity, and frequency of use of personal care products (e.g., shampoos, moisturizing agents, cosmetics). Any current skin problems, including onset, symptoms, course, and treatment, should be recorded, as well as the frequency of use and the sun protection factor (SPF) of sunscreen products.
Nutritional History. A diet history reveals the adequacy of nutrients essential to healthy skin such as vitamins A, D, E, and C; dietary fat; and protein. The nurse should question the patient regarding recent dietary changes; any food allergies that cause a skin reaction; and conditions of the skin such as dehydration, edema, and pruritus (itching), which can indicate alterations in fluid balance. If urinary or fecal incontinence is a problem, the nurse should determine the condition of the skin in the anal and perineal areas.
Social, Environmental, and Occupational Health History. The patient should be questioned about environmental factors that affect the skin such as occupational exposure to chemicals, irritants, sun, and unusually cold or unhygienic conditions. Contact dermatitis caused by allergies and irritants is a common problem associated with occupation, as well as with some hobbies. The patient's participation in any recreational activities involving significant sun exposure should be determined and documented, as should any changes in the skin during exercise or other activities.
Cognitive–Perceptual. The patient's perception of the sensations of health, cold, pain, and touch should be determined. The nurse should note any discomfort associated with a skin condition, especially when observed in intact skin. As well, joint pain and the mobility of joints should be assessed and recorded, since a skin condition may cause alterations in mobility.
Coping Abilities. The patient should be asked about the role that stress may play in creating or exacerbating the skin condition. The nurse should determine what coping strategies the patient uses to manage the skin condition. For example, pruritus can be distressing and cause major alterations in normal sleep paerns, while acne can be disfiguring and lead to significant threat to self-image.