Assessment of the skin
William Smaile is a 65-year-old man who presents to his general practitioner’s office with complaint of right forearm swelling, redness, and pain. He was recently discharged from the hospital where he had been receiving intravenous antibiotics for a respiratory infection.
Subjective Data
- Pain level is a 5/10 location = right forearm, aching
- Retired foreman at a local industrial plant
Objective Data
- Vital signs: BP 150/68, T 37 degrees Centigrade, P 80, R 16
- Swelling and reddened right forearm, warm to touch
- + pulses, brachial and radial (R)
- +2 capillary refill fingers right hand
- What other assessments should be included for this patient?
- From your readings, what is the most probable cause of the swelling?
- What is your nursing diagnosis?
- What would be included in the nursing care plan?
- What interventions might be included in the plan of care for this patient?
- APA FORMAT
- REFERENCE:
Jarvis, C. (2016). Physical examination & health assessment (7th ed.). Philadelphia, PA: Saunders.
- Chapter 12: Skin, Hair, and Nails
- pp. 199-225 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
- p. 250 (Summary Checklist)
- Chapter 13: Head, Face, and Neck, including Regional Lymphatics
- pp.251–270 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
- Chapter 14: Eyes
- pp. 281–311 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
- Chapter 15: Ears
- pp. 325–341 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
- Chapter 16: Nose, Mouth, and Throat
- pp. 353–374 (Structure, Function, Subjective and Objective Data, Documentation and Critical Thinking)
- Chapter 12: Skin, Hair, and Nails
10 years ago
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