Several erythematous plaques
Patient is an alert young woman, sitting comfortably on the examination table. BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F. Several erythematous plaques scattered over the cheeks and the bridge of nose, sparing the nasolabial folds. Normocephalic, atraumatic. Sclera white, conjunctivae clear; pupils constrict from 4 mm to 2 mm and equal, round, and reactive to light and accommodation. Oropharynx moist with erythema in the posterior pharyngeal wall; no exudates; shallow ulcers in the buccal mucosa bilaterally. Neck supple without cervical lymphadenopathy or thyromegaly. Full range of motion; no swelling or deformity; muscles with normal bulk and tone.
Instructions:
Make a whole history and physical examination in a comprehensive manner with all its elements included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS (write your presentation in H&P format no paragraph format).
Based on this information, what is your presumptive nursing diagnosis? All nursing diagnosis that apply to the case ( Minimum 3) written in
NANDA format related to … and evidence by…., NO MEDICAL DIAGNOSIS.
Teaching plan and nursing care plan per each nursing diagnosis on this case.
Requirements.
1- All written assignment and documentations must be in APA 6th edition format.
2- Double spaces, minimum 4 pages long , minimum 3 up to date bibliography. (UP to date means last 3 years.), Note: you can use your test book as bibliography too, bibliography have to be written in APA format.
