Case Study: Joint Pain, Rash, Hair Loss - What's Going On?

[SafetyNurse1968]

Chief Complaint

R.W. is a married, 34-year-old Hispanic female with two young children who presents to her primary care provider with a productive cough, stiffness and pain in her hands and feet that comes and goes. She states, "It moves around from joint to joint. I'm worried I've got RA like my sister.” Her PCR test for COVID-19 has come back negative.

History of Present Illness

Five years ago, R.W. went to her PCP after four months of rashes that appeared on her arms and legs whenever she went into the sun. She had lost several small patches of hair on her scalp and stated she thought it was related to stress. She also complained of fatigue that required her to take daily naps. She had mild arthritic pain in her fingers and elbows but thought it was related to aging. A tissue biopsy of one of the multiple rash-like lesions from her arm revealed vasculitis (white blood cells within the walls of blood vessels). Her CBC indicated mild anemia, but microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape size and color, ruling out iron, folate and vitamin B12 deficiencies. A two-month course of prednisone caused all signs and symptoms to resolve.

Past Medical History

Unremarkable, current with all vaccinations including influenza.

Family History

She has two brothers and one sister. Her older sister has rheumatoid arthritis, and an aunt has pernicious anemia. Her mother has Graves' disease.

Social History

No smoking or drinking

Medications

Naproxen for joint pain, antacid for heartburn, no other over the counter drugs

Allergies

NKA

Vital Signs

• BP 141/90 sitting, RA
• HR 105
• RR 20
• T 100^o F
• HT 5'6"
• WT 105 lbs

Review of Systems (only abnormal values presented)

• Skin: Slight jaundice 
• HEENT: yellowing of the sclera
• Lungs/Thorax: Auscultation reveals abnormal lung sounds
• Musculoskeletal: joint stiffness and pain
• Immune: enlarged axillary and inguinal lymph nodes  

Questions

What is causing the lung symptoms, jaundice, joint stiffness and pain?

What happened 5 years ago?

Imagine you only get 5 questions. What information should you ask for that will give you the most information for a diagnosis?

What labs do you want?

What other diagnostic tests should we run?

Ask me some questions!

[magellan]

9 hours ago, nursej22 said:

No, but it is within our scope to teach and reinforce what the provider has taught about a condition, including diagnosis and treatment. I believe case studies teach us so we can teach our  patients. 

She should asked us what's our nursing diagnosis basing from NANDA not to guess the medical diagnosis. Are you able to medically diagnose the condition of the patient in your practice and give prescription as an RN. 

[TheMoonisMyLantern, ADN, LPN, RN]

Of course we can't officially diagnose as that is out of our scope of practice. However, in some settings and some facilities there isn't an MD in house, when an issue arises the assessment you do is vital in allowing the MD to provide guidance over the phone. That being said, having an idea with what's going on with patient through a medical lens versus a NANDA lens is going to be more helpful the MD and ultimately the patient. Knowing what diagnostic tests to anticipate, the corresponding treatment, complications, and possible other diagnosis to consider that may be causing your patient's problem are vital. Physicians are often receptive to what you have to say regarding your assessment and what you believe the patient needs. Yes, they make the ultimate diagnosis but often nurses are the ones paving the way for that diagnosis.

Case studies are designed to push us beyond our normal mode of thinking to learn to consider additional possibilities. They are a learning tool, no one is advocating for you to practice medicine without a license.

[magellan]

39 minutes ago, TheMoonisMyLantern said:

Of course we can't officially diagnose as that is out of our scope of practice. However, in some settings and some facilities there isn't an MD in house, when an issue arises the assessment you do is vital in allowing the MD to provide guidance over the phone. That being said, having an idea with what's going on with patient through a medical lens versus a NANDA lens is going to be more helpful the MD and ultimately the patient. Knowing what diagnostic tests to anticipate, the corresponding treatment, complications, and possible other diagnosis to consider that may be causing your patient's problem are vital. Physicians are often receptive to what you have to say regarding your assessment and what you believe the patient needs. Yes, they make the ultimate diagnosis but often nurses are the ones paving the way for that diagnosis.

Case studies are designed to push us beyond our normal mode of thinking to learn to consider additional possibilities. They are a learning tool, no one is advocating for you to practice medicine without a license.

Not even in any discussions, nurses are not to give diagnosis medically.

[TheMoonisMyLantern, ADN, LPN, RN]

3 minutes ago, magellan said:

Not even in any discussions, nurses are not to give diagnosis medically.

Oh okay, so do you tell physicians your nursing diagnosis when you call them and just let them figure it out from there?

[magellan]

Its the doctors call to give medical diagnosis in whatever or whenever circumstances they are in. It's not ours the RN. We are the eyes and the ears of the patient but to identify medical diagnosis, its a big no no. They can slam us with hefty penalties with our license if we diagnose medically the patient. We don't have the qualification to do so, just the nursing diagnosis based from NANDA. Don't get lost in the medical field just because we practice much at bedside. We work side by side with them not behind or infront.

[TheMoonisMyLantern, ADN, LPN, RN]

1 hour ago, magellan said:

Its the doctors call to give medical diagnosis in whatever or whenever circumstances they are in. It's not ours the RN. We are the eyes and the ears of the patient but to identify medical diagnosis, its a big no no. They can slam us with hefty penalties with our license if we diagnose medically the patient. We don't have the qualification to do so, just the nursing diagnosis based from NANDA. Don't get lost in the medical field just because we practice much at bedside. We work side by side with them not behind or infront.

I agree that we should not officially diagnose but are you telling me you've never said any of the following things to a physician:

"I think the patient may be in fluid overload."

"I think the patient may have pneumonia."

"I think the patient may have a UTI."

"I think the patient may have a broken hip."

"I think the patient may be septic."

"I think the patient may be having a CVA."

"I think the patient may be having a heart attack."

 

No you may not know what's wrong with every patient but physicians don't want a big long story when you call them, they usually want you to just spit out why you're calling, what's going, SBAR, etc. Ultimately the physician may disagree and diagnose/treat with something completely different and that's fine that's their role. 

[evastone, BSN, RN]

1 hour ago, magellan said:

Its the doctors call to give medical diagnosis in whatever or whenever circumstances they are in. It's not ours the RN. We are the eyes and the ears of the patient but to identify medical diagnosis, its a big no no. They can slam us with hefty penalties with our license if we diagnose medically the patient. We don't have the qualification to do so, just the nursing diagnosis based from NANDA. Don't get lost in the medical field just because we practice much at bedside. We work side by side with them not behind or infront.

So tell me, why do we learn pathophysiology and pharmacology? Why are we expected to know the rationale to certain treatments that are being provided? Why do we gain extensive hospital training on understanding EKGs?

The physicians I work with are busy and rely on our assessment skills to keep patients safe and comfortable. I'm not just going to tell the doctor that the patient is at risk for ineffective airway clearance related to possible infectious etiology as evidenced by elevated temperature and cough. I'll say the patient has symptoms consistent with croup and has strider at rest. I will ask the doctor if she wants racemic epinephrine or if she has an alternative plan. The doctor will give the patient a quick look and determine what is wrong and what the plan of care should be. 

We are not automatons. We don't just deal with treatment of pain and fevers. This is why nurses will often be disciplined for giving the wrong medication to patients even if it was ordered by a doctor. A nurse should know better than to give metoprolol to someone with a slow heart rate or low blood pressure - even if there were no parametersfor holding the medication. We are expected to have some knowledge of medical conditions, indicated labs, and treatment. We are THE LAST LINE OF DEFENSE. Case scenarios like this are important for expanding knowledge. We are not diagnosing and ordering medications and I always make it clear that I am not providing an actual diagnosis. What we are doing is making suggestions to the doctors based on our assessments so that timely, streamlined care is administered. 

And yes, my charting DOES contain the NANDA required diagnoses rather than medical diagnosis. I leave it to the doctors to make the final decisions and chart the medical stuff. 

[magellan]

Yes, you have a good assessment skills and clinical judgements basing on your objective and subjective data from the patients signs and symptoms but you can't write out in any patients chart about medical diagnosis. It's the physicians call and scope of practice. Don't get lost and because your manager, administrator or colleague said so but its not your scope of practice, don't just do it. Imagine, if you write out a medical diagnosis in the chart and MD consultants after consultants will follow those diagnosis and then will prescribe treatments, its gonna be a disaster.

[Tinap, BSN, RN]

2 hours ago, magellan said:

Yes, you have a good assessment skills and clinical judgements basing on your objective and subjective data from the patients signs and symptoms but you can't write out in any patients chart about medical diagnosis. It's the physicians call and scope of practice. Don't get lost and because your manager, administrator or colleague said so but its not your scope of practice, don't just do it. Imagine, if you write out a medical diagnosis in the chart and MD consultants after consultants will follow those diagnosis and then will prescribe treatments, its gonna be a disaster.

Ummm, I didn't diagnose anything. I asked if a Lymes panel had been done. Too early in the morning for such drama!!

[magellan]

Good job for not giving a medical diagnosis because its not our scope.

[tnbutterfly - Mary, BSN]

Thanks to all who participated in this CSI.  

Here is the link to the newest CSI posted this morning:

Case Study: Newborn with Vomiting and Diarrhea

For additional CSIs, click on the CSI tab at the top of the Homepage.

[nursej22, MSN, RN]

6 hours ago, magellan said:

Yes, you have a good assessment skills and clinical judgements basing on your objective and subjective data from the patients signs and symptoms but you can't write out in any patients chart about medical diagnosis. It's the physicians call and scope of practice. Don't get lost and because your manager, administrator or colleague said so but its not your scope of practice, don't just do it. Imagine, if you write out a medical diagnosis in the chart and MD consultants after consultants will follow those diagnosis and then will prescribe treatments, its gonna be a disaster.

Keep in mind that not all nursing is done in a hospital at the bedside. And yes, actually advanced practice RNs (APRNs) may legally diagnosis and treat illnesses. My local hospital utilizes ARNPs as hospitalists, who admit, diagnose and treat patients.

I won't even touch the whole issue about the uselessness of NANDA for anyone other than a student.