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Case Study: Health Assessment

Max, a 48-year-old man, comes for his yearly checkup. He has multiple moles on his back, arms, and legs. A suspicious mole on his left arm has grown larger over two years and become itchy in the past two weeks. His aunt died of skin cancer. The physical assessment will focus on inspecting and palpating his skin using the ABCDE criteria to evaluate the mole. Potential nursing diagnoses include readiness for enhanced power related to his healthy lifestyle, disturbed body image due to his multiple moles, and death anxiety given his family history of skin cancer. Inferences include that Max may be ignoring his skin issues and family history due to lack of sun protection and medical follow up.

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65 views25 pages

Case Study: Health Assessment

Max, a 48-year-old man, comes for his yearly checkup. He has multiple moles on his back, arms, and legs. A suspicious mole on his left arm has grown larger over two years and become itchy in the past two weeks. His aunt died of skin cancer. The physical assessment will focus on inspecting and palpating his skin using the ABCDE criteria to evaluate the mole. Potential nursing diagnoses include readiness for enhanced power related to his healthy lifestyle, disturbed body image due to his multiple moles, and death anxiety given his family history of skin cancer. Inferences include that Max may be ignoring his skin issues and family history due to lack of sun protection and medical follow up.

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J
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© © All Rights Reserved
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Case Study

Health Assessment
Case Scenario #1

Max, a 48 year old single man comes to the clinic for his yearly check-up. T 168

lbs; Ht 6. VS: B/P-110/68 T-36.8C P-70 R 18. Max is a computer programmer

who spends most of the work week indoors. On week indoors. On weekends,

however, he typically goes for 5-mile run and spends much of his afternoons

gardening.
Case Scenario #1 Continue

He has a light complexion, blonde hair, and reports that he sunburns easily but

uses protective sunscreen only sporadically. A suspicious-looking mole was

noticed on the back of his left arm, just proximal to the elbow. He reported that

he has had that mole for several years, but thinks that it may have gotten larger

over the past two years.


Case Scenario #1 Continue

Max reported that he has noticed itchiness in the area of this mole over the past two

weeks. He had multiple other moles on his back, arm, and legs, none of which

looked suspicious. Head, neck, thorax, and abdominal exams were normal, with the

exception of a hard, enlarged, non-tender mass felt in the left axillary region.
Case Scenario #1 Continue
In addition, a 1.6 x 2.8 cm mole was noted on the dorsal upper left arm. Max

reports that an aunt had died in her late forties of skin cancer, but has no other

details about her illness. He denies any mayor surgeries or illnesses. He takes no

prescription medications; however he does take a multivitamin daily. He quit

smoking 15 years ago; denies any alcohol or recreational drug use.


Systematic Approach Physical Examination
& Health Assessment
Review of Systems:
General, Skin, Neck, Breasts, Respiratory, Cardiovascular,
Gastrointestinal, Urinary, Genital, Peripheral Vascular,
Musculoskeletal, Psychiatric, Neurologic, Endocrine
Systematic Approach Physical Examination
& Health Assessment
Physical Examination:
Vital Signs, Skin, Head,Eyes,Ears,Nose,Throat, Neck, Lymph Nodes
Thorax and Lungs, Cardiovascular, Breasts, Abdomen, Genitalia,
Rectal,
Extremities, Peripheral Vascular, Musculoskeletal, Neurologic
Systematic Approach Physical Examination
& Health Assessment
Laboratory Data: Any labs provided in the case scenario/study
Assessment (Problem) and Plan (Orders/Interventions) Disregard
this point as you will be addressing it in Question #5 (see slide 12).
Objetive and Subjetive Data
Objetive information Subjetive information
Head, neck, thorax, and abdominal Max reported that he has noticed
exams were normal, with the exception itchiness in the area of this mole
of a hard, enlarged, non-tender mass over the past few weeks. He had
felt in the left axillary region. In multiple other moles on his back,
addition, a 1.6 x 2.8 cm mole was arms, and legs, none of which
noted on the dorsal upper left arm. looked suspicious.
Question / Answer
What assessment tools are needed for the
physical assessment?
What other questions would be essential to
ask the patient?
How long ago you discover the mole?
What size it was at that moment?
What shape was the mole and color when you discover it ?
When start the itchiness around the mole? Do it turns red ?
Is someone in your family with skin problems?
Are you allergic to medications or foods?
What body system would be the focus of the
physical assessment?

The integumentary system, which is the system responsible for

the skin, hair, nails, glands and nerve receptors.


Describe how the physical assessment would
be performed and provide rationales
We start by doing the ABCDE, to discard any melanoma

A- Asymmetry, to check if the melanoma is benign we check for


symmetry, an imaginary line is drawn if the two sides are symmetrical the

mole, skin tag or melanoma is benign.

B- Border, the border must be smooth for it to be benign


Continue

C- Color, Most benign moles are all one color often a single shade of

brown. Having a variety of colors is another warning signal. A number of

different shades of brown, tan or black could appear. A melanoma may

also become red, white or blue.


Continue

D- Diameter, Benign moles usually have a smaller diameter than

malignant ones. Melanomas usually are larger in diameter than the eraser

on your pencil tip ( inch or 6mm), but they may sometimes be smaller

when first detected.


Continue

E- Evolving, Common, benign moles look the same over time. Be on the

alert when a mole starts to evolve or change in any way. Any change in

size, shape, color, elevation, or another trait, or any new symptom such as

bleeding, itching or crusting points to danger.


Continue

In this assessment we will also be using 2 physical skills which are:


Inspection, to monitor, observe and inspect the patients body of any skin

problem and look for any problem and palpation, to feel the patients skin of

any abnormalities, such as bumps, size, swelling, rigidity and presence of

slumps or masses.
Nursing Diagnosis 3 actual; 2 risk,
and 1 wellness
Wellness Diagnosis
Readiness for enhanced power related to the enhancement of power evidenced
by exercising and maintaining healthy vital sings results.
A pattern of participating knowingly in changes for well-being, which can be
strengthened. (2006, 2013; LOE 2.1)
Domain: Coping/Stress Tolerance
Class: Coping Responses
00187
Nursing Diagnosis
Risk Diagnosis
Disturbed body image related to the moles in his body evidenced by the
amount of moles on his body and being single at 48y. (1973, 1998)
Confusion in mental picture of ones physical self.
Domain: Self-Perception
Class: Body Image
00118
Nursing Diagnosis
Risk Diagnosis
Death anxiety related to mole skin cancer evidenced by the death of his aunt for
the same condition and lack of treatment. (1998, 2006; LOE 2.1)
Vague, uneasy feeling of discomfort or dread generated by perceptions of a real or
imagined threat to ones existence.
Domain: Coping/Stress Tolerance
Class: Coping Responses
00147
Based on the information provided (objective
& subjective) what inferences could you draw?
Max is trying to live a healthy life and he is exercising, maintaining good vital
signs numbers, and he is able to run 5 miles weekly. He is ignoring the moles
in his body because he is not using sunblock all the time as he should and
ignoring his family history. Max could be experiencing anxiety and
hopelessness since his aunt died of a similar situation. Max is not seeking
medical intervention for treatment of moles. Early detection of skin cancer
through established methods or newer technologies is critical for reducing
both skin cancer mortality and the overall skin cancer burden Loescher,
Janda, Soyer, Shea & Curiel-Lewandrowski (2013).
References
Loescher, L. J., Janda, M., Soyer, H. P., Shea, K., & Curiel-Lewandrowski, C.
(2013). Advances in Skin Cancer Early Detection and Diagnosis. Seminars
in Oncology Nursing, 29(3), 170-181. doi:10.1016/j.soncn.2013.06.003
Credits
Betsy Alicea: Question 1 & 2
Christian Alba: Question 3 & 4
Jose: Question 5 & 6
Amy Rosa: Spelling, Grammar, Art

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