CORTEZ, JOVEL E.

BSN 1Y2-6 EVELYN – NCP 4

I. IDENTIFY ABNORMAL FINDINGS

SUBJECTIVE DATA:

 Evelyn states that her skin has been dry and scaly for the past several months,
unrelieved by numerous moisturizers.
 She expresses concern about “fly-away hair that I can’t do anything with” and about
brittle, easily broken fingernails. 
 She explains that she is supposed to take Synthroid daily for “my low thyroid” but
cannot afford to get the prescription filled.
 She has a poor appetite, and with “not enough money to go around,” she has been
nibbling on crackers, lunch meat, and sodas daily.
 She lacks energy, and she is rarely able to get through a day without one or two 30-
minute naps.
 Evelyn takes a shower and washes her hair using ivory soap and baby shampoo.
 She applies moisturizer to her skin and conditioner to her hair but states that neither
helps for any length of time.
 She keeps her nails cut short because they break so easily.
 She states that she cut down on her cosmetic sales appointment because “I look like I
never use my own products.”

OBJECTIVE DATA:

The physical assessment reveals:

 Dry flaking skin that is cool to the touch and yellow tinged.
 Facial and preorbital edema are present.
 Client’s facial expression is blank
 She has multiple bruises on both forearms and anterior lower legs, which are in various
stages of healing and tender when touched.
 Scalp hair is dry and dull and breaks easily.
 Her scalp is scaling.
 Sparse hair is noted in the axillae and the pubic area. 
 Her fingernails are short and dry; her cuticles are dry and torn. Her toenails are thick
and yellow.

II. IDENTIFY CUE CLUSTERS

 Dry and scaly for the past several months.
 Dry scalp
 Lack of energy and appetite
 Facial and preorbital edema
 Easily cracked and tom dry nails
 III. DRAW INFERENCES
 Nail problems such as dry easily broken nails as well as dry, scaly scalp and skin occur
with low thyroid level in which drawbacks on the appetite and energy occurs.
 Risk factors include drinking sodas daily and not being able to eat properly meal and the
history of not being of taking daily prescription of Synthyroid because of lacking the
capability financially.

IV. LIST POSSIBLE NURSING DIAGNOSES

 Risk for Impaired Skin Integrity as evidence by nail problems, dry skin and scalp
 Risk for Impaired Skin Integrity related to frequent scratching and dry skin.
 Risk for Myxedema related to Imbalance nutrition as evidence by decreased appetite

V. IDENTIFY DEFINING CHARACTERISTICS

Impaired Skin Integrity

 Inflammation
 Dry, flaky skin
 Erosions, excoriations, fissures
 Pruritus, pain, blisters

Dermatitis

 Itchiness (pruritus)
 Dry skin.
 Rash on swollen skin that varies in color depending on your skin color.
 Blisters, perhaps with oozing and crusting.
 Flaking skin (dandruff)
 Thickened skin.
 Bumps in hair follicles.

VI. CONFIRM OF RULE OUT DIAGNOSES

 Talking to a client about signs and symptoms
 Examining your skin to note the pattern and intensity of your rash.

Conclusion:

To diagnose dermatitis, your doctor will likely talk with you about your symptoms and examine
your skin. You may need to have a small piece of skin removed (biopsied) for study in a lab, which helps
rule out other conditions.

Wellness Diagnosis

Readiness for enhance comfort related to physical appearance as verbalization that she looks like
never use cosmetic products.
 Risk Diagnosis

Risk for Impaired Skin Integrity related to frequent scratching and dry skin.

Actual Nursing Diagnosis

Dermatitis related to Impaired skin integrity related to contact with irritants or allergens.
Disturbed body image related to visible skin lesions. Risk for infection related to excoriations and breaks
in the skin.

VII. NURSING DIAGNOSES THAT ARE APPROPRIATE FOR THE CLIENT

 Dermatitis related to Impaired skin integrity related to contact with irritants or allergens.
 Risk for Impaired Skin Integrity related to frequent scratching and dry skin.
 Risk for Myxedema related to Imbalance nutrition as evidence by decreased appetite

VIII. POTENTIAL COLLABORATIVE PROBLEMS

Eczema (also called atopic dermatitis)This is the condition that causes your skin to
become dry, red, itchy and bumpy. It's one of many types of dermatitis.

IX. POTENTIAL REFERRAL

 Patch testing if allergic contact dermatitis suspected
 When persistent symptoms despite treatment
 Severe disease
 Treatment episode