Jason’s Case Study

Abstract
Jason, a twenty six year old male, is seen in the urgent care clinic with a laceration to his arm. He cut his arm on roof sheeting while at work. While assessing the laceration on Jason’s arm, the nurse notices that he has a sunburn, freckles and moles on his skin. While Jason is still in the urgent care, the patient’s wife calls and asked if the medical staff would assess a mole on her husband. The nurse also educated Jason regarding sunburns, changes in freckles, moles, and lesions. His complexion, hair and eye color puts Jason at a higher risk for cancer and complications of being in the sun. The nurse also reminded Jason to make an appointment to have his family doctor check the laceration on his arm to make sure no infection or complications have developed.

Jason’s Case Study After the nurse introduces herself to Jason, she gets his vital signs, height and weight. The nurse or the doctor per facility protocol should cleanse the wound to remove any dirt or debris from the laceration site. The nurse measures the laceration in length and width. The nurse checks the laceration for foreign bodies or debris in his arm. The doctor may order an x-ray of his arm to rule out any foreign bodies that may be in Jason’s arm. Saline gauze should be placed over the laceration site until the doctor comes into the examination room to see the patient. The nurse asks Jason if he has had a tetanus shot in the past five years. Jason should have the tetanus injection updated at this time since he does not know when he had his last tetanus injection. The Immunization Action Coalition website states that if someone experiences a deep or puncture wound or a wound contaminated with dirt, an additional booster may be given if the last dose was more than five years ago. Immunization Action Coalition (2009). The vaccination schedule for adults and adolescents advises there is an increase of whooping cough (Medicine Net. P. 2) so the doctor may order Tdap to be administered. Gloves should be worn by the nurse when giving any intramuscular injection. His skin should be rubbed vigorously with alcohol at the injection site before the Tdap is given. After the physician orders the Tdap or tetanus injection and the injection is given, a card should be given to Jason telling what and when it was given. After giving any medication, the patient could have a reaction. The nurse should try to give any medication as soon as it is ordered so the patient can be monitored while he is being treated for the complaint that he came into the clinic for. Jason should be given the Tdap or tetanus injection before sutures are placed so the medical staff can be aware of any reactions that may arise. The nurse asks for Jason’s medical history, whether he has allergies to medications, if he uses tobacco, alcohol or recreational drugs. The nurse asks Jason if he is a diabetic, because healing would take longer if he had diabetes. Assessments need to be done and questions asked for the nurse to have a better idea if nerve or tendon damage has occurred. The nurse should palpate Jason’s radial pulses bilaterally to make certain that they are equal, strong and palpable. Jason’s capillary refill and warmth of his skin should be compared bilaterally. She should make sure that Jason has feeling in all fingers, hand and arm below the laceration and that the feeling in the injured arm is the same as the feeling in the unaffected arm. The nurse should have Jason touch all his fingers of the affected arm to the thumb to assess for tendon damage. Another evaluation task the nurse has Jason complete is to make a fist with the affected hand. After accessing his laceration, Jason’s sunburn should be addressed and education provided. Jason should be notified that his wife called the clinic to inform the nurse and staff that he has an area on his back that she is concerned about. Since Jason is in the gown waiting for the doctor, this is a good time to assess his skin to look for any areas that need to be addressed. First the nurse inquires if Jason wants the clinic staff to check the area in question or if he would like for his family physician to assess it. Jason agreed that he would like the clinic to check it. The nurse begins with the following questions that need to be asked:
▪How often does he get sunburned?
▪When he gets sunburned, how bad is it?
▪Does he or his family members have a history of skin cancer? (in Jason’s case, his father has a history of skin cancer)
▪Does he use sun block or ultraviolet blocking clothing to cover his skin when outside even on cloudy days?
▪Does he wear a hat or sunglasses?
▪Does he have any areas on his body that he is concerned about?
▪What is his occupation?
▪Has he noticed a rash or lesion anywhere?
▪Has he noticed any changes in his nails?
▪Does he have any moles that have changed size, color, or shape?
▪Did he have a lot of sun burns as a child? Going over Jason’s medication is important also. Certain medications like sulfonamide, thiazide diuretics, oral hypoglycemic agents, and tetracycline may increase sunlight sensitivity. These would increase Jason’s chance of getting sunburns. Jason needs to be aware that his light skin and hair color causes him to be at an increased risk of having damage from the sun which can lead to skin cancer. He needs to be reassured that he is not being told that he has cancer, but since he has attributes that put him in a higher category to get cancer, he needs to be more aware of his body and look for changes in freckles, moles etc… He needs to understand that the sooner skin cancer is found, the better chance of survival the patient has. He needs someone to look at areas that he cannot see so any changes can be found like his wife has done in this situation. He can stand in front of a mirror without clothes to examine his back, sides, axilla, soles of feet, scalp and he needs to be informed to look between his fingers and toes. The nurse should inform him that freckles are a sign of sun exposure. When assessing the mole that his wife called about, the nurse should document color, elevation (flat, raised or pedunculated), pattern or shape (distinctness of lesion), size of the mole in centimeters, location and distribution of the mole on his body and if there is any exudate noted. Before assessing any lesions, the nurse should put gloves on. The nurse should also look at Jason’s scalp and ears for any lesions or concerning areas. His scalp hair should be assessed; healthy hair is shinny not dull, coarse or brittle. Information should be given to Jason about changes in nails. Brown linear streaks that suddenly appear are abnormal in light-skinned people and may indicate melanoma. Jason needs to be educated about moles or lesions that he notices on his body. He needs to know what to look for and what is normal and what is abnormal. Normal is a mole (compound nevus) that is tan to brown in color, raised or flat, with smooth borders. An abnormal mole (malignant melanoma) is tan, brown, black, purple, pink-red or mixed pigmentation. Abnormal moles can have irregular borders. They can be scaly, flakey and/or have an oozing texture. Jason needs to be aware that malignant melanoma may arise from preexisting nevus. The nurse needs to let Jason know that this is a very serious condition and that checking for any changes in skin, freckles, and moles should become a part of his monthly routine. He also needs to be told that malignant melanoma is a deadly form of skin cancer and can metastasis to other organs and lead to death. To help Jason remember all the ways that can suggest an abnormal skin problem, the nurse tells him the ABCDE mnemonic which is Asymmetry, Border irregularity, Color variation and Diameter greater than six millimeters, and Elevation and Enlargement. Once the doctor has sutured Jason’s laceration, the antibiotic ointment and dressing the doctor ordered needs to be applied. He can be informed that the laceration site needs to have a thin layer of Neosporin applied to the sutures twice a day. Jason needs to cover the wound when doing something that would get it dirty. He can take the dressing off when at home if he is not doing anything that would get dirt in it. He needs to keep the area clean and dry. The sutures should be removed per the doctor’s recommendation. Jason can return to the clinic or go to his family physician to have the sutures removed. Jason also needs to be aware of signs of infection which include redness around the wound, red streaks going up his arm, the area around the wound feeling warm to touch, foul smelling drainage or increased pain. Verbal and written discharge and prescription instructions of antibiotics if ordered by the physician need to be given to Jason. If antibiotics are ordered, he needs to be instructed to finish all of the antibiotics and take them as directed. If he is not allergic, he can take acetaminophen or ibuprofen for pain. If he has any questions, he can call the clinic at any time. Before he leaves, his vital signs should be taken again and he needs to advised to have a yearly visit with his primary doctor for blood work, cancer screening (testicular, melanoma…) and a general assessment. The nurse should also talk to him about injury prevention since he works outside. Jason should be educated to wear sun block with a high SPF, clothing that reflects ultraviolet rays, eye protection, hard hat, and metatarsal boots. The nursing diagnosis is that Jason has a risk for infection.

References
Jarvis, C.P. (2008). Physical examination and health assessment, fifth edition. St. Louis: Saunders Elsevier.

http://www.medicinenet.com/immunizations/article.htm

http://www.vaccineinformation.org/tetanus/qandavax.asp