Description
Properly identifying the cause and type of a patient’s skin condition involves a process of elimination known as differential diagnosis. Using this process, a health professional can take a given set of physical abnormalities, vital signs, health assessment findings, and patient descriptions of symptoms, and incrementally narrow them down until one diagnosis is determined as the most likely cause.
In this Lab Assignment, you will examine several visual representations of various skin conditions, describe your observations, and use the techniques of differential diagnosis to determine the most likely condition.
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
SOAP NOTE DOCUMENTATION
DURING WEEK 4, You will start writing SOAP notes!
You will be MAKING UP the necessary information needed to do your Soap notes for Assignment 1. You will do the same for Week 5, and 9.
For Week 3 Assignment 1, Please DO NOT include a copy of the picture in the SOAP note. Put the PIC# in the CC
FOLLOW the Template for each SOAP note.
To say N/A or Non contributory is NOT acceptable.
PLEASE, Remove the INSTRUCTIONS/DIRECTIONS on your templates before submitting your FINAL copy.
The directions are for YOU not for grading purposes.
Please REMOVE the INSTRUCTIONS prior to Submitting your Assignment.
For Episodic/Focus Soap Notes, you do not have to Review all the systems, only the ones that are related to the Chief Complaint (CC).
ALWAYS Review and Examine the Respiratory and Cardiovascular systems no matter the complaint.
**You will need to MAKE UP the missing information in the note (Information you will have to MAKE UP, INCLUDES BUT NOT LIMITED TO: Allergies, Medications, Past Medical History, Surgical History, Family History, parts of the Review of Systems (ROS) and Physical Exam).
You NEED TO KNOW what information to include in a SOAP note.
S- Subjective – What the patient tells you. Please be sure your ROS exemplify this.
O – Objective – What you find when you examine your patient, is what you observe, feel, hear and find when doing your exam.
A – Assessment – This is where your diagnoses and differential diagnoses are documented.
In this class you are functioning as an Nurse Practitioner, not as a Registered Nurse (RN).
Please do not put a Summary of findings in the Assessment area, this is RN documentation for Assessment.
P- Planning – Not required for this class. No points are given if you provide this information.
In the ASSESSMENT/PLAN, you will document your differential diagnoses as per the assignment.
List different possible conditions for the patient’s differential diagnosis.
YOU WILL MAKE UP INFORMATION IN ORDER TO COMPLETE THE SUBJECTIVE AND OBJECTIVE INFORMATION for SOAP notes. This DOES NOT apply to Shadow Health SOAP notes!
Each WEEK you will use the SOAP NOTE Template that is designated for this assignment. It is near the bottom of your Resource LIST!
It will be the Comprehensive SOAP Template or Episodic/Focused SOAP Note Template depending on the WEEK.
Examples of SOAP notes are provided under your Resources for each Week.
TO PREPARE
Review the Skin Conditions document provided in this week’s Learning Resources, and select one condition to closely examine for this Lab Assignment.
Consider the abnormal physical characteristics you observe in the graphic you selected. How would you describe the characteristics using clinical terminologies?
Explore different conditions that could be the cause of the skin abnormalities in the graphics you selected.
Consider which of the conditions is most likely to be the correct diagnosis, and why.
Search the Walden library for one evidence-based practice, peer-reviewed article based on the skin condition you chose for this Lab Assignment.
Review the Comprehensive SOAP Exemplar found in this week’s Learning Resources to guide you as you prepare your SOAP note.
Download the SOAP Template found in this week’s Learning Resources, and use this template to complete this Lab Assignment.
THE LAB ASSIGNMENT
Choose one skin condition graphic (identify by number in your Chief Complaint) to document your assignment in the SOAP (Subjective, Objective, Assessment, and Plan) note format rather than the traditional narrative style. Refer to Chapter 2 of the Sullivan text and the Comprehensive SOAP Template in this week’s Learning Resources for guidance. Remember that not all comprehensive SOAP data are included in every patient case.
Use clinical terminologies to explain the physical characteristics featured in the graphic. Formulate a differential diagnosis of five possible conditions for the skin graphic that you chose. Determine which is most likely to be the correct diagnosis and explain your reasoning using at least three different references, one reference from current evidence-based literature from your search and two different references from this week’s Learning Resources.
Week 4
Skin Comprehensive SOAP Note TemplatePatient Initials: _______ Age: _______ Gender: _______
SUBJECTIVE DATA: This is what the patient tells you!Chief Complaint (CC): This is the reason the patient comes to see you. Should be a Statement. (Make it up). Be sure to include the Pic # in the CC). (You are making up this information).History of Present Illness (HPI): The tells the story as to why the patient came. Start off with age and sex of patient i.e, 24 y/o Caucasian female presented to clinic with complaint of ……
Include Location, Onset, Character, Associated S/S, Timing, Exacerbating/Relieving Factors and Severity. (LOCATES)
(You are making up this information).Medications: You will make up the medications, LIST them each on a separate line. (You are making up this information).Allergies: List each allergy on a separation with the reaction. (You are making up this information).Past Medical History (PMH): Include all past and present medical history and medical problems. (You are making up this information).Past Surgical History (PSH): Include all Surgical history, past and present. (You are making up this information). Sexual/Reproductive History: This includes Partners, Practices, Past History of STIs Protection, (WOMEN ONLY) Pregnancies, Onset of Menses, LMP, and Pregnancy Prevention and Reproductive Life Plan.
(You are making up this information).Personal/Social History: Include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
(You are making up this information).Health Maintenance: Include tings like, Breast Cancer Screening, Colorectal Cancer Screening, Cervical Cancer Screening, Diabetes Eye Exam, Advanced Care Plan.
(You are making up this information).Immunization History: Include immunization status (note date of last tetanus for all adults). For children, include all immunizations.
(You are making up this information).Significant Family History: Review of Systems: This is what the patient tells you!
(You are making up this information). It is what the patient denies, admits to, endorses, reports, etc.
General:
HEENT:
Respiratory:
Cardiovascular/Peripheral Vascular:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Skin/hair/nails: This is the system where the CC is, be sure to think about what you would say if you had the assigned condition. What would you c/ and what you would say. Document it here.
(You are making up this information).
OBJECTIVE DATA: Physical Exam: This is your findings when you examine your patient. Cannot say, N/A, WNL, Not examined. (You are making up this information).
Vital signs:
General:
HEENT:
Neck:
Chest/Lungs:
Heart/Peripheral Vascular:
Abdomen:
Genital/Rectal:
Musculoskeletal:
Neurological:
Skin: This is the system where the CC is, be sure to think about what you see when you examine your patient. Document what you see on the picture. Use clinical terminologies to explain the physical characteristics featured in the graphic.Diagnostic results: You are to make these up diagnosis according to the readings. What diagnostics are relevant to your assigned picture. You are coming up with these.ASSESSMENT:
Formulate a different diagnosis of three to five possible considerations for the skin graphic. Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
PLAN: This section is not required for the assignments in this course (NURS 6512), but will be required for future courses.
NURS_6512_Week_4_Assignment_1_Rubric
NURS_6512_Week_4_Assignment_1_Rubric
Criteria Ratings Pts
This criterion is linked to a Learning OutcomeUsing the SOAP (Subjective, Objective, Assessment, and Plan) note format: · Create documentation, following SOAP format, of your assignment to choose one skin condition graphic (identify by number in your Chief Complaint). · Use clinical terminologies to explain the physical characteristics featured in the graphic.
35 to >29.0 pts
Excellent
The response clearly, accurately, and thoroughly follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response clearly and thoroughly explains all physical characteristics featured in the graphic using accurate terminologies.
29 to >23.0 pts
Good
The response accurately follows the SOAP format to document one skin condition graphic and accurately identifies the graphic by number in the Chief Complaint. The response explains most physical characteristics featured in the graphic using accurate terminologies.
23 to >17.0 pts
Fair
The response follows the SOAP format, with vagueness and some inaccuracy in documenting one skin condition graphic, and accurately identifies the graphic by number in the Chief Complaint. The response explains some physical characteristics featured in the graphic using mostly accurate terminologies.
17 to >0 pts
Poor
The response inaccurately follows the SOAP format or is missing documentation for one skin condition graphic and is missing or inaccurately identifies the graphic by number in the Chief Complaint. The response explains some or few physical characteristics featured in the graphic using terminologies with multiple inaccuracies.
35 pts
This criterion is linked to a Learning Outcome· Formulate a different diagnosis of three to five possible considerations for the skin graphic. · Determine which is most likely to be the correct diagnosis, and explain your reasoning using at least three different references from current evidence-based literature.
50 to >44.0 pts
Excellent
The response clearly, thoroughly, and accurately formulates a different diagnosis of five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained clearly, accurately, and thoroughly using three or more different references from current evidence-based literature.
44 to >38.0 pts
Good
The response accurately formulates a different diagnosis of three to five possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained accurately using at least three different references from current evidence-based literature.
38 to >32.0 pts
Fair
The response vaguely or with some inaccuracy formulates a different diagnosis of three possible considerations for the skin graphic. The response determines the most likely correct diagnosis with reasoning that is explained vaguely and with some inaccuracy using three different references from current evidence-based literature.
32 to >0 pts
Poor
The response formulates inaccurately, incompletely, or is missing a different diagnosis of possible considerations for the skin graphic, with two or fewer possible considerations provided. The response vaguely, inaccurately, or incompletely determines the most likely correct diagnosis with reasoning that is missing or explained using two or fewer different references from current evidence-based literature.
50 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.
5 to >4.0 pts
Excellent
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria.
4 to >3.0 pts
Good
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive.
3 to >2.0 pts
Fair
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic.
2 to >0 pts
Poor
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided. 5 pts This criterion is linked to a Learning OutcomeWritten Expression and Formatting - English writing standards: Correct grammar, mechanics, and proper punctuation 5 to >4.0 pts
Excellent
Uses correct grammar, spelling, and punctuation with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) grammar, spelling, and punctuation errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) grammar, spelling, and punctuation errors.
2 to >0 pts
Poor
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
5 pts
This criterion is linked to a Learning OutcomeWritten Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.
5 to >4.0 pts
Excellent
Uses correct APA format with no errors.
4 to >3.0 pts
Good
Contains a few (1 or 2) APA format errors.
3 to >2.0 pts
Fair
Contains several (3 or 4) APA format errors.
2 to >0 pts
Poor
Contains many (≥ 5) APA format errors.
5 pts
Total Points: 100
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Unformatted Attachment Preview
Section One
Dermatological Procedures
Chapter
I
Punch Biopsy
Margaret R. Colyar
CPT Code
21550
21920
23066
24065
23066
27040
27323
27613
11 I00
Biopsy of soft tissue of neck or thorax
Biopsy of soft tissue of back or flank, superficial
Biopsy of soft tissue of shoulder; superficial
Biopsy of upper arm and elbow area
Biopsy of soft tissue of forearm or wrist. superficial
Biopsy of soft tissue of pelvis and hip area
Biopsy of soft tissue of pelvis and hip area
Biopsy of soft tissue of leg and ankle area
Skin lesion-Depends on the srte, technique, and if benign
or malignant lesions
Biopsy is th e removal ofa small piece of tissue from the skin for microscopic exami
nation. Partial or full thickness of skin over the lesion is removed for evaluation.
OVERVIEW
Punch biopsy is used for full and partial dermal lesions such as
• Basal cell carcinoma
• Squamous cell carcinoma
• Actinic lceratoses
• Sebonheic keratoses
• Lcntigo (freckles)
• Lipomas
• Melanomas
• Nevi
• W:1rts- vcrruca vulgaris
irape the area.
• !>111 on gloves.
• luj l’CI I % lidocaine under the lesion using a 27- co 30-gauge needle to crcare rt
whe:il.
• l1 11· i.~e lc:si on parallel ro the skin (Fig. 2.1).
• l’l:it’l: the tiSSll Cin a conrainer of 10% formalin.
• ( :. 11 11 eri~.c rhe base of the wound or apply Monsel’s solution to retard bleeding.
Mt1.’l’11 o n 2-CURETTAGE BIOPSY
• Po~it i1111 the patient for comfort with the area of the skin lesion easily acccssihlc,
• l ‘ 11′.l l lM.’ the skin lesion and a 3-inch-diameter area around the lesion.
• I li.l[ll’ tl1e area.
• 1’111 1111 gloves.
• lu j1·11 I ‘Y.• lidocainc under the lesion using a 27- to 30-gauge needle ro creat e a
wlh”.11.
• 11 l ol[H’ tltl’ lesio n with tbe curette (Fig. 2.2).
• Jll,11 ‘ tltt’ tissue in a container of 10% fo rmalin.
• l ollil !’iln · the h:ise o f rhe wound or apply Monsel’s solution to reta rd blecd l11g.
!l 11 1’11rni J – -lu.1P’l’I CAL Exc1s10NAL B i opsy
!1 ‘1111 I) HllMAJ. T 1ll C l( NlSS)
I l’n~ ltl1 1 11 1h t· p111 le111 for eo111fo rt wi th 1lic t1rl’a o l’ thc skin 111rniqlll:t
l :lovt:.~-srcrile
I )rape – src.:rilc
I lcmostat- stcrilc
Su rgid .~cissors-steri l c
S11l:ll l s1r:1igh1 hcmostar- stcl’lk•
• ( :011 on .~w: 1hs-s1crilc
Sll w·1 11i1 r;11r stlc:i<
Hll 11,i 111 HH'to plw1wl
43
44
Chapter JO I Nail Removal
Section One I Dermatological Procedures
45
• Alcohol swabs
• Alcohol
• Antibiotic ointment (Bactroban, Bacitracin, or Polysporin)
• Nonadherent dressing-Telfa or Adaptic
• Bandage roll (tube gauze)
Procedure
METHOD I -
COTTON WICK INSERTION
• Have the client lie supine with knees flexed and feet flat.
• Cleanse affected toe with antiseptic cleanser.
• File middle thi rd of nail on the affected side with a nail file or emery board as
illustrated (Fig. 10.2).
• Roll cotton to form a wick.
• Gently push the cotron wick under the distal portion of d1e lateral nail groove
on me affected side using splinrer forceps (Fig. 10.3) .
• Identify me offending spicule and remove it.
• Continue to insert cotton wick to separate the nail from the nai l groove (1 cm
of cotron wick should remain free).
• Apply tincture of iodine to the cotton wick.
• Cauterize granulomarous tissue with silver nitrate stick.
• Bandage the toe.
-
Figure I 0.3 Gently push a conon wick
under d1e lateral nail groove.
Client Instructions
• Change bandage daily, and apply tincture of iodine every omer day.
• Return to th e office weekly for cotton w ick replacement.
METHOD 2-PARTIAL AVUI.SION WITH PHENOLIZATION
t lnjimned cowmt req11 ired
• Have the diem lie supine with knees flexed and feet flat.
• For d igital nerve block, prepare 3 to 5 mL of lidocaine without epinephrine to
anesmetize the affected area.
illl
_..
I
-naur~ 10.2
Fiie· tlw 111lddl1• tlilul 11f d11 tHll
• 'fo anesrl1etize th e nerves innervating the proximal phalanx on th e extensor
surface, insert the needle toward the planrar surface on the affected side.
• Injection sites are below the nail on me outer edges of the toe (Fig. 10.4). Be
c:m:Ful not to pierce the plantar skin surface.
• Inject I 10 2 mL oflidocaine while withdrawing the needle. Do not withdraw
1li e needle from the skin.
• Red irect rhe needle across the extensor surface, and insert me needle further.
lnjecr 1 mL of lidocaine while wimdrawing needle.
• Repeat procedure on opposite side of the d igit.
• Allow 5 minutes for lidocaine to take effect before beginning procedure.
• Sl't'u b rhc toe with antiseptic, rinse, dry, and drape with sterile drapes.
• Place the tourniquet around the base of the toe. Perform proced ure in 15
111i 11111cs or less to avoid ischemia.
• Inscl'I a single blade of a small hemostat between the nailbed and the toe tO
op'n a tract (Fig. 10.5). Remove hemostat.
• l'l:in: thc blade of the scissors in the tract, and cut the nail plate from d isr;i l
1·dgc 10 1he proximal nail base (Fig. 10.6).
• llt·111ovc 1he nai l with a small hemostat, using genrle rotation row:ird rhc
1lfl i:~·1 l·d nail (Pig. 10. 7).
• l J,,l ng a hcmos1a1, i11spccr rhe nail g1•onvt1 1111' ~p lc11lcs.
• 1)1 )' di ~ 11nvly c.~ posd n:illhcd.
46
Chapter JO I Nail. Removal
Section O ne I Dermatological Procedures
47
Figure I 0.6 Cm the nail plate from distal edge co
proximal nail base.
Figure I0.4 Anesthetize th e nerve innervating the proximal
phalanx. Inject the roe on the outer edges just below the
nail.
Figure 10.7 Remove the nail using gen tle ou1 ward
Figure I O.S Insen a single blade of a
rotation toward the affected nail.
hemostat between the nailbed and the toe
to open a tracr.
• Rub cotro n swab saturated wi th phenol on germinal matrix beneath the c111 il:k·
for 2 m inutes.
• Cau terize granulomas with silver nitrate stick.
• Remove ro11rniq11cl and cleva1 c font for 15 111i11u1 c~.
• Pl:11:e :1 dress I11g In ii 1c Ille.
Client lnstrua ions
or
• Avo id bchc111 ia !CW hy l1Jtl~l'lll 1111 ili l h.111d,1nl' :i 11d hangi ng roOI dow n.
• Nn1 Hy 11 1l'~ nr gn:e n 01· y(·llmv di~~'h.uw;
I'< j lrl'Sl'll I.
48
Section One I Dermatological Procedures
• If roes become cold and pale
Elevate foot above heart level
• Flex the roes
Check circulation by pressing on the roe and watching for return of redness
when pressure is released
Call the practitioner if symptoms do not subside within 2 hours
• Use pain medications as ordered. Take Tylenol No. 3 every 4 to 6 hours for the
first 24 hours; then take an NSAID such as ibuprofen.
• Take ordered antibiotics for 5 days (cephalexin, tetracycl ine, trimethoprim·
sulfamethoxawle, amoxicillin).
• Return to the office for follow-up visit in 2 days.
81 BLIOGRAPHY c:::;;:;=;;;;;;;;;;;;;::;;:;:;;;:;;.:::;;.:;::;...
Heidelbaugh JJ, Lee H. Management of rhe ingrown toenail. Am Fam Physician.
2009;79(4):303-308.
Pfenninger JL, Fowler GC. Procedures for Primmy Care Physicians. Sr. Louis, MO: Mosby;
2011.
Zuber TJ. Ingrown toenail removal. Am Fam Physician. 2002;65(12):2547-2550.
Chapter
Ring Removal
Cynthia R. Ehrhardt
( r C.o :le
20670
20680
Superficial removal of constricting metal band
Deep removal of constricting metal band
Occasionally, a ring must be removed from a digit. Whenever possible, a nondesrruc
cive method is preferred. Only when conservative methods have been exhausted
shou ld a ring cutter be used.
OVERVIEW
• Complicating facto rs
• Swelling or edema ro the digit
• Increased pain and sensitivity to area
• Embedding of metal filings into digit
General Principles
• Minimize 1hc amoun1 of pain.
• S11H>o1h 1ccl111iquc min imizes fo rtht·r 1r:i 111ll:1 to :11nt,
68
Section One I DermaLOlogical l>rot:t’d111 cs
Chapter 15 I Skin Lesion Removal
/
Chapter
Skin Lesion Removal
69
Epidermis [
Keloids, Moles, Corns, Calluses
Dermis
Margaret R. Colyar
C””T r .>de
11050
11056
11057
11300-33
I 1305-38
Paring or curettement of benign hyperkeratotic skin
lesion with or without chemical cauterization (verrucae,
callus, corns), single lesion
Two to four lesions
Greater than four lesions
Shaving of epidermal or dermal lesion, single lesion;trunk.
arms, or legs
Shaving of epidermal or dermal lesion, single lesion; scalp,
neck, hands. feet. genitalia
Skin lesions such as keloicls, moles, corns, and call uses are removed easily. Keloids
are benign, hard, fibrous proliferations of collagen that expand beyond the original
size and shape of the wound, sometimes 20 times normal size. They invade sur
rounding soft tissue in a d awlike fashion. Moles, or nevi, are discolorations of cir
cumscribed areas of the skin resulting from pigmentation. They can be congenital
or acquired. Acquired nevi usually appear first in childhood and in sun-exposed areas.
These nevi extend into the dermis and epidermis (Fig. 15.1) by late adolescence and
intradermis by late adulthood. Nevi always should be assessed for
• Asymmetry
• Border irregularities
• Color val’iation
• Diameter greater than 6 mm
• Elevation above the skin surface
Corns, or keratomas, are hyperkeratotic lesions or horny indurations with thick
ening and nucleation of the skin, usually on the toes. Hard corns are located on the
dorsal aspect of the toes. Soft corns are located between the digits, usually the fo urth
interdigital space.
Calluses are hypertrophied, hyperkeratotic thickenings of the srratum corneum,
usually located around the heel of the foot, great toe, metatarsal heel, and distal
aspect of the first three digits of the dominant hand or palmar aspccr of’ 1lw meta
carpal head. There is no underlying nucleus (core) .
Fat
I l1:urc 15.1
Anatomy and layers of skin.
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