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Nursing Case Study

While making a prescription, a nurse must carefully examine the patient. There are many symptoms that are similar to different infections. Therefore, it is important to perform different tests while determining the type of illness. A nurse should examine patient’s history and also family history since some diseases can be inherited. This paper analyzes a case study by providing historical analysis, nursing diagnosis, physical examination, and care plan.

History and Physical Examination

Patient’s name: Mary.

Age: 35.

Date: 4/2/2014.

Referral source: out-patient.

Main complaints: Rash on the face, fatigue, fever, mouth soreness, and muscle ache.

History of the Illness


It was the first time that Mary sought medical attention for the treatment of rash on her face. She experiences fatigue, fever, muscle aches, rash on the face, and mouth soreness. The first time when Mary noticed the rash, she was camping and hiking in Appalachians. The rashes are painful and itchy. The rashes become worse after going outdoors. The rash appears only on the face but not on any other part of the body. Mary has never had this type of rash before. Mary has not consumed any foods that could lead to the skin rash, and she has not applied any new lotions or soaps that could have caused the rash.

Mary had a tonsillectomy at the age of nine; however, she has been healthy throughout her adult life. She has never been hospitalized, and she does not have children. Her mother has rheumatoid arthritis, but her father is not suffering from any sickness. As per her unhealthy habits, Mary does not smoke; therefore, the illness could not have been caused by smoking. Mary takes a glass of wine nearly every day. However, she does not use illicit drugs.

Physical Examination

  • Vital Signs: Temperature 100.3°F BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min.
  • The patient has several erythematous plaques spread over the cheeks and the bridge of the nose, sparing the nasolabial folds.
  • Pupils: constrict from 4 mm to 2 mm; they are equal, reactive to light, and round.
  • She has a moist oropharynx with erythema in the posterior pharyngeal wall.
  • Shallow ulcers in the buccal mucosa bilaterally.
  • Neck is supple.
  • The patient has full range of movement; she does not have any swelling or defects; muscles with normal bulk and tone.
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Presumptive Nursing Diagnosis

The above symptoms show that the patient could be suffering from a viral infection. The symptoms are closely related to influenza and viral syndrome. The symptoms of the viral syndrome are mild while those of influenza are severe. Therefore, the patient is likely to be suffering from influenza. The patient has a moist oropharynx with erythema and several erythematous plaques spread over the cheeks and the bridge of the nose. The symptom shows that the virus is severe in comparison with viral syndrome, and it is a common symptom of influenza. Flu virus tends to be strong in a cold climate. Mary contracted the disease while she was camping. The camping location could have exposed her to cold and increase the chances of getting the virus. Mary did not use any new products on her skin, and she did not consume any food that could have caused an allergy. Therefore, the skin rashes were not allergenic but rather the flu virus could have caused them. Flu is an infectious illness that can affect different parts of the body. Influenza does not cause a skin rash to all people; the signs of influenza can slightly differ from one person to another.

The disease was diagnosed as flu and not a cold because cold is milder than flu, and cold lasts for a shorter period. Mary has had this infection for a week now. Therefore, the infection cannot be a cold. With a cold, the first symptom to develop is a sore throat; Mary does not have a sore throat, but she has a sore mouth. For a cold, the patient must have running nose, cough, and congestion, which is not the case with Mary. The soreness in the mouth and infected oropharynx could not have been caused by tonsillitis since her tonsils were removed when she was nine years old. The analysis of whether Mary could have an inherited disease from her parents shows a negative result. Her mother suffers from rheumatoid arthritis, but Mary does not show any signs of rheumatoid arthritis.

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People who are susceptible to allergic skin reactions and have flu are more likely to get a rash (Simon, 2014). The flu virus is an invasive disease, and an allergic reaction to the virus occurs resulting in the development of urticaria, which appears as a rash on the skin. Urticaria develops as a result of the body reaction to the allergen. Everyone with flu has a fever; the fever comes due to the reaction of the body trying to kill the virus. Fever is triggered by pyrogens that are released into the blood to control temperature. When they bind into the brain cells, body temperature rises to create heat required to kill the virus. Mary's muscles ache because they are using much energy to fight the virus. Muscle pain increases, and flu becomes severe. Mild flu only causes a slight pain. As the muscles fight the virus, they use much energy and become exhausted; that is why Mary is often feeling fatigue.

Flu is a contagious disease, and one can get infected due to close interaction with infected persons (Simon, 2014). It can spread through propelling of droplets through cough, talking, or sneezing of an infected person. Flu can spread through touch when someone gets into contact with the infected person’s nasal secretions. People also get infected by touching objects that carry the virus. Flu is contagious from the day before the signs appear up to the tenth day of the symptoms. People who have a weak health system remain contagious for a longer period. Flu virus changes constantly, and the body becomes immune to if it is infected by the same virus more than once (Dixit, Khandaker, Ilgoutz, Rashid, & Booy, 2013). When the virus infects a person for the first time, the body develops antibodies against the virus. The antibodies can lessen or even prevent the infection. However, the antibodies cannot prevent the body from the new viruses. The flu causes complications if it goes untreated. It can cause complications such as asthma, sinus infection, and pneumonia (Simon, 2014).

A lab test should be conducted to prove that the patient suffers from flu. A lab test is recommended in this case. A sample should be collected immediately from the nasal cavity (Simon, 2014). The most effective tests can provide results in 15 minutes. Some of the tests are used for influenza virus. These tests include rapid antigen testing, viral cultures, and serology. The best test to use is the rapid antigen testing because it only takes 15 minutes to get the results. It may take up to 10 days to get the results with a serology test. The test also does not provide the results that can be used in decision-making (George, 2012).

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Nursing and Teaching Care Plan

Viruses that cause influenza change from one year to another; therefore, it is important for a nurse to be sure in the type of virus contracted by the patient before treatment (George, 2012). The flu should be treated with decongestants and antihistamines (Dixit et al., 2013). Pain relievers are also important to reduce muscle pain. The patient should also take aspirin to reduce fever and relieve pain. In addition, the patient should drink a lot of water as the body becomes easily dehydrated by the virus.

Mary should take a rest at home to heal quickly and avoid infecting other people in the workplace and social places. Since the infection is spread through contact, the patient should reduce her contact with other people to prevent infecting them.

The patient should take precautionary measures in order not to spread the virus and should also get advice on how to control the infection and how to avoid it in the future. For prevention purposes, the patient should get an influenza vaccine. The patient should also adopt hygienic habit such as washing her hands often (Goldschmidt, 2014). She should use hand sanitizer in case she comes into contact with a person infected with the virus. One should also avoid sharing items such as a towel, eating utensils, drinking glasses, and phones with an infected person (Peaper & Landry, 2014). Mary should cover her mouth whenever she is sneezing. One should avoid contact with infected persons.


An in-depth analysis of the symptoms shows that Mary has a flu virus. She could have contracted the flu while camping in Appalachians. The level of the flu is uncomplicated, and the treatment can be achieved more easily. The flu can be treated with decongestants and antihistamines. Administration of aspirin is also important for reducing the fever. The patient should also be given pain killers to relieve muscle pain. The patient is advised on the importance of fluid intake and taking precautions such as proper hygiene and avoiding contact with infected people.

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