Psoriasis - Nursing Case Study

Pathophysiology

• Primary mechanism: Psoriasis is driven by an overactive immune system. Specifically, T-cells (a type of white blood cell) mistakenly attack healthy skin cells, which triggers an inflammatory response. This inflammation leads to accelerated skin cell reproduction, which the body cannot shed quickly enough.

• Secondary mechanism: The overproduction of skin cells results in the formation of thick, scaly patches known as plaques. These plaques are often itchy and painful, and can occur anywhere on the body. The severity and location of plaques can vary widely among individuals.

• Key complication: Psoriatic arthritis can develop in some individuals with psoriasis. This condition causes inflammation, pain, and swelling in the joints, and can lead to joint damage if not properly managed.

Patient Profile

Demographics:

45-year-old, Male, Office Worker

History:

• Key past medical history: Mild to moderate psoriasis for 15 years, hypertension

• Current medications: Topical corticosteroids for psoriasis, Lisinopril for hypertension

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Worsening of psoriasis plaques, experiencing joint pain

• Key symptoms: Silver, scaly plaques on skin, particularly on elbows and knees, joint pain especially in the morning, itchiness, fatigue

• Vital signs: Blood pressure 145/95 mmHg, Heart rate 85 bpm, Body temperature 98.6°F, Respiratory rate 16 breaths per minute

Section 1

New Diagnostic Results:

The patient's blood tests returned, showing a high sedimentation rate (ESR 35 mm/hr) and C-reactive protein (CRP 25 mg/L), both indicating ongoing inflammation in the body. Additionally, rheumatoid factor (RF) was negative. X-rays of the most painful joints (hands and knees) were ordered to ascertain the extent of the joint damage. The X-rays revealed joint space narrowing, bone erosion, and "pencil-in-cup" deformities characteristic of psoriatic arthritis.

The dermatologist also performed a skin biopsy of the most severe plaque, confirming the diagnosis of psoriasis. The biopsy showed hyperkeratosis, acanthosis, and parakeratosis, characteristic histological features of psoriasis.

These results confirm a worsening of the psoriasis into psoriatic arthritis. The negative RF helps rule out rheumatoid arthritis. The high blood pressure reading taken during the patient's appointment, in conjunction with the patient's history of hypertension, indicates that the patient's hypertension is not well-controlled. This could be due to a number of factors, including medication noncompliance, inadequate dosage, or the body's increased production of certain substances due to the psoriasis inflammation that raise blood pressure. The patient's healthcare provider needs to consider all these factors in their plan of care.

Section 2

Change in patient status:

In the following weeks, the patient's status deteriorated. He reported increased joint pain and stiffness, particularly in the hands and knees, which was affecting his mobility and ability to perform daily activities. He also complained of increasing fatigue and a lack of energy. His blood pressure remained elevated at 160/90 mmHg despite medication adjustments. On physical examination, his affected joints exhibited increased swelling, warmth, and tenderness. His psoriatic plaques appeared more extensive and inflamed.

Furthermore, the patient reported the onset of pain and redness in his right eye, indicative of potential uveitis, a common complication in individuals with psoriatic arthritis. The patient's healthcare provider recommended an immediate consultation with an ophthalmologist to prevent further ocular damage. This new development highlights the systemic nature of psoriasis and reflects the complexity of managing multiple comorbid conditions. The healthcare provider must now consider the treatment options for the psoriatic arthritis, the uncontrolled hypertension, and the potential uveitis in their plan of care.

Section 3

Change in Patient Status:

The patient's condition continued to worsen over the next few days. He reported escalating joint pain, and the stiffness in his hands and knees made ambulation increasingly difficult. His fatigue also intensified, and he began experiencing bouts of dizziness. Upon reassessment, his blood pressure had further increased to 170/95 mmHg, and his resting heart rate was elevated at 100 beats per minute. The redness and pain in his right eye had also worsened, with the patient noting blurry vision.

The patient's psoriatic plaques had spread to cover more than 10% of his body surface, classifying his psoriasis as moderate to severe. The plaques were particularly prominent on his elbows, knees, and scalp, presenting as thick, red patches covered with silvery scales. The healthcare provider noted the onset of nail changes, such as pitting and discoloration, indicative of worsening psoriatic arthritis. The healthcare provider recommended immediate hospitalization for further evaluation and management, highlighting the urgent need for a multidisciplinary approach to care. The patient's condition necessitates a careful balance between managing his escalating hypertension, deteriorating psoriatic arthritis, and potential uveitis.

Section 4

New Diagnostic Results:

Further diagnostic testing revealed several notable findings. A complete blood count (CBC) identified a mild anemia with a hemoglobin of 11.5 g/dL and a hematocrit of 34.5%. His blood urea nitrogen (BUN) was elevated at 24 mg/dL, and his creatinine was also slightly high at 1.2 mg/dL, suggesting reduced kidney function. The patient's rheumatoid factor was negative, but his erythrocyte sedimentation rate (ESR) was significantly elevated at 60 mm/hr, and his C-reactive protein (CRP) level was also high at 15 mg/L, indicating heightened systemic inflammation.

An X-ray of the patient's hands and knees showed joint space narrowing and erosions typical of psoriatic arthritis, confirming the healthcare provider's suspicions. An ophthalmologic examination revealed inflammation in the anterior chamber of his right eye, consistent with uveitis. These findings indicated that the patient's psoriasis had progressed to a more systemic condition, affecting not only his skin and joints but also his kidneys, eyes, and possibly his cardiovascular system. The complexity of his condition necessitated a comprehensive, multidisciplinary management plan, which would need to address his escalating hypertension, worsening psoriatic arthritis, and emerging uveitis, as well as his potential renal and cardiac issues.

Section 5

Change in Patient Status:

Over the next few days, the patient's condition took a turn for the worse. He began to complain of increasing joint pain, especially in his hands and knees, which was impacting his mobility. His blood pressure continued to rise, reaching a peak of 160/95 mmHg in spite of antihypertensive medication. His skin lesions became more widespread and inflamed, causing him significant discomfort and making it difficult for him to sleep.

In addition, his renal function continued to deteriorate, with his BUN rising to 28 mg/dL and his creatinine climbing to 1.4 mg/dL, suggesting worsening renal impairment. His hemoglobin and hematocrit levels also dropped further to 10.8 g/dL and 32%, respectively, indicating a progression of his anemia. These findings, coupled with the persistent elevation of his inflammatory markers (ESR 65 mm/hr and CRP 18 mg/L), pointed to an exacerbation of his systemic inflammation and psoriatic condition. This deterioration called for a reevaluation of his current treatment plan and a reconsideration of his overall management strategy.