Psoriasis - Nursing Case Study

Pathophysiology

• Primary mechanism: Psoriasis is primarily driven by an overactive immune system. T cells, a type of white blood cell, mistakenly attack skin cells, leading to inflammation and an accelerated growth of skin cells.

• Secondary mechanism: As a result of the immune response, the skin cells multiply rapidly and move to the surface of the skin within days, as opposed to the usual month-long process. These excess skin cells form thick, scaly patches known as plaques.

• Key complication: Chronic inflammation from psoriasis can lead to systemic complications, such as psoriatic arthritis, which affects up to 30% of individuals with psoriasis. This can lead to joint pain, stiffness, and swelling.

Patient Profile

Demographics:

45-year-old male, working as a construction worker.

History:

• Key past medical history: Diagnosed with moderate psoriasis for 10 years, hypertension for 5 years.

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

• Allergies: No known drug allergies.

Current Presentation:

• Chief complaint: worsening of psoriasis symptoms and associated joint pain.

• Key symptoms: Increased red patches on the skin, covered with silvery scales, particularly on elbows, knees, and back. Joint stiffness and swelling, particularly in the morning.

• Vital signs: Blood pressure 145/90 mmHg, heart rate 88 bpm, temperature 98.6°F, respiratory rate 16 breaths per minute, oxygen saturation 98%.

Section 1

New Diagnostic Results:

The nurse decided to recommend further tests to better understand the patient's condition. The dermatologist ordered a complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) to assess the level of inflammation in the body. The patient also underwent rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) tests to exclude rheumatoid arthritis as a differential diagnosis.

The results of the tests showed a slightly elevated ESR of 35mm/hr (normal range: 0-22mm/hr) and CRP level of 12mg/L (normal range: <10mg/l), indicating an ongoing inflammatory process. The CBC was within normal limits. The RF and anti-CCP tests were negative, which made rheumatoid arthritis less likely. However, given the patient's long-term history of psoriasis and emerging joint symptoms, these findings suggested that he might be developing psoriatic arthritis.

Change in Patient Status:

The patient reported that he was finding it increasingly difficult to do his job due to the pain in his joints, particularly in the morning. He also mentioned that the red patches on his skin were spreading to other areas and becoming more noticeable, leading to embarrassment and psychological distress. His blood pressure was slightly elevated at 150/95 mmHg, which could be related to his pain and stress levels. His heart rate was stable at 88 bpm, temperature was 98.6°F, respiratory rate was 16 breaths per minute, and oxygen saturation was 98%. This change in the patient's status highlighted the need for a more effective management plan for his psoriasis and potential psoriatic arthritis.

Section 2

New Complications:

The patient returned to the clinic after a week, complaining of increased pain and stiffness in his joints, especially in the morning hours. He also mentioned experiencing fatigue and having difficulty sleeping due to the discomfort. His skin condition had worsened, with the presence of more inflamed, scaly patches. The patient also reported a decreased appetite and unintentional weight loss of 5 pounds over the week. On examination, there was noticeable swelling and tenderness in his distal joints. His blood pressure had increased to 155/100 mmHg, likely due to pain and stress.

These new complications indicated a potential progression of psoriatic arthritis, highlighting the need for urgent intervention. The patient's weight loss and decreased appetite suggested a decrease in his overall health status, which can also exacerbate his current conditions. The nurse decided to re-evaluate the patient's treatment plan and discuss the introduction of disease-modifying antirheumatic drugs (DMARDs) with the dermatologist. It was also necessary to consider the patient's psychological distress and incorporate a psychological support component into his care plan. The nurse planned to consult with a nutritionist to help address the patient's weight loss and decreased appetite.

Section 3

New Diagnostic Results:

Upon re-evaluation, the nurse conducted a full body assessment and noted that the patient's joints were warm to touch, especially at the distal interphalangeal joints. His body temperature was slightly elevated at 99.7°F, which could be an indication of systemic inflammation due to psoriatic arthritis. The nurse also noted a significant increase in the Psoriasis Area Severity Index (PASI) score, indicating the severity of his skin condition.

Laboratory tests showed an increased erythrocyte sedimentation rate (ESR) of 28 mm/hr and C-reactive protein (CRP) level of 15 mg/L, both markers of inflammation in the body. The patient's rheumatoid factor (RF) was negative, consistent with psoriatic arthritis. The complete blood count (CBC) showed mild anemia with a hemoglobin level of 11.5 g/dL, which could be a result of chronic inflammation or poor nutrition due to decreased appetite.

These diagnostic results confirmed an exacerbation of both the patient's psoriasis and psoriatic arthritis, necessitating a review and possible modification of his treatment plan. The results also highlighted the need for nutritional support to address the patient's weight loss and anemia. The nurse considered these findings while planning the next steps. The nurse knew that managing the patient's pain and inflammation was paramount, but also recognized the need to address the patient's overall health and well-being.

Section 4

Change in Patient Status:

Over the next few days, the patient's condition began to worsen. His body temperature consistently ranged between 100°F and 101°F, indicating a persistent systemic inflammation. His pain levels were elevated, particularly in the distal interphalangeal joints, impeding his ability to perform basic activities like eating or dressing, further exacerbating his poor nutritional intake. The nurse noted a decrease in his weight by another two pounds and his skin condition worsened, with increased erythema and scaliness observed.

A repeat laboratory test showed a further increase in ESR to 35 mm/hr and CRP to 20 mg/L, confirming the escalating inflammation. Hemoglobin levels dropped to 10 g/dL, indicating worsening anemia. The nurse had to reassess the patient's current treatment plan and consider more aggressive interventions. The nurse knew that the increase in inflammatory markers and worsening anemia suggested that the current treatment was not effectively controlling the inflammation or addressing the underlying causes. The nurse also recognized that the patient's quality of life was severely impacted, not just from the physical symptoms, but also from the psychological toll of the chronic condition. This highlighted the importance of a holistic approach in managing the patient's care, including the need for mental health support.

Section 5

New Diagnostic Results:

In an attempt to better understand the patient's deteriorating condition, the nurse requested for additional diagnostic tests. A comprehensive metabolic panel (CMP) showed elevated liver enzymes (ALT 80 U/L and AST 70 U/L) suggesting possible hepatic inflammation. A Rheumatoid Factor (RF) was also ordered and came back positive with a titer of 1:160, indicating the possibility of an autoimmune disorder such as rheumatoid arthritis, which could explain the joint pain. Additionally, the patient's serum albumin was low at 2.5 g/dL, which could be a result of malnutrition or due to the chronic inflammation.

The nurse knew that these new findings complicated the patient's condition further. The elevated liver enzymes could be a result of the systemic inflammation, or possibly a side effect from the current psoriasis treatment. The positive RF suggested that the patient could be suffering from a co-existing autoimmune disorder which may be contributing to the joint pain and systemic inflammation. The low albumin level indicated a poor nutritional status and also raised the risk for edema. These findings warranted a reassessment of the treatment plan and a possible referral to a rheumatologist. The nurse also made a note to monitor the patient's liver function and nutritional status closely. The nurse reasoned that these new findings presented a chance for better targeted treatment and improved patient management.