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Case Presentation: Vesicular Rash
- 1. CASE PRESENTATION: VESICULAR RASH ATHENA NATHAN, CONSTANZA BRIDGES, & RAELA STANDER TEXAS TECH HEALTH SCIENCES CENTER NURS5320 SUMMER 2014
- 2. SUBJECTIVE: PATIENT DEMOGRAPHICS Gender- Hispanic female Age- 71 year old Chief Complaint- : “The left side of my head hurts even more and now I have more blisters on my head and face” Onset- 2 days ago Location- Left side head/face Duration: Continuous for 2 days Character- Burning/itching Aggravating/Alleviating-No known aggravating or alleviating factors Radiation- Accompanied with headache Timing- Pain is constant with increasing severity Severity- Rates pain at 10/10. Interferes with sleep. Prior- Presented to clinic 2 days ago complaining of waking up with a headache and 2 blisters to the left side of forehead. (Microsoft, 2014)
- 3. SUBJECTIVE: REVIEW OF SYSTEMS Past Medical History (PMHx) Childhood illness: Chickenpox Past Surgical History Medications Allergies Health maintenance Immunizations Flu (2013) Social history Married and lives with husband of 54 years Retired secretary Cares for granddaughter intermittently Health habits Family History
- 4. SUBJECTIVE: REVIEW OF SYSTEMS + GENERAL: States headache/chills/difficulty sleeping and burning/itching to left side of head/face x2days. Denies night sweats or weight changes. + INTEGUMENTARY: Positive for rash to left-side of head. Denies bruising, changes in moles or pigment. + NEUROLOGIC: Headaches. Denies head trauma, loss of consciousness, dizziness, or problems with balance/coordination. EYES: Uses bifocal glasses for reading. Denies any blurry/double vision, vision changes, trauma, eye diseases. States last eye exam August 2013. ENT: Denies any hearing loss/changes, pain, tinnitus, recent infections. Denies epistaxis or difficulty swallowing. Denies nasal congestion or scratchy throat. Denies dentures, ulcers, or tooth problems. Last dental exam January 2014. CARDIOVASCULAR: Denies any night sweats, chest pain, edema, palpitations. RESPIRATORY: Denies any cough, hemoptysis, shortness-of-breath, dyspnea on exertion, exposure to TB. GASTROINTESTINAL: Denies incontinence, changes in bowel patterns, heartburn. No hematochezia, hematemesis. MUSCULOSKELETAL: Denies any pain, heat, swelling to joints. Denies problems with range of motion. + MENTAL STATUS: Positive for increased stress related to caring for a young child. Denies any confusion, memory deficits, mood changes, thoughts of hurting self or others.
- 5. OBJECTIVE: PHYSICAL EXAM + VITAL SIGNS: BP 117/84 P 79 regular R 20 regular T 101oral Ht: 5’0” Wt: 135 BMI: 26.4 GENERAL APPEARANCE: Ms. V is a pleasant, well-kept 71 year old Hispanic female who appears younger than her stated age and is alert, cooperative, and able to independently ambulate and move all extremities. She is a good historian with clear speech without evidence of cognitive impairment. + HEENT: No cephalic deformities. Various fluid-filled vesicles to left frontal/temporal/zygomatic area. PERRLA. Fundoscopic exam shows disc margins sharp without no cupping, hemorrhage, or exudate. Tympanic membranes intact and pearly gray bilaterally without erythema or effusion. Nares patent bilaterally without rhinorrhea or redness. Pharynx without exudate or pustules. Buccal mucosa moist, pink, without lesions. Gums pink without inflammation or bleeding. + SKIN: Rash as noted above. Intact, no other rashes, lesions, or bruises noted. Good turgor. No pallor, cyanosis, or jaundice noted. NEUROLOGIC: Alert and oriented to person/place/time. Appropriate mood and affect. CN II-XII grossly intact. Motor 5/5 bilateral upper/lower extremities. Deep tendon reflexes 2+. No tremors noted. RESPIRTORY: Breath sounds clear to all lung fields. No increased work of breathing. Chest wall expansion symmetrical. CARDIOVASCULAR: S1S2, regular rate and rhythm. No thrills, splitting, murmurs, gallops, or rubs. Pedal pulses 3+ bilaterally. No peripheral edema. GASTROINTESTINAL: Bowel sounds present x4. Soft, nontender, obese. No distension, masses, organomegaly, or aortic pulsation. No dullness to percussion. MUSCULOSKELETAL: Fully weight-bearing with full range of motion of all extremities. No erythema/pain/inflammation noted to joints. (Microsoft, 2014)
- 6. DIFFERENTIAL DIAGNOSIS: THOUGHT PROCESS (Microsoft, 2014)
- 7. DIFFERENTIAL DIAGNOSIS: CONTACT DERMATITIS Thorough history to include any contact exposures to possible irritants. Notation of dermatitis pattern. (Weaver-Agostoni, 2014)
- 8. DIFFERENTIAL DIAGNOSIS: CONTACT DERMATITIS (Usatine, 2014)
- 9. DIFFERENTIAL DIAGNOSIS: FOLLICULITIS Involves the hair follicle Most common areas for presentation include face, scalp, thighs, buttocks, axillae and inguinal areas. Presents as a pustule. Biopsy recommended when unclear of diagnosis or if empirical antibiotic therapy is ineffective (Ely, 2014)
- 11. DIFFERENTIAL DIAGNOSIS: HERPES ZOSTER (Hutchinson & Miller, 2014)
- 12. DIFFERENTIAL DIAGNOSIS: HERPES ZOSTER (Usatine, 2014)
- 13. DIFFERENTIAL DIAGNOSIS Contact dermatitis possible, however given no changes in habits and no exposure to irritating contributors unlikely. Folliculitis possible, however given presentation and PMHx, not likely. Herpes zoster likely, PMHx of chickenpox, systemic response (febrile), dermatomal distribution of vesicular lesions, and does not cross midline of face. Presentation without thorough history of symptoms led patient to having diagnosis after second visit.
- 14. DIFFERENTIAL DIAGNOSIS Herpes zoster: reactivation of varicella zoster Lifetime risk: 10-20% Risk factor: Age, immunocompromised, cancer Prevention: Zoster vaccination (average cost is $194.00). Level of evidence: A (SORT*). Presentation: Rash is vesicular and unilateral, dermatomal pattern. Level of evidence C (SORT*). Diagnosis: Diagnostic testing not recommended. Level of evidence: C (SORT*). (Hutchinson & Miller, 2014) *Strength of Recommendation Taxonomy
- 16. AVAILABLE DIAGNOSTIC TESTING Test Name Positive Likelihood Ratio Negative Likelihood Ratio Sensitivity Specificity Polymerase Chain Reaction (PCR)* 95.00 0.050 95% 99% Viral culture* 20.00 0.810 20% 99% Immunofluorescence* 3.40 0.240 82% 76% *Assumption that pretest probability is 50% (Bader, 2013; Hutchinson & Miller, 2014)
- 17. AVAILABLE DIAGNOSTIC TESTING Test Name Clinical Pathology* Any Lab Test Now* PCR $47 Not offered Viral culture Not offered Not offered Immunofluorescence $17 $39 • Out of pocket expenses: • FirstCare • HMO • Lab testing ordered during provider visit covered under copay • Medicare part B • Lab testing deemed medically necessary • Approved provider *prescription required Any Lab Test Now Representative, personal communications, July 9th, 2014; Clinical Pathology Representative, personal communications, July 9th, 2014; FirstCare Representative, personal communications, July 9th, 2014.
- 18. AVAILABLE DIAGNOSTIC TESTING • No diagnostic testing recommended Test Name Negative Likely Positive ICD 9 code CPT code PCR < 499 DNA copies per mL n/a > 500- 2,000,000 DNA copies per mL 053.9 87799 Immunofluorescen ce < 0.9 ISR* 0.91-1.09 ISR* > 1.10 ISR* 053.9 86787 (Quest Diagnostics, 2014a; Quest Diagnostics 2014b)) • Interpretation: *ISR = Immune Status Ratio
- 19. TREATMENT Antiviral: Initiation of treatment within 72 hours with antiviral is recommended in patients over 50. Level of evidence A (SORT). Pain control: Amitriptyline initiated within 48 hours reduces the incidence of postherpatic pain after 6 months in patients over 60. Acute pain can be managed with gabapentin, tramadol, NSAIDS, and tricyclic antidepressants. Level of evidence B (SORT). Corticosteroids have a modest benefit to acute treatment and are not routinely recommended. Level of evidence B (SORT). (Hutchinson & Miller, 2014)
- 20. TREATMENT Antiviral Dose How often Duration Costco pricing Acyclovir* 800mg 5 times/day 7 days $15.18 Valacyclovir 1000mg 3 times/day 7 days $30.77 Famciclovir 500-750mg 3 times/day 7 days $29.71 * On $4 prescription list at Wal-Mart Valacyclovir is superior to Acyclovir Famciclovir has similar results to Valacyclovir (Costco, 2014; Walmart, 2014)
- 21. ETHICAL CONSIDERATIONS United Nations Educational, Scientific and Cultural Organization (UNESCO) Human dignity Human rights Autonomy and individual responsibility Benefit and harm Respect for cultural diversity and pluralism Social responsibility and health (Baumann, 2010; O’Mathuna, 2011)
- 22. ETHICAL CONSIDERATIONS Patient- centered care Incorporating patient/family preferences in decision- making process Mrs. V is a private person and does not want her family at appointments Patient autonomy Keeping patient informed and respecting their health decisions Risk/benefit of antiviral treatment Dignity of the individual Respected decision to not involve family Discussed treatment options Supported her decision (Bell, 2014; CDC, 2012; Microsoft, 2014 )
- 23. LEGAL CONSIDERATIONS APRN Scope of Practice Tasks that can be performed under a given licensure Outlines patient population, duties, and compensation Guidelines set by national professional organizations AANP Evaluates NP professional role, education, accountability, and responsibility Case Study Acted as primary care providers for a geriatric patient Diagnosing and overseeing new and existing medical conditions (AANP, 2013; Texas Board of Nursing, 2005)
- 24. LEGAL CONSIDERATIONS APRN Standards of Care What another provider would do given the same circumstance Determination if patient received safe and effective care with best possible outcome Case Study Met through assessment, diagnosis, development, and implementation of the treatment plan. Gave detailed follow-up instructions to evaluate treatment plan Barriers to practice or patient care: none (AANP, 2013; Buppert, 2008; Office, 2014)
- 25. QUESTIONS??
- 26. REFERENCES American Association of Nurse Practitioners. (2013a). Scope of practice for Nurse Practitioners. Retrieved from https://www.aanp.org/images/documents/publications/scopeofpractice.pdf American Association of Nurse Practitioners. (2013b). Standards of practice for Nurse Practitioners. Retrieved from https://www.aanp.org/images/documents/publications/standardsofpractice.pdf Any Lab Test Now Representative, personal communications, March 29th, 2014. Bader, M. S. (2013). Herpes zoster: Diagnostic, therapeutic, and preventive approaches. Postgraduate Medicine, 125(5), 78-91. doi:10.3810/pgm.2013.09.2703 Bell, L. (2014). Patient-centered care. American Journal of Clinical Care, 23(4), 325. doi: 10.4037/ajcc2014383 Baumann, S.L. (2010). The limitations of evidence-based practice. Nursing Science Quarterly. 23(3), 226-230. doi: 10.1177/0894318410371833 Buppert, C. (2008). Nurse Practitioner's business practice and legal guide. (3rd ed.). Sudbury, Massachusetts: Jones and Bartlett. Centers for Disease Control and Prevention. (2012, September 01). Self-study modules on tuberculosis. Retrieved from http://www.cdc.gov/tb/education/ssmodules/module7/ss7reading2.htm Clinical Pathology Representative, personal communications, March 29th, 2014. Costco (2014). Pricing information. Costco Pharmacy. Retrieved from: http://www2.costco.com/Pharmacy/druginformation.aspx?p=1&SearchTerm= Ely, J.W. (2014). Folliculitis. Essential Evidence. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/733 Essential Evidence Plus (2013). Herpes zoster. EBM Guidelines. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/ebmg_ebm/17 FirstCare Representative, personal communications, March 29th, 2014. Hutchinson, A. & Miller, M. (2014). Herpes zoster (shingles). Essential Evidence. [Algorithm: diagnostic approach]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/313Bottom of Form
- 27. REFERENCES Hutchinson, A. & Miller, M. (2014). Herpes zoster (shingles). Essential Evidence. [Table: diagnostic testing]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/313Bottom of Form Microsoft (2014). Microsoft Clip Art. [Pictures] Retrieved from: www.office.com O'Mathuna, D. P. (2011). Ethical considerations for evidence implementation and evidence generation. In B. M. Melnyk & E. Fineout-Overholt (Eds.), Evidence-Based practice in nursing and healthcare: A guide to best practice (2nd ed., pp. 474-487). Philadelphia, PA: Lippencott Williams and Wilkens. Quest Diagnostics. (2014a). Varicella-Zoster virus antibodies. Retrieved from http://www.questdiagnostics.com/testcenter/BUOrderInfo.action?tc=34128&labCode=DAL Quest Diagnostics. (2014b). VZV,QN,PCR. Retrieved from http://www.questdiagnostics.com/testcenter/BUOrderInfo.action?tc=19493X&labCode=QBA Texas Board of Nursing. (2005, October 10). Guidelines for determining APN scope of practice. Retrieved from http://www.bon.texas.gov/practice/apn- scopeofpractice.html United Nations Educational, Scientific and Cultural Organization. (2006). Universal declaration on bioethics and human rights. Retrieved from http://unesdoc.unesco.org/images/0014/001461/146180E.pdf Usatine, R. (2014). Herpes zoster (shingles). Derm Expert. [Pictures: facial presentation]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Usatine, R. (2014). Contact dermatitis. Derm Expert. [Pictures: facial presentation]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Usatine, R. (2014). Folliculitis. Derm Expert. [Pictures]. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/tools/dermExpert/index.cfm Weaver-Agostoni, J.S. (2014). Contact dermatitis. Essential Evidence. Retrieved from: http://www.essentialevidenceplus.com.ezproxy.ttuhsc.edu/content/eee/726 Walmart (2014). Retail prescription program drug list. Retrieved from: http://i.walmartimages.com/i/if/hmp/fusion/customer_list.pdf
Editor's Notes
- Mrs. V is 71 year old female of Hispanic descent who is an established patient at this clinic, but is new to this practitioner. Mrs. V complains of a painful burning and itching to the left side of her head and face for the past two days, with pain rating 10/10. She states she has not “felt well” for the past two days and is progressively “feeling worse”. Mrs. V presented to the clinic two days ago complaining of waking up with a headache and having two blisters to the left side of her forehead. She voiced chills “on and off”, headache for 2 days, and difficulty sleeping because of the burning and itching. She denies any use of medications or herbal remedies for the symptoms. Mrs. V denies any aggravating or alleviating factors.
- PAST MEDICALHISTORY: Medical: Hypercholesterolemia Vitamin D deficiency Childhood illness includes chickenpox Surgical: C-section (1968); Cholecystectomy (1986); Denies recent hospitalizations, transfusions Medications: Lovaza 1gm twice daily after meals Citracal with Vitamin D 630/500 once daily in the morning Alprazolam 0.5mg at bedtime as needed for insomnia Over-the-counter medications include acetaminophen for occasional aches and pain. Allergies: Denies allergies to food/medications Health maintenance: Ms. V states her last PAP smear and mammogram was last year and last colonoscopy was five years ago. Her last physical exam was in May 2014. Immunizations: She states she received her flu vaccine last October, but this is not indicated in the clinic’s record. Clinic records indicate she is due for her Tdap, pneumococcal, and Zoster vaccines. Personal history: Mrs. V states she is Hispanic, married, and a retired secretary. She lives in a one-story home with her husband of 54 years. She intermittently cares for her granddaughter. Health habits: She denies any tobacco/alcohol/illicit drug use and states she attends English classes once a week. FAMILY HISTORY: Mrs. V states her father died at age 86 due to diabetes mellitus (DM) complications. Her mother also had DM, but died at age 75 from an intracranial bleed after sustaining a fall at home. She states she has one sister who has diabetes and history of breast cancer diagnosed at age 66 and one brother who has DM. Mrs. V has one daughter and one son who are in generally good health; and, she denies any miscarriages/abortions.
- + GENERAL: States headache/chills/difficulty sleeping and burning/itching to left side of head/face x2days. Denies night sweats or weight changes. + INTEGUMENTARY: Positive for rash to left-side of head. Denies bruising, changes in moles or pigment. + NEUROLOGIC: Headaches. Denies head trauma, loss of consciousness, dizziness, or problems with balance/coordination. EYES: Uses bifocal glasses for reading. Denies any blurry/double vision, vision changes, trauma, eye diseases. States last eye exam August 2013. ENT: Denies any hearing loss/changes, pain, tinnitus, recent infections. Denies epistaxis or difficulty swallowing. Denies nasal congestion or scratchy throat. Denies dentures, ulcers, or tooth problems. Last dental exam January 2014. CARDIOVASCULAR: Denies any night sweats, chest pain, edema, palpitations. RESPIRATORY: Denies any cough, hemoptysis, shortness-of-breath, dyspnea on exertion, exposure to TB. GASTROINTESTINAL: Denies incontinence, changes in bowel patterns, heartburn. No hematochezia, hematemesis. MUSCULOSKELETAL: Denies any pain, heat, swelling to joints. Denies problems with range of motion. + MENTAL STATUS: Positive for increased stress related to caring for a young child. Denies any confusion, memory deficits, mood changes, thoughts of hurting self or others.
- Upon examination, Mrs. V is noted to have a fluid-filled vesicular rash across the frontal, temporal, and zygomatic areas.
- Contact dermatitis can be clinically diagnosed with no further testing with a thorough patient history. Generally, the patient will have been exposed to a known irritant (i.e. cosmetic, jewelry, chemical, topical, etc.). Treatment includes removal or discontinuation of irritant, ointments, mild soap, and possibly topical corticosteroids to help with inflammation (Weaver-Agostoni, 2014).
- Note the linear pattern of skin eruption. It is localized to a specific area where the irritant was in contact with the skin.
- Folliculitis can be clinically diagnosed based on presentation. First- line treatment includes the use of antibacterial soaps. Antibiotics should be reserved for extensive involvement (Ely, 2014).
- Note the pustule presentation. Folliculitis does not appear clustered because it is an infection of the hair follicle(s).
- This simple flowchart depicts the thought process on the diagnosis of herpes zoster in the clinical setting. Usual presentation is on the trunk or face (Essential Evidence Plus, 2013). Understanding the classical presentation of unilateral rash, pain due to PNS innervation of the herpes zoster, and vesicular nature helps providers make this clinical diagnosis. It is important to remember that the patient must have had previous exposure to the varicella zoster for this presentation, through either the shingles vaccine or previous history of chickenpox (Hutchinson & Miller, 2014).
- The images above represent facial presentation of herpes zoster. Note that only one side of the face is affected, following a dermatomal pattern. Also note how the rash appears in clusters, classical of herpes zoster. Remember, the facial presentation of herpes zoster may include cranial nerve innervation, specifically of the trigeminal nerve (Hutchinson & Miller, 2014).
- Current literature does not support routine testing for herpes zoster as the diagnosis is generally made by a detailed history and physical exam (Hutchinson & Miller, 2014). Testing is reserved for cases that are not easily distinguishable due to a disseminated disease process that involves multiple dermatomes (Bader, 2013). The easiest and most widely available test is direct fluorescent antigen assay, which measures the varicella IgG titers. Immunofluorescence has a higher sensitivity and specificity than viral culture but is not as precise as the herpes zoster PCR testing for viral DNA (Bader, 2013).
- For a patient who does not have insurance or Medicare coverage, out of pocket expense may make lab testing difficult. Immunofluorescence is available at several local laboratories including Clinical Pathology and Any Lab Test Now. According to I. C., a technician at Clinical Pathology, they offer a varicella IgG and IgM titer for $17 with results being available 24-72 hours after testing (personal communication, July 9, 2014). Clinical Pathology offers a varicella PCR test for $47. K. M., with Any Lab Test Now, states that the Lubbock branch offers the varicella IgG and IgM titer test for $39 in the same amount of time (personal communication, July 9, 2014). Any Lab Test Now does not offer varicella PCR testing. They do not offer varicella viral culture testing at either company. Both companies require a prescription for the lab test before the test can be run, which means that a provider visit is necessary prior to the lab testing. According to A. C. with FirstCare, an HMO that serves Covenant Health System employees, laboratory testing that is ordered during a provider visit is covered under the copay, regardless of whether that testing is recommended in current guidelines (personal communication, July 9, 2014). Medicare Part B covers lab testing that is deemed medically necessary and is ordered by an approved provider.
- While titers do differentiate between herpes simplex and herpes zoster, a positive test does not answer the question of whether a current infection is zoster. Results less than or equal to 0.9 are negative, 0.91-1.09 are suggestive, and results above 1.10 are considered to be positive for a varicella IgG titer (Quest Diagnostics, 2014a). Quantitative polymerase chain reaction (PCR) testing for varicella virus DNA is highly specific and is a definitive answer if multiple differential diagnoses are possible and results are available 48-72 hours after testing. PCR testing for varicella is considered positive if there are >500-2,000,000 DNA copies per mL of serum (Quest Diagnostics, 2014b). In the case of our patient, no diagnostic testing is recommended. She falls within the guidelines for diagnosis by comprehensive health history and classic signs and symptoms of herpes zoster. Her vesicular rash is secluded to the trigeminal 1 dermatome with scattered involvement of the trigeminal 2 dermatome, both on the left side of her face. Lab testing would not change the care that will be provided. The ICD 9 code for herpes zoster without complication is 053.9. The CPT code for varicella IgG titer is 86787. The CPT code for varicella virus PCR is 87799.
- Choosing the best antiviral for the patient is necessary to not only enhance compliance with medication regiment, but so that the patient can afford the medication. Above is an out of pocket pricing example for the generic brands of each drug.
- Ethical Considerations: Patients with the same disease process may not benefit from the same course of treatment because of factors affecting each life which impact the clinician’s decision in selecting the best course of treatment. The United Nations Educational, Scientific and Cultural Organization (UNESCO) established the following ethical principles: human dignity and human rights, autonomy and individual responsibility, benefit and harm, respect for cultural diversity and pluralism, and social responsibility and health (as cited in O’Mathuna, 2011, p. 475). These principles are compromised when the clinical focus is solely on measureable outcomes (Baumann, 2010). For this reason, we made sure to combine Mrs. V’s belief of needing medication with current evidence-based research.
- Patient Centered Care: Involves incorporating the patient’s and their family’s preferences in the decision-making process (Bell, 2014). Mrs. V states she is a private person and does not want her family to attend appointments with her. Therefore, our care plan was exclusively based-upon the patient’s wishes. Patient Autonomy: As providers, we must always keep the patient informed and respect their health care decisions to ensure their right to autonomy (Centers for Disease Control and Prevention [CDC], 2012). It is for this reason that we informed Mrs. V of the risks and benefits of starting an antiviral drug and supported her decision to take the medication. Dignity of the Individual: We were able to empower and maintain Mrs. V’s dignity by: respecting her decision to not involve her family; discussing the treatment options with her; and, supporting her choice to begin taking the medication (Bell, 2014; CDC, 2012).
- APRN Scope of Practice: Scope of practice refers to the tasks that can be performed under a given licensure and outlines the following: patient population for which the NP can provide care; duties that can be performed; and, impacts on compensation for provided services (Texas Board of Nursing [BON], 2005). An NP’s scope of practice is best defined through guidelines set forth by national professional organizations (BON, 2005). The American Association of Nurse Practitioners (AANP) (2013a) addresses the scope of practice for NPs through evaluating their professional role, education, accountability, and responsibility. Nurse practitioners can provide primary care in ambulatory clinics to diagnose and manage acute illnesses by ordering and interpreting laboratory tests, prescribing therapies, and educating patients and families (AANP, 2013a). For the purpose of this case study, we acted as primary care providers for a geriatric patient as this is in keeping with our educational preparation as NPs. Furthermore, we performed as licensed, independent practitioners providing primary care in an ambulatory clinic while diagnosing and overseeing new and existing medical conditions (AANP, 2013a).
- APRN Standards of Care: Defining the standard of care is evolving from what another provider would do given the same circumstance to addressing whether the right action was taken at the right time and determining if the patient received safe and effective care with the best possible outcome (Buppert, 2008). Governmental agencies are beginning to adopt the standards set by professional organizations (Buppert, 2008). We met the NP standards of care through our assessment, diagnosis, development and implementation of the treatment plan for the patient (AANP, 2013b). We further complied by giving the patient detailed follow-up instructions so we can evaluate our treatment plan for Herpes Zoster (AANP, 2013b). Barriers: No barriers to practice or patient care were encountered. However, if Mrs. V had been a poor historian regarding the onset of symptoms, insisted on an antibiotic, or refused to take the antiviral, then our approach and treatment plan would have had to change to accommodate her needs as best as possible