care for a client with sle pericarditis

8/8/2019 Care for a Client With Sle Pericarditis

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CARE FOR A CLIENT WITH SLE PERICARDITIS

Submitted by:

Labang, Joy Cypress L.

MN-MSN

Submitted to:

Mrs. Norma Hinoguin

Dean,College of Nursing

USPF


2/16

Systemic Lupus Erythematosus

an autoimmune disease characterized by a malfunction of the immune system one in which the immune

system cannot distinguish between the body's own cells and tissues and that offoreign matter, like viruses.

Complications from SLE affecting the heart are common in lupus patients

What is Pericarditis?

inflammation of the pericardium

What is Lupus Pericarditis?

most common form of heart involvement in Lupus.

patients tend to develop pericarditis more than any other disease of the heart.The trigger, it seems, is antigen-antibody complexes produced during activelupus.

occurs when antigen-antibody complexes-also known as immune complexes-aremade during active lupus and cause inflammation within the pericardium.

Clinical Manifestations:

Fatigue Arthralgia Arthritis Fever

Skin rashes Anemia Edema Pleurisy Facial rash Photosensitivity Alopecia (hair loss) Seizures Mouth or noise ulcers


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American College of RheumatologyCriteria for Classifying SLE

Malar rash

Discoid rash

Photosensitivity

Oral ulcers

Arthritis

Serositis (pleuritis or pericarditis)

Renal disorder (persistent proteinuria or cellular casts)

Neurological disorder (seizures or psychosis)

Hematologic disorder (anemia, leukopenia or lymphopenia on two or moreoccasions, thrombocytopenia)

Immunologic disorder (abnormal anti-dsDNA or anti-Sm, positive

antiphospholipid antibodies)

Abnormal ANA titer

Complications:

Cardiac Tamponade

Prognosis:

Survival for lupus patients with central nervous system, major organ involvementand/or kidney disease is likely to be shorter than those with only skin and/or joint

disease related to lupus. The most common cause of death associated with lupus is infection due to

immunosuppression, caused by medications used to manage the disease.


4/16

GENERAL DATA

Name : F.M.

Age : 15 years old

Sex : Female

Address : Ubaub, Argao, Cebu

PAST MEDICAL HISTORY

Non-hypertensive Non-diabetic Non-asthmatic Sore throat during childhood No history of PTB exposure

No FDA No Vices

HISTORY OF PRESENT ILLNESS

9 mos PTA ,(+) migratory

joint painsassociatedwith on & offfever.

6 mos PTA,(+) productivecough with whitishsputum, associatedwith night sweating,low grade fever &weight loss (~50%).

4 mos PTA, consulted

at VSMMC-OPD.

CXR revealed

pneumonia with min

pleural effusion.

Given Co-amoxiclav,

Azithromycin,

Furosemide &

Salbutamol


5/16

3 mos PTA, admitted atVSMMC due todyspnea, & dx withCAP-MR & RHD withpulmonary HPN & minpericardial effusion.

Treated with genta,

ceftri, clarithromycin,

metoprolol,

spironolactone+butizide

& trimetazidine.

Noted skin rashes on

elbows & feet & falling

of hair.

2 mos PTA,px wasadmittedat Kintanar,Argao due todyspnea.

9 days PTA,+recurrence &worsening ofdyspneaassociated with

orthopnea,R hip & knee jointpain, thus re-admitted atKintanar, Argao.

2 days PTA,conditionpersistedwhich

prompted tosee acardiologist.

Admitted inSacred Heart Hospital


6/16

PHYSICAL EXAMINATION

Examined conscious, coherent, in mild respiratory distress, non-ambulatory andunderweight with the ff v/s:

BP- 90/60mmHg RR- 26cpm

PR- 120bpm Temp- 37.5oCWt- 45kg

Skin : dry, pale, (+)hyperpigmented areas over the elbow,(+)bed sore gluteal area (gr.2)

HEENT : thinning hair, pale palpebral conjunctivae,(+)NVE, (-)LAD, (+)dental carries

C/L : absent BS at R lung with decreased Breath Sound on Left mid tobasal lung field, (-)wheeze

CVS : DHS, tachycardic, regular rhythm,

(+) 3/5 holosystolic murmur mitral area radiating to the axilla,(+) S3, no S4

Abd : scaphoid, soft, NABS, no tenderness,no mass palpated, no organomegaly

Ext : wasted, absence of fat with prominent bones,tenderness & swelling of R hip & knee joints with LOM,

(+)pain on leg raising

Motor : 5/5 in all areas except for 3-4/5 in R lower extremity


7/16

CRITERIA DAY 1

1. DAILY OUTCOME Chief Complaint: DyspneaNursing Diagnosis:Impaired Gas exchange r/t decreasedCardiac Output as evidenced by decreased

O2 Sat, cyanosis and dyspnea on exertion.Indicators:

O2 sat - 87-90%

RR - 22 cpm

Uses accessory muscles inbreathing

Weakness and pallor noted.Goal:Within 1 hour of nursing intervention, pthas adequate gas exchange as evidencedby normal RR with normal depth and

pattern and O2 sat >92%.2. ASSESSMENT AND TESTS Physical Assessment:

RR - 22 cpm

Uses accessory muscles inbreathing

Weakness and pallor noted.

O2 sat - 87-90%Physical Exam Result:

C/L :absent BS at R lung withdecreased Breath Sound on Leftmid to basal lung field, (-)wheeze

CVS :DHS, tachycardic, regular

rhythm, (+) 3/5 holosystolic murmurmitral area radiating to the axilla,(+) S3, no S4

Tests:A. CXP- PA (6/08/09):

Moderate pleural effusion, Right,small amt at the Left. Cardiomegaly

B. UTZ of R hemithorax

Moderate bilateral pleural effusion,~2238 ml R and~ 1222 ml L.

No definite areas of septae,loculation or mass lesions.

C. UTZ of whole abdomen

Small amt of GB sludge but nostone detected.

Normal liver, biliary ducts, spleen,pancreas & KUB.

Incidental finding of bilateral pleuraleffusion.


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D. ABG Analysis

pH 7.411

pCO2 30.0

pO2 68.1

HCO3 18.6 mmol/LBE (ecf) -6.0 mmol/L

O2 sat 94.1%E. Urinalysis

Specific Gravity 1.025

pH 5.0

Albumin and Blood +

Ketone andGlucose

negative

WBC 5-8/hpf

RBC 4-7/hpf

F. Pleural Fluid

Glucose 97 mg/dlTotal Protein 5.8 g/dl

LDH 175 u/lG. Pleural Fluid Analysis

Color ColorlessTransparency Hazy

WBC 15/cu mm

RBC 100/cu mm

Total Cell Count 115/ cu mm

Segmenters 3

Lymphocytes 97

No AFB seen G/S: no organism seen

3. TREATMENT 1. Assess breath sounds and respirationsat least every 4 hours.2. Assess breathing effort for adequatedepth at least every 2 hours.3. Monitor O2 saturation, report satreadings of 92% or less.4. Provide supplemental oxygen asprescribed, typically 2-3 LPM,by nasalcannula.5. Place patient in Semi-fowlers or high

fowlers position to ease on the heart,which will help decrease effort of breathing.

Procedure:1. Emergency Pericardiocentesis

is a procedure where fluid isaspirated from the pericardium


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Except in emergencies (eg, cardiactamponade), pericardiocentesis, apotentially lethal procedure, shouldbe done using echocardiographicguidance.

2. Chest Tube Insertion

involves the surgical placement of ahollow, flexible drainage tube intothe chest

inserted to drain blood, fluid, or airand to allow the lungs to fullyexpand.

4. PATIENT EDUCATION 1. Teach patient to breath deeply.2. Teach the use of incentive spirometer.3. Teach cascade cough to reducestressful coughing which increases pain.4. Advise the patient to be in bed rest andget enough sleep.5. Schedule diagnostic tests andprocedures to allow adequate rest. Explainall tests and procedures.6. Teach the patient and family s/sx ,ofcardiac problems including warning signsof heart attack. Reinforce the importance ofreporting them to the physician.

5. MEDICATIONS Cardiovascular Drugs:1. Digoxin (LAnoxin) 0.25 mg tab OD2. Carvedilol (Dilatrend) 6.25 mg 1 tab BIDDiuretics:1. Spinorolactone (Aldactone) 50 mg 1 tabBID2. Furosemide (Lasix) 40 mg tab ODRespiratory Drugs:1. Ipratropium + Salbutamol (Combivent) 1neb every hour.

6. DIET / NUTRITION 1. Well balanced diet2. Low fat, Low cholesterol diet isrecommended.3. Fluid restriction 800 ml/ day.4. Restrict salt (particularly for pt with signsof high BP or kidney disease.

7. PSYCHOLOGICAL CARE 1. Help patients gain control over feelingsand emotions. The nurse should assist thepatient or suggest professionals who canhelp.2. Patients emotional stressors should becarefully assessed, because they may playa role in triggering a flare. Instruct pt toavoid theses stressors.


10/16

CRITERIA DAY 21. DAILY OUTCOME Problem: Joint Pain

Nursing Diagnosis:Acute Pain r/t inflammatory process.Goal:Within 24 hour of nursing interventions,

patients subjective perception of paiondecreases from 8/10 to 4/10.

2. ASSESSMENT AND TESTS Physical Assesment:

1. Sharp chest pain thatradiates to the back, neck orleft shoulder or arm.

2. Pain increases duringcoughing or deepinspiration, movement orlying down.

3. Pain eases upon sitting upand leaning forward.

4. Facial grimacing noted5. Tachycardia- PR-120bpm6. PS: 8/107. Dyspnea

Physical Exam Findings:

CVS :DHS, tachycardic, regularrhythm, (+) 3/5 holosystolic murmurmitral area radiating to the axilla,(+) S3, no S4

Ext :wasted, absence of fat with

prominent bones, tenderness &swelling of R hip & knee joints withLOM, (+)pain on leg raising

Motor : 5/5 in all areas except for3-4/5 in R lower extremity

Laboratory Tests:1. CBC Result

WBC 4.05

Neu 76.2

Lym 15.8

Hgb 7.82

Hct 23.2%

Plt 2422. Serum Creatinine

Na 135.6 mmol/LK 4.42 mmol/L

ESR 138 mm/hr (0.20)HGT 101 mg/dl


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3. Protime

Patient 14 secs

Control 11.3 sec(10.2-13.0)

INR 1.24 (0.82-1.2)

% Activity 80.71%(70-100%)

3. TREATMENT 1. Auscultate heart sounds for thepresence of friction rub as an indicator ofpericardial inflammation.2. Assess and document character,intensity and duration of pain.3. Administer pain medications asprescribed, and document effectivenessusing the pain scale.4. Use the ff interventions to enhancemedication effectiveness:a. Support the patient in a side-lyingposition with pillows or in Fowlers position.b. Pad over-the-bed table with pillows orbath blankets to support the patient.c. Control environmental stimuli by limitingvisitors.5. Administer O2 as prescribed.6. Administer NSAIDS, steroids andantibiotics as prescribed to manage thepericardial inflammation.

4. PATIENT EDUCATION 1. Instruct patient and family regarding theuse of prescription and non prescriptionmedications.2. Suggest warm showers or baths tolessen stiffness and pain.3. Teach the patient to avoid coldtemperature and to keep hands and feetwarm.

5. MEDICATIONS 1. NSAIDS: to combat fever, reduceinflammation and control pain.2. Corticosteroids

highly effective in reducinginflammation, relieving muscle and

joint pain and fatigue andsuppressing immune system.

Prednisone 20 mg 2 tabs BID3. Antibiotics

Clindamycin 300 mg 1 cap every 6hours.

Penicillin (Penicillin G) 4M unitsIVTT every 6 hours.


12/16

6. DIET / NUTRITION 1. Take extra Calcium and Vit D2. Diet rich in polyunsaturated fat, found invegetable oils like margarine and corn oil.3. Omega 3 fatty acids found in fish oil andflax seed.

7. PSYCHOLOGICAL CARE 1. Help patient gain control over their newphysical limitations.

CRITERIA DAY 31. DAILY OUTCOME Problem: Fatigue and weakness

Nursing Diagnosis:Activity Intolerance r/t imbalance betweenO2 supply and demand secondary toinflammation or cardiac muscle.Goal:

During activity, patient exhibits cardiactolerance to activity as evidenced by SBPwithin 20 mmHg.

2. ASSESSMENT AND TESTS CVS : DHS, tachycardic, regularrhythm, (+) 3/5 holosystolic murmurmitral area radiating to the axilla,(+) S3, no S4

Ext : wasted, absence of fat withprominent bones, tenderness &swelling of R hip & knee joints withLOM, (+)pain on leg raising

Motor : 5/5 in all areas except for3-4/5 in R lower extremities.

1. Pleural FluidGlucose 97 mg/dl

Total Protein 5.8 g/dlLDH 175 u/l

2. Pleural Fluid Analysis

Color Colorless

Transparency Hazy

WBC 15/cu mm

RBC 100/cu mm

Total Cell Count 115/ cu mm

Segmenters 3Lymphocytes 97

3. TREATMENT 1.Ensure that patient maintains bed restduring febrile period.2. Anticipate patients needs by placingpersonal articles within easy reach.3. Monitor V/S for changes, indicative ofcardiac or pulmonary decompensation,such as pallor, diaphoresis, dysrythmias,


13/16

decreasing BP and increasing HR or RR.4. Assist with turning at least every 2 hoursand provide passive ROM exercises atfrequent intervals.

4. PATIENT EDUCATION 1. Advise patient about importance offrequent rest periods during

convalescence.5. MEDICATIONS 1. Moriamin Forte 1 tab BID

2. Sangobion 1 tab BID3. Epoietin alfa (Recormon) 5000 units SQ2x week.

6. DIET / NUTRITION 1. Supplements of Vitamin B12, B6 andFolate may be necessary.2. Advise pt to avoid dairy and meatproducts may help protect the kidneys.3. Advise pt to avoid poorly cooked or rawfood because it contains bacteria.

7. PSYCHOLOGICAL CARE1. Teach patient to gain control medically.Teach them about warning signs of

impending flare.

Warning Signs of impending flare:

Increased fatigue

New or higher fever

Increased pain

Development ,or worsening of rash

Swollen joints

Development of new symptoms


14/16

DISCHARGE PLAN

Medications : Advise patient to comply to medications prescribed by thephysician such as antibiotics and multi vitamins.

Exercise : Develop a well designed exercise program to maintain strength, endurance and

overall fitness.

Educate family to make a simple plan of work activities.This can help patient toorganize the events of her life and ensure a good balance of rest and activity.

Treatment :

For sun sensitive patients- teach to use the best sunscreen, the

one that protects against UVA and UVB rays.

Instruct patient to return to follow up check-up to her physician.

Health Teachings :

Reduce exposure to sun and to some sources of artificial light.

Limit outdoor activity between thw hours ,of 10 am to 4 pm.

If mouth ulcer develops, teach patient to rinse mouth with salt water and to eatsoft foods.

Advise patient to wear protective clothing such as wide-brimmed hats and longsleeves.

Observable Signs :

Notify physician if any rash or sore that appears or get worse.

Teach patient to report warning signs of an impending lupus flare to the

physician.Warning Signs of impending flare:

Increased fatigue

New or higher fever

Increased pain

Development ,or worsening of rash

Swollen jointsDevelopment of new symptoms

Diet :

Diet rich in fruits and vegetables is the best, to prevent complicatiuons.

Diet rich in polyunsaturated fat.

Avoid poorly cooked or raw foods.

Spiritual Advise :

Encourage patient to pray and ask for Divine Providence for early recovery.


15/16

APPENDIXA: PATIENTS ACTUAL CHEST X-RAY RESULT

CXP- PA (6/08/09):Moderate pleural effusion, Right, Lumbosacral Spine APL:

small amt at the Left. No significant lesion notedCardiomegaly

Right Hip Joint:Sclerosis with cystic changes at the roof of the acetabulum,suggestive of chronic inflammatory process.


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care for a client with sle pericarditis

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