systemic lupous erythematosus(sle) part 2

V. Medical Management

A. General Management

Ideal Management

1. Optimize the Use of Immunosuppressives Corticosteroids, such as prednisone, are a mainstay of lupus therapy because

they suppress the immune system and reduce inflammation..

Cyclophosphamide also suppresses the immune system and has antiinflammatory properties. Treatment with cyclophosphamide improves many severe manifestations of lupus. Unfortunately, cyclophosphamide can produce serious toxicities.

Mycophenolate mofetil (CellCept®) is another immunosuppressant used to treat severe lupus.

2. Tests for Blood Cell Abnormalities Blood cell abnormalities often accompany SLE. People suspected of having lupus are usually tested for anemia, leukopenia, and thrombocytopenia.

Anemia Tests for anemia include those for

1. hemoglobin, 2. hematocrit3. red blood cell (RBC) counts

In addition, the levels of iron, total iron-binding capacity, and ferritin may be tested. The anemia may be caused by iron deficiency, gastrointestinal (GI) bleeding, medications, and autoantibody formation to RBCs, or “chronic disease.”

Leukopenia and Thrombocytopenia Abnormalities in the white blood cell (WBC) and platelet counts are an important indicator of SLE. Leukopenia, a decrease in the number of WBCs, is very common in active SLE and is found in 15 to 20 percent of patients. Leukopenia can occur from lupus or from prednisone. Thrombocytopenia, or a low platelet count, occurs in 25 to 35 percent of patients with SLE. This can be serious problem when platelet count is very low.

3. Measurements of Autoimmunity When certain autoantibodies are present, this provides valuable diagnostic information for SLE. The most specific tests are those that detect high levels of these autoantibodies. These are the most common and specific tests for autoantibodies and other elements of the immune system:

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Antinuclear Antibody (ANA) A screening test for ANA is standard in assessing SLE because it is positive in close to 100 percent of patients with active SLE. Patients with SLE tend to have high titers of ANA. False-positive results are found during the course of chronic infectious diseases, such as subacute bacterial endocarditis, tuberculosis, hepatitis, and malaria. The sensitivity and specificity of ANA determinations depend on the technique used.

C-reactive protein test CRP is a protein found in serum or plasma at elevated levels during a inflammatory processes. The protein can be measured via a variety of methods for the quantitative or semiquantitative determination of C-reactive protein in human serum. CRP binds to part of the capsule of Streptococcus pneumoniae. It is a sensitive marker of acute and chronic inflammation and infection, and in such cases is increased several hundred-fold.

Anti-Sm Anti-Sm is an immunoglobulin specific against Sm, a ribonucleoprotein found in the cell nucleus. This test is highly specific for SLE. However, only 30 percent of patients with SLE have a positive anti-Sm test.

Anti-dsDNA Anti-dsDNA is an immunoglobulin specific against native (double-stranded) DNA. This test is highly specific for SLE. Fifty percent of patients with active SLE have a positive anti-dsDNA test. For many patients with anti-dsDNA, the titer is a useful measure of disease activity. The presence of antidsDNA is associated with a greater risk of lupus nephritis.

Anti-Ro(SSA) and Anti-La(SSB) These immunoglobulins, commonly found together, are specific against RNA proteins. Anti-Ro is found in 30 percent of SLE patients. Anti-La is found in 15 percent of people with lupus. Anti-Ro is highly associated with photosensitivity.

Complement Complement proteins constitute a serum enzyme system that helps mediate inflammation. Complement components are triggered into an activated form by such immunologic events as interaction with immune complexes. Complement components are identified by numbers (C1, C2, etc.). Genetic deficiencies of C1q, C2, and C4, although rare, are commonly associated with SLE. A test to evaluate the entire complement system is called CH50. The most commonly measured complement components are the serum levels of C3 and C4.

Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP) Tests for ESR and CRP are nonspecific tests to detect generalized inflammation. Levels are generally increased in patients with active lupus and decline when corticosteroids or nonsteroidal anti-inflammatory drugs are used to reduce inflammation. However, they do not directly reflect disease activity.

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Antiphospholipid Antibodies (APLs)

APLs are autoantibodies that react with phospholipids. Recent data indicate that APLs recognize a number of phospholipid-binding plasma proteins (e.g., prothrombin, ß2 glycoprotein I) or protein-phospholipid complexes rather than phospholipids alone. APLs are present in 50 percent of people with lupus. Most lupus anticoagulant antibodies are directed against ß2 glycoprotein I or prothrombin.

Anticardiolipin antibodies (ACA). Sensitive enzyme-linked immunoabsorbent assays (ELISAs) using cardiolipin as the putative antigen are commonly performed to detect APLs. In patients with antiphospholipid syndrome, most antibodies detected in anticardiolipin ELISAs are directed against cardiolipin-bound ß2 glycoprotein I.

Anti-ß2 glycoprotein I. Because ELISAs do not recognize cardiolipin unless ß2 glycoprotein I is present, anti-ß2 glycoprotein detection assays have been developed. These assays have revealed that anti-ß2 glycoprotein I antibodies may be more strongly associated with antiphospholipid syndrome than are anticardiolipin antibodies.

4. Tests for Kidney Disease Several tests can be done to assess a patient for kidney disease.

Measurement of Glomerular Filtration Rate and Proteinuria The glomerular filtration rate is a measure of the efficiency of kidneys in filtering blood to excrete metabolic products. Typically this is done by collecting a 24-hour urine sample for measurement of creatinine clearance. Impairment of renal function by lupus nephritis results in reduced levels of creatinine clearance. The 24-hour urine sample can also quantify protein loss.

Protein/Creatinine Ratio Performed on a one-time voided specimen, rather than from a 24hour collection, this test is useful as a measure of protein loss and is more convenient for patients.

Urinalysis Urinalysis can indicate the presence or extent of renal disease. For example, proteinuria can be a reliable indicator of renal disease. The presence of RBCs,WBCs, and cellular casts, particularly red cell casts, in the urine also indicates renal disease.

Measurement of Serum Creatinine Concentration Creatinine is a waste product of muscle metabolism that is excreted by the kidneys. Loss of renal function as a consequence of lupus nephritis causes increases in serum levels of creatinine. The concentration of creatinine in the serum can be used to assess the degree of renal impairment.

Kidney Biopsy Kidney biopsy can be used to determine the presence of immune complexes and the presence, extent, and type of inflammation in the glomeruli. Diagnosing the extent and

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type of inflammation may help to determine a treatment program for lupus.5. Medications

NSAIDs Comprise a large and chemically diverse group of drugs that possess analgesic, anti-inflammatory, and antipyretic properties. Pain and inflammation are common problems in patients with SLE, and NSAIDs are usually the drugs of choice for patients with mild SLE and little or no organ involvement. Patients with serious organ involvement may require more potent anti-inflammatory and immunosuppressive drugs.

CorticosteroidsSLE patients with symptoms that do not improve or who are not expected to respond to NSAIDs may be given a corticosteroid. Although corticosteroids have potentially serious side effects, they are highly effective in reducing inflammation, relieving muscle and joint pain and fatigue, and suppressing the immune system. They are also useful in controlling major organ involvement associated with SLE.

Immunosuppressive agents Used in serious, systemic cases of lupus in which major organs such as the kidneys are affected or in which there is severe muscle inflammation or intractable arthritis. Because of their steroid-sparing effect, immunosuppressives may also be used to reduce or sometimes eliminate the need for corticosteroids, thereby sparing the patient from undesirable side effects of corticosteroid therapy.

Intravenous Immunoglobulins (IVIGs)This drug is thought to reduce antibody production or promote the clearance of immune complexes from the body.

Actual Management TPR every shift DAT Problem: Lupus nephritis

IVF: D5 0.3% NaCl @ KVO rate Urinalysis CBC with platelet count ESR ECG 12 leads FBS Blood Chemistry: Creatinine, Sodium, Potassium

Daily Dressing of wound at lower extremitiesC-reactive Protein Laboratory TestANA determination testMEDICATIONS:

Cefuroxime 750mg IVTT q8 (-)ANST

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Cloxaccillin 500 mg IVTT q6 ANST (-) Cyclophosphoride 1.5 gm Dexamethasone 10 mg amp Metoclopramide 1 tab P.O. PRN Metronidazole 500 mg IVTT q8 ANST (-) Paracetamol 500mg 1 tab q4 PO (for temp. above 38C) Gentamycin 80mg IVTT

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B. DRUG STUDY

Generic Name: Cefuroxime SodiumClassification: Second Generation Cephalosporin Antibiotic Dosage/ Administration/ Route: 750mg IVTT q8h

ANST(-)

INDICATION THERAPEUTIC EFFECTS

MECHANISM OF ACTION

CONTRA-INDICATION

PHARMACOKINETICS/ PHARMACODYNAMICS

SIDE EFFECTS

ADVERSE EFFECTS

NURSING CONSIDERATION

Skin or skin-structure infection caused by Streptococcus Pneumoniae and S. pyogenes, Haemophilus influenza, S. aureus, E. coli, Moraxella catarrhalis

Absence or minimized signs and symptoms of infection

Inhibits cell wall synthesis, promoting osmotic instability; bactericidal

Hypersensitivity to Cephalosporins or Penicillins

Metabolized in the liver; excreted in the urine.

NauseaVomitingDiarrheaAnorexiaAbdominal painFlatulence

Pseudomembranous colitisBloody diarrheaNephrotoxicitySuperinfection

Check patient for hypersensitivity to cephalosporins and penicillins

For P.O., give drug with food. Crush tablet if patient has difficulty with swallowing

Advise patient to take drug as prescribed , even after patient feels better

Instruct patient to notify prescriber if rashes or superinfection occurs

Frequent small

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feedings Comfort

measures for pain relief

Advise to report discomfort at IV insertion site

Notify prescriber if loose stools/ diarrhea occurs

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Generic Name: MetronidazoleClassification: Antiprotozoal Dosage/ Administration/ Route: 500mg IVTT

q8 ANST (-)

INDICATIONTHERAPEUTIC EFFECTS

MECHANISM OF ACTION

CONTRAINDICATION


SIDE EFFECTS

ADVERSE EFFECTS


Acute infection caused by susceptible strains of anaerobic bacteria

Resolution of infection

Inhibits DNA synthesis of specific anaerobes, causing cell death; mechanism of action as anitprotozoal and amebical are not known

Hypersensitivity to drugPregnancy


DizzinessWeaknessNauseaVomiting Metallic tasteDarkening of urine

HeadacheFeverChills

Arrange for appropriate culture and sensitivity test before beginning therapy to ensure proper drug for susceptible organisms

Administer the complete course of the drug to get full beneficial effects

Monitor hepatic function before and periodically during treatment to arrange to effectively stop the drug if signs of failure or worsening liver function occurs

Provide comfort

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and safety measures if CNS effects occur such as side rails and assistance with ambulation if dizziness and weakness are present

Provide small frequent , nutritional meals if GI upset is severe to ensure proper nutrition

Provide proper oral hygiene

Instruct patient that urine may darken in color

Warn patient about metallic taste of the medication

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Generic Name: GentamicinClassification: Aminoglycosides / Antibiotic Dosage/ Administration/ Route: 80mg IVTT q8h

ANST(-)


MECHANISM OF ACTION

CONTRAINDICATION


SIDE EFFECTS

ADVERSE EFFECTS


Treatment of Pseudomonas infection and a wide variety of gram negative infection

Resolution of bacterial infection

Inhibits protein synthesis in susceptible strains of gram-negative bacteria, disrupting functional integrity of the cell membrane and causing cell death

Hypersensitivity to aminoglycosidesRenal disease Pre-existing hearing loss which could be intensified by toxic drug effects on the auditory nerveActive infection with herpes or mycobact

Distribution: extracellular fluids, crosses placenta, poorly distributed in CSF


DizzinessSinusitisNauseaVomitingDiarrheaPalpita-tionsHypo-tensionNumbessTinglingConfusion

RashFeverNephrotoxicitySinusitisNeurotoxicityBone marrow suppressionOtotoxicity

Check culture and sensitivity reports to ensure that this is the drug of choice for the patient

Ensure that the patient receives the full course of aminoglycoside as prescribed, divided around the clock, to increase effectiveness and decrease risk for development of resistant strain of bacteria

Monitor patient for signs of bone marrow suppression, nephrotoxicity, and neurotoxicity to

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erial infectionsMyasthenia gravis or ParkinsonismLactation

effectively arrange dosage, as appropriate, if any of these toxicity occurs

Provide safety measures to protect patient if CNS effects occur

Ensure that the patient is hydrated at all times during drug therapy to minimize renal toxicity from drug exposure.

Evaluate patient’s hearing before and during therapy. Notify prescriber if patient complains of tinnitus, vertigo or hearing loss

Watch out for signs and symptoms of superinfection

Encourage increase fluid intake.

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Generic name: CyclophosphamideClassification: Antineoplastic Dosage/Route/Administration: 1.5 gms

INDICA-TIONS

THERA-PEUTIC EFFECTS

MECHANISM OF ACTION

CONTRAINDICATIONS


SIDE EFFECTS

ADVERSE REACTION

NURSING RESPONSIBILTIES

Treatment of immune system disorders

Death of rapidly replicating cells, particularly malignant ones

Interferes with DNA and RNA Transcription, ultimately disrupting protein synthesis

Hypersensitivity

Inactive parent drug is absorbed from the Gastrointestinal tract. Converted to active drug by the liver.Widely distributed. Limited penetration of the blood-brain barrier. Converted to active drug by the liver; 30% eliminated unchanged by the kidneys

Anorexia, nausea and vomitingHematuriaAlopecia

Pulmonary Fibrosis Myocardial FibrosisHemorrhagic cystitis Leukopenia

• Instruct patient to take dose early in the morning• Monitor BP, pulse, respiratory rate, and temperature frequently during administration. Report significant changes•Monitor urinary output frequently. To reduce the risk of hemorrhage cystitis, fluid intake should be at least 3000 ml/day.•Monitor for bone marrow suppression •asses cardiac and respiratory status for dyspnea, rales/crackles, weight gain, edema • monitor for signs

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and symptoms of cystitis. If occurs, stop the drug and notify prescriber•provide adequate hydration•warn patient that hair loss is reversible•instruct to void by the clock (q1-2hrs)•watch for infection or bleeding•small frequent feedings •oral hygiene •frequent rest periods

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Generic Name: Metoclopramide Classification: GI stimulants Dosage/Route/Administration: 1 tab PO

PRN

INDICATIONTHERAPEUTICEFFECTS

MECHANISMOF ACTION

CONTRA-INDICATIONS


SIDE EFFECTS

ADVERSE REACTION

NURSING RESPONSIBILITIES

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Prevention of chemotherapy-induced emesis

Decreas-ed nausea and vomiting

Blocks dopamine receptors in chemoreceptor trigger zone of the CNS

Hypersensi-tivityGI obstructionHemorrhage History of depression

Well absorbed from the GI tract, from rectal mucosa and from IM sites. Widely distributed into body tissues and fluids. Crosses blood brain barrier.Partially metabolized by the liver, 25% eliminated unchanged in the urine.

Drow-sinessExtrapyramidal reactions RestlessnessConstipationdiarrhea

Anxiety, depression, irritability, tardive dyskinesia Arrythmias,Hyperten-sion, hypotensionGynecomastia

•Administer at least 15mins ac meal and at HS•Instruct patient to medication at the same time each day.

• Instruct patient to monitor weight biweekly

•Caution patient to change position slowly to minimize orthostatic hypotension.

•Safety precaution when performing activities that require alertness especially 2 hrs after dose

Generic Name: Cloxacillin Classification: Penicillin Dosage/Route/Administration: 500mg IVTT q 6hrs ANST (-)

INDICATION THERAPEUTIC

MECHANISM OF ACTION

CONTRAINDICATION

PHARMACOKINETICS/ PHARMACOD

SIDE EFFECTS

ADVERSE REACTION


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EFFECTS YNAMICSSkin and skin structure infections

Bactericidal action

Bind to bacterial cell wall, leading to cell death.Resist the action of penicillinase , an enzyme capable of inactivating penicillin

Hypersensitivity to penicillins

Moderately absorbed following oral administrationWidely distributed; penetration into CSF is minimalSome metabolism by the liver 9-22% and some renal excretion of unchanged drug 30-45%

Diarrhea, nausea and vomiting, phlebitis, rashes

SeizuresPseudomembranous colitis, drug-induced hepatitisInterstitial nephritisAnaphylaxis and serum, sickness, superinfection

•Administer medication around the clock on an empty stomach at least 1 hr before or 2 hours after meals. Take with a full glass of water; acidic juices may decrease absorption.•Instruct patient to notify health care professionals if fever and diarrhea develop, especially if stool contains blood pus, or mucus•Advise patient to report signs of superinfection

Generic Name: DexamethasoneClassification: Coticosteroids Dosage/Route/Administration: 10mg 1 ampule

IVTT

INDICATIONTHERAPEUTIC MECHANISM CONTRA-

PHARMACOKINETICS/ SIDE ADVERSE NURSING

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EFFECTS OF ACTION INDICATION PHARMACODYNAMICS

EFFECTS REACTION RESPONSIBILTIES

•Autoimmune disorders•Diagnostic agent in adrenal disorders•Short term treatment of inflammation disorders

•Suppression of inflammation and modification of the normal immune response•Anti-inflammatory and immunosuppressive effects to allow the body to heal from effects of inflammation

Suppress inflammation and the normal immune response of the bodyBlock action of arachidonic acid which leads to a decrease in prostaglandin and leukotriene productionImpair ability of phagocytes to leave the blood stream and move to injured tissuesBlocks antibody productionInhibit lymphocyte

HypersensitivityActive untreated infectionsTartrazine hypersensitivity or intolerance

Well absorbed after oral administration.Widely distributed.Metabolized by the liver.

Headache restlessnessNausea andvomiting

Depression, EuphoriainsomniacataractsPeptic ulceration HypertensionAdrenal suppressionhyperglycemiafluid retentionpotential CHFIncreased appetite Weight gainHair loss increased susceptibility to infection

•Administer medication in the morning to coincide with the body’s normal secretion of cortisol.•Discuss possible effects on body image•Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stool occurs•Do not give vaccination when patient is immunosuppressed•Protect patient from unnecessary exposure to infection

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activity in immune system

Generic Name: Paracetamol Classification: Anti-inflammatory Dosage/Route/Administration: 500mg 1 tab q 4hrs PRN temp =

>38oC PO


MECHANISM OF ACTION

CONTRAINDICATION


SIDE EFFECTS

ADVERSE REACTION


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Fever Antipyretic Acts directly on the thermoregulatory cells in the hypothalamus to cause sweating and vasodilatation; analgesic effects are thought to be a result of blocking pain impulses, probably inhibiting prostaglandin release

Hypersensitivity

Rapidly Absorbed in the GIT extensively metabolized in the liver and excreted in the urine

Nausea and vomitingDrowsinessdizziness

RashFeverChest painLiver toxicityfailureBone marrow depression

•instruct patient that drug is for short term use only; consult prescriber if given for more than 10 days•use only when temperature is > 38.5C or for recurrent fever or as ordered

VI. NURSING MANAGEMENT

CUES NURSING DIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:“Nanghupong man ko adtong pagka-admit nako. Dani sa akong

Fluid volume excess related to decreased oncotic pressure

Short term:At the end of 30 minutes of nursing

Independent:1. Weigh

regularly.

Independent:1. To provide

comparative baseline and

Short term:At the end of 30 minutes of nursing

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nawong og tiil. Naa pa gani sya hantud karun,” as verbalized by the patient.

Objective: Non-pitting

facial and bipedal edema

Proteinuria= +3

Weight gain (from 65-70kgs in 2weeks time)

secondary to Lupus Nephritis as evidenced by proteinuria of +3 and manifested by non-pitting facial and bipedal edema.

intervention patient will be able to demonstrate behaviors to monitor fluid status, reduce recurrence of fluid excess and verbalize understanding of individual dietary and fluid restrictions.

Long Term:At the end of 2 days of nursing intervention patient will be able to display appropriate urinary output, vital signs within patient’s normal range and minimized edema.

2. Measure abdominal girth daily.

3. Record intake and output regularly.

4. Evaluate edematous extremities and change position frequently as tolerated.

5. Place in semi-Fowler’s position.

6. Promote early ambulation.

7. Discus importance of fluid and sodium

evaluate degree of excess.

2. To note for changes that may indicate increasing fluid retention or edema.

3. To calculate fluid balance.

4. To reduce tissue pressure and risk of skin breakdown.

5. To facilitate movement of diaphragm improving respiratory effort.

6. To promote mobilization of excess fluids.

7. To facilitate understanding and

intervention patient was able to demonstrate behaviors to monitor fluid status, reduce recurrence of fluid excess and verbalize understanding of individual dietary and fluid restrictions.

Long Term:At the end of 2 days of nursing intervention patient did not have an appropriate urinary output but vital signs are within patient’s normal range and progression of edema was minimized.

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restrictions.

Collaborative:1. Restrict water

and sodium intake.

promote wellness.

1. To reduce excessive water retention.


OBJECTIVES INTERVENTIONS

RATIONALE EVALUATION

Subjective:“Lisod kayo ko maglihok tungod sa hubag ug

Acute pain related to tissue injury from lesions in the left

Short term:At the end of 1 hour of nursing intervention,

Independent:1. Develop a therapeutic relationship with

Independent:1. This facilitates patient’s expression of feelings about

Short term: At the end of 1 hour of nursing intervention,

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samad sa akong tiil, dapat alalayan pajud ko aron dli kaau sakit, lisod na matumba palang ko” as verbalized by the patient.“Gakatulog ko’g 12 sa gabii dayon mata2x jud ko permi … tungod kay sakit akong tiil.” as verbalized by the patient.“Sukad sa pagkasamad nako ani na burot, sakit jud ako gakabatiun unya dili mawala ang sakit,” as verbalized by patient.“Dili ko ganahan mag-lihok2x kay musakit ug samot akong tiil. Pagmusakit akong tiil musakit pud akong ulo”,

lower leg as evidenced by pain score of 6/10, 10 as the most painful.

patient will be able to report decreased pain intensity from 6/10 to 4/10.

Long term:At the end of 8 hrs of nursing intervention, patient will be able to report pain is controlled if not relieved.

the patient.2. Provide a clean and soothing environment by keeping the bedside free from unnecessary trash and clutter by arranging linens.3. Administer cold application for 15 minutes.4. Provide backrub.

5. Facilitate deep breathing as tolerated by the patient.

6. Assist the patient to a tolerable position every two hours.

pain.2. Helps improve mental and physical health.

3. Provide pain reduction and reduce swelling and inflammation.4. Provides cutaneous stimulation, blocks pain so as to promote comfortable sleep and relaxation.5. Deep breathing is both a relaxation and distraction technique by stimulating baroreceptors in the atria and carotid sinuses.

6. To provide comfort and prevent complications.

patient was able to report decreased pain intensity from 6 to 4/10.

Long term:At the end of 8 hrs of nursing intervention, patient was able to report pain is controlled.

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as verbalized by the patient. Objective: Pain scale =

6/10, 10 being the most painful

Reduced hours of sleep = 4 hours

Swollen lower left leg

Sighing Limping Guarding

behavior Avoids physical

activity Requesting

help with walking

Lying down during the day

Moving very slowly

Reduced interaction with people

Dependent:1. Collaborate in treatment of underlying condition/disease process causing pain and proactive management of pain such as assisting in wound dressing.

1. To assist client to explore methods for the alleviation/control of pain.

CUESNURSING

DIAGNOSIS OBJECTIVES INTERVENTIONS

RATIONALE EVALUATION

Subjective: Hyperthermia Short term: Independent: Independent: Short term:

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“Init akong paminaw. Tan-awa daw kung gihilantan ba ko,” as verbalized by the patient.

Objectives: Temperature =

37.9 C Skin warm to

touch Heart rate= 94

bpm Respiratory

rate= 25 cpm

related to inflammatory process as manifested by increased body temperature beyond 37.8 °C, warm skin, increased heart rate and respiration rate.

At the end of 30 minutes of nursing intervention, patient will have stable vital signs reduced body temperature from 37.9 °C to 37.5 °C

Long term:At the end of 8 hours of nursing intervention, patient will be able to maintain a body temperature ranging from 36.5 C to 37.4 C and experience no further complications.

1. Provide tepid sponge bath.

2. Ensure proper room ventilation by opening windows or turning the ceiling fan on.

3. Let the client wear non-constrictive and light clothing.

4. Provide ample fluids per orem.

5. Provide adequate rest.

6. Monitor temperature and note for chills or profuse diaphoresis.

1. To promote heat loss by evaporation & conduction.

2. To promote heat loss by convection.

3. To promote heat loss by conduction.

4. To maintain hydration since fluid loss contributes to fever.

5. To reduce metabolic demand and oxygen consumption.

6. To note for changes in vital signs and maintain it within normal.

At the end of 30 minutes of nursing intervention, patient had reduced body temperature from 38 °C to 37.5 °C and normal vital signs.

Long term:At the end of 8 hours of nursing intervention, patient was able to maintain a body temperature from 36.5 °C to 37.2 °C and experienced no further complications.

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Dependent:1. Administer

Paracetamol 500 mg 1 tab q4° for T≥ 38°C as ordered.

2. Provide ample fluids via intravenous route. Administer D50.3%NaCl 500cc and regulate at KVO rate.Collaborative:1.Provide a high calorie diet, as advised by dietician.

1. Pharmacologic intervention to reduce fever

.2. To support

circulating volume.

1.To meet increased metabolic demands of the body.



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Subjective:“Mahilig jud ko ug karne labin nag baboy. Usahay pag walay kwarta, isda nalang. Dili kayo ko hingaon ug gulay, makabuot man pud ko kay ako man ang galuto. Dili pud kaau ko makakaon ug prutas kay wala may kwarta”as verbalized by the patient.

“Dili pud ko mahilig ug gatas, Kape nuon kaisa sa usa ka adlaw. Usahay pud juice kung wala jud, tubig akong ga.imnon” as verbalized by the patient.Objective:

Proteinuria

Imbalanced nutrition less than body requirements related to increased glomerular permeability secondary to lupus nephritis as manifested by presence of protein in the urine, increased level of RBCs in the urine and reduced serum potassium level.

Short term:At the end of 30 minutes of nursing intervention, patient will be able to identify ways on how to improve nutritional status.

Long term:At the end of 8 hours of nursing intervention, patient will be able to consume full share with good appetite.

Independent:1. Encourage

good oral hygiene.

2. Ensure a pleasant environment for eating by covering the wound with dressing and closing the door of the comfort room.

3. Suggest food sources that are rich in protein, iron, and potassium such as fish, beans and banana that are within patients financial capabilities.

4. Instruct to adhere to low-fat, high-protein and high-potassium diet as tolerated.

5. Provide

Independent:1. To enhance

appetite and oral intake.

2. To provide a conducive environment for eating.

3. To provide information on nutritious and affordable food to take.

4. To ensure intake of needed nutrients and prevent complications.

5. To provide

Short term:At the end of 15 minutes of nursing intervention, patient was able to identify ways on how to improve nutritional status by enumerating foods she is advised to eat .

Long term:At the end of 8 hours of nursing intervention, patient was able to consume full share with good appetite.

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= +3 RBC in

urine = 13-15/hpf

Pale conjunctiva

patient teaching on importance of well balanced and nutritious intake.

Collaborative:1. Prepare

tolerable diet specific to the needs of the patient.

knowledge on what foods to take.

1. To provide for lacking nutrients and ensure adequate intake of such.



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Subjective:“Tulo mani ka burot, isa ka dako ug duha ka gagmay, sa pagka-admit nako dani nibuto ni ang pinakadako…,” as verbalized by the patient.

“Lisod kayo ko maglihok tungod sa hubag ug samad sa akong tiil…,” as verbalized by the patient.

Objective:

Lesions at left lower leg

Impaired skin integrity related to lesions at left lower leg.

Short term:At the end of 30 minutes of nursing intervention, patient will be able to identify means on how to prevent further skin integrity impairment such as skin care.

Long term:At the end of 8 hours of nursing intervention patient will be able to demonstrate proper skin care and prevent further skin integrity impairment.

Independent:1. Clean, dry and

moisturize intact skin. Use warm water.

2. Encourage adequate nutrition and hydration. Serve foods rich in calories such as beans.

3. Instruct to avoid harsh chemicals e.g. detergents and not to use soaps or lotions with alcohol.

4, Protect self form exposure to sunlight such as using sun block and long-sleeved clothing.


medications as ordered:

-Cefuroxime IVTT

Independent:1. To keep skin

intact.

2. To promote healing and prevent infection.

3. To prevent skin irritation. Alcohol dries the skin which exacerbates the condition.

4. To prevent exacerbations since rashes are also triggered by sunlight exposure.

Dependent:1. To treat

underlying cause and prevent infection

Short term:At the end of 30 minutes of nursing intervention, patient was able to identify means on how to prevent further skin impairment.

Long term:At the end of 8 hours of nursing intervention patient was able to demonstrate proper skin care and prevent further skin impairment.

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q8° (-) ANST.-Cloxacillin 500

mg IVT q6° ANST (-)

-Gentamycin 80 mg IVTT q8° ANST (-)

-Metronidazole 500 mg IVTT q8° ANST (-)

-Dexamethsone 10 mg amp

2. Assist in everyday wound dressing.

thus facilitating wound healing.


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Subjective:“Gakatulog ko’g 12 sa gabii dayon mata-mata jud ko permi tungod sa saba ug sa mga tao dani sa akong palibot ug tungod kay sakit akong tiil.” as verbalized by the patient.“Pangbawi sa akong tulog matulog ko ug ginagmay sa buntag ug hapon” as verbalized by the patient.Objective: Decreased

number of hours of sleep = 4 hours

Sleep during the day, at most 2 hours.

Sleep pattern disturbance related to pain at left lower leg and environmental factors such as noise and temperature as manifested by reduced number of hours of sleep.

Short term:At the end of 20 minutes of nursing intervention, patient will be able to identify methods on how to improve quality of sleep.

Long term:At the end of 16 hours of nursing intervention, patient will be able to increase in the number of hours of sleep and feeling rested on awakening.

Independent:1. Minimize the

environmental noise by closing the door properly always and maintain comfortable temperature and proper ventilation as much as possible.

2. Assist in wearing comfortable clothes and washing her face

3. Assist patient in performing bedtime rituals and provide sleeping aids such as pillows.

4. Provide comfort

Independent:1. To provide an

environment conducive for sleeping.

2. To provide comfort and freshness.

3. To promote relaxation.

4. To promote rest and

Short term:At the end of 20 minutes of nursing intervention, patient was able to initiate sleep.

Long term:At the end of 16 hours of nursing intervention, patient was be able to improve sleep pattern as evidenced by increase in the number of hours of sleep and feeling rested on awakening.

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measures by doing back rub and placing patient flat on bed with head elevated by a pillow.

5. Organize nursing care.

6. Limit fluids before bedtime.



-Cefuroxime IVTT q8° (-) ANST.

-Cloxacillin 500 mg IVT q6° ANST (-)-Gentamycin 80 mg IVTT q8° ANST (-)-Metronidazole 500 mg IVTT q8°

relaxation.

5. To promote minimal interruption in sleep/rest.

6. To reduce need for voiding during the night.

Dependent:1. To treat

underlying cause and prevent infection thus facilitating wound healing.

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ANST (-)-Dexamethsone 10 mg amp-Cyclophospha-mide 1.5 g 2. Assist in

everyday wound dressing.


CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

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DIAGNOSISSubjective:“Lisod kayo ko maglihok tungod sa hubag ug samad sa akong tiil, dapat alalayan pajud ko aron dli kaau sakit, lisod na matumba palang ko” as verbalized by the patient.“Galisod jud ko ug lakaw unya mahadlok pud ko musakit ug samot akong tiil mao nang gapatabang ko sa akong bana sa pag.cr,” as verbalized by the patient. “Dili ko ganahan mag-lihok2x kay musakit ug samot akong tiil. Pagmusakit akong tiil musakit pud akong ulo”, as verbalized by the patient.

Activity intolerance related to local inflammatory process at lesions on left lower leg and surrounding areas as manifested by avoiding physical activity, lying down during the day and reduced interaction with people.

Short term:At the end of 8hrs of nursing intervention, patient will be able to report measurable increase in activity tolerance as evidenced by ability to ambulate to comfort room as tolerated.

Long term:At the end of 16hrs of nursing intervention, the patient will be able to perform activities of daily living with minimal limitations due to pain.

Independent:1. Assist patient with activities.

2. Promote comfort measures such as deep breathing and safe environment.3. Provide positive atmosphere while acknowledging difficulty of the situation for the patient.4. Increase exercise/activity levels gradually.5. Involve significant others in planning and doing activities.

Collaborative:1. Administer


-Cefuroxime IVTT q8° (-) ANST.-Cloxacillin 500 mg IVT q6° ANST

Independent:1. To protect the

patient from injury.

2. To enhance the patient’s ability to participate in activities.

3. Helps minimize frustrations and rechannels energy.

4. To assess level of activity tolerance.

5. To encourage ongoing support for the patient.

1. To prevent infection thus facilitating wound healing.

Short term:At the end of 8hrs of nursing intervention, patient was able to report increased activity tolerance as evidenced by ability to ambulate to comfort room with minimal assistance.

Long term:At the end of 16hrs of nursing intervention, patient was able to perform activities of daily living with reports of minimal limitations caused by pain.

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Objective: Avoiding

physical activity Lying down

during the day Reduced

interaction with people

(-)-Gentamycin 80 mg IVTT q8° ANST (-)-Metronidazole 500 mg IVTT q8° ANST (-) 2. Assist in

everyday wound dressing.


ASSESSMENT NURSING DIAGNOSIS

OBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective:“Dili nako ganahan na mag.gawas2x sa balay kai pangit na kaau ko ” as verbalized by the patient.“Gusto ko ako ra

Disturbed body image related to presence of malar rash at the bridge of the nose as evidenced by change in social involvement and

Short term:At the end of 1 hour of nursing intervention, patient will verbalize understanding that changes in

Independent:1. Establish a therapeutic nurse-client relationship conveying an attitude of caring.

2. Acknowledege

Independent:1. To develop a sense of trust.

2. To assist client

Short Term:At the end of nursing intervention, patient was able to verbalize understanding that the change in

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isa dili ko ganahan makit-an sa uban na inani akong nawong Sakit pud akong tiil maypag magpuyo, arang2x pa kung ako nalang isa.” as verbalized by the patient.

Objective: Change in

social involvement

Not looking at self in the mirror

Behaviors of avoidance

Presence of malar rash at the bridge of the nose

verbalizations of social withdrawal.

physical appearance are part of the disease process.

Long term: At the end of 32 hours of nursing intervention, patient will be able to talk to family about the changes in self-concept without negative self-esteem and develop realistic goals and plans for the future.

and accept feelings of grief and hostility by encouraging verbalization of feelings and by listening attentively.

3. Encourage client to look at and touch affected body parts.

4. Give complements and appraisals such as praising her for positive traits.

5. Provide holistic care such as providing body care and good grooming.

6. Involve the family in increasing the patient’s self-esteem by avoiding negative

in issues of self-concept.

3. To promote acceptance of body changes.

4. To boost the clients self-esteem.

5. To recognize patient’s positive traits than focusing on negative ones.

6. To minimize patient’s self belittling.

physical appearance is part of the disease process as evidenced by beginning to care and accept self by grooming and looking at the mirror.

Long Term:At the end of nursing intervention, patient was able to talk to family about the changes in self-concept without negative self-esteem and develop realistic goals and plans for the future.

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comments about her and non-verbal cues of discrimination.

ASSESSMENT NURSING DIAGNOSIS

OBJECTIVES INTERVENTION RATIONALE EVALUATION

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Subjective:“Akong gabutangan ug botelya na naai bugnaw na tubig ang ibabaw sa akong samad aron mahubsan ang ka-sakit.” –as verbalized by client.

Objective: Increased

temperature = 38 C

WBC count = 13,720mm3

Open wound at left lower leg with moist dressing.

Swollen and warm area around the wound.

Risk for spread of infection related to inadequate primary defense as evidenced by broken skin and traumatized tissue in the lower left leg of the patient.

Short term:At the end of 1 hour of nursing intervention, patient will be able to demonstrate ways in preventing and reducing the risk of infection through proper use of aseptic techniques.

Long term:At the end of 8hrs of nursing intervention, patient will achieve stable temperature noting to be afebrile and will not manifest further signs and symptoms of infection.

Independent:1. Observe for

localized signs of infection.

2. Wash hands before contact with patient and between procedures with patient.

3. Maintain proper environmental sanitation through cleaning patient’s bed and bedside.

4. Emphasize importance of proper hygiene especially proper hand washing.

Independent:1. To assess

causative/ contributing factors.

2. Washing between procedures reduces risk of transmitting pathogens from one area of the body to another.

3. To minimize environmental pathogens.

4. To minimize acquiring infections.

At the end of 1hr of nursing intervention, patient was able to identify and demonstrate ways of preventing and reducing risk for infection.

At the end of 8hrs of nursing intervention, patient has a stable temperature noting to be afebrile.

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5. Limit access to the open site.

6. Prepare a calorie- and protein- rich diet.

Dependent: 1. Assist in wound dressing and maintaining strict asepsis. 2. Administer antibiotics such as -Cefuroxime IVTT q8° (-) ANST,Metronidazole 500 mg IVTT q8° ANST (-).

5. To prevent introduction of microorganisms

6. To maintain optimal nutritional status.

1. To prevent entry of microorganism to lesion.

2. To prevent further spread of infection.

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VII. DISCHARGE PLANNING

Medications

o Encourage strict adherence to the medication regimen to attain therapeutic effects.

o Instruct patient to strictly follow orders for take home medications upon discharge as prescribed by physician.

o Instruct patient to take medications as prescribed such as: Cyclophosphoride 1.5 gm Metoclopramide 1 tab Paracetamol 500mg 1 tab q4 PO (for temp. above 38C) Prednisolone 5mg 3-0-3 Calcium lactate 300mg 1-1-1 Chloroquinine 150 mg 1 tab OD Diphenhydramine 10 mg TID For 3 days

o Instruct patient to follow right dose and timing of medications, and not to stop taking them abruptly without physician’s order.

o Report any adverse effects and drug-drug interactions/drug-food interactions of the medications to the physician.

o Warn patient about the increased risk towards superinfections and immunosuppression; Observe aseptic technique and proper sanitation and hygiene to prevent spread of microorganisms.

Exercise

o Encourage patient to individualized exercise program (e.g. active or active-self assisted ROM exercises) is recommended for patients with SLE to prevent joint stiffness (especially on the affected leg) and increase mobility.

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o Mild analgesic may be suggested before exercise.

o Encourage deep breathing exercises to decrease feelings of pain and discomfort.

Health Teachings

Physical Rest: o Eight to 10 hours a night of restful

sleep, naps, and “timeouts” during the day are basic guidelines. Physical activity should be encouraged as the patient can tolerate it.

o Encourage patient to plan for additional rest periods throughout the day, as needed. Emphasize the need for avoidance of exhaustion.

Emotional Rest:o Discuss to family members on the

issue of avoiding stressful situations by providing them with information regarding patients condition and obtaining their support. Advocate counseling for both the patient and the family.

Protection from direct sunlight:o Inform patient that all people with

lupus should avoid direct, prolonged exposure to the sun especially between 10 a.m. and 4 p.m., and wear protective clothing, such as wide-brimmed hats and long sleeves.

Out-patient/Follow-up

o Advocate appropriate follow-up in collaboration with the healthcare team.

o Make use of health care resources in the community and instruct patient to have a visit to their health center from time to time.

o Instruct patient to recognize the 92

warning signals of a flare(increased fatigue, a new or higher fever, increased pain, development or worsening of a rash and development of symptoms you haven’t had before and swollen joints) and to seek medical help.

o Instruct patient to consult physician before receiving any immunization. Routine immunizations, including those for the flu and pneumonia.

Diet

o A low-fat, low-cholesterol diet is recommended, given the increased risk of heart disease in SLE.

o Instruct patient to limit their dietary intake of sodium.

o Recommend a high-fiber diet.o Increase protein intake.o Use flavoring agents (e.g. lemon

and herbs) to enhance food satisfaction and stimulate appetite.

Spirituality

o Encourage the patient to hear masses regularly to strengthen her spiritual life.

o Encourage patient to pray constantly and surrender all her worries to God especially her present condition to lessen anxiety and to promote presence of mind.

o Have her join in prayer groups and meeting offered by the church or community.

Social

o Encourage patient to verbalize feelings to support persons (e.g. husband) and to participate in

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other support groups which can provide disease information, daily management tips and social support.

o Encourage the patient to seek out other supportive mechanisms, such as: in local support groups an in educational and self-management programs.

o Develop a support system that includes family, friends, medical or nursing professionals, community organizations, and support groups.

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VIII. PROGNOSIS

CRITERIA GOOD POOR

Health Seeking Behavior

Late Diagnosis

Frequent Exposure to UV light

Experiences extreme stress

Defective Organs:

Kidney

Heart

Brain (CNS and PNS)

Skin

Lungs

Liver

Compliance to medical regimen such as:

Chemotherapy

Steroid Therapy

Antibiotic Therapy

√

√

√

√

√

√

√

√

√

√

√

4/11 7/11

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Basing on the above criteria, the patient’s prognosis is poor. At present, there is

no cure for her disease. Death usually results from complications such as organ

failures. The patient already has defective organs – kidney, heart and skin. She also

experiences extreme stress and frequent exposure to UV light, such as the sunlight –

which are known factors that could exacerbate the disease. The medical treatment she

is undergoing are only palliative and are only given to treat the signs and symptoms.

IX. CONCLUSION

In conclusion, the group was able to come up with a comprehensive case

presentation on Systemic Lupus Erythematosus (SLE), especially concerning our client,

Patient X. Information presented here were factual, basing on our actual assessments

by interview and by using available secondary sources, such as her chart. The group

was able to work together to surface this case study in the best way that we can, using

every resource we can find useful in making every part of this write up.

In the process, we were able to enhance our knowledge about SLE, its signs and

symptoms and treatment modalities, as well as on how we, future nurses, can care for

patients similar to Patient X. Moreover, we have taken our grand case presentation

enactment to the next level, owing this to our extensive learning from our experiences

this semester as well as our previous wisdom acquired in the classroom and hospital

settings. Lastly, the group has developed a better working relationship with one another,

especially through this challenging and demanding stretch of our student life.

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X. RECOMMENDATION

Recommendations are necessary for patient X to be able to minimize signs and

symptoms and prevent further complications as possible. This, in turn, will consider

having a better health status – be it physically, emotionally, mentally, and spiritually.

For Patient X, recommendations would include but not limited to the following:

First, patient X should be able to develop an optimistic attitude towards the situation in

order to promote a positive inclination of mental and emotional dimension of health.

Second, she should strictly comply with the medication regimen since personal

adherence is a determinant of willingness and eagerness to recover. Third, she should

also be able to verbalize feelings, especially regarding pain to prompt the support

persons to take emotional care and actions. This is essential when associated health

seeking behavior. She should also be able to express any discomfort in order for the

health care provider to carry out certain measures. Patient X should be able to establish

a direct open communication with her husband and health care practitioner to link care

and needs. Thus, the proponents of this case study are able to understand the

significance of a good health seeking behavior and medical treatment. Fourth, she

should be able to strengthen or maintain strong faith since spiritual health is an

important factor to be considered in achieving a healthy status. Patient X must be willing

to follow low salt low fat, and low protein diet having known that she has a lupus

nephritis. She should eat foods high in vitamins D & E and calcium such as liver, milk,

cheese, fish and others. She should be advised to avoid gas-irritant foods such as

cabbage, beans, spinach, garlic, tea, and coffee.

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Patient X’s husband and support persons can prove functional when they are

able to provide comfort, care measures, and assistance. They can encourage patient X

to follow care provider’s instruction particularly on medication adherence. Patient X

should be encouraged to avoid exposure of sunlight. She should use umbrella and

sunscreen to prevent production of rashes.

As health care providers, we should be able to provide quality health care

services to patient X. As nurses and physicians, individualized care should be carried

out. Open and welcome approach should be initiated to the patient, and most especially

by showing empathy and recognizing that there is no enough words to overrule her

feelings of heaviness and despondency. Sensitivity to the patient X has verbalized is

also necessary for us to consider in planning care. Physical, social, spiritual, emotional,

and mental feedbacks and motivations can also be considered in imparting to the client.

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XI. BIBLIOGRAPHY

Black, JM., and Hawks, JH. Medical-Surgical Nursing Clinical Management for Positive

Outcomes volume 1 &2. 7th edition, El Sevier Saunders, Singapore, 2004

Doenges, Marilynn E et al. Nurse’s Pocket Guide Diagnosis, Prioritized Interventions &

Rationales. 10th edition, F.A. Davis Company, 2006

Karch, Amy M. Focus on Nursing Pharmacology. 3rd edition, Lippimcott Williams and

Wilkins, 2006

Karch, Amy M. Lippincott’s Nursing Drug Guide Lippincott Williams and Wilkins, 2007

Kozier, B., Erb, G., and Berman, A. Fundamentals of Nursing: Concepts, Process and

Practice. 6th edition, Upper Saddle River, NJ: Prentice-Hall Inc., 2000

Pillitteri, Adele. Maternal and Child Health: care of the Childbearing and Childrearing

Family. 5th edition, Lippincott Williams and Wilkins, 2006

Brunner , Sudarth . Textbook of Medical-Surgical Nursing volume 1 & 2. 11th edition,

Lippincott Williams and Wilkins, 2007

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XII. APPENDIX

A. HISTORY OF PRESENT ILLNESS:

2002

Patient X verbalized she had her prenatal check ups at Tabique Clinic,

18th-1st Street, Brgy. Nazareth, CDO and was advised to maintain an intake of

Ferrous Sulfate (FeSO4) during her pregnancy. Last November 9, 2002, the

patient gave birth to a healthy full term baby boy through a normal spontaneous

vaginal delivery (NSVD) at Northern Mindanao Medical Center (NMMC) and was

admitted for 3 days for safe recovery. After a week, patient returned to NMMC for

a consultation regarding her sensations of pain during urination and was given

medications for 1 week, but no progress was noted. She then referred to

Polymedic Hospital and was submitted for urine culture. Results showed bacteria

present in her urine and was given another set of medications to be taken for the

next week. After completing the full medication regimen, patient reported relief of

pain in urination. While she was experiencing these, she was also breastfeeding

her baby for 6 months before she changed to bottle formula.

2003 - 2007

Patient only recalled instances of weakness in the lower extremities in

prolonged standing accompanied by “palpitations”.

2007

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For a year, patient worked as a housekeeper for a 2-storey house, where

she experienced inadequate rest periods for she reported 6 am everyday, went

home by 10pm, then slept at 12 midnight. She looked after 6 children with

minimal assistance and did the laundry under the heat of the sun for 2 – 3 hours

for 3 days in a week.

2008

Early January, patient X manifested alopecia and observed a metallic

taste in her saliva, both manifestations lasted more than a month. She went to

Sabal Hospital for a check up having complaints of urinary retention and frequent

urination in small amounts. The resident doctor then ordered for urinalysis which

resulted to high bacterial infection in urine. She was then prescribed a set of

medications to be maintained for a week to treat the infection, but this showed no

progress. She returned to the doctor to report the same problems, the doctor

recommended her to take another set of medications, yet still there was no sign

of progress evident. She returned to the doctor for 4 times taking different sets of

medications, but still, there was no improvement in her condition. She then

stopped seeing the doctor in Sabal Hospital, and sought medical help to another

physician in Polymedic Hospital. There, she was submitted for hematology and

an ultrasound of the kidney which showed normal results. With this, the doctor

decided not to issue her medication. Unfortunately, this didn’t help in the relief of

her manifestations.

In February, small rashes started to show by the side of her cheeks along

with painless oral ulcers, but she didn’t consult any medical help regarding these

abnormal findings. A few weeks after, she was admitted to Maria Reyna Hospital

(MRH) due to persistent vomiting for 4 days. The resident doctor diagnosed her

with ulcer, but the patient could not recall the specifics of the diagnosis. She was

then given IVTT meds and stayed in the hospital for 3 days. Yet the patient didn’t

complain about her rashes for she thought it was of no significance.

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By the 2nd week of April, patient consulted her doctor in Tabique Clinic

because she was confused about her condition and the manifestations she

experienced. The patient was referred by Dr. Tabique to Dr. Fabia, who is a

specialist at MRH. The doctor suspected for Systemic Lupus Erythematosus

(SLE) basing on the actual symptoms then encouraged the patient to undergo an

anti-nuclear antibody (ANA) assay, which showed positive results and confirmed

the diagnosis. Dr. Fabia said the disease was genetic but the patient didn’t know

anyone in her family who had the disease. As recalled by the patient, she was

then given medications, such as: Prednisone (5mg OD), Godex (OD), Imuran

(1/2 tab OD), Isoniazid (OD), and lastly Chloroquine (OD), with varying dosages

based on her condition, to be taken every month and followed by monthly check

ups and laboratory tests such as: complete blood count (CBC), urinalysis (UA),

erythrocyte sedimentation rate (ESR) and serum glutamic-pyruvic transaminase

(SGPT). Due to financial concerns, patient often missed taking her daily

medications. Because of this, she tried seeking help at J.R. Borja City Hospital

hoping to access free medical assistance. To her dismay, the doctors available

didn’t specialize in her disease condition which left her the option to seek medical

attention at MRH for 6 months.

When September came, she had her last check up under Dr. Fabia then

stopped seeking treatment due to serious financial constraints. She finally

decided to go to German Doctor’s Hospital, also known as Xavier University

Community Health Care Center (XU-CHCC), and was under the care of Dr.

Gabatan, who advised her to come back with laboratory test taken at JR Borja

City Hospital such as erythrocyte sedimentation rate (ESR), C-reactive protein

(CRP), urinalysis (UA), Na+, K+, creatinine, FBS and liver profile. She was then

given medications to take such as hydroxychloroquine, Godex (OD), INH(1tab

OD) Azathioprine (1/2tab OD) and Prednisone. She was then subject to monthly

checkups from then on until January of 2009. While at home care, the patient at

times experienced edema in her face, as well as in her extremities, but the doctor

explained to her that these were just side effects of the drugs she is taking.

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Around December, patient X verbalized that with constant movement of

the hands (like doing the laundry) both her thumbs would adduct and would

stiffen which lasted for 5 minutes. She never reported this to the doctor.

For the entire year of 2008, the major abnormalities the patient noticed

were the occurrences of 5 missed menses, but she never reported this to her

doctor, along with her other manifestations (the adducting of the fingers,

alopecia, and palpitations).

2009

On January 10, 2009 patient was admitted at German Doctor’s Hospital

under the care of Dr. Gabatan due to worsening of the symptoms of her SLE and

was referred to Dr. Saavedra in Cagayan de Oro Medical Center (COMC). By

January 12, 2009, Dr. Saavedra referred her back to Dr. Gabatan for an advised

chemotherapy to be done monthly in a span of 6 months. He also confirmed the

diagnosis of Lupus Nephritis. During her chemotherapy (Cyclophosphamide

therapy), the patient’s alopecia was not as worse as that of the first encounter.

The same medications were given with an additional dose of Calcium to be

maintained until the first week of February. On January 27, 2009 patient was

referred back to Dr. Saavedra and was advised to take Ciprofloxacin for a week

to treat her UTI and a repeat chemotherapy on February 10, 2009 at German

Doctors Hospital.

By first week of February, patient noticed 3 swollen lesions on her left leg.

Thus, the supposed chemotherapy for the month was postponed due to the

found lesions. On the morning of February 13, 2009, the largest lesion burst but

the other two remained small and swollen. By mid-February, we had our duty, the

lesions were still present and she was wearing a diaper since she was not

ambulatory.

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B. DOCTORS ORDER

Patient’s Name: Patient X Age: 25 y.o.Diagnosis: Systemic Lupus Erythematosus (SLE) Attending Physician: Dr. GabatanDate/time DOCTOR’S ORDER2/10/09 >please admit under the service of me

>consent to care>DAT>TPR q shift>problem Lupus Nephritis>IVF: D5 0.3% NaCl at KVO rate >labs. FBS, creatinine, Na+ K+, CBC with platelet count, ESR, ECG 12 leads>meds.:

1. Cloxacillin 500mg IVTT q6o ANST2. Paracetamol 500mg 1 tab q4o for temp. > 38oc

>please prepare:Metoclopramide tab #1Dexamethasone 10mg ampuleCyclophosphamide 1.5gm>Dr. Saavedra informed>refer for any unusualities>refer accordingly Dr. Gabatan (Signed)> daily dressing of wound at LE Dr. Gabatan (signed)

2/11/09 > FBS, creatinine, Na+ K+ - error>please follow up results Dr. Gabatan (Signed)

2/12/09 10:45am

>Cefuroxime 750g IVTT q80 ANST

Dr. Gabatan (Signed) 2/13/09 4:45pm

>repeat UA tomorrow

Dr. Gabatan (Signed)2/16/09 11:25pm

>D/C Cefuroxime

>Gentamycin 80g IVTT q8o ANST>Metronidazole 50g IVTT q8o ANST Dr. Gabatan (Signed)

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2/17/09 9:35am

>continue medications

2/18/09 10:55am

>CBC with Platelet count Dr. Gabatan (Signed)

C. NURSES NOTES

Patient’s Name: Patient X Age: 25 y.o.Diagnosis: Systemic Lupus Erythematosus (SLE) Attending Physician: Dr. GabatanDate/time NURSE`S NOTES2/10/09 >Admitted a 25y.o. female with chief complaint of facial lesions

>afebrile>due labs. Requested

3-112/10/09 >Received awake ambulatory from ER with ongoing IVF of D5NaCl

500cc at 500cc level regulated at KVO rate infusing well at left arm3:30pm >placed on bed safely

>conscious and coherent>with pale conjunctiva>with verbal report of throbbing pain on left leg with a pain scale of 5/10 with 10 as the most painful>with edematous face and upper and lower extremities- non pitting>with purulent, open wound on left ankle>initial vital signs taken and recorded= T: 37oc, RR:28cpm, PR: 98bpm, BP: 120/70mmHg>legs kept elevated>deep breathing exercises initiated>placed on moderate high back rest

DAT >served and consumed whole of share with fair appetite>health teaching imparted with emphasis on:

a. Proper hygiene ex. handwashingb. Medication compliancec. Precautionary measures to protect self from infection

11:00pm >endorsed with latest vital signs of :T=37.1oc, RR=25cpm, PR=95bpm, BP=110/70mmHg

XUSN3 (signed)11-7

11:00pm >Received awake on bed with IVF of D5NaCl 500cc regulated at KVO rate>vital signs taken and recorded>anasarca noted>due meds. given>intake and output measured and recorded>cared for>endorsed

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Signed by NOD2/11/09 7-3

>Received awake on bed with IVF D5 0.3%NaCl 500cc at 80cc level regulated at KVO rate>with facial and bipedal edema-noted>for blood chemistry today-taken>daily dressing- done >vital signs taken and recorded>endorsed

Signed by NOD3-11

3pm >Received lying on bed with ongoing IVF of #2 D5 0.3% NaCl 500cc at 490cc level regulated at 10 gtts/min. infusing well at right arm>anasarca noted>with dry and intact dressing on lower left leg>with complaints of throbbing headache>with initial vital signs of T=38.7oc, RR=14cpm, PR=98bpm, BP=110/80mmHg

2pm >febrile, T=38.7oc>tepid sponge bath done

3pm >paracetamol 500mg 1 tab PO PRN given for fever T=38.7oc>back massage provided>adequate rest given

3:30pm >temp. Rechecked T=38.5oc>continuous tepid sponge bath done>afternoon and bedside care done

DAT >served and consumed whole amount of share of 1 cup of rice and 1 serving of chopsuey with good appetite >health teachings rendered with emphasis on:

a. Strict medication complianceb. Adequate nutritionc. Proper hygiene to prevent infection

>intake and output monitored and recorded>kept watched for any unusualities>endorsed with latest vital signs of T=37.6oc, PR=92bpm, RR=21cpm, BP=110/80mmHg

XUSN3(Signed)2/11/09 11-7

>Receivewd awake on bed with D5 0.3%NaCl at KVO rate at 200cc level>with wound dressing at left lower leg- dry and intact>with complaints of pain at wound area>due medications given>intake and output measured and recorded

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>needs attended>endorsed

Signed by NOD2/12/09 7-37am >Received awake on bed with ongoing D5 0.3% NaCl at 100cc level

regulated at KVO rate infusing well at right arm>with wound dressing at left lower extremity-slightly soaked but intact>with open wound at left lower extremity with diameter of 2cm>with complaints of throbbing pain at wound site with pain scale of 8/10 with 10 as most painful>verbalized feelings of generalized body weakness>generalized non pitting edema noted>swelling on left lower extremity and around the IV site noted>with initial vital signs of T=37.4oc, PR=107bpm,RR=23cpm, BP=110/80mmHg>morning care done: bed linens changed, tucked, and well pressed>turned to sides at frequent intervals to prevent pressure ulcer>placed on moderate high back rest position>encouraged deep breathing exercises and tolerated for 30 seconds>kept left lower extremity elevated with towel>back rub done>environmental stimuli restricted

DAT >consumed full share with good appetite9:15am >daily dressing aseptically done at wound by NOD10:25am >seen and examined by Dr. Gabatan with new orders carried out by

NOD10:40am >febrile with T=38.2oc 10:45am >Paracetamol 500mg given

>continuous TSB done10:50am >above IVF consumed and followed up with same IVF and regulated at

same rate11:15am >temperature rechecked: T=37.8oc

>health teachings given with emphasis on:a. Medication complianceb. Adequate nutritionc. Proper hygiene such as bathing and frequent handwashing to

prevent infectiond. Proper wound caree. Turning to side at frequent intervals

>intake and output measured and recorded>kept watched for any unusualities-none noted>endorsed with latest vital signs: T=37.8oc, PR=93bpm, RR=24cpm,BP=100/70mmHg

,XUSN3(signed)

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2/12/09 3-112pm >Received awake lying on bed with ongoing IVF of #3 D5 0.3% NaCl at

500cc level regulated at 10gtts/min infusing well on right arm>with complaints of pain at left leg with a pain scale of 9/10 with 10 as most painful>with dressing on lower left leg- dry and intact>non-pitting edema noted on left leg>with initial vital signs of T=37.8oc,PR=90bpm,RR=24cpm,BP=120/80mmHg

2pm >febrile T=37.8oc>tepid sponge bath done>adequate rest given and provided

3pm >temperature rechecked T=34.4oc>continuous tepid sponge bath done>lower extremities elevated with towel>encourage to do deep breathing exercise and relaxation techniques>afternoon and bedside care done

DAT >served and consumed whole of share with good appetite>health teachings reinforced>intake and output taken and recorded

10pm >endorsed with latest vital signs of T=37.6oc,PR=91bpm,RR=22cpm,BP=110/80mmHg

XUSN3 (signed)2/12/09 11-711pm >received asleep on bed with D5 0.3%NaCl at 400cc level regulated at

KVO rate>with wound dressing at left lower leg- dry and intact>vital signs taken and recorded>due medications given>needs attended>endorsed

Signed by NOD2/13/09 7-37am >received awake lying on bed with IVF of D5 0.3% NaCl regulated at

KVO rate>vital signs taken and recorded>due medications given>kept comfortable on bed>cared for>endorsed


>Received asleep on bed with ongoing IVF of #3 D5 0.3% NaCl regulated at 10gtts/min infusing well on right arm

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>afebrile>due medications given>kept comfortable>needs attended>endorsed


>Received with D5 0.3% NaCl regulated at 10gtts/min infusing well on right arm>vital signs taken and recorded>daily dressing done>due medications given>kept comfortable

>endorsedSigned by NOD

2/14/09 3-11>on bed with D5 0.3% NaCl regulated at KVO rate>vital signs taken and recorded>due medications given>needs attended>endorsed


>Received with D5 0.3% NaCl regulated at KVO rate>vital signs taken and recorded>due medications given>cared for>endorsed


>Received with D5 0.3% NaCl regulated at KVO rate>vital signs taken and recorded>due medications given>cared for>endorsed


>Received with D5 0.3% NaCl at 400cc level regulated at KVO rate>with wound dressing at left lower leg-dry and intact>afebrile

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>due medications given>needs attended>cared for>endorsed


>Received with D5 0.3% NaCl at 220cc level regulated at KVO rate>due medications given>vital signs taken and recorded>needs attended>endorsed Signed by NOD

2/16/09 7-3>Received awake on bed with D5 0.3% NaCl regulated at KVO rate>vital signs taken and recorded>dressing changed>IVF site changed>due medications given>cared for>endorsed


>Received with D5 0.3% NaCl 500cc at 100cc level regulated at KVO rate>vital signs taken and recorded>due medications given>cared for>endorsed


>Received awake on bed with IVF of D50.3 NaCl @ 50cc level regulated at KVO rate>due meds on time given>above IVF consumed and followed up with D50.3 NaCl 500cc at same rate>vital signs taken and recorded>endorsed


>Received lying on bed with ongoing IVF of D50.3% NaCl 500cc @ 450cc level regulated @ KVO rate infusing well on left arm

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>conscious and coherent>with wound dressing at left lower extremity slightly soaked but intact>inflammation at left lower extremity around the wound noted >with complaints of throbbing pain at wound site with pain scale of 6/10 with 10 as most painful> generalized non-pitting edema noted>with initial vital signs of T=37.30C , PR=79bpm, RR=25cpm, BP=120/80mmHg >morning care done; bed linens changed, tucked and well pressed

9:35am >seen and examined by Dr. Gabatan with new orders carried out by NOD

9:40am >daily dressing aseptically done at wound site by Dr. Gabatan >placed on comfortable position>turned to sides at frequent intervals to prevent pressure ulcers>encouraged deep breathing exercises as tolerated for 30 seconds>kept left lower extremity elevated with towel >back rubbing done>diversional activities provided>adequate rest periods provided>consumed full share with good appetite >health teachings given with emphasis on:

a. Medication complianceb. Adequate nutrition with food low in sodium and potassium

contentc. Proper hygiene to prevent infection d. Proper wound care

>input and output recorded>kept watched for other unusualities-none noted>endorsed with latest vital signs T=37.70C, PR=90bpm, RR=25cpm, BP=110/70mmHg

XUSN3 (signed)3-11

3pm >Received awake lying on bed with ongoing IVF of D50.3 NaCl 500ml at 460cc level regulated @ KVO infusing well at left arm

>pale and dry lips noted>weakness noted>with sanguinous, open wound at left ankle>with presence of wound at lower left extremity>with complaint of pain at wound area, with pain score of 7 out of 10 with 10 as the most painful>initial vital signs taken and recorded with HR: 94bpm; RR:25cpm; temp: 37.90C; BP:110/70mmHg>afternoon care done>placed in a dorsal recumbent position

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>tepid sponge bath done4:00pm >rechecked temperature: 37.50C

>continuous tepid sponge bath doneDAT >served and consumed share with fair appetite

>health teachings imparted with emphasis on:a. Proper hygieneb. Proper nutrition such as eating foods high in vitamin C, limiting

fluid intake to 1000ml c. Oral care to deviate oral discomfortd. Strict medication compliance

>intake and output measured and recorded>endorsed with latest vital signs: HR: 98bpm; RR: 27cpm; temp: 37.80C; BP: 110/70 mmHg

XUSN3 (signed)2/17/09 11-7

>Received on bed awake with IVF of D50.3% NaCl at 300cc level regulated KVO rate >with wound dressing- dry, intact>vital signs taken and recorded>due meds given>needs attended>endorsed Signed by NOD

2/18/09 7-37:00am > Received awake sitting on bed with newly hooked IVF of D50.3 NaCl

500cc regulated at KVO rate infusing well at right arm >conscious, responsive and coherent >with presence of wound at left lower leg with diameter of 2cm-with dressing and wrapped elastic bandage-dry and intact>with redness and swelling at left lower leg> with complaints of throbbing pain at left lower leg rated as 5/10 in the pain scale 0-10, 10 as most painful> generalized pitting edema noted>with numerous dark skin lesions on the face and darker at anterior portion of the nose>initial vital signs taken and recorded, T=36.80C; HR=110bpm; RR=26cpm; BP=110/70mmHg>morning care done, bed linen changed, tucked and well-pressed>place on supine position>left lower extremity kept elevated with rolled towel>deep breathing exercises initiated and tolerated for 1-2minutes>turned to sides at frequent intervals>diversional activities offered such as socialization>adequate rest period provided

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>environmental stimuli restrictedDAT >served and consumed share with poor appetite9:55am >seen and examined by Dr. Gabatan with new orders carried out by

NOD10:05am >daily dressing at wound site aseptically done by Dr. Gabatan

>health teachings given with emphasis on:a. Compliance of medication and treatment regimenb. Adequate nutritionc. Proper hygiene; handwashing; daily bathingd. Proper wound caree. Pain management

>for CBC with platelet count-requested>kept watched for any unusualities-none noted

3:00pm >endorsed with latest vital signs of temp:37.30C; HR:99bpm; RR:25cpm; BP:110/70mmHg

2/18/09 3-113pm >Received awake lying flat on bed with IVF#8 of D5 0.3%NaCl

@450cc level, regulated at 10gtts/min.-infusing well at left arm>conscious, coherent and oriented to time, date, place>noted to be calm and neatly dressed>with complaints of pain on left leg with a pain scale of 6 in a 1-10 pain scale- 10 as the most painful>with newly dressed wound on left leg-dry and intact>with initial vital signs of: Temp= 37.70C; PR=87bpm; RR=28cpm; BP=100/70mmHg>tepid sponge bath continuously done>left leg elevated with pillows>bedside care and nail care done>diversional activities given

DAT > served and consumed whole share with good appetite>health teachings imparted with emphasis on:

a. Relaxation and deep breathing exercise – for pain managementb. Increased oral fluid intakec. Proper environmental sanitation- to prevent infection

7:20pm >above IVF-kept set sterile9:45pm >above IVF regulated at left arm-infusing well

>intake and output monitored and recorded10pm >endorsed with latest vital signs of: T=37.70C; PR=88bpm; RR=28cpm;

BP=100/70mmHg XUSN3 (signed)

2/18/09 11-7>Received asleep lying on bed with IVF of D50.3% NaCl, regulated at 10gtts/min, infusing well at left arm >dressing at left leg kept dry and intact

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>vital signs taken and recorded>due meds given>provided with adequate rest>cared for>endorsed Signed by NOD

2/19/09 7-37:00am >Received awake sitting on bed with IVF of D5 0.3%NaCl 500cc @

90cc level,at KVO rate-infusing well at left arm>alert and responsive>still with redness and swelling on left lower leg>generalized pitting edema noted >still with numerous dark skin lesions on the face and darker at anterior portion of the nose>initial vital signs taken and recorded T=37.20C, HR=98bpm, RR=26cpm, BP=110/70mmHg >morning care done>placed on modified high back rest >left leg extremity kept elevated with rolled towel>deep breathing exercises measured for 1-2 minutes>turned to sides at frequent intervals >adequate rest period provided>environmental stimuli restricted

DAT > served and consumed full share with good appetite>above IVF consumed and followed up with D5 0.3NaCl 500cc regulated at same rate

9:00am > seen and examined by Dr. Gabatan 10:00am > daily dressing at wound site aseptically done by Dr. Gabatan

>health teachings given-endorsed>kept watched for other unusualities-none noted> endorsed with latest vital signs of temp:37.30C; HR:97bpm; RR:29cpm; BP:110/70mmHg XUSN3 (signed)

2/19/09 3-11>Received with IVF of D5 0.3NaCl @ 280cc level regulated at KVO rate>vital signs taken and recorded>with wound dressed; dry and intact >cared for>due meds given>low-salt /DAT-consumed with good appetite>endorsed Signed by NOD

2/19/09 11-7>Received with IVF of D5 0.3NaCl regulated at KVO rate, infusing well>vital signs taken and recorded>due meds given

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>wound dressing kept dry and intact>endorsed Signed by NOD

2/20/09 7-3>Received awake on bed with IVF of D5 0.3NaCl 500cc at KVO rate>with wound dressing at left lower leg-dressing done>vital signs taken and recorded>due meds given>adequate rest provided>endorsed

Signed by NOD

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D. ECG STRIP

Figure 1

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Figure 2

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systemic lupous erythematosus(sle) part 2

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