INTRODUCTION

The Immune System functions as the bodys defense mechanism against invasion. But
when a bodys immune system attacks itself, it is probably having an autoimmune disease. The
individuals immune system attacks the healthy cells in the body by mistake instead of protecting
it from illness and infection. Systemic Lupus Erythematosus (SLE) is a chronic inflammatory
disease characterized by highly diverse clinical manifestations and the presence in the serum of
antibodies reacting with different cell nuclei components. The clinical course of the disease is
characterized by flares, periods of chronic disease, and periods of remissions (Pediatric
Nephrology Lippincott Williams and Wilkins, 2004).
Lupus Nephritis is a kidney inflammation and one of the most serious complications that
can result from SLE. Evidence suggests that 35% of adults in the United States show signs of
nephritis at the time of a lupus diagnosis and approximately 40% to 60% of people will develop
kidney involvement during the course of the disease. If not diagnosed and treated early enough,
lupus nephritis can lead to significant illness and sadly, even death.
According to the United States statistics as of April 2014, estimates of the prevalence of
clinical renal involvement in persons with SLE ranges from 30% to 90% in published studies.
The true prevalence of clinical lupus nephritis in persons with SLE is probably around 50%,
being higher in certain ethnic groups and in children. SLE is more common among women in the
third decade of their life and SLE Nephritis typically occurs in patients aged 20 to 40 years.
Children with SLE are at higher risk of renal disease than adults and tend to sustain more disease
damage secondary to more aggressive disease and treatment associated toxicity.
In the Philippines, it is estimated that 80% to 92% of the lupus population is female. The
prevalence trends also seem to exhibit variability based on geographic location. China and
Philippines show a greater incidence than Japan. The treatment for SLE Nephritis is almost the
same as from any other countries.

There were many organizations and foundations created for lupus patients. Locally, the
Lupus Foundation of Southern Mindanao, Inc. (LFSMI) was created starting with 41 members,
one of whom is Dr. Llewellyn Hao-Tanapo, an Internist and Rheumatologist, of Davao Doctors
Hospital. On September 21, 2000, the LFSMI was registered with Securities and Exchange
Commission (SEC), and the membership increased to 140 lupus patients.
SLE Nephritis is an interesting and quite complicated disease. The proponent conducted
this study to know and find out the probable cause of the clients occurrence of the said disease.
Knowing the fact that it is an autoimmune disease, the proponents never hesitated on choosing
this case with hopes that it would save and maintain the life integrity of the client and to other
Filipinos as well. Moreover, the importance of this study is recognized since it helps build the
proponents competence and skill in dealing such condition.
The proponent chose this case with high hopes that it would address the need of
information dissemination to the Filipinos on every corner of the country. We cannot deny the
fact that the country where majority of the population are living under the poverty line. With the
financial constraints, it has proved to be hard for the people to have access to education even to
the very basic health care facilities. With information and health teachings that will be given, it
would probably help every individual on how to deal with patients having this kind of disease.
Overall, by understanding SLE Nephritis, how it acts, what we can do to manage it, and
how to implement those actions, we can influence our patients future health tremendously, while
potentially improving their current life.

OBJECTIVES
General Objective:
Within 4 days of the patients stay at Pediatric Specialty Wing (PSW) Unit at Southern
Philippines Medical Center (SPMC) in Davao City, the proponent should be able to present a
comprehensive study on SLE Nephritis and understand the problem in order to develop adequate
knowledge and skills related to nursing procedures that will aid in the competency and
proficiency of the Nurses enrolled in the Degree of Master of Arts in Nursing at University of the
Visayas, Cebu City.
Specific Objectives:
The proponent also created certain aims that will help them in achieving their general
objectives. Within the 4 days of the patients stay at PSW Unit at SPMC in Davao City, the
proponent shall be able to:
I. Cognitive:
1. Identify the patients genogram;
2. Interpret the present developmental stage of the patient;
3. Comprehensively discuss the anatomy of the body systems involved;
4. Define the complete diagnosis that would explain the condition of our patient;
5. Determine the causative factors present to learn how the patient developed the illness;
6. Identify the signs and symptoms associated with the disease to grasp its cause;
7. Explain and trace the pathophysiology of Systemic Lupus Erythematosus;
8. Interpret the doctors orders by justifying the rationale;
9. Interpret laboratory findings;
10. Name and identify the proper dose, action, route, frequency, and nursing responsibilities
of each medication given to the patient;
11. Identify actual and potential nursing diagnosis;

12. Plan appropriate nursing interventions with patients condition to be able to provide
appropriate interventions and to render proper care; and
13. Evaluate the progress of clients condition and outcomes of care.
II. Psychomotor:
1. Display competence in performing the different procedures with the patient;
2. Gather pertinent data about the patient through detailed chart taking and interview;
3. Record the past and present health history of the patient;
4. Perform a comprehensive physical assessment on patient;
5. Render health teachings to the patient and her significant others to promote health; and
6. Implement plan of care with patient and significant others.
III. Affective:
1. Establish rapport with the patient and significant others;
2. Actively listen to the patient and significant others;
3. Attend to the needs and concerns of the patient genuinely;
4. Develop a caring, non-judgmental, and therapeutic attitude towards the patient and
significant others; and
5. Promote personal and professional growth of self and others.

PATIENT FROFILE
Name:

Jomueld

Age/Sex:

5 years old/ Male

Address:

Echavia, Mantiao, Mati City

Birth Date:

March 30, 2009

Religion:

Iglesia Ni Cristo

Educational Attainment:

Kinder 1

Name of Father:

Bonifacio Jr.

Occupation:

Tricycle Driver

Educational Attainment:

Grade 6

Name of Mother:

Mary Ann

Occupation:

Housewife

Educational Attainment:

1st year High School

Date of Admission:

October 29, 2014

Admitting Diagnosis:

Systemic Lupus Erythematosus Nephritis

Department:

Pediatrics

FAMILY HEALTH HISTORY AND BACKGROUND

Jomuelds diagnosis has no significant connections with his family and relatives. Both of his
grandparents, on his maternal side, are still alive and both have bronchial asthma. Recently, both of
his grandparents had suffered from bronchial pneumonia and they were treated. His grandfather has
hypertension-uncontrolled while his grandmother was diagnosed with pulmonary tuberculosis and
was managed several years ago.
Edmundo and Erlinda have six children and one of them is Mary Ann, Jomuelds mother, is
the third among the six children and these children had no known diseases and as reiterated by Mary
Ann, they are all healthy.
On his paternal side, both of his grandparents and uncles are already deceased in which his
grandmother died from leukemia and his grandfather died from pulmonary tuberculosis. Bonifacio
Sr. and Renata had three children, however, the eldest child died from vehicular accident and next to
eldest child died from tetanus infection. The youngest child, Bonifacio Jr., claimed to be healthy and
he had no previous hospitalizations or serious diseases.
Bonifacio Jr. and Mary Ann got married for seven years and have three children namely,
Jomaryl, Jimuel and Jomueld, via NSVD. Jomaryl, the eldest child, had no known diseases and as
claimed by the mother, was healthy and active. After a year, she got pregnant, and was surprised
that she carried twins after she delivered the babies alive. She neither had any prenatal check-ups
nor any medications taken during those pregnancies and there were no complications as claimed by
the mother. Both of Jomuelds siblings are healthy and only suffered from minor illness such as
cough and colds. Jomueld, on the other hand, was the weakest among the three children in which he
was hospitalized several times already and diagnosed with SLE Nephritis this year.

PAST HEALTH HISTORY

Mary Ann, the patients mother did not have any prenatal check-ups during her pregnancy,
and was surprised that she carried twins. She hadnt had any diseases or problem during her
pregnancy such as rubella, diabetes, or spotting. Her usual blood pressure ranged from 90/60mmHg
to 100/60mmHg. She did not take any oral nor injectable medications during her pregnancy. She
delivered via NSVD at Davao Oriental Provincial Hospital in Mati City and stayed in the hospital
for three days. Jomueld was born with the birth weight of 2,200 grams and was immunized
religiously in a Barangay Health Center in Mati City.
However, when Jomueld was eight months old, he had a three-minute seizure and as
described by his mother as a sudden rigidity and staring blankly.

After the incident, they

immediately went to the clinic to seek for consultation and was prescribed with a medication that
she failed to remember the name.
Last February, he had an onset of relapsing fever for a week and as high as 40 degrees
Celsius. They consulted to Dr. Paredes, a Pediatrician, and were advised to submit their son for
CBC pc laboratory and the result showed an ongoing blood infection. They were prescribed with
Co-Amoxiclav suspension, an antibiotic, and Paracetamol syrup, an anti-pyretic, for fever and were
sent home. With no relief after one week, they consulted back to Dr. Paredes and the antibiotic was
shifted to Erythromycin suspension. Still with no relief after one week, they consulted another
physician in which they were asked to submit Jomueld for CBC pc and Urinalysis which revealed
with blood infection and Urinary Tract Infection (UTI). He was prescribed with Co-Amoxiclav
suspension and Paracetamol syrup and was asked to come back after two weeks of medication.
On the day of the follow-up check-up, Jomueld submitted urine specimen for repeat
Urinalysis and revealed no UTI and was asked to continue the antibiotic for another three days. Still
with no relief with his fever, his family finally went to Provincial Hospital in Mati City for further
evaluation under Dr. Jacob service and was asked to submit for an executive check-up. The CBC pc
result revealed still with blood infection, X-ray result was normal, Thyphidot was negative, and
Urinalysis revealed normal.

Last March, they were then referred to Southern Philippines Medical Center in Davao City
for further evaluation and management. On the way to the hospital, he experienced a 5-minute
seizure and as described by the mother, he suddenly went stiff and went unconscious.
In the Emergency Room of the SPMC, they were then admitted under the service of General
Pediatrics where they stayed for 32 days in the Pediatric General Wing (PGW) Unit with the
diagnosis of Benign Febrile Convulsion. Series of laboratory tests were done, serum Pro-calcitonin
test revealed high at 6.42, Typhidot was negative, WBC revealed high at 23.94 x10^3/ul,
Reticulocyte came low at 1.0, LDH as high as 1,515 u/L and serum Creatinine and Electrolytes were
normal.

The Pediatric Resident Physicians had hard time figuring out what the diagnosis of the

patient is. During his stay in the PGW Unit, his health was getting deteriorated according to his
mother wherein, he is too weak to walk, frequent sleepiness, paleness, cracked lips, mosquito bitelike rashes, and bleeding episodes such as hemoptysis and melena. His repeat CBC pc result
revealed that Hemoglobin was as low as 67 g/L and, thus, was given two units of packed RBC
blood transfusion. After two units of blood transfusion, the repeat Hemoglobin count was increased
to 97 g/L. Aside from his hematologic problem, the patient had also experienced joint pains,
difficulty of walking, relapsing moderate-grade fever and loss of appetite.
Midst April, Jomueld was then referred to the Hematology Service for evaluation and comanagement wherein his antibiotic was changed to Meropenem IV and ordered Diazepam for active
seizure. He was also requested to undergo ANA and Anti-dsDNA blood serology test which resulted
to negative ANA and positive Anti-dsDNA. With that result, he was then referred to Nephrology
Service and was transferred to Pediatric Specialty Wing (PSW) Unit for Methylprednisolone Pulse
Therapy. With these controlled previous signs and symptoms after pulse therapy such as decreased
joint swelling, resolved fever and increased in appetite and energy level, his diagnosis was changed
to SLE Nephritis.
After a month of stay in the PSW Unit, he was discharged in the institution with the
following home medications: Prednisone 20 mg/tablet two tablets to be taken once in every other
day, Azathioprine 50 mg/tablet one-half tablet once a day, Isoniazid 200mg/5ml syrup, to give five
milliliters once a day and lastly, Calcium Carbonate 500mg/tablet one tablet once a day.

End of July, Jomueld had an onset relapsing moderate-grade fever, in which her mother gave
him Paracetamol syrup with some relief. However, few days after his relapsing moderate-grade
fever he had an onset of five-minute grand-mal seizure and as described by the mother, had an
upward rolling of the eyes, stiffening of upper and lower extremities and increased in salivation.
Hence, this prompted admission to SPMC and with the initial impression of the Resident on duty
revealed Benign Febrile Convulsion, SLE Nephritis.
In the Emergency Room, Jomueld had an episode of epistaxis, seven times vomiting, and
high-grade fever. Vital Signs were taken and as followed: Blood Pressure 80/50mmHg, Pulse Rate
108bpm, Respiratory Rate 38cpm, and Temperature of 39 degrees Celsius. Initial laboratory results
revealed with normal Hemoglobin and WBC count and slightly low serum Calcium and
Magnesium. He was then given Paracetamol IVTT for fever, Odansetron IVTT for vomiting and
Tranexamic Acid IVTT for epistaxis. He was admitted back to the PSW Unit under the Nephrology
service and advised for pulse therapy with Methylprednisolone for three cycles and
Cyclophosphamide for one cycle. He was also prescribed with Cal-Mg tablet for correction of his
decreased serum Calcium and Magnesium. Repeat serum electrolytes and CBC pc were ordered and
both revealed with normal values.
After five days of stay in the PSW Unit, he was then discharged in the institution with the
following same home medications: Prednisone 20 mg/tablet two tablets to be taken once in every
other day, Azathioprine 50 mg/tablet one-half tablet once a day, Isoniazid 200mg/5ml syrup, to give
five milliliters once a day and lastly, Calcium Carbonate 500mg/tablet one tablet once a day.

HISTORY OF PRESENT ILLNESS

Patient has a diagnosed case of Systemic Lupus Erythematosus Nephritis since April 2014.
He had undergone series of pulse therapy such as Methylprednisolone for three cycles and
Cyclophosphamide for one cycle. He has maintenance medications such as Prednisone tablet,
Azathioprine tablet, Isoniazid syrup and Calcium Carbonate tablet. He came for the consultation
due to scheduled pulse therapy of Methylprednisolone and Cyclophosphamide.
SOCIAL HISTORY
The patient lives with his parents together with his two siblings. The father is the bread
winner of the family earning from PhP 300 to PhP 450 a day as a tricycle driver while his mother is
a plain housewife. They live in an owned house that was passed over his fathers parents and has no
identified hazards known in their house premise. His father happens to be a chain smoker,
consuming a pack of cigarettes a day. He smokes even at home in front of the children.
DIET AND EXERCISE
The patient is fond of eating chips and soft drinks daily. He eats three square meals a day
and eats fruits and vegetables as well. He is also active in class, plays with other children, but he is
now frequently absent because of his present medical illness.

10

GENOGRAM
EDMUNDO Sr., 67

ERLINDA, 56

MARY ANN, 36

GABBY, 38

ALLAN, 37

GINO, 45

ALBERT, 24

JOMARYL, 6

JIMUELD, 5

JOMUELD, 5

LEGEND:
Hypertension
Bronchial Asthma
Bronchopneumonia

Deceased
Leukemia

BONIFACIO Jr., 43

JOVANI, 47

JOVENSON, 34

EDMUNDO Jr., 35

RENATA, 60

BONIFACIO Sr., 61

Pulmonary Tuberculosis
Vehicular Accident

Tetanus

11

DEVELOPMENTAL DATA
Erik Erikson envisions life as a sequence of levels of achievement. Each stage signals a task
that must be achieved. The resolution can be complete, partial, or unsuccessful. He believes that the
greater achievement, the healthier the personality of the person. The developmental task can be
viewed as a series of crises and successful resolution of these crises is supportive to the persons
ego. Failure to achieve a task influences the persons ability to achieve the next task. He also
emphasizes that people must change and adapt their behavior to maintain control over their lives. In
this view, no stage in personality development can be bypassed, but people can become fixated at
one stage or regress to previous stage.
Jomueld, a five-year old patient, is considered to be in the late childhood according to
Eriksons Psychosocial Developmental Stages. This stage occurs during the preschool years,
between the ages of three and five. The central task in this stage is initiative versus guilt where
learning the degree of assertiveness and purpose influence the environment. The ability to evaluate
ones own behavior takes place. On the contrary, the indicators of negative resolution in this stage is
lack of confidence, pessimism, fear of wrong doing, over control and over restriction of own
activity takes place.
The patient exercised his initiative where he began to assert power and control over the
surroundings through directing play and other social interaction. As observed by the mother, the
child was able to interact regularly with his friends and classmates in school. He played happily
with other children and enjoyed lots of physical games as well as stories. He was full of confidence
in doing and exploring things especially in their activities. He can go to the toilet on his own, use
toilet paper properly and flush the toilet. He can also dress himself providing the fastenings are not
too difficult and able to feed himself with minimal supervision. Even at home, he loved to interact
with his siblings. Jumping, running and playing simple computer games were among of his
activities. Jomueld frequently asked many questions as his thirst for knowledge grows about the
world and why things happen and how that thing happens.

12

At his age, Jomueld was able to identify his emotions. If he finds something funny, he
laughs. If something makes him feel sad or angry, he cries. When he does things that is not accepted
such as pushing or shouting and is reprimanded by his mother, he has the initiative to apologize. He
showed understanding of right and wrong.
The patient was able to achieve the task that Erikson identified in this stage which is
intimacy vs. guilt.

13

PHYSICAL ASSESSMENT
General Appearance:
Affect and facial expression appropriate to situation. Speech is clear and comprehensible. He
is wearing a shirt and shorts, hair well combed and appears tidy. Vital Signs were taken prior the
examination and were as followed: Blood Pressure 90/60 mmHg, Cardiac Rate 107 bpm,
Respiratory Rate 24 cpm and Axillary Temperature 36.7 degrees Celsius.
Skin:
The color of the childs skin is evenly distributed and is warm to touch, soft, smooth over the
entire body with brown complexion. Skin with good turgor rapidly returns to its previous contour.
Head:
Hair is distributed evenly over the scalp, soft in texture, black in color and well combed and
no presence of dandruffs or lice noted. Fontanels are already closed. The head circumference is 50
centimeters and facial expression is symmetrical. Minimal abrasion noted at the left cheek.
Eyes:
No changes and problem in vision and he does not wear glasses. Sclera is white and clear,
conjunctiva color is pink and pupils are round, clear, and equal in size, equally brisk and reactive to
light at two millimeters in size. No abnormal pigmentations, hemorrhages or exudates noted. The
child has fine extraocular movement and able to follow objects without any difficulty.
Ears:
Both ears are clean and no discharges noted upon inspection. No changes in hearing, and
does not wear hearing aids.
Nose:
Pink in color and no discharges noted upon the time of examination, the septum is at
midline. No nasal flaring noted.
Mouth and Throat:

14

Teeth are present and in good dentition, however there are some cavities noted upon
inspection, the tongue is in midline, pink in color, moist and there are no lesions. Gums and
mucosal membrane have no swelling, bleeding, or inflammation noted. Tonsils are normal and
noted to be at grade 2+. Positive gag reflex with no difficulty of swallowing noted.
Neck:
Active range of motion, normal flexion and extension, lateral rotation and tilting noted
without any difficulty. Trachea is midline and mobile. No lesions or masses noted upon palpation.
Chest:
The respiratory rate is 24 cycles per minute, regular in rhythm, unlabored and without the
use of accessory muscles noted. Chest expansion is equal with normal and clear breath sounds on
all areas upon auscultation. No lesions and any abnormalities noted.
Abdomen:
Abdomen is flat and soft, not distended, with bowel sounds of 3 times per minute. No
tenderness or masses noted upon palpation. No lesions observed.
Genital:
The patient is still not circumcised, no hypospadias or phimosis noted. No difficulty of
urination noted.
Upper and Lower Extremities:
Upper: Nails are pinkish in color, no signs of cyanosis or clubbing noted. Palms are pinkish
in color, with smooth texture. Range of motion is normal, has strong hand grip on both hands and
can both flex and extend without any difficulties, no pain on joints upon movements. No
deformities noted any difficulties in locomotion. Radial pulse is strong and not easily obliterated.
Lower: Toenails are pinkish in color. Range of Motion on both feet is normal and can flex
and extend without any deformities and no pain on joint movements. Minimal abrasions noted on
both feet but no discharges noted. No problem with walking and locomotion. Normal gait noted.
ANATOMY AND PHYSIOLOGY

15

Immune and Lymphatic System

The
lymphatic

immune
systems

and

are

two

closely related organ systems

that share several organs and
physiological

functions.

The

immune system is our bodys

defense system against infectious
pathogenic viruses, bacteria, and
fungi

as

well

as

parasitic

animals. The immune system

works to keep these harmful
agents out of the body and
attacks those that manage to
enter.
The lymphatic system is a system of capillaries, vessels, nodes and other organs
that transport a fluid called lymph from the tissues as it returns to the bloodstream. The lymphatic
tissue of these organs filters and cleans the lymph of any debris, abnormal cells, or pathogens. The
lymphatic system also transports fatty acids from the intestines to the circulatory system.
RED BONE MARROW AND LEUKOCYTES
Red bone marrow is a highly vascular tissue found in the spaces between trabeculae of
spongy bone. It is mostly found in the ends of long bones and in the flat bones of the body. Red
bone marrow is a hematopoietic tissue containing many stem cells that produce blood cells. All of
the leukocytes, or white blood cells, of the immune system are produced by red bone marrow.
Leukocytes can be further broken down into two groups based upon the type of stem cells that
produces them: myeloid stem cells and lymphoid stem cells. Myeloid stem cells produce
monocytes and the granular leukocyteseosinophils, basophils, and neutrophils.

16

MONOCYTES
Monocytes are agranular leukocytes that can form two types of cells:
1.

Macrophages
Monocytes respond slowly to infection and once present at the site of infection, develop into

macrophages. Macrophages are phagocytes able to consume pathogens, destroyed cells, and debris
by phagocytosis. As such, they have a role in both preventing infection as well as cleaning up the
aftermath of an infection.
2.

Dendritic cells
Monocytes also develop into dendritic cells in healthy tissues of the skin and mucous

membranes. Dendritic cells are responsible for the detection of pathogenic antigens which are used
to activate T cells and B cells.
GRANULAR LEUKOCYTES
1. Eosinophils
Eosinophils are granular leukocytes that reduce allergic inflammation and help the body
fight off parasites.
2. Basophils
Basophils are granular leukocytes that trigger inflammation by releasing the chemicals
heparin and histamine. Basophils are active in producing inflammation during allergic reactions and
parasitic infections.
3. Neutrophils
Neutrophils are granular leukocytes that act as the first responders to the site of an infection.
Neutrophils use chemotaxis to detect chemicals produced by infectious agents and quickly move to
the site of infection. Once there, neutrophils ingest the pathogens via phagocytosis and release
chemicals to trap and kill the pathogens.
Lymphoid stem cells produce T lymphocytes and B lymphocytes.
1. T LYMPHOCYTES

17

T lymphocytes, also commonly known as T cells, are cells involved in fighting specific
pathogens in the body. T cells may act as helpers of other immune cells or attack pathogens directly.
After an infection, memory T cells persist in the body to provide a faster reaction to subsequent
infection by pathogens expressing the same antigen.
2. B LYMPHOCYTES
B lymphocytes, also commonly known as B cells, are also cells involved in fighting specific
pathogens in the body. Once B cells have been activated by contact with a pathogen, they form
plasma cells that produce antibodies. Antibodies then neutralize the pathogens until other immune
cells can destroy them. After an infection, memory B cells persist in the body to quickly produce
antibodies to subsequent infection by pathogens expressing the same antigen.
NATURAL KILLER CELLS
Natural killer cells, also known as NK cells, are lymphocytes that are able to respond to a
wide range of pathogens and cancerous cells. NK cells travel within the blood and are found in the
lymph nodes, spleen, and red bone marrow where they fight most types of infection.
LYMPH CAPILLARIES
As blood passes through the tissues of the body, it enters thin-walled capillaries to facilitate
diffusion of nutrients, gases, and wastes. Blood plasma also diffuses through the thin capillary walls
and penetrates into the spaces between the cells of the tissues. Some of this plasma diffuses back
into the blood of the capillaries, but a considerable portion becomes embedded in the tissues as
interstitial fluid. To prevent the accumulation of excess fluids, small dead-end vessels called
lymphatic capillaries extend into the tissues to absorb fluids and return them to circulation.
LYMPH
The interstitial fluid picked up by lymphatic capillaries is known as lymph. Lymph very
closely resembles the plasma found in the veins: it is a mixture of about 90% water and 10% solutes
such as proteins, cellular waste products, dissolved gases, and hormones. Lymph may also contain
bacterial cells that are picked up from diseased tissues and the white blood cells that fight these
pathogens. In late-stage cancer patients, lymph often contains cancerous cells that have

18

metastasized from tumors and may form new tumors within the lymphatic system. A special type of
lymph, known as chyle, is produced in the digestive system as lymph absorbs triglycerides from the
intestinal villi. Due to the presence of triglycerides, chyle has a milky white coloration to it.
LYMPHATIC VESSELS
Lymphatic capillaries merge together into larger lymphatic vessels to carry lymph through
the body. The structure of lymphatic vessels closely resembles that of veins: they both have thin
walls and many check valves due to their shared function of carrying fluids under low pressure.
Lymph is transported through lymphatic vessels by the skeletal muscle pumpcontractions of
skeletal muscles constrict the vessels to push the fluid forward. Check valves prevent the fluid from
flowing back toward the lymphatic capillaries.
LYMPH NODES
Lymph nodes are small, kidney-shaped organs of the lymphatic system. There are several
hundred lymph nodes found mostly throughout the thorax and abdomen of the body with the highest
concentrations in the axillary (armpit) and inguinal (groin) regions. The outside of each lymph node
is made of a dense fibrous connective tissue capsule. Inside the capsule, the lymph node is filled
with reticular tissue containing many lymphocytes and macrophages. The lymph nodes function as
filters of lymph that enters from several afferent lymph vessels. The reticular fibers of the lymph
node act as a net to catch any debris or cells that are present in the lymph. Macrophages and
lymphocytes attack and kill any microbes caught in the reticular fibers. Efferent lymph vessels then
carry the filtered lymph out of the lymph node and towards the lymphatic ducts.
LYMPHATIC DUCTS
All of the lymphatic vessels of the body carry lymph toward the two lymphatic ducts: the
thoracic duct and the right lymphatic ducts. These ducts serve to return lymph back to the venous
blood supply so that it can be circulated as plasma.

1. Thoracic Duct

19

The thoracic duct connects the lymphatic vessels of the legs, abdomen, left arm, and the left
side of the head, neck, and thorax to the left brachiocephalic vein.
2. Right Lymphatic Duct
The right lymphatic duct connects the lymphatic vessels of the right arm and the right side
of the head, neck, and thorax to the right brachiocephalic vein.
LYMPHATIC NODULES
Outside of the system of lymphatic vessels and lymph nodes, there are masses of nonencapsulated lymphatic tissue known as lymphatic nodules. The lymphatic nodules are associated
with the mucous membranes of the body, where they work to protect the body from pathogens
entering the body through open body cavities.
TONSILS
There are five tonsils in the body: two lingual, two palatine, and one pharyngeal. The lingual
tonsils are located at the posterior root of the tongue near the pharynx. The palatine tonsils are in the
posterior region of the mouth near the pharynx. The pharyngeal pharynx, also known as
the adenoid, is found in the nasopharynx at the posterior end of the nasal cavity. The tonsils contain
many T and B cells to protect the body from inhaled or ingested substances. The tonsils often
become inflamed in response to an infection.
PEYERS PATCHES
Peyers patches are small masses of lymphatic tissue found in the ileum of the small
intestine. Peyers patches contain T and B cells that monitor the contents of the intestinal lumen for
pathogens. Once the antigens of a pathogen are detected, the T and B cells spread and prepare the
body to fight a possible infection.
SPLEEN
The spleen is a flattened, oval-shaped organ located in the upper left quadrant of the
abdomen lateral to the stomach. The spleen is made up of a dense fibrous connective tissue capsule
filled with regions known as red and white pulp. Red pulp, which makes up most of the spleens

20

mass, is so named because it contains many sinuses that filter the blood. Red pulp contains reticular
tissues whose fibers filter worn out or damaged red blood cells from the blood. Macrophages in the
red pulp digest and recycle the hemoglobin of the captured red blood cells. The red pulp also stores
many platelets to be released in response to blood loss. White pulp is found within the red pulp
surrounding the arterioles of the spleen. It is made of lymphatic tissue and contains many T cells, B
cells, and macrophages to fight off infections.
THYMUS
The thymus is a small, triangular organ found just posterior to the sternum and anterior to
the heart. The thymus is mostly made of glandular epithelium and hematopoietic connective tissues.
The thymus produces and trains T cells during fetal development and childhood. T cells formed in
the thymus and red bone marrow mature, develop, and reproduce in the thymus throughout
childhood. The vast majority of T cells does not survive their training in the thymus and are
destroyed by macrophages. The surviving T cells spread throughout the body to the other lymphatic
tissues to fight infections. By the time a person reaches puberty, the immune system is mature and
the role of the thymus is diminished. After puberty, the inactive thymus is slowly replaced by
adipose tissue.
LYMPH CIRCULATION
One of the primary functions of the lymphatic system is the movement of interstitial fluid
from the tissues to the circulatory system. Like the veins of the circulatory system, lymphatic
capillaries and vessels move lymph with very little pressure to help with circulation. To help move
lymph towards the lymphatic ducts, there is a series of many one-way check valves found
throughout the lymphatic vessels. These check valves allow lymph to move toward the lymphatic
ducts and close when lymph attempts to flow away from the ducts. In the limbs, skeletal muscle
contraction squeezes the walls of lymphatic vessels to push lymph through the valves and towards
the thorax. In the trunk, the diaphragm pushes down into the abdomen during inhalation. This
increased abdominal pressure pushes lymph into the less pressurized thorax. The pressure gradient
reverses during exhalation, but the check valves prevent lymph from being pushed backwards.
TRANSPORT OF FATTY ACIDS

21

Another major function of the lymphatic system is the transportation of fatty acids from the
digestive system. The digestive system breaks large macromolecules of carbohydrates, proteins, and
lipids into smaller nutrients that can be absorbed through the villi of the intestinal wall. Most of
these nutrients are absorbed directly into the bloodstream, but most fatty acids, the building blocks
of fats, are absorbed through the lymphatic system.
In the villi of the small intestine are lymphatic capillaries called lacteals. Lacteals are able to
absorb fatty acids from the intestinal epithelium and transport them along with lymph. The fatty
acids turn the lymph into a white, milky substance called chyle. Chyle is transported through
lymphatic vessels to the thoracic duct where it enters the bloodstream and travels to the liver to be
metabolized.
TYPES OF IMMUNITY
The body employs many different types of immunity to protect itself from infection from a
seemingly endless supply of pathogens. These defenses may be external and prevent pathogens
from entering the body. Conversely, internal defenses fight pathogens that have already entered the
body. Among the internal defenses, some are specific to only one pathogen or may be innate and
defend against many pathogens. Some of these specific defenses can be acquired to preemptively
prevent an infection before a pathogen enters the body.
INNATE IMMUNITY
The body has many innate ways to defend itself against a broad spectrum of pathogens.
These defenses may be external or internal defenses. The internal defenses include fever,
inflammation, natural killer cells, and phagocytes.
EXTERNAL DEFENSES
The coverings and linings of the body constantly prevent infections before they begin by
barring pathogens from entering the body. Epidermal cells are constantly growing, dying, and
shedding to provide a renewed physical barrier to pathogens. Secretions like sebum, cerumen,
mucus, tears, and saliva are used to trap, move, and sometimes even kill bacteria that settle on or in
the body.

22

Stomach acid acts as a chemical barrier to kill microbes found on food entering the body.
Urine and acidic vaginal secretions also help to kill and remove pathogens that attempt to enter the
body. Finally, the flora of naturally occurring beneficial bacteria that live on and in our bodies
provide a layer of protection from harmful microbes that would seek to colonize our bodies for
themselves.
INTERNAL DEFENSE
1. Fever
In response to an infection, the body may start a fever by raising its internal temperature out
of its normal homeostatic range. Fevers help to speed up the bodys response system to an infection
while at the same time slowing the reproduction of the pathogen.
2. Inflammation
The body may also start an inflammation in a region of the body to stop the spread of the
infection. Inflammations are the result of a localized vasodilation that allows extra blood to flow
into the infected region. The extra blood flow speeds the arrival of leukocytes to fight the infection.
The enlarged blood vessel allows fluid and cells to leak out of the blood vessel to cause swelling
and the movement of leukocytes into the tissue to fight the infection.
3. Natural Killer Cells
Natural killer (NK) cells are special lymphocytes that are able to recognize and kill virusinfected cells and tumor cells. NK cells check the surface markers on the surface of the bodys cells,
looking for cells that are lacking the correct number of markers due to disease. The NK cells then
kill these cells before they can spread infection or cancer.
4. Phagocytes
The term phagocyte means eating cell and refers to a group of cell types including
neutrophils and macrophages. A phagocyte engulfs pathogens with its cell membrane before using
digestive enzymes to kill and dissolve the cell into its chemical parts. Phagocytes are able to

23

recognize and consume many different types of cells, including dead or damaged body cells.
CELL MEDIATED IMMUNITY
When a pathogen infects the body, it often encounters macrophages and dendritic cells of the
innate immune system. These cells can become antigen-presenting cells (APCs) by consuming and
processing pathogenic antigens. The APCs travel into the lymphatic system carrying these antigens
to be presented to the T cells and B cells of the specific immune system.
Inactive T cells are found in lymphatic tissue awaiting infection by a pathogen. Certain T
cells have antigen receptors that recognize the pathogen but do not reproduce until they are
triggered by an APC. The activated T cell begins reproducing very quickly to form an army of
active T cells that spread through the body and fight the pathogen. Cytotoxic T cells directly attach
to and kill pathogens and virus-infected cells using powerful toxins. Helper T cells assist in the
immune response by stimulating the response of B cells and macrophages.
After an infection has been fought off, memory T cells remain in the lymphatic tissue
waiting for a new infection by cells presenting the same antigen. The response by memory T cells to
the antigen is much faster than that of the inactive T cells that fought the first infection. The increase
in T cell reaction speed leads to immunitythe reintroduction of the same pathogen is fought off so
quickly that there are few or no symptoms. This immunity may last for years or even an entire
lifetime.
ANTIBODY-MEDIATED SPECIFIC IMMUNITY
During an infection, the APCs that travel to the lymphatic system to stimulate T cells also
stimulate B cells. B cells are lymphocytes that are found in lymphatic tissues of the body that
produce antibodies to fight pathogens (instead of traveling through the body themselves). Once a B
cell has been contacted by an APC, it processes the antigen to produce an MHC-antigen complex.
Helper T cells present in the lymphatic system bind to the MHC-antigen complex to stimulate the B
cell to become active. The active B cell begins to reproduce and produce two types of cells: plasma
cells and memory B cells.
1. Plasma cells

24

Plasma cells become antibody factories producing thousands of antibodies.

2. Memory B cells
Memory B cells reside in the lymphatic system where they help to provide immunity by
preparing for later infection by the same antigen-presenting pathogen.
Antibodies are proteins that are specific to and bind to a particular antigen on a cell or virus.
Once antibodies have latched on to a cell or virus, they make it harder for their target to move,
reproduce, and infect cells. Antibodies also make it easier and more appealing for phagocytes to
consume the pathogen.
ACQUIRED IMMUNITY
Under most circumstances, immunity is developed throughout a lifetime by the
accumulation of memory T and B cells after an infection. There are a few ways that immunity can
be acquired without exposure to a pathogen. Immunization is the process of introducing antigens
from a virus or bacterium to the body so that memory T and B cells are produced to prevent an
actual infection. Most immunizations involve the injection of bacteria or viruses that have been
inactivated or weakened. Newborn infants can also acquire some temporary immunity from
infection thanks to antibodies that are passed on from their mother. Some antibodies are able to
cross the placenta from the mothers blood and enter the infants bloodstream. Other antibodies are
passed through breast milk to protect the infant.

Urinary System

25

The urinary system consists

of the kidneys, ureters, urinary
bladder, and urethra. The kidneys
filter the blood to remove wastes
and produce urine. The ureters,
urinary

bladder,

and

urethra

together form the urinary tract,

which acts as a Pluming system to
drain urine from the kidneys, store
it and then release it during
urination. Besides filtering and
eliminating wastes from the body,
the urinary system also maintains the homeostasis of water, ions, pH, blood pressure, calcium and
red blood cells.
KIDNEYS
The kidneys are a pair of bean-shaped organs found along the posterior wall of the
abdominal cavity. The left kidney is located slightly higher than the right kidney because the right
side of the liver is much larger than the left side. The kidneys, unlike the other organs of the
abdominal cavity, are located posterior to the peritoneum and touch the muscles of the back. The
kidneys are surrounded by a layer of adipose that holds them in place and protects them from
physical damage. The kidneys filter metabolic wastes, excess ions, and chemicals from the blood to
form urine.
URETERS
The ureters are a pair of tubes that carry urine from the kidneys to the urinary bladder. The
ureters are about 10 to 12 inches long and run on the left and right sides of the body parallel to
the vertebral column. Gravity and peristalsis of smooth muscle tissue in the walls of the ureters
move urine toward the urinary bladder. The ends of the ureters extend slightly into the urinary

26

bladder and are sealed at the point of entry to the bladder by the ureterovesical valves. These valves
prevent urine from flowing back towards the kidneys.
URINARY BLADDER
The urinary bladder is a sac-like hollow organ used for the storage of urine. The urinary
bladder is located along the bodys midline at the inferior end of the pelvis. Urine entering the
urinary bladder from the ureters slowly fills the hollow space of the bladder and stretches its elastic
walls. The walls of the bladder allow it to stretch to hold anywhere from 600 to 800 milliliters of
urine.
URETHRA
The urethra is the tube through which urine passes from the bladder to the exterior of the
body. The female urethra is around 2 inches long and ends inferior to the clitoris and superior to the
vaginal opening. In males, the urethra is around 8 to 10 inches long and ends at the tip of the penis.
The urethra is also an organ of the male reproductive system as it carries sperm out of the body
through the penis. The flow of urine through the urethra is controlled by the internal and external
urethral sphincter muscles. The internal urethral sphincter is made of smooth muscle and opens
involuntarily when the bladder reaches a certain set level of distention. The opening of the internal
sphincter results in the sensation of needing to urinate. The external urethral sphincter is made of
skeletal muscle and may be opened to allow urine to pass through the urethra or may be held closed
to delay urination.
MAINTENANCE OF HOMEOSTASIS
The kidneys maintain the homeostasis of several important internal conditions by controlling
the excretion of substances out of the body.
IONS
The kidney can control the excretion of potassium, sodium, calcium, magnesium, phosphate,
and chloride ions into urine. In cases where these ions reach a higher than normal concentration, the
kidneys can increase their excretion out of the body to return them to a normal level. Conversely,

27

the kidneys can conserve these ions when they are present in lower than normal levels by allowing
the ions to be reabsorbed into the blood during filtration.
pH
The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate ions in
the blood to control blood pH. H+ ions are produced as a natural byproduct of the metabolism of
dietary proteins and accumulate in the blood over time. The kidneys excrete excess H+ ions into
urine for elimination from the body. The kidneys also conserve bicarbonate ions, which act as
important pH buffers in the blood.
OSMOLARITY
The cells of the body need to grow in an isotonic environment in order to maintain their
fluid and electrolyte balance. The kidneys maintain the bodys osmotic balance by controlling the
amount of water that is filtered out of the blood and excreted into urine. When a person consumes a
large amount of water, the kidneys reduce their reabsorption of water to allow the excess water to be
excreted in urine. This results in the production of dilute, watery urine. In the case of the body
being dehydrated the kidneys reabsorb as much water as possible back into the blood to produce
highly concentrated urine full of excreted ions and wastes. The changes in excretion of water are
controlled by antidiuretic hormone (ADH). ADH is produced in the hypothalamus and released by
the posterior pituitary gland to help the body retain water.
BLOOD PRESSURE
The kidneys monitor the bodys blood pressure to help maintain homeostasis. When blood
pressure is elevated, the kidneys can help to reduce blood pressure by reducing the volume of blood
in the body. The kidneys are able to reduce blood volume by reducing the reabsorption of water into
the blood and producing watery, dilute urine. When blood pressure becomes too low, the kidneys
can produce the enzyme renin to constrict blood vessels and produce concentrated urine, which
allows more water to remain in the blood.

28

FILTRATION
Inside each kidney are around a million tiny structures called nephrons. The nephron is the
functional unit of the kidney that filters blood to produce urine. Arterioles in the kidneys deliver
blood to a bundle of capillaries surrounded by a capsule called a glomerulus. As blood flows
through the glomerulus, much of the bloods plasma is pushed out of the capillaries and into the
capsule, leaving the blood cells and a small amount of plasma to continue flowing through the
capillaries. The liquid filtrate in the capsule flows through a series of tubules lined with filtering
cells and surrounded by capillaries. The cells surrounding the tubules selectively absorb water and
substances from the filtrate in the tubule and return it to the blood in the capillaries. At the same
time, waste products present in the blood are secreted into the filtrate. By the end of this process, the
filtrate in the tubule has become urine containing only water, waste products, and excess ions. The
blood exiting the capillaries has reabsorbed all of the nutrients along with most of the water and
ions that the body needs to function.
STORAGE AND EXCRETION OF WASTE
After urine has been produced by the kidneys, it is transported through the ureters to the urinary
bladder. The urinary bladder fills with urine and stores it until the body is ready for its excretion.
When the volume of the urinary bladder reaches anywhere from 150 to 400 milliliters, its walls
begin to stretch and stretch receptors in its walls send signals to the brain and spinal cord. These
signals result in the relaxation of the involuntary internal urethral sphincter and the sensation of
needing to urinate. Urination may be delayed as long as the bladder does not exceed its maximum
volume, but increasing nerve signals lead to greater discomfort and desire to urinate.
Urination is the process of releasing urine from the urinary bladder through the urethra and out
of the body. The process of urination begins when the muscles of the urethral sphincters relax,
allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth
muscle in the walls of the urinary bladder contract to expel urine from the bladder.
PRODUCTION OF HORMONES
The kidneys produce and interact with several hormones that are involved in the control of
systems outside of the urinary system.

29

CALCITROL
Calcitriol is the active form of vitamin D in the human body. It is produced by the kidneys
from precursor molecules produced by UV radiation striking the skin. Calcitriol works together with
parathyroid hormone (PTH) to raise the level of calcium ions in the bloodstream. When the level of
calcium ions in the blood drops below a threshold level, the parathyroid glands release PTH, which
in turn stimulates the kidneys to release calcitriol. Calcitriol promotes the small intestine to absorb
calcium from food and deposit it into the bloodstream. It also stimulates the osteoclasts of
the skeletal system to break down bone matrix to release calcium ions into the blood.
ERYTHROPOIETIN
Erythropoietin, also known as EPO, is a hormone that is produced by the kidneys to
stimulate the production of red blood cells. The kidneys monitor the condition of the blood that
passes through their capillaries, including the oxygen-carrying capacity of the blood. When the
blood becomes hypoxic, meaning that it is carrying deficient levels of oxygen, cells lining the
capillaries begin producing EPO and release it into the bloodstream. EPO travels through the blood
to the red bone marrow, where it stimulates hematopoietic cells to increase their rate of red blood
cell production. Red blood cells contain hemoglobin, which greatly increases the bloods oxygencarrying capacity and effectively ends the hypoxic conditions.
RENIN
Renin is not a hormone itself, but an enzyme that the kidneys produce to start the ReninAngiotensin Aldosterone System (RAAS). The RAAS increases blood volume and blood pressure
in response to low blood pressure, blood loss, or dehydration. Renin is released into the blood where
it catalyzes angiotensinogen from the liver into angiotensin I.
Angiotensin I is further catalyzed by another enzyme into Angiotensin II. Angiotensin II
stimulates several processes, including stimulating the adrenal cortex to produce the hormone
aldosterone. Aldosterone then changes the function of the kidneys to increase the reabsorption of
water and sodium ions into the blood, increasing blood volume and raising blood pressure. Negative
feedback from increased blood pressure finally turns off the RAAS to maintain healthy blood
pressure levels.

30

DEFINITION OF COMPLETE DIAGNOSIS

Systemic Lupus Erythematosus (SLE) is a chronic inflammatory disease characterized by
highly diverse clinical manifestations and the presence in the serum antibodies reacting with
different call nuclei components. The skin, joints, lings, heart, kidneys, nervous system, and other
organs are involved. The clinical course of the disease is characterized by flares, periods of chronic
disease, and periods of remissions (Pediatric Nephrology 5th Edition Lippincott Williams and
Wilkins, 2004).
The American Association of Rheumatology (AAR) developed diagnostics criteria of SLE to
establish with certainty the diagnosis of SLE and to distinguish it from other rheumatic diseases.
The 1982 revised AAR of Rheumatology criteria for classification of SLE are as follows: (1) malar
rash; (2) discoid rash; (3) photosensitivity; (4) oral ulcers; (4) arthritis; (5) serositis: pleuritis or
pericarditis; (6) prteinuria: >0.5 g/d or red blood cell casts; (7) psychosis or seizures; (8)
hematologic problems such as hemolytic anemia: <4,000/mm3 or lymphopenia: <1,500/mm3 or
thrombocytopenia: <100,000/mm3; (9) antinuclear antibodies; and (10) anti-dsDNA or anti-Sm
antibodies or false positive Treponema Pallidum Immobilization or VDRL, or positive lupus
erythematosus cell test. When four of these criteria are present, the sensitivity of the diagnosis of
SLE is 95% and the specificity is 96%. Some patients with the disease may not satisfy the criteria
initially but may develop other manifestations later then develop the full criteria for the diagnosis of
SLE (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
The etiology of the SLE remains unknown, despite the progress that has been made during
the recent years in understanding the pathogenic mechanisms of the disease. SLE is characterized
by the development of autoantibodeis directed against a variety of self-components, and contrary, to
other autoimmune diseases, there are no stigma of organ-specific autoimmunity (Pediatric
Nephrology 5th Edition Lippincott Williams and Wilkins, 2004). There are contributing factors to be
considered for the development of SLE such as genetic factors, environmental, drug-induced and
infectious factors, and hormonal factors.

31

The evidence for a genetic susceptibility to SLE is based on familial aggregation. The
prevalence of SLE is estimated to be 2.6% to 3.5% in 1st-degree relatives of matched controls. No
single causal gene has been identified. Instead, multiple genes appear to influence a person's chance
of developing lupus when triggered by environmental factors. The most important genes are located
in the HLA region on chromosome 6, where mutations may occur randomly (de novo) or may be
inherited. HLA class I, class II, and class III are associated with SLE, but only classes I and II
contribute independently to increased risk of SLE (Pediatric Nephrology 5th Edition Lippincott
Williams and Wilkins, 2004).
Based on twin concordance studies, the induction of SLE requires more than genetic factors.
Environment, hormonal, toxic, and infectious factors have been proposed. The high degree of
homology between a small peptide sequence of the Epstein-Barr Virus (EBV) nuclear antigen-2 and
the SmD1 ribonucleoprotein, a target of autoantibodies in SLE patients, suggests that antibodies
elicited by the viral antigen may cross-react with SmD1. Thus, EBV may be causative factor in
SLE. Photosensitivity is a common feature of SLE, and the disease is aggravated by sun exposure in
40% to 70% of patients. Ultraviolet light induce apoptosis of keratinocytes, which may, in turn,
develop small surface blebs containing lupus autoantigens such as the Ro particle. Similarly, druginduce lupus such as chlorpromazine, procainamide, isoniazid, quinidine, phenytion, and
hydralazine are capable of inducing apoptosis. However, symptoms of drug-induced lupus generally
disappear once the medication that triggered the episode is stopped and is reversible condition
(Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
The female predominance in SLE is particularly strong during childbearing ages, suggesting
that hormonal differences may contribute to the increased risk of the disease. Reduced androgen
levels and increased estradiol and prolactin exacerbate levels have been reported in SLE patients.
Moreover, whereas administration of androgens leads to improvement, estrogen and prolactin
exacerbate disease severity (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins,
2004).
SLE is often acute in onset and includes general symptoms of fever and fatigued associated
with cutaneous and articular symptoms. SLE may also begin with an isolated symptom such as a

32

hemolytic anemia, a nephritic syndrome with hematuria, chorea, or pericarditis. General symptoms,
particularly weight loss, anorexia, and asthenia, are virtually constant in SLE. Episodic fever is
frequent during acute phase of the disease or during infection. Pulmonary or urinary tract infections
are frequent during the course of SLE. Opportunistic infections may be life threatening. A number
of factors may favor a relapse of the disease, including exposure to UV light, infection, stress,
surgery or pregnancy (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
Arthralgia is the most common manifestation of SLE. Both large and small articulations,
especially of the hands, are affected, causing moderate pain and articular swelling. Arthritis is very
rarely deforming, and synovial fluid contains relatively few cells. Myalgia is less frequent,
Avascular osteonecrosis, which often affects femoral heads, may occur in the absence of treatment
with corticosteroids (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
The most classic skin lesion of SLE is the butterfly or malar rash over the cheeks and nose,
which is present in one-third of cases. The rash is often appears after sun exposure. Maculopapular
eruptions on the upper portion of the trunk as well as any areas exposed to light are the most
common. Popular lesion and squamous lesions on the trunk, face and palms of the hands can be
observed in the less severe cutaneous forms of the disease. Raynauds phenomena of the extremities
cause painful white marble-like lesions, leg ulcers, and periungual or finger-pad erythema.
Urticarial

eruptions

and

pigmentation

anomalies

are

sometimes

observed.

Cutaneous

photosensitivity is noted especially in white patients. Mucosal lesions, particularly in the forn of
oral ulcerations, are common. Alopecia is observed in some children, especially those with active
forms of the disease (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
Pulmonary involvement occurs in more than 75% of children. Pleuritis, observed in 40% of
children, is often asymptomatic or maybe present as thoracic pain. The pleural fluid is exudates,
containing a large number of neutrophils and lymphocytes. Anomalies in diaphragmatic function
have been reported and can be responsible or dyspnea. Pulmonary damage may be manifested as an
acute pneumonitis with thoracic pain, dyspnea, and fever. Pulmonary arterial hypertension is a rare
but severe problem that may be secondary to repeated pulmonary embolism. Acute pulmonary
hemorrhage during the acute phase of the disease or during infections may be life threatening.

33

Pericarditis is frequent in SLE and is often diagnosed on echocardiography. Myocarditis

with congestive heart failure is rare. Endocarditis of Liebman-Sachs is often affects the mitral valve
and is associated with antiphospholipid.
Neuropsychiatric symptoms are present in 30% to 45% of children with SLE. These
symptoms can either be a direct of SLE or secondary to arterial hypertension, renal insufficiency,
infectious complication hemostasis abnormalities, or various treatments, particularly corticosteroids.
Headache is the most frequent neurologic manifestation of SLE and is often accompanied by
localized or generalized seizures. Psychiatric symptoms consist of difficulties with attention or
memory, disorientation, behavioral problems, depression, or psychotic states with hallucinations
and delirium (Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004).
Both the retina and the cornea can be affected by SLE. Keratoconjunctivitis sicca is the most
common ocular manifestation. The retinal lesions consist of white, cotton-like exudates lesions of
the optic nerve, papillary edema, or thrombosis of the central retrial artery (Pediatric Nephrology 5 th
Edition Lippincott Williams and Wilkins, 2004).
Hematologic manifestations are common in SLE. Anemia, observed on more than one-half
of cases, is usually normochromic and normocytic, and its degree reflects the activity of the disease.
Hemolytic anemia present, and is often, in less than 10% of cases, accompanied by reticulytosis, a
positive Coombs test, an increase in free bilirubin levels, and a decrease in haptoglobin levels.
Leukopenia, noted in more than 50% of cases, is partially responsible for an increased sensitivity to
infections. Thrombocytopenia, noted in 10 to 25% of cases, is accompanied by an increase in
megakaryocytes in the marrow, indicating peripheral destruction of platelets.
About half of cases of SLE demonstrate signs of lupus nephritis at one time or another.
Renal-specific signs include proteinuria (100%), nephrotic syndrome (55%), granular casts (30%),
red cell casts (10%), microhematuria (80%), macrohematuria (2%), reduced renal function (60%),
RPGN (30%), ARF (2%), hypertension (35%), hyperkalemia (15%) and tubular abnormalities
(70%).

34

The World Health Organization has divided lupus nephritis into five stages based on the
biopsy. This classification was defined in 1982 and revised in 1995. Class I is minimal mesangial
glomerulonephritis which is histologically normal on light microscopy but with mesangial deposits
on electron microscopy. It constitutes about 5% of cases of lupus nephritis. Renal failure is very rare
in this form. Class II is based on a finding of mesangial proliferative lupus nephritis. This form
typically responds completely to treatment with corticosteroids. It constitutes about 20% of cases.
Renal failure is rare in this form. Class III is focal proliferative nephritis and often successfully
responds to treatment with high doses of corticosteroids. It constitutes about 25% of cases. Renal
failure is uncommon in this form. Class IV is diffuse proliferative nephritis. This form is mainly
treated with corticosteroids and immunosuppressant drugs. It constitutes about 40% of cases. Renal
failure is common in this form. Class V is membranous nephritis and is characterized by extreme
edema and protein loss. It constitutes about 10% of cases. Renal failure is uncommon in this form.

35

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38

39

40

41

42

43

NURSING THEORY
Florence Nightingales Environmental Theory
Nightingale believed that the environment was a major factor or component of nursing care.
She believed that the physical environment, when clean, can increase the chance of patients
recovering to the fullest. Nightingale identified different items that could help in the patients
recovery such as ventilation, warming, lighting, noise, bed and beddings, cleanliness of room and
walls, personal cleanliness and nutrition.
Factors
Pure fresh air

Rationale
Patient must be provided a fresh air during his hospital stay. This will
aid her fast recovery because inhaling fresh air helps her to feel calm
and comfortable. This feeling of calmness aids in fast recovery of the

Pure water

patient.
Must be given with pure and clean water in order for the patient to heal
faster. Pure water helps hydrate the patient. It also aids in correcting

Sufficient

fluid and electrolyte imbalance of the body.

food Sufficient food is needed because it supplements the bodys needs every

supply

day. Having such foods would help our body to be strong which will

Cleanliness

also help us prevent infections or viral diseases.

The hospital is clean which really helps the patient to recover faster.
Cleanliness in such would alleviate the patient health. Maintaining
cleanliness of the environment helps in preventing infection to occur or

Light

passing of diseases from one to another.

The hospital prominences have proper ventilation because there are
enough windows for sunlight to pass through. Furthermore the room has
a good ventilation and lighting because hospital technicians assures that
all wirings are working and if ever there are busted bulbs of light they
assure to change it and recheck again if it is malfunctioning. Because of
such, this helps the patients present condition because the hospital itself

provided such particular need of a certain patient.

Virginia Hendersons Nursing Need Theory

44

Henderson believed that the unique function of the nurse is to assist the individual, sick or
well, in the performance of those activities contributing to health or its recovery (or to a peaceful
death) that he would perform unaided if he had the necessary strength, will or knowledge. And to
do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1991).
There are fourteen components based on human needs that make up nursing activities:
1. Breathe normally
Patients breathing pattern was normal. To maintain it, overcrowding environment was
controlled by limiting visitors.
2. Eat and drink adequately
Parents were encouraged to feed in small amounts frequently when patient refuses to eat.
3. Eliminate body wastes
Patient was advised to maintain cleanliness of peri-anal area after voiding or defecating.
4. Move and maintain desirable postures
Patient was not restricted in position. He maintained desirable positions and moved around.
5. Sleep and rest
Promoted and maintained a quiet environment for a sound sleep and rest.
6. Select suitable clothes
Encouraged the patient and parents to frequently change soiled or dirty clothes.
7. Maintain body temperature within normal range by adjusting clothing and modifying
environment
Temperature was maintained during hospitalization. Encouraged on wearing appropriate
clothes. Room was made well ventilated.
8. Keep the body clean and well groomed and protect the integument
Hygiene maintained. Routine care provided and taught parents about importance of hygiene.
9. Avoid dangers in the environment and avoid injuring others
Maintained a safe environment.
10. Communicate with others in expressing emotions, needs, fears, or opinions
Encouraged verbalization of feelings and listened to what the patient has to say.
11. Worship according to ones faith

45

Respected the religion of patient and family.

12. Work in such a way that there is sense of accomplishment
Patient and family were satisfied with nursing care rendered to patient.
13. Play or participate in various forms of recreation
Encouraged patient to walk around. Television was available as recreation.
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the
available health facilities
Parents showed curiosity about disease. A brief health teaching was done to inform the
family when to get their child to the hospital.
It is equally important to realize that these needs are satisfied by infinitely varied pattern of
living, no two of which are alike (Henderson, 1960).

46

Date
&

Cues

Need

Nursing Diagnosis

Objectives of Care

Nursing Interventions

Evaluation

Time
Objective:

Risk for Injury related That within my 8 hours 1. Establish rapport.

Oct. 29, 2014 at

Patient has history

to possible occurrence span of care, the patient To gain patients trust.

3 PM

of seizure attacks

of convulsion.

GOAL MET

that lasted three to

five minutes

convulsion

Patient was

visible

will be free from injury, 2. Monitor and record

seizure

or specifically,

is

sign

the significant others will be To obtain baseline data.

of

previously

diagnosed with

electrical system that

understanding

Benign Febrile

controls your brain. A

individual

Convulsion

single

that

Body weakness

have

Febrile episodes

2014
at
7AM

Subjective:
Mother verbalized
usahay na mukalit
lang na siya mukirig,

the a.) Verbalize

seizure

hours span of

safety needs/ injury

care, the patient

of prevention.

was free from

factors To prevent injuries in

contribute

to the setting.

injury,
specifically, the

such as a high fever

of the patient and within a culture of safety.

significant others

and lack of oxygen.

take steps to correct To prevent errors

were able to:

Hemoglobin

situation;

protein in red blood

promote client safety and

understanding

cells

model safety behaviors for

of individual

oxygen.

human

is

that

resulting in client injury,

carries b.) Demonstrate

Therefore,

levels

hemoglobin
H

causes,

3. Ascertain knowledge of

patients

Low

many

can

Within my 8

possibility of injury 4. Provide health care

manggahi tapos ang

mata musulirap labaw

in

a able to:

29,

problem

the Vital Signs.

in

body

of
the
may

behaviors,

lifestyle client/significant others.

a.) Verbalize

factors that

changes to reduce 5. Identify

contribute to

risk

possibility of

factors

and interventions/safety

protect patient from devices.

injury of the

47

na pag mag kalintura

result

to

seizure.

injury; and

During

episodes

convulsion,

are prone to injuries

as

since they may strike

enhance safety.

of

To promote safe

patient and take

physical environment and

steps to correct

patients c.) Modify environment individual safety.

indicated

situation;

to 6. Discuss importance of
self monitoring of

b.) Demonstrate

different objects due

conditions/ emotions.

behaviors,

to

Conditions/emotions

lifestyle changes

muscle spasms.

can contribute to

to reduce risk

occurrence of injury.

factors and

7. Provide an environment

protect patient

that is conducive for

from injury; and

resting.

One factor that could

trigger seizure is if the

environment as

patient lacks of sleep and

indicated to

is anxious with his

enhance safety.

uncontrollable

surroundings.
7. Evaluate patients
response to violence in
surroundings.
May enhance disregard
P

for own/others safety.

8. Stay with the patient if

48

c.) Modify

seizure/convulsion occurs.

Nurse can easily

promote safety if he/she

stays with the patient.

Nurses are obliged to time

the seizure attack to
identify the cerebral area
of involvement.
9. Administer medication
such as Diazepam PRN as
ordered.
Diazepam is commonly
used to treat conditions
such as anxiety, panic
attacks, seizure, etc.
10. Instruct patient to limit
oral fluid intake at least 1
1.5L / day
To prevent

bladder

distention
1.

11.
intake

and

accurately

49

Monitor
output

To

record

any

significant differences
2.

12.

Discuss

with patient the different

techniques that facilitate
voiding such as stroking
the inner thigh, or turning
the faucet on and let the
water run.
To stimulate reflex arc
3.

13.

Encourage

patient to apply warm and

cold compress alternately
on the hypogastric area.

To

stimulate

and

facilitate voiding
4.

14. During bath,

encourage patient to use
warm water

To help

muscles

relax

which

the
can

facilitate voiding
5.

15.

50

Assist

patient on standing steady

To provide functional
position of voiding
6.

16.
patient

to

Encourage
keep

area

(genitals) clean
To prevent urinary tract
infection
7.
patient

16.

Encourage

to

verbalize

concerns
Open expression allow
patient

to

deal

problems

and

with
begin

solving it
8.

17. Watch for

any signs of abnormalities
such as: blood in the urine,
severe pain, and cloudy
urine.
For the patient to
immediately
medical attention.

51

receive

DATE

CUES

NEED

TIME

NURSING

OBJECTIVE OF CARE

DIAGNOSIS

NURSING

EVALUATION

INTERVENTIONS

OBJECTIVE:

Risk for Infection

Within the 8 hours span

1. Minimize the patients

Drugs used:
Methylpredniso

related to

of care the patient will

risk for infection by

Immunosuprressive

not exhibit any signs of

washing hands before and

Patients vital

Medications

infection such as an

after providing care

signs remains in

elevation of temperature

Hand washing is the

normal range

greater than 37.5C

single best way to avoid

T
O
B
E
R
30,
2014
@
3PM

lone therapy
Prednisone
Azathioprine
Cyclophospha

T
H

Systemic Lupus

GOAL MET

Erythematosus is an

spreading pathogens.

Results of

autoimmune disease,

2. Wearing gloves to

laboratory studies

in which the immune

maintain asepsis when

indicate negative

system attacks the

providing direct care or

in infection

body's own tissues as

when in contact with

though they were

blood or body secretions.

Patient remains

foreign substances.

Gloves reduce the

free from signs

Immunosuppressive

possibility of transmitting

and symptoms of

medicines reduce

disease

infection.

inflammation and

3. Monitor WBC count, as

suppress the immune

ordered and promptly

system.

report abnormal values.

mide therapy

A total WBC count of

above 11,000 uL indicates
H

increase in production of

52

leukocytes by bone

marrow, usually in

response to bacterial

pathogens.

4. Follow the facilitys

infection control

To minimize the risk of

nosocomial infection

5.Use strict sterile

technique when

performing invasive

procedures such as IV line

insertion

To minimize the risk of

introducing pathogen to

the system
6. Assess IV site every 4
hours, noting the presence
of redness and warmth.
Change IV tubing every
72 hours or as indicated

by facility policy.
These measures prevent

53

keep pathogens from

entering the body.

7. Ensure adequate

nutritional intake.

A diet high in protein,

iron and vitamin C helps

promote healing
8. Assess the patient for
generalized sign and
symptoms of infection
Prompt detection of
infection helps minimize
complications.

Date

Cues

Need

Nursing Diagnosis

Objectives of Care

Nursing Interventions

54

Evaluation

&
Time
O

Objective:

Hyperthermia related to

Short Term

Independent:

Temp- 37.9

disease process

After 1 hour of

1. Monitor vital signs.

RR 28cpm

appropriate nursing

Vital signs provide more

PR 135bpm

intervention the

accurate indication of

Flushed skin

patients temperature

core temperature.

Skin warm to

will decrease to

2. Provide tepid sponge

37.5oC.

bath. Do not use

B
E
R
29,

touch

Diagnosed with

1PM

alcohol.
Long Term

TSB helps in lowering

After 4 hours of

the body temperature

appropriate nursing

and alcohol cools the

intervention the

skin too rapidly, causing

medyo init iyahang

patients vital signs

shivering. Shivering

lawas sir,

will return to normal

increases metabolic rate

makuyawan jud ko

range; with a

and body temperature.

ani kay pag

temperature of 36.5-

3. Remove excess

maghilanat siya,

37.5oC, pulse rate of

clothing and covers.

magkombulsyon

80-100bpm and

To promote clear flow

baya ni

respiratory rate of 20-

of air in the patients

24 cycles per min.

area. One way of

Subjective:
Mother verbalized

H
E

@
2 PM
GOAL MET
Within an hour of my
span of care, the
patients temperature

SLE Nephritis
2014

Oct 29, 2014

promoting heat loss.

55

decreased to 37 C
RR 24cpm
PR 91bpm

Promote a well-

ventilated area to

patient.

4. Advise patient to
increase oral fluid

intake.

Additional fluids help

prevent elevated

temperature associated

with dehydration.

5. Maintain bed rest.

Reduce metabolic

demands/ oxygen

consumption.

6. Provide high-calorie
diet.
To meet increased
metabolic demands.
7. Educate and advise
support system to do

TSB when patient feels

hot.

- Luke warm water only.

56

- Make sure that armpits

and groins were

included in doing TSB.

Teaching the support

system right away to do
TSB will help in
knowing what to do in
case the patients
temperature increases.
8. Monitored VS and
recheck.
To know the
effectiveness of nursing
interventions done and
to know the progress of
patients condition.

Dependent:
1. Provide antipyretic
medications as
indicated.

57

These drugs inhibit the

prostaglandin that serves
as mediators of pain and
fever.

DAT

CUES

E
O

Objective:

NEE
DS
A

NURSING DIAGNOSIS

OBJECTIVE OF

INTERVENTIONS

Fatigue related to decrease

CARE
After my 8 hour span

1. Establish rapport.

Diagnosed with SLE

hemoglobin production

of care, the patient

Nephritis

secondary to lupus

will be able to

cooperation.

EVALUATION
GOAL MET

To gain trust and

58

Within my 8 hour

Febrile episodes

Lethargic

Muscle weakness

Hgb level of 115g/L

R
29,
2014
@
7

Subjective:
Medyo luya ning bataa sukad pag-admit

nephritis

participate in desired

2. Determine ability to

span of care my

activity at level of

participate in activities/

patient was able to

ability as evidence by:

level of mobility.

participate in
recommended

most common symptoms

1. Participation in

of lupus. Over 81% of

recommended

patient is capable of,

treatment program

those with SLE, both active treatment program.

which is necessary prior

and able to perform

and inactive, will

to setting realistic goals.

ADL such as range

experience troublesome

2. Tolerates activity of

3. Assess psychological

of motion exercises

fatigue that will impair

daily living such as

and personality factors

with minimal

their ability to live

range of motion

that may affect reports

assistance.

normally.

exercises.

of fatigue level.

Fatigue is among the

Aids in defining what

Assess the capacity of

the patient in doing an

activity. External factors

may affect the patients
mobility such as
excessive exercise

4. Note daily energy

pattern.

determining pattern/

timing of activity.

Helpful in

59

5. Evaluate need for

individual assistance/

assistive devices.
To note the level of
activity the patient can
tolerate with or without
assistance.
6. Measure
physiological response
to activity such as
changes in blood
pressure or

heart/respiratory rate.
Abnormalities in vital
signs may indicate
intolerance.
7. Establish realistic
activity goals with

patients.
Enhances
commitment to

60

promoting optimal
outcomes.
8. Encourage patient to

do whatever possible.
Performing activities
uses muscles, helping to
maintain their function.
9. Provide environment
conducive to relief

fatigue.
Temperature and level
of humidity are known
to affect exhaustion.
10. Instruct patient or
significant others in
ways to monitor
responses to activity and
significant signs and

symptoms.
Indicates the need to
alter activity level.
11. Provide

61

supplemental oxygen as

indicated.
Presence of
anemia/hypoxemia
reduces oxygen
available for cellular
uptake and contributes
fatigue.
12. Assist patient to
identify appropriate

coping behaviors.
Promotes sense of
control and improves
self esteem.

62

MEDICAL MANAGEMENT
DATE/TIME

DOCTORS

RATIONALE

REMARKS

ORDER
October 29,

Please

admit

to The patient falls under the Pediatric Specialty DONE

2014 @

Nephro ward

Unit Nephro Room of SPMC.

5:35 AM

Low Salt and

The physician ordered low salt, low fat diet DONE

Low Fat Diet

since salty and fatty foods can worsen the

condition of the patient.
Metabolic disturbances such as high levels of
sugar or sodium in the blood can cause a
seizure disorder.
A diet low in saturated fat and cholesterol
produces

significant

reduction

in

LDL

LABS:

cholesterol in patients with SLE

Ordered in order for the physician to have a DONE

CBC pc

baseline data.

serum Na, K, Ca,

Mg

CBC with PC may reveal anemia and

decreased numbers of white blood cells and
platelets, which can occur with lupus
These

are

general

laboratory

tests.

Abnormalities in blood cell counts, including

white blood cells and red blood cells, may
occur in people with lupus. This may be
related to the lupus, lupus treatments, or
infection. For example, leukopenia, a decrease
in the number of WBCs, is found in about 50%
of people with lupus. Thrombocytopenia, or a
low platelet count, occurs in about 50% of

63

people with lupus, as well. Doctors can use

this test to monitor these potentially serious
problems.
May show blood, urinary casts, or protein in DONE

UA

the

urine,

which

can

indicate

kidney

involvement.
Creatinine

Serum creatinine is also a measure of kidney DONE

function and rises when the kidney is
functioning abnormally. Because the kidneys
are one of the primary target tissues in SLE,
close monitoring is of great importance. In
addition,

number

of

anti-rheumatic

medications can cause injury to the kidney that

may be reversed when detected early.
This test is performed on a one-time urine
sample. It measures for protein loss, which is
an indicator of kidney function.
IVF D5 0.3 NaCl @ IVF is ordered as a solvent for drugs that are to DONE
10cc/hr

be administered parenterally to replace body

Meds:

fluids.
To control Hyperthermia, administered as

Paracetamol

needed.

250mg/5mL,

DONE

give

5ml q4 PRN
Salbutamol 1 neb Q6 For

smooth

muscle

relaxation

and DONE

bronchodilation
Ampicillin 1gm q8

Antibiotic to control possible pathogens that DONE

causes hyperthermia

Prednisone 20mg/tab Glucocorticoids which suppress inflammation.

DONE

2 tabs once in every

64

other day
Azathioprine

Helps reduce signs and symptoms of SLE

DONE

50mg/tab tab
Calcium Carbonate Helps to buffer acidity in the stomach.

DONE

500mg/tab 1 tab OD
Hold Ampicillin and

DONE

Salbutamol
Start

It decreases the immune system's response to DONE

Methylprednisolone

various diseases to reduce symptoms such as

333mg IVTT OD for swelling, pain, and allergic-type reactions. This

3

days

100cc medication is a corticosteroid hormone.

D5Water to run in 4
hrs
Prehydration:
D5

0.3

May help control skin rashes and joint pain. DONE

NaCl

at May also control more severe lupus symptoms,

90cc/hr to run in such as inflammatory conditions of the kidneys

6hrs

and tissues around the heart and lungs.

DONE

Cyclophosphamide
707mg

100cc

D5Water
Posthydration:
D5

0.3

NaCl

DONE
at

90cc/hr to run in
6hrs
DRUG STUDY

65

Generic Name

Azathioprine

Brand name
Classification
Mechanism of

Azasan, Imuran
Immunosuppressants
Azathioprine antagonizes purine metabolism and may inhibit synthesis of

Action

DNA, RNA, and proteins. It may also interfere with cellular metabolism and
inhibit mitosis. Its mechanism of action is likely due to incorporation of
thiopurine analogues into the DNA structure, causing chain termination and

Route, Dosage,
Frequency
Pharmacokinetics

cytotoxicity.
Azathioprine 50 mg tablet p.o once a day

Half-life: Approximately 5 hours (unchanged drug and metabolites)

Onset of action: In rheumatoid arthritis6 to 8 weeks {01}.
In other inflammatory disorders4 to 8 weeks {03}.
Time to peak concentration: Serum1 to 2 hours {01}.
Duration of action:
ImmunosuppressantClinical effects may persist for long periods after

the medication is eliminated.

Elimination:
Hepatic (biliary)
Renal (1 to 2% unchanged).
In dialysisPartially removable by hemodialysis
Indicated as an adjunct for the prevention of rejection in renal

Indication

homotransplantation. It is also indicated for the management of active

rheumatoid arthritis to reduce signs and symptoms, lupus nephritis (offContraindication

label), crohns disease (off-label).

Conditions:
Hepatosplenic T-cell Lymphoma, A Blood Clot in a Vein of the Liver, Acute
Inflammation of the Pancreas, Pregnancy, Severe Infection, Malignant
Lymphoma, Moderate to Severe Kidney Impairment, Severe Anemia,
Decreased Blood Platelets, Severe Decrease in White Blood Cells,

66

Thiopurine S-Methyltransferase Deficiency

Allergies:
Adverse Reactions
and Side Effects

Drug Interactions

MERCAPTOPURINE ANALOGUES (THIOPURINES)

Black, tarry stools
bleeding gums
blood in the urine or stools
chest pain
cough or hoarseness
fever or chills
lower back or side pain
painful or difficult urination
pinpoint red spots on the skin
shortness of breath
sore throat
sores, ulcers, or white spots on the lips or in the mouth
swollen glands
unusual bleeding or bruising
unusual tiredness or weakness
Other purine analogues such as allopurinol inhibit xanthine oxidase, the
enzyme that breaks down azathioprine, thus increasing the toxicity of
azathioprine. On the other hand, low doses of allopurinol have been shown
to safely enhance the efficacy of azathioprine, especially in inflammatory
bowel disease non-responders. This may still lead to lower lymphocyte
counts and higher rates of infection, therefore the combination requires
careful monitoring.
Azathioprine decreases the effects of the anticoagulant warfarin and of nondepolarizing muscle relaxants, but increases the effect of depolarizing
muscle relaxants. It can also interfere with niacin (vitamin B3), resulting in
at least one case to pellagra and fatal medullary aplasia. It has also been

Nursing
Responsibilities

reported to cause vitamin B12 deficiency.

Know the patients 10 rights.
Check the chart and the patient before administering medication.
Assess the patients condition before giving the medication to be able to

identify if there is a sudden reaction of the medication to the patient.

Assess for patients history: Allergy to azathioprine; rheumatoid arthritis
patients previously treated with alkylating agents; pregnancy or male

67

partners of women trying to become pregnant; lactation

Assess patients skin color, lesions, liver evaluation, bowel sounds, renal

function tests, CBC

Gastrointestinal upset may be reduced by giving oral azathioprine in

divided doses or after meals.

Advice patient to avoid infections; avoid crowds or people who have

infections. Notify once injured.

Report unusual bleeding or bruising, fever, sore throat, mouth sores,
signs of infection, abdominal pain, severe diarrhea, darkened urine or
pale stools, severe nausea and vomiting.

Generic Name

Cyclophosphamide

Brand name
Classification
Mechanism of Action

Cytoxan
Anti-neoplastic
Cyclophosphamide is a drug that is used primarily for treating several types
of cancer. In order to work, cyclophosphamide first is converted by
the liver into two chemicals, acrolein and phosphoramide. Acrolein and
phosphoramide are the active compounds, and they slow the growth of
cancer cells by interfering with the actions of deoxyribonucleic acid (DNA)
within the cancerous cells. Unfortunately, normal cells also are affected,

68

and this results in serious side effects. In addition to slowing the growth of
cancerous cells, cyclophosphamide also suppresses the immune system and
Route, Dosage,

is referred to as immunosuppressive.
707mg + 100cc d5W

Frequency
Pharmacokinetics

Metabolized in the liver to both active antineoplastic alkylating agents and

inactive metabolites. The active metabolites alkylate nucleic acids, thus
interfering with the growth of neoplastic and normal tissues. The cytotoxic
action is due to cross-linking of strands of DNA and RNA and inhibition of
protein synthesis. Also possesses immunosuppressive activity. t: 312 hr,
but remnants of drug and/or metabolites detectable in serum after 72 hr; in
children, the t averages 4.1 hr. Metabolites are excreted through the urine
with

Indication

up

to

25%

of

cyclophosphamide

excreted

unchanged.

Cyclophosphamide is also excreted in milk.

Cyclophosphamide is used alone for the treatment of several types of
cancers but often in combination with other drugs to treat breast
cancer, leukemia and ovarian cancer.

It also is approved for treating nephrotic syndrome (a disease of the

kidneys) in children.

Unapproved uses include the treatment of Wegener's granulomatosis,

severe rheumatoid arthritis, lupus erythematosus, advanced mycosis

Contraindication

funguides, and several forms of vasculitis.

Cyclophosphamide is excreted in breast milk and could cause serious
problems in the nursing infant.

Use of cyclophosphamide during pregnancy may affect the fetus.

Fetuses exposed to cyclophosphamide may be born with missing
fingers, toes and a poorly-developed heart. Cyclophosphamide should

Adverse Reactions

and Side Effects

not be administered during pregnancy.

Hair loss, vomiting, diarrhea, mouth sores, weight loss, sterility,
and jaundice.

Causes kidney failure and may affect the heart and lungs

Cyclophosphamide suppresses production of blood cells from the bone

69

marrow, including white blood cells (leukopenia), red blood cells

(anemia) and platelets (thrombocytopenia).

Leukopenia reduces the ability of the body to fight infection,

thrombocytopenia impairs the ability of blood to clot, and anemia
reduces the ability of blood to carry oxygen.

Suppresses the immune system which may result in serious and

sometimes fatal infections. Severe allergic reactions also may occur.

May cause inflammation of the urinary bladder with bleeding

(hemorrhagic cystitis). This can result in lower abdominal painfrom the
bladder, problems urinating due to blood clots, and anemia due to loss

Drug Interactions

of blood.
Allopurinol (Zyloprim) enhances the ability of cyclophosphamide to
reduce production of blood cells from the bone marrow.

Cyclophosphamide increases the occurrence of heart failure that is

caused by doxorubicin (Adriamycin),

Nursing
Responsibilities

Increases the action of blood thinners such as warfarin (Coumadin)

Decreases the effectiveness of quinolone antibiotics (Cipro).

Know the patients 10 rights.
Check the chart and the patient before administering medication.
Assess the patients condition before giving the medication to be able to
identify if there is a sudden reaction of the medication to the patient.

Before taking cyclophosphamide, tell your doctor or pharmacist if you

are allergic to it; or to other chemotherapy drugs (e.g., busulfan,
chlorambucil); or if you have any other allergies. This product may
contain inactive ingredients, which can cause allergic reactions or other
problems. Talk to your pharmacist for more details.

This medication should not be used if you have certain medical

conditions. Before using this medicine, consult your doctor or
pharmacist if you have: decreased bone marrow function (e.g., anemia,
leukopenia, thrombocytopenia).

Before using this medication, tell your doctor or pharmacist your

70

medical history, especially of: liver disease, kidney disease, surgery to

remove your adrenal glands.

Do not have immunizations/vaccinations without the consent of your

doctor and avoid contact with people who have recently received oral
polio vaccine.

Use caution with sharp objects like safety razors or nail cutters and
avoid activities such as contact sports to lower the chance of getting cut,
bruised or injured.

Wash your hands well to prevent the spread of infections.

Before having surgery, tell your doctor or dentist that you are using this
medication.

Caution is advised when using this drug in the elderly because they may
be more sensitive to its effects.

Caution is advised when using this drug in children because they may
be more sensitive to its effects, especially possible infertility later in
life.

This drug is not recommended for use during pregnancy. It may cause
harm to an unborn baby. Women of childbearing age and men should
use reliable form(s) of birth control during treatment with this drug and
for some period afterwards.

This drug passes into breast milk. Because of the potential risk to the
infant, breast-feeding while using this drug is not recommended.
Consult your doctor before breast-feeding.

71

Generic Name

Calcium Carbonate

Brand name

Cal-Carb Forte, Calcium 600, Caltrate 600, Nephro-Calci, Os-Cal 500,

Classification
Mechanism of Action

Oysco 500, Oyst-Cal 500, Oyster Shell Calcium, Trial Antaci

Calcium salt
Calcium carbonate is a basic inorganic salt that acts by neutralizing
hydrochloric acid in gastric secretions. It also inhibits the action of
pepsin by increasing the pH and via adsorption. Cytoprotective effects
may occur through increases in bicarbonate ion (HCO3-) and
prostaglandins. Neutralization of hydrochloric acid results in the
formation of calcium chloride, carbon dioxide and water. Approximately
90% of calcium chloride is converted to insoluble calcium salts (e.g.

Route, Dosage,

calcium carbonate and calcium phosphate).

1 tablet once a day PO

Frequency
Pharmacokinetics

Bioavailability: 25-35%; food increases absorption 10-30%; antacid

action dependent on gastric emptying time
Peak plasma time: 20-60 min (fasting state); up to 3 hr (ingested 1 hr
after meals)
Distribution
Protein bound: 45%
Elimination
Renal clearance: 50-300 mg/day

Indication

Contraindication

Excretion: Feces, as unabsorbed calcium (80%); urine (20%)

Mild hypocalcemia
Antacid (including heartburn, sour stomach, and acid indigestion)
Antihyperphosphatemic.
Hypersensitivity
Hypercalciuria

72

 Renal calculi
Hypophosphatemia
Hypercalcemia
Suspected digoxin toxicity
Adverse Reactions and upset stomach
vomiting
Side Effects
stomach pain
belching
constipation
dry mouth
increased urination
loss of appetite
metallic taste
Drug Interactions
Calcium carbonate can decrease the absorption of other drugs. Some
examples of affected drugs include tetracycline antibiotics (such as
doxycycline, minocycline), bisphosphonates (such as alendronate),
estramustine, iron, levothyroxine, pazopanib, strontium, quinolone
Nursing
Responsibilities

antibiotics (such as ciprofloxacin, levofloxacin), among others.

Know the patients 10 rights.
Check the chart and the patient before administering medication.
Assessment:
1. Note indications for therapy, client age, and physical condition.
2. Obtain serum calcium level before therapy and monitor
periodically during therapy; ensure normal renal function.

Client/Family Teaching:
1. Take as directed. Increase fluid intake and bulk in diet to prevent
constipation.
2. When used as a supplement take 1-1 hr after meals; as an
antacid take 1 hr after meals and at bedtime.
3. If using the gum, do not take more than 17 pieces/day of the 450
mg strength or more than 26 pieces/day of the 300 mg strength.
Do not take the maximum dose for more than 2 weeks.

73

Generic Name

Isoniazid

Brand name
Classification
Mechanism of Action

Niazid, Isotamine
Antitubercular
Interferes with lipid and nucleic acid metabolism of growing bacteria,

74

Route, Dosage,

resulting in alteration of the bacterial wall.

200mg/5ml syrup 5 ml once a day

Frequency
Pharmacokinetics

Readily absorbed after PO and parenteral (IM) administration and widely

distributed in body tissues, including cerebrospinal, pleural, and ascitic
fluids. Peak plasma concentration: PO, 12 hr. t, fast acetylators: 0.5
6 hr; t, slow acetylators: 25 hr. Liver and kidney impairment increase

Indication

these values. Metabolized in liver and excreted primarily in urine.

Tuberculosis caused by human, bovine, and BCG strains
ofMycobacterium tuberculosis. Not to be used as the sole

tuberculostatic agent.
Prophylaxis of tuberculosis in the following: HIV, close contacts with
those newly diagnosed with infectious tuberculosis, recent converters,
abnormal chest radiographs, IV drug users, those with increased risk of
tuberculosis, those less than 35 years of age with tuberculin skin test
reaction 10 mm or greater, and children less than 4 years of age if they
have greater than 10 mm induration from a purified protein derivative

Contraindication

Mantoux tuberculin skin test.

Investigational: To improve severe tremor in clients with multiple
sclerosis.
Severe hypersensitivity to isoniazid or in clients with previous

Adverse Reactions

isoniazid-associated hepatic injury or side effects.

Active liver disease
Neurologic: Peripheral neuropathy characterized by symmetrical numbness

and Side Effects

and tingling of extremities (dose-related). Rarely, toxic encephalopathy,

optic neuritis, optic atrophy, seizures, impaired memory, toxic psychosis.
GI: N&V, epigastric distress, xerostomia.
Hypersensitivity: Fever, skin rashes and eruptions, vasculitis,
lymphadenopathy.
Hepatic: Liver dysfunction, jaundice, bilirubinemia, bilirubinuria, serious
and sometimes fatal hepatitis (even many months after
treatment) especially in clients over 50 years of age. Increases in serum
AST and ALT.

75

Hematologic: Agranulocytosis, eosinophilia,

thrombocytopenia, hemolytic, sideroblastic, or aplastic anemia.
Metabolic/Endocrine: Metabolic acidosis, pyridoxine deficiency, pellagra,
hyperglycemia, gynecomastia.
Miscellaneous: Tinnitus, urinary retention, rheumatic syndrome, lupus-like
Drug Interactions

syndrome, arthralgia.
Al salts / Effect of isoniazid R/T GI tract absorption

Aminosalicylate / Effect of isoniazid by blood levels

Anticoagulants, oral / Anticoagulant effect

Atropine / Side effects of isoniazid

Benzodiazepines / Effect of benzodiazepines that undergo oxidative

metabolism (e.g., diazepam, triazolam)

Carbamazepine / Risk of carbamazepine and isoniazid toxicity

Chlorzoxazone / Chlorzoxazone peak levels and plasma elimination

t R/T liver metabolism

Cycloserine / Risk of cycloserine CNS side effects

Disulfiram / Risk of acute behavioral and coordination changes

Enflurane / May high levels of hydrazine defluorination of

enflurane

Ethanol / Chance of isoniazid-induced hepatitis

Halothane / Risk of hepatotoxicity and hepatic encephalopathy

Hydantoins (phenytoin) / Hydantoins effect R/T liver breakdown

Ketoconazole / Serum ketoconazole levels effect

Meperidine / Risk of hypotension or CNS depression

Niacin / Possible of niacin requirements

Pyridoxine / Possible of pyridoxine requirements

Rifampin / Additive liver toxicity

Administration/Storage:

Nursing
Responsibilities

1. Store in dark, tightly closed containers.

2. Solutions for IM injection may crystallize at low temperature; warm
to room temperature if precipitation is evident.

76

3. Anticipate a slight local irritation at the site of injection. Rotate and

document injection sites.
4. Administer with pyridoxine, 1050 mg/day, in malnourished,
alcoholic, or diabetic clients to prevent symptoms of peripheral
neuropathy.
Assessment:
1. Document indications for therapy, type/onset of symptoms and note
if travel outside of country. List other therapies used and outcome.
2. Obtain baseline labs, CXR, and AFB sputums; note date of PPD
conversion. Monitor renal and LFTs; reduce dose with dysfunction.
3. New PPD converters without symptoms still require treatment and
then yearly CXR. +AFB clients require treatment and isolation
initially and tracking/treatment of contacts if +AFB or PPD
converters.
4. Perform pulmonary assessment; note cough/sputum characteristics.
Client/Family Teaching:
1. Take on an empty stomach 1 hr before or 2 hr after meals.
2. Consume 23 L/day of fluids to ensure adequate hydration.
3. Pyridoxine is given to prevent neurotoxic drug effects (peripheral
neuritis). Report any numbness or tingling of hands or feet.
4. Avoid alcohol to prevent hepatic toxicity. Client may be advised to
avoid certain foods (tyramine-containing) during therapy.
5. Withhold drug and report fatigue, weakness, malaise, yellow
eyes/skin, dark urine, and loss of appetite (S&S of liver problems).
6. Report any visual disturbances; may precede optic neuritis.
7. With diabetes, monitor FS closely.
8. Take drugs as ordered, missing doses may require retreatment;
therapy may take 6 months to a year. Report for periodic lab,
provider visits, and eye exams.

77

Generic Name

Brand name

Methylprednisolone

Oral: Medrol

IM injection: depMedalone, Depo-Medrol, Depopred40

IV, IM injection: A-Methapred, Solu-Medro

Classification
Corticosteroid
Mechanism of Action Decreases inflammation by suppression of migration of polymorphonuclear

Route, Dosage,

leukocytes and reversal of increased capillary permeability.

Methylprednisone 240mg IVTT od x 3days + 100cc D5 water to run in 4 hrs

Frequency

78

Pharmacokinetics

Low incidence of increased appetite, peptic ulcer, psychic stimulation, and

sodium and water retention. May mask negative nitrogen balance.
Onset: Slow, 1224 hr. t,
Plasma: 78188 min.
Duration: Long, up to 1 week. Rapid onset of sodium succinate by both IV

Indication

and IM routes. Long duration of action of the acetate.

Short-term management of various inflammatory and allergic disorders,
such as rheumatoid arthritis, collagen diseases (eg, SLE), dermatologic
diseases (eg, pemphigus), status asthmaticus, and autoimmune disorders

Hematologic disorders: Thrombocytopenia purpura, erythroblastopenia

Ulcerative colitis, acute exacerbations of MS, and palliation in some

leukemias and lymphomas

Contraindication

Trichinosis with neurologic or myocardial involvement

Prevention of nausea and vomiting associated with chemotherapy

Unlabeled use: Septic shock, respiratory distress syndrome, acute spinal

cord injury
Serious infections except septic shock or tuberculous meningitis; viral,
fungal and tubercular skin lesions; admin of live virus vaccines.
Preparations containing benzyl alcohol preservative are contraindicated

Adverse Reactions

in infants.
Edema, hypertension, arrhythmia;

and Side Effects

CNS, endocrine, metabolic and GI effects;

hirsutism, acne, skin atrophy, bruising, hyperpigmentation;

transient leukocytosis;

arthralgia, muscle weakness, osteoporosis, fractures, cataracts,

glaucoma;

Drug Interactions

Infections, hypersensitivity reactions, avascular necrosis, secondary

malignancy, intractable hiccups.

Increased toxicity with long-term, excessive ethanol ingestion

Increased hypoprothrombinemic effect of oral anticoagulants

Increased risk of hepatotoxicity and possible decreased therapeutic

79

effects with barbiturates, carbamazepine, hydantoins, rifampin,

sulfinpyrazone

Possible delayed or decreased effectiveness with anticholinergics

Possible reduced absorption of acetaminophen with activated

charcoal

Nursing
Responsibilities

Possible decreased effectiveness of zidovudine

Know the patients 10 rights.
Check the chart and the patient before administering medication.
Assess the patients condition before giving the medication to be able to

identify if there is a sudden reaction of the medication to the patient.

Assess for:

History: Infections; kidney or liver disease, hypothyroidism, ulcerative

colitis, diverticulitis, active or latent peptic ulcer, inflammatory bowel
disease, CHF, hypertension, thromboembolic disorders, osteoporosis,
seizure disorders, diabetes mellitus; pregnancy; lactation

Physical: Weight, T, reflexes and grip strength, affect and orientation, P,

BP, peripheral perfusion prominence of superficial veins, R and
adventitious sounds, serum electrolytes, blood glucose

Use caution with the 24-mg tablets marketed as Medrol; these contain
tartrazine, which may cause allergic reactions, especially in people who
are allergic to aspirin.

Give daily dose before 9 to mimic normal peak corticosteroid blood

levels.

Increase dosage when patient is subject to stress.

WARNING: Taper doses when discontinuing high-dose or long-term

therapy to allow adrenal recovery.

WARNING: Do not give live virus vaccines with immunosuppressive

doses of corticosteroids

Do not to stop taking the oral drug without consulting your health care
provider.

Avoid exposure to infections.

80

Report unusual weight gain, swelling of the extremities, muscle

weakness, black or tarry stools, fever, prolonged sore throat, colds or
other infections, worsening of disorder.

Generic Name

Paracetamol

Brand name
Classification
Mechanism of Action

Biogesic
Antipyretic
Reduces fever by acting directly on the hypothalamic heat-regulating center

Route, Dosage,

to cause vasodilation and sweating, which helps dissipate heat.

Paracetamol 250/5mL, 5ml q 4hrs PRN for fever

Frequency
Pharmacokinetics

Absorption: paracetamol is readily absorbed from the gastrointestinal

tract.
Distrubution: peak plasma concentrations occur about 10 to 60 minutes
after oral doses. Paracetamol is distributed into most body tissues. It
crosses the placenta and is present in breast milk. Plasma-protein
binding is negligible at usual therapeutic concentrations but increases

with increasing concentrations.

Metabolism: It is metabolised in the liver. A minor hydroxylated
metabolite which is usually produced in very small amounts by mixedfunction oxidases in the liver and which is usually detoxified by
conjugation with liver glutathione may accumulate following

81

paracetamol overdosage and cause tissue damage.

Elimination: It is excreted in the urine, mainly as the glucuronide and
sulphate conjugates. The elimination half-life varies from about 1 to 4

hours.
Analgesic-antipyretic in patients with aspirin allergy, hemostatic

disturbances, bleeding diatheses, upper GI disease, gouty arthritis

Arthritis and rheumatic disorders involving musculoskeletal pain (but

lacks clinically significant antirheumatic and anti-inflammatory effects)

Common cold, flu, other viral and bacterial infections with pain and

fever
Unlabeled use: Prophylactic for children receiving DPT vaccination to

Contraindication

reduce incidence of fever and pain

Contraindicated with allergy to acetaminophen.
Use cautiously with impaired hepatic function, chronic alcoholism,

Adverse Reactions

pregnancy, lactation.
CNS: Headache
CV: Chest pain, dyspnea, myocardial damage when doses of 58 g/day

Indication

and Side Effects

are ingested daily for several weeks or when doses of 4 g/day are

ingested for 1 yr
GI: Hepatic toxicity and failure, jaundice
GU: Acute kidney failure, renal tubular necrosis
Hematologic: Methemoglobinemiacyanosis; hemolytic anemia
hematuria, anuria; neutropenia, leukopenia, pancytopenia,

Drug Interactions

thrombocytopenia, hypoglycemia
Hypersensitivity: Rash, fever
Drug-drug

Increased toxicity with long-term, excessive ethanol ingestion

Increased hypoprothrombinemic effect of oral anticoagulants
Increased risk of hepatotoxicity and possible decreased therapeutic
effects with barbiturates, carbamazepine, hydantoins, rifampin,

Nursing
Responsibilities

sulfinpyrazone
Possible delayed or decreased effectiveness with anticholinergics
Possible reduced absorption of acetaminophen with activated charcoal
Possible decreased effectiveness of zidovudine
Know the patients 10 rights.
Check the chart and the patient before administering medication.

82

Assess the patients condition before giving the medication to be able to

identify if there is a sudden reaction of the medication to the patient.

Do not exceed the recommended dosage.
Consult physician if needed for children < 3 yr; if needed for longer
than 10 days; if continued fever, severe or recurrent pain occurs

(possible serious illness).

Avoid using multiple preparations containing acetaminophen. Carefully

check all OTC products.

Give drug with food if GI upset occurs.
Discontinue drug if hypersensitivity reactions occur.
Treatment of overdose: Monitor serum levels regularly, Nacetylcysteine should be available as a specific antidote; basic life

support measures may be necessary.

Do not exceed recommended dose; do not take for longer than 10 days.
Take the drug only for complaints indicated; it is not an anti-

inflammatory agent.
Avoid the use of other over-the-counter preparations. They may contain
acetaminophen, and serious overdosage can occur. If you need an over-

the-counter preparation, consult your health care provider.

Report rash, unusual bleeding or bruising, yellowing of skin or eyes,
changes in voiding patterns.

Generic Name

Prednisone

83

Brand name
Classification
Mechanism of Action

Rayos, Sterapred
Antiasthmatics, Corticosteroids
Glucocorticoids are naturally occurring hormones that prevent or
suppress inflammation and immune responses when administered at
pharmacological doses. At a molecular level, unbound glucocorticoids
readily cross cell membranes and bind with high affinity to specific
cytoplasmic receptors. This binding induces a response by modifying
transcription and, ultimately protein synthesis to achieve the steroid's
intended action. Such actions may include: inhibition of leukocyte
infiltration at the site of inflammation, interference in the function of
mediators of inflammatory response, and suppression of humoral
immune responses. Some of the net effects include reduction in edema
or scar tissue, as well as a general suppression in immune response.
The degree of clinical effect is normally related to the dose
administered. The anti-inflammatory actions of corticosteroids are
thought to involve phospholipase A2 inhibitory proteins, collectively
called lipocortins. Lipocortins, in turn, control the biosynthesis of
potent mediators of inflammation such as prostaglandins and
leukotrienes by inhibiting the release of the precursor molecule
arachidonic acid. Likewise, the numerous adverse effectsrelated to
corticosteroid use are usually related to the dose administered and the

Route, Dosage,

duration of therapy.
40 mg every other day p.o

Frequency
Pharmacokinetics

Prednisone is rapidly absorbed across the GI membrane following

oral administration. Peak effects can be observed after 12 hours.
The circulating drug binds extensively to the plasma proteins albumin
and transcortin, with only the unbound portion of a dose active.
Systemic prednisone is quickly distributed into the kidneys, intestines,
skin, liver and muscle. Corticosteroids distribute into the breastmilk
and cross the placenta. Prednisone is metabolized by the liver to the
active metabolite prednisolone, which is then further metabolized to

84

inactive compounds. These inactive metabolites, as well as a small

portionof unchanged drug, are excreted in the urine. The plasma
elimination half-life is 1 hour whereas the biological half-life of
Indication

prednisone is 1836 hours.

Prednisone is indicated in all conditions where corticosteroid therapy
is likely to be of benefit. These include acute haemolytic disorders,
allergic disorders, asthma, leukaemia, thrombocytopenic purpura,
coeliac

Contraindication

disease,

insulin

resistance

in

diabetes

mellitus,

immunosuppression, liver disorders and ulcerative colitis.

Peptic ulcer, osteoporosis, psychoses or severe psycho-neuroses.
They should be used with great caution in the presence of
congestive heart failure, in patients with diabetes mellitus,
infectious diseases, chronic renal failure, uraemia and in elderly

persons.
Tuberculosis active or possibly latent is a contra-indication unless
adequate

amounts

of

suitable

anti-tubercular

drugs

are

simultaneously administered. Simultaneous administration of

barbiturates or phenytoin may reduce the effectiveness of
prednisone by increasing its metabolism and the action of

anticoagulants may be modified.

In many cases of severe illnesses, where prednisone may be
lifesaving, they may be administered notwithstanding the above
contra-indications due caution and observation being exercised

by the physician.
It should be noted that prednisone has less tendency than many
corticosteroids to cause fluid retention and mineral imbalance but

Adverse Reactions

and Side Effects

it has a somewhat higher incidence of gastric symptoms.

CNS: Vertigo, headache, paresthesias, insomnia, seizures,
psychosis, cataracts, increased IOP, glaucoma (long-term therapy);

euphoria, depression
CV: Hypotension, shock, hypertension and CHF secondary to fluid
retention, thromboembolism, thrombophlebitis, fat embolism,
cardiac arrhythmias

85

Electrolyte imbalance: Na+ and fluid retention, hypokalemia,

hypocalcemia
Endocrine: Amenorrhea, irregular menses, growth retardation,
decreased carbohydrate tolerance, diabetes mellitus, cushingoid
state (long-term effect), increased blood sugar, increased serum
cholesterol, decreased T3 and T4 levels, HPA suppression with

systemic therapy longer than 5 days

GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention,
nausea, vomiting, increased appetite, weight gain (long-term

therapy)
Hypersensitivity: Hypersensitivity or anaphylactoid reactions
Musculoskeletal: Muscle weakness, steroid myopathy, loss of
muscle mass, osteoporosis, spontaneous fractures (long-term

therapy)
Other: Immunosuppression, aggravation or masking of infections;
impaired wound healing; thin, fragile skin; petechiae, ecchymoses,

Drug Interactions

purpura, striae; subcutaneous fat atrophy

Increased therapeutic and toxic effects with troleandomycin,

ketoconazole
Increased therapeutic and toxic effects of estrogens, including

hormonal contraceptives
Risk of severe deterioration of muscle strength in myasthenia
gravis patients who also are receiving ambenonium, edrophonium,

Nursing
Responsibilities

neostigmine, pyridostigmine
Decreased steroid blood levels with barbiturates, phenytoin,

rifampin
Decreased effectiveness of salicylates
Know the patients 10 rights.
Check the chart and the patient before administering medication.
Assess the patients condition before giving the medication to be
able to identify if there is a sudden reaction of the medication to

the patient.
Assess patients weight, reflexes and grip strength, affect and
orientation, pulse, BP, peripheral perfusion, adrenal insufficiency,
crackles/rales, dyspnea and cerebral edema.

86

Administer once-a-day doses before 9 AM to mimic normal peak

corticosteroid blood levels.

Taper doses when discontinuing high-dose or long-term therapy to

avoid adrenal insufficiency.

Do not give live virus vaccines with immunosuppressive doses of

corticosteroids.
Monitor intake and output of patient and daily weight.
Avoid exposure to infections.
Report unusual weight gain, swelling of the extremities, muscle
weakness, black or tarry stools, fever, prolonged sore throat, colds
or other infections, worsening of the disorder for which the drug is
being taken.

87

DIAGNOSTIC AND LABORATORY EXAMINATIONS

A. ACTUAL
COMPLETE BLOOD COUNT
Date

Basic Test

Rationale

Result

Clinical Significance

Nursing Interventions

Ordered with Normal

October

Values
Hemoglobin To

29, 2014

135-175 g/L amount

measure

the

115.0

of

LOW

hemoglobin in the
blood,

which

Increased

vera
Acute

carrying

thermal

and to measure the

injury

and the response to

Hemoconcent

It

also

monitors blood loss

and

response

blood
replacement

to
loss

Fluid
retention

Dehydration

therapy.

Recent
bleeding

severity of anemia

PRETEST:
-Identify the patient, and check the

Polycythemia

reflects its oxygen

capacity

Decreased

Hemolysis
of red blood cells

requisition form with the patients

identification bracelet
-Explain

the

the

patient and significant others

-Inform patient that the test requires

Pregnancy

blood sample taken with the use of

Hemorrhage

the syringe

COPD

Anemia

-Obtain

Cirrhosis of
the liver
Hyperthyroi
dism

for

laboratory and diagnostic test to the

ration

purpose

health

history

of

the

patients complaints, including a list

of known allergies
-Obtains a list of medications the
patient is taking including herbs and

88

Hematocrit
0.40-0.52

To

measure

the

0.41

number of RBCs NORMAL

and

the

size

of

Addisons
disease

Recent
hemorrhage

Polycythemia Anemia

RBCs. It gives a

vera

Fluid overload

percentage of RBCs

Acute

Fluid retention

found in the whole

thermal

blood. This also test

injury

for the presence of

Extreme

anemia., leukemia,
diet

decency,

other

physical

or

exertion

medical

Hemoconcent

condition

Cirrhosis
Hemolytic anemia

4.20-6.10
X10^6/uL

To

measure

the

4.20

number of RBCs NORMAL Smoking

and
to
help
Dehydration
diagnose

different

kinds of anemia and

other

condition

affecting red blood

cells.

correct period of time

-Inform the significant others that
the

specimen

collection

takes

approximately 5-10 minutes

-Inform

Lymphoma

perform the venipuncture and when

the

patient

who

will

and note that transient discomfort

may be felt from the needle
puncture
Bleeding
Anemia
Fluid overload
Malnutrition

Polycytemia

Cirrhosis

COPD

as pretest fasting to follow the

Leukemia

Hypoxia

vera

could interfere with test results such

-Check vital signs of the patient

Dehydration
RBC Count

-Note any recent procedure that

Hemodilution

ration

COPD
Cigarette

nutritional supplements

and

pressure

of

the

tourniquet
-The patient may be seated or in the
supine position. The patients arm is
in extension, with easy access to the
antecubital fossa
DURING THE TEST:
-Ensure that the blood is not taken

89

WBC Count

To

assess

for

7.44

of NORMAL

Bacterial

Typhoid fever

from the hand or arm that has

5.0-10.0

presence

X10^6/uL

infection

and

Lymphoma

infections intravenous line. Hemodilution with

intravenous fluids causes a false
(influenza,

inflammation,

the

Leukemia

rubella, hepatitis)

need for further test

such

as

WBC

differential

bone

Chronic
infection
Mumps

biopsy. It monitors
response

infection

to

intestines)
Tissue

radiation therapy

necrosis
(burns,
gangrene,
myocardial
infarction)
Varicella

55-75 %

To

monitor

hyponatremia

or

hypernatremia
indicating

fluid

excess or deficit.

Dengue fever

78
HIGH

Acute
Infection

decrease in the values of some test

-Inspect the antecubital fossae of
both arms to select the best vein for

Malaria
Pernicious anemia

Cancer (liver, Aplastic anemia

chemotherapy and

Neutrophil

Viral

the venipuncture
-Ask the patient to open and close
hand a few times to help make the

Radiation

veins more visible

Antineoplastic

-Cleanse the skin with 70% alcohol,

drugs

and allow it to air-dry

Toxic ingestion of -Provide support to the family

heavy metals or during the test
chemical poisons
Systemic

lupus POSTTEST:

erythematosus
Aplastic anemia

-Instruct the patient to continue

compression of the puncture site for
2 to 5 minutes or until bleeding

Chemotherapy

stops

Acute stress

Influenza

-Assess the patients arm to ensure

Eclampsia

Radiation therapy

that subdermal bleeding has ceased.

Gout

Apply an adhesive bandage as

90

An

Myelocytic

important

indicator

of

leukemia

infection

Viral infection

needed

Widespread

-If a hematoma develops at the site,

bacterial apply warm compress

-If a hematoma is large, monitor
infection
pulses distal to the site

Rheumatoid

severe

arthritis
Rheumatic

-Monitor patients intake and output

fever

and vital signs after the tests

Thyroiditis
Lymphocytes To assess levels of
20-35%

lymphocyte
production.
test

19%

Trauma
Infectious

LOW

hepatitis

This

Cytomegalov

differentiates

irus infection

count.

Tuberculosis

WBC

Important to verify
bacterial
infection

or viral

-Evaluate test results in relation to

Right-sided heart patients symptoms and other test
performed
failure
-Determine if the test was correctly

Hodgkins

performed according to appropriate

diseases
Systemic

lupus

erythematosus

Syphilis
Lymphocytic

Aplastic anemia

leukemia

HIV infection

Infectious

momonucleo
sis

procedure
-Check other signs of on infection
and inflammation such as redness,
swelling, heat, and pain in the
infected site

Military -Inform
physician
for
any
tuberculosis
unusualities in vital signs or the
Renal failure
patients condition
Terminal cancer
Thoracic
drainage

-Listen to the patient and significant

duct others expressed anxiety and fear

concerning the test

91

Monocytes
2-10

To assess levels of
monocytes.

Major NORMAL

Acute
infection

caution in the cell.

(bacterial,

It

viral)

regulates

Hairy

cell -Clarify

failure

answer

additional

questions of patient and significant

leukemia
Bone

or

marrow others
-Tell patient

to

report

any

osmolarity of acid-

Tuberculosis

Aplastic anemia

unusualities or changes observed

base balance. They

Syphilis

Stress response to

after the procedure

increase in chronic

Ulcerative

infection

colitis
Myeloprolife

colon trauma
Shock
Burns

rative disease Surgery

Multiple
Mental distress
myeloma
Hodgkins

Cushings
syndrome

disease
Platelet

To assess levels of

Count

thrombocytes

150-400

which

are

X10^3/uL

cells

that

NORMAL
blood
are

involved in cellular
mechanisms

of

primary
homeostasis

313

that

Myeloprolife
rative disease

Autoimmune
disease

Polycythemia Chemotherapy
vera
Myelofibrosi

Thrombocytopeni
a

s
Iron

92

leads to formation

deficiency

of blood clots

anemia
Acute

or

chronic
infection
Inflammation
diseases
Chronic renal
Mean

Calculates

the

Corpuscular

weight

Hemoglobin

hemoglobin in the

25.7-32.20

average

pg
Mean

erythrocytes.
Measures

Corpuscular

average

Hemoglobin

concentration

or

Concentratio

percentage

of

n (MCHC)

hemoglobin in the

32.30-36.50

average erythrocyte

of

27.5

the NORMAL

the

33.4
NORMAL

disease
Heditary
spherocytosis

Heditary
spherocytosis

Iron

deficiency

anemia

Iron

deficiency

anemia

g/dl

93

URINE ANALYSIS
Date

Basic Test

Ordered

with Normal

October

Values
Appearance

29, 2014

Color

Rationale

Result

Clinical

Nursing Interventions

Significance
Some

medications

and

chemicals

are Clear

NORMAL

Explain that this test aids

responsible causes of urine colour changes.

in

Any change in clarity indicates a distinct

urinary tract disease and

result.
Urine ranges from pale yellow to amber Dark

the

helps

NORMAL

diagnosis

evaluate

of

overall

renal function.

because the pigment urochrome (product of Yellow

bilirubin metabolism). The colour indicates

Inform patient that he

need not to restrict any

concentration of the urine and varies with

food or fluid intake.

Specific

specific gravity
It is the measurement of the ability of the 1.03

Gravity

kidneys to concentrate and excrete the urine.

a clean catch midstream

(1.005-1.03)

Measurement of the concentration of particles

urine collection.

NORMAL

(including wastes and electrolytes) in the

Protein

urine.
Presence of albumin is an indicator of Trace
kidney function.
A high urine pH may be due to kidney failure, 6.0

4.6-8

UTI, and vomiting. A low urine pH may be

Instruct

to

collect

sample

preferably

arising in the morning.

glomerular disease. Sensitive indicator of

pH

Explain the procedure for

NORMAL

due to diabetic ketoacidosis, diarrhea, too

94

a
on

Glucose

much acid in the body fluids and starvation

It is an indicator of significant hyperglycemia Negative

NORMAL

RBC

and diabetes mellitus.

Normally, a few RBCs are present in urine 8.0

NORMAL

0-11 u/L

sediment, inflammation, injury, or disease in

the kidneys or elsewhere in the urinary tract,
for example, in the bladder or urethra, can
cause RBCs to leak out of the blood vessels
into the urine. RBCs can also be a
contaminant due to an improper sample
collection and blood from hemorrhoids or

WBC

menstruation
The number of WBCs in urine sediment is 18

6-11 u/L

normally low. When the number is high, it

indicates

an

infection

or

HIGH

inflammation

somewhere in the urinary tract. WBCs can

also be a contaminant, such as those from
Epithelial cell

vaginal secretions.
Normally in men and women, a few epithelial 7.0

0-11u/L

cells from the bladder (transitional epithelial

NORMAL

cells) or from the external urethra (squamous

epithelial cells) can be found in the urine
sediment. Cells from the kidney are less
common. In urinary tract conditions such as

95

infections, inflammation, and malignancies,

Cast

more epithelial cells are present.

These are cylindrical particles sometimes NONE

0-1u/L

found in urine that are formed from

NORMAL

coagulated protein secreted by kidney cells.

Different types of casts are associated with
different kidney diseases, and the type of casts
found in the urine may give clues as to which
Bacteria

disorder is affecting the kidney.

The urinary tract is sterile; there will be 2 u/L

0-111u/L

no microorganisms seen

in

the

NORMAL

urine

sediment. Bacteria from the surrounding skin

can enter the urinary tract at the urethra and
move up to the bladder, causing a UTI. If the
infection is not treated, it can eventually move
to the kidneys and cause pyelonephritis. Less
frequently, bacteria from a blood infection
may move into the urinary tract.
BLOOD CHEMISTRY
Date

Basic

Tests Rationale

ordered

With Normal

October

Values
Creatinine

The most common

Result

33.52

Clinical Significance

Increased

Decreased

Nursing Interventions

Pretest:

96

29,

53.00-115.00 laboratory

2014

umol/L

test

LOW

used to evaluate
estimate

the

effectiveness

of

working well
dehydrated

filtration. It is an
acid

Obtain a history of

deficiency creatinine are not

common, but they
anemia
kidneys
aren't are also not usually

glomerular
amino

Low blood levels of

Iron

renal function and

to

Myelofibrosis

low blood volume

and

eat a large amount

waste product of
metabolism.

take

Calcium

Measures the total

2.40

medications.
Consumed

1.75-2.39

amount of calcium

HIGH

mmol/L

in the blood.

with conditions that

gastrointestinal,

result in decreased

genitourinary,

muscle mass.

hepatobiliary

Metastatic

systems, as well as the

results

Steomalacia
Pagets Disease

of

performed

nutrients

previously
tests

and

list

of

procedures.
Obtain

medications the patient

Low blood level

bone Vitamin

tumor

and

musculoskeletal

is

of albumin

of

patients cardiovascular,

sm

Hyperpathyroidis

list

They can be seen

Hypoparathyroidi

HIV/AIDS

Obtain a history of the

too Malabsorption of

vitamin D

including

a cause for concern.

certain

much calcium or

complaints,

known allergies.

of meat

protein

patients

taking,

herbs,

deficiency
Magnesium

including
nutritional

supplements

and

nutraceuticals.

the

requesting health care

deficiency

practitioner

Kidney failure

97

and

Monitor

3.4-5.4

function, acid-base NORMAL Crushed

balance, glucose
injury

mmol/L

renal

metabolism.

4.40

Addisons disease

Potassium

To

disorders and to

Too

the

origin

Red

arrhythmias.
Magnesium is one

Magnesium

of

0.74-1.03

intracellular

mmol/L

cations

of

the

body.

It

is

the

m
much Not

major

measured
evaluate
electrolyte
disorders,
hypocalcemia,

to

1.09
HIGH

blood

Low

containing
antacids

There

are

fluid,

or

medication

Instruct the patient to

refrain from excessive

dietary

exercise for 8 hours

before the test.
Review the procedure
with

the

patient.

Explain that the patient

diabetes
Long

food,

restrictions unless by

Uncontrolled
of

no

medical direction.

Hyperparathyroidi Gastrointestinal
disorders
sm
Dehydration

when

reviewing results.

intake

Hypothyroidism

magnesium

consideration

potassium on diet

cell Vomiting

Kidney failure

Use

effects can be taken into

enogh

destruction

Serum

regularly using these

products so that their

Hyperaldosteronis

potassium on diet

of

deficiency

or Use of diuretics

acidosis

be

advised if the patient is

Chronic diarrhea

respiratory

endocrine

laboratory should

anemia

Metabolic

neuromuscular and

determine

tissue Iron

Kidney failure

evaluate

Liver disease
Myelofibrosis

may

term

have

discomfort

diuretic use

with

slight
the

needle puncture and the

or Prolonged
diarrhea

tourniquet.

98

hypokalemia, and

Severe burns

laxatives

Inform the patient that

acid-base

the specimen collection

Sodium

imbalance.
To detect changes

approximately takes 5

135-145

in water balance NORMAL

problems

mmol/L

rather than sodium

cushing syndrome

balance.

To

determine
electrolytes, acidbase

balance,

water

balance,

water intoxication,
and dehydration.

138

Adrenal

glan Addisons disease

to 10 minutes.

like Dehydration,

vomiting, diarrhea Intratest:

Diabetes insipidus Ketonuria

Direct the patient

Increased
fluid Use of diuretics,
to breathe normally and
loss

morphine

Too much salt or

sodium

and

to avoid unnecessary

SSRI
antidepressants

movement.

bicarbonate in diet
Use

Observe

standard

precautions

of

when

obtaining blood.

corticosteroids,
laxative, lithium,

Posttest:

and NSAIDS

Observe
venipuncture site for
bleeding or hematoma
formation.

Apply

pressure bandage.

Evaluate

test

results in relation to the

99

patients symptoms and

other tests performed.

B. POSSIBLE
Serology Blood Test
Anti-SM

Rationale
Nursing Intervention
Anti-Sm is an antibody directed against Sm, a specific protein Pretest:
found in the cell nucleus. The protein is found in up to 30% of

Obtain

history

of

patients

people with lupus. It's rarely found in people without lupus. So

complaints, including a list of

Antiphospholipid

a positive test can help confirm a lupus diagnosis.

APLs are a type of antibody directed against phospholipids.

known allergies.

Antibodies (APLs)

APLs are present in up to 60% of people with lupus. Their

There are no food, fluid, or

100

Anti-Ro

(SSA)

Anti-La(SSB)

presence can help confirm a diagnosis. A positive test is also

medication restrictions unless by

used to help identify women with lupus that have certain risks

medical direction.

that require preventive treatment and monitoring. Those risks

Instruct the patient to refrain from

include blood clots, miscarriage, or preterm birth. APLs may

excessive exercise for 8 hours

also occur in people without lupus. Their presence alone is not

before the test.

enough for a lupus diagnosis.

and Anti-Ro(SSA) and Anti-La(SSB) are two antibodies that are

Review the procedure with the

patient. Explain that the patient

commonly found together. They are specific against ribonucleic

may have slight discomfort with

acid (RNA) proteins. Anti-Ro is found in anywhere from 24%

the

to 60% of lupus patients. It's also found in 70% of people with

another autoimmune disorder called Sjgren's syndrome. AntiLa is found in 35% of people with Sjgren's syndrome. For this

Inform

potentially

serious

problem

in

newborns.

In pregnant women, a positive Anti-Ro (SSA) or Anti-La(SSB)

C-Reactive
(CRP)

warns doctors of the need to monitor the unborn baby.

Protein CRP is a protein in the body that can be a marker of

monitor inflammation. Results of the test could indicate

the

the

patient

that

the

takes 5 to 10 minutes.
Intratest:

Direct the patient to breathe

normally and to avoid unnecessary
movement.

inflammation. The test looks for inflammation, which could

indicate active lupus. In some cases, the test could be used to

and

specimen collection approximately

disorders. Both antibodies are associated with neonatal lupus, a

but

puncture

tourniquet.

reason, their presence may be useful in diagnosing one of these

rare

needle

Observe standard precautions

when obtaining blood.

changes in disease activity or in response to treatment. Because

there are many causes for an elevated result, including

101

infection, the test is not diagnostic for lupus. Nor can it Posttest:
distinguish a lupus flare from an infection. Also, the level of

Complement

Observe venipuncture site for

CRP doesn't directly correlate with lupus disease activity. So it

bleeding or hematoma formation.

isn't necessarily useful for monitoring disease activity.

Complement proteins are involved in inflammation. The test

Apply pressure bandage.

can look for levels of specific complement proteins or for total

complement. Complement levels are often low in patients with
active disease, especially kidney disease. So doctors may use

Evaluate test results in relation to the

patients symptoms and other tests
performed

the test to gauge or monitor disease activity. Like other tests,

complement must be taken in the context of clinical findings
and other test results. A low complement in itself is not
Erythrocyte
Sedimentation
(ESR)

diagnostic of lupus.
ESR measures the speed of red blood cells moving toward the
Rate bottom of a test tube. When inflammation is present, blood
proteins stick together and fall and collect more quickly as
sediment. The more quickly the blood cells fall, the greater the
inflammation. ESR is used as a marker of inflammation.
Inflammation could indicate lupus activity. This test could be
used to monitor inflammation, which could indicate changes in
disease activity or response to treatment.

102

Test
Tissue

Rationale
A biopsy procedure involves removal of a small bit of

Nursing Intervention
Observe standard precautions when obtaining blood

Biopsies

tissue that the doctor then examines under a

Advise patient to tell the doctor if you are pregnant or if

microscope. Almost any tissue can be biopsied.

The skin and kidney are the most common sites

you have any drug allergies or bleeding problems.

biopsied in someone who may have lupus.

Chest
ray

Make sure the health care team knows what medications

you are taking.

The results of the biopsy can show the amount of

Instruct patient to avoid foods or fluids before the test.

inflammation and any damage being done to the

Tell that the amount of pain during and after the

tissue.

procedure depends on the patient. Because a local

Further tests on the tissue sample can detect

anesthetic is used, discomfort during the procedure is

autoimmune antibodies and determine whether

usually minimal. The anesthetic may burn or sting when

lupus or another factor such as infection or

first injected. After the procedure, the area may feel

medication is responsible.
X- An image of your chest may reveal abnormal shadows
that suggest fluid or inflammation in your lungs.

tender or sore for a few days.

Explain the procedure to the patient
Remove jewelleries prior to test
Provide privacy

103

104

PROGNOSIS
CRITERIA

GOOD

FAIR

POOR

JUSTIFICATION
The patient is five years old. SLE in children is
uncommon but fatal. Most deaths in children with SLE
are the result of infection, nephritis, renal failure,
neurologic

disease,

or

pulmonary

hemorrhage.

Myocardial infarction may occur in the young adult

Age

years as a complication of persisting inflammation and,

possibly, long-term corticosteroid use. The immature
developing body organs and systems of a child is a
consideration in any disease process. Serious illnesses
in childhood usually will cause stunted growth and
immune responses primarily which could pose other
health issues in the future.
According to longitudinal cohort studies, childhoodonset SLE continues to carry a high mortality burden. It
has a more aggressive course than adult-onset disease,
with patients accumulating damage more quickly.
Treatment itself is a relative debilitating factor to age;

Onset

younger patients are subjected to prednisone and

of

illness

immunosuppressive therapies thus predisposing them

to many complications. It was found out that in
younger patients, renal involvement is common and
survival is decreased if this is the case in almost all
cases of SLE even in adult-onset disease. This shows
that childhood onset may be related to increased

Duration
illness

of

genetic susceptibility and greater biologic vulnerability.

Based from the onset of signs and symptoms of the
disease which have had occurred just recently,
diagnosis was considerably early but there was a rapid
progression and has already affected a vital organ, the
kidney. Aggressive treatment was already instituted.

105

Studies show that renal disease is very common in

SLE, with clinical symptoms of renal involvement
occurring in 30%-70% of patients. In the absence of
appropriate treatment the child may die from the
disease or progress rapidly to renal failure. However,
aggressive

treatment

regimens,

in

particular

corticosteroids, carry the risk of growth retardation,

accelerated atherosclerosis, and severe infectious
complications.
The Pediatric Specialty Wing of SPMC homes
immunosupressed individuals. Being a part of a
hospital, still it poses a risk for nosocomial infections
thus discharge from hospital was prompt. They are
living in a home they own and the surrounding has a
fair and typical rural environment. With the health
education
Environment

provided

by

the

nurses

regarding

maintenance of clean surroundings and good personal

hygiene,

refraining

from being exposed to ill

individuals, promoting healthy lifestyle (e.g. avoiding

smoking inside their home) and etc. Nevertheless,
immunosupressed

individuals

are

vulnerable

to

pathogens. Periodic admission to the hospital was

scheduled for future therapies which will possibly
Family
support

expose the patient to hospital-borne diseases.

The childs parents are struggling in life but they are
together in facing the burdens of life and the condition
of their child. Despite of the complexities of their
situation, they are optimistic that they will be able to
overcome and surpass their challenges in life. The
familys love for the patient is unquestionable, it is their
greatest hope that the day will come that he will be
cured and recuperate from the disease. During the

106

patients admission in the hospital, high regard to the

child is evident in the care provided by the mother and
as well by the father. As the youngest of the siblings, he
was the most benefiting from the attention of all
household members.
Since the patient is a child, it is in the disposition of the
parents to comply with therapy and hospitalization
requirements including financial burdens of long-term
medication which include some expensive drugs and

Willingness
to

take

procedures

particularly

monitoring

through

immunosuppressant

medications

the

drugs.

frequent

blood
Their

laboratory

studies

and

socio-economic

condition can be an impediment to uninterrupted and

not delayed treatment. Also, the patient has other
siblings whom the parents should provide to. The
proponent advised the parents to seek financial support
from charity institutions and individuals. The parents
displayed willingness to do so upon learning some of
possible available community or even political
resources.
Among the identified precipitating factors there are two
factors that can be established and these are: smoking
and environmental factor. Though the patient is a nonsmoker but the father is and so the child is exposed to

Precipitating
factors

second hand smoke in their household and use of

firewood for their cooking may also contribute.
Environmental factor includes frequent ultraviolet light
exposure whereby the patient is a child and part of their
growing is playing outdoors with other children thus

Predisposing
factors

too much exposure to sunlight is often occurring.

Among the five identified predisposing factors there
are three factors that can be established and these are;

107

age, genetics and race. The stakes are high for the
condition to occur as found out if the patient is between
three to five years old. Genetic implications arise from
having a twin brother. Studies show that having lupus
between twin siblings is high or having familial
tendencies in having twins in the family is commonly
associated to having autoimmune diseases. Since the
child patient is a Filipino, moreover an Asian. It is a
popular knowledge that Lupus is common to Asians or
having an Asian descent.
TOTAL

COMPUTATION

PROGNOSIS RATING
POOR

FAIR
GOOD

RESULT

TOTAL

TOTAL = 16/8 = 2.00

Legend

Range

Poor = 1

1.00 - 1.69

Fair = 2

1.70 - 2.39

Good = 3

2.40 - 3.00
NARRATIVE PROGNOSIS

The overall prognosis of the patient based on the computed weigh among criteria is 2.00 and
its range falls under the fair prognosis. In the past, almost all diagnosed case of SLE and its

108

complications are categorically considered under poor prognosis. In todays advent of improving
and sophisticating advancements in medicine, particularly with regards to therapy and diagnostic
procedures whereby diseases such as SLE can be easily detected at early stages and therefore
provided with prompt medications. There are already promising specific therapy as a result of
continuous and rigid studies or researches. Tests are still being conducted to prove its efficacy and
effectiveness. Although at present there are already existing medicines that control or alleviate
conditions caused by flares of the diseases. It is much fortunate that patients are able to continue
with normal lives without much of the burden of disease and so it can be considered that quality of
life is restored. Compliance of the patient and or his family is vitally important. The treatment
process is long and could be overpowering, motivation is imperative thus they should look through
their situation as a binding factor and to strengthen them in facing not only this challenge but as
well others that may come.

DISCHARGE PLAN
Medications

Corticosteroids are used in all patients with clinically significant renal disease.

109

Immunosuppressive

agents,

particularly

cyclophosphamide,

azathioprine,

and

mycophenolate mofetil, are used in patients with aggressive renal lesions because they
improve the renal outcome. They may also be used in patients with inadequate response or
excessive toxicity to corticosteroids.

Patients with hypertension should be aggressively treated. If hypertension is a consequence

of corticosteroid therapy, consider immunomodulating medications as steroid-sparing agents
to help control hypertension.

Use lipid-lowering therapy such as statins for hyperlipidemia secondary to nephrotic

syndrome.

All patients with SLE who are on corticosteroids or who have arthritis are at increased risk
for osteopenia and its complications. Supplementation with vitamin D and calcium are
important tools for bone health in these patients. Of note, natural production of vitamin D
involves skin exposure to sun, which is discouraged in the SLE population, increasing the
risk of vitamin D deficiency.

Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is intermittent,
this therapy probably has the fewest adverse effects. If preventing subsequent febrile
seizures is essential, this would be the treatment of choice.

Although it does not prevent simple febrile seizures, antipyretic therapy is desirable for
other reasons.

Can decrease number of subsequent febrile seizures when given with each febrile episode.
By increasing activity of GABA, a major inhibitory neurotransmitter, depresses all levels of
CNS, including limbic and reticular formation.

Exercise/Environment

Encourage patients with SLE to maintain a normal lifestyle.

Exercise is important in maintaining bone density and an appropriate weight.

110

Caution patients and/or their family that fatigue and stress have been associated with disease
flares.

Caution patients to avoid sunlight and to liberally apply waterproof sunblock every 2 hours
when exposed to the sun.

Treatment

The goal of therapy is to control disease manifestations, allowing the child to have a good
quality of life without major disease exacerbations, while preventing serious organ damage
that adversely affects function or life span. At the same time, the physician is challenged to
prevent intolerable adverse effects from the therapeutic regimen.

Before treatment, identify organ system involvement and exclude other possible diagnoses.

Many of the therapeutic options have serious adverse effects, contraindications, and drug
interactions. A high risk for infection, infertility, and future cardiovascular disease is noted.
The most important management tool in the treatment of systemic lupus erythematosus
(SLE) is meticulous and frequent reevaluation of patients.

Reevaluation includes clinical and laboratory evaluation, allowing prompt recognition and
treatment of disease flare that is essential to patient outcome.

On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant

therapy is indicated for children who have experienced 1 or more simple febrile seizures.

HEALTH TEACHING

111

The patient and his or her family must have a thorough understanding of SLE, its potential
severity, and the complications of the disease and its therapy.

Treatment is difficult. The health providers and parents should expect issues, including
depression and noncompliance, to arise.

The best method for deterrence is to thoroughly educate the patient and family through
discussion, support groups, and literature.

Educate all patients with SLE with regard to the serious complications possible from poor
compliance, and infection. Poor compliance, in particular, is a significant prognostic factor.

Out-patient Referral

A Rheumatologist should be an integral part of the medical care team supporting the lupus
patient.

Other consultations depend on the type of organ involvement. Consider consultation with a
Nephrologist for severe end-organ disease.

Diet

Dietary restrictions are driven by the patients medical therapy. Most patients require a

course of corticosteroids and should be on a low-salt, low-fat, calcium-sufficient diet.

Recognize that patients and/or their family frequently try nontraditional medical remedies
and food supplements. These remedies should be met with an open and supportive response.

Monitoring nontraditional remedies and food supplements is important, because they may
Alter metabolism of more traditional medications.

INSIGHTS AND UPDATES

112

Systemic Lupus Erythematosus is a chronic disease that can affect a variety of different
body parts or organs. The human body is equipped with an internal immune surveillance system
which detects the presence of invading pathogens and other foreign elements that could be harmful
to the body. In some instance, a disorder may occur such as in the case of lupus and other
rheumatologic problems whereby the bodys immune system could not properly identify its real
enemy and produces antibodies which in this case it attacks its own thus causing damage within and
will manifest inflammation in different body parts or systems. Sometimes, on a rare occasion basis,
lupus nephritis can be the sole symptom of lupus. Childhood onset presents a few manifestations
thus arriving to a correct diagnosis more difficult. The hallmark signs and symptoms of lupus
nephritis are sometimes suggestive of other diseases as well. Perhaps the exact onset of the disease
on the patient can be traced back to an earlier period that there is already kidney involvement but
that would also be doubtful since progression of the disease can be erratic and rapid in progression.
Another complex problem is the management of lupus itself. The need to use both
immunosuppressants and corticosteroid suggests enormous caution on the part of the parents and
the child patient himself. Seemingly it will not only be the childs physical growth and development
that will be affected but as well as the psychological growth and development is at risk for
retardation due to several disease-imposed restrictions to impede normal functioning and living. He
can never be careless and reckless like other children. The family will be having a lot of difficulty
coping to the demands of their childs condition, there is a possibility that it will not only the patient
who will suffer physically and emotionally but it will be a burden to the whole family. Their
economic status can be a factor for the decline of survivability of the patient. Thus the condition of
the patient may have greater impact to their socioeconomic status. The real sacrifice is in the long
process of treatment which is almost a lifetime not until a real cure to this condition will be
available. Todays existing goals of therapy are usually directed to prevention of flares of lupus.
In a publication of the American Association of Kidney Patients, An update on Lupus
Nephritis, states that currently, the only way to truly confirm the most effective treatment of lupus
nephritis is to perform a kidney biopsy. If the urine and blood studies suggest this diagnosis, a
biopsy is used to confirm it and to determine the degree and severity of kidney involvement. This is
very important as it provides a guide as to what medicines may be required to treat it. In children (as
in adults), kidney biopsies are generally done in the hospital or outpatient surgery centre with

113

general anaesthetic or conscious sedation. A biopsy needle is inserted through the skin of the back
and small pieces of the kidney tissue are removed. This tissue is then examined with a microscope
to see how much permanent (scar) or reversible damage has occurred. These findings are reported
based on the World Health Organization (WHO) classification system. Understanding the type of
lupus nephritis a child has helps in assessing the best treatment approach, and long term prognosis.
Another breakthrough is in the treatment regimens for lupus and lupus nephritis. Through research,
the understanding of how lupus nephritis occurs is slowly improving. This is leading to the
development of newer more specific medications for treatment of this condition. Bone marrow
transplant and plasmapheresis have also been utilized in very severe cases of lupus nephritis that
have not responded to conventional therapy. Occasionally, despite aggressive and long-term therapy,
children with lupus nephritis lose their kidney function. In this setting the patient is placed on either
hemodialysis or peritoneal dialysis until there is little or no evidence of lupus activity at which point
they are referred for kidney transplant. Lupus does not commonly recur in transplanted kidneys.

REFERENCE
http://emedicine.medscape.com/article/1008066-overview#aw2aab6b2b4

114

https://www.aakp.org/education/resourcelibrary/dialysis-resources/item/an-update-on-lupusnephritis.html
http://emedicine.medscape.com/article/1176205-followup#a2651
http://www.medpagetoday.com/Rheumatology/Lupus/21556
http://www.mayoclinic.org/diseases-conditions/lupus/basics/risk-factors/con-20019676
Anatomy and Physiology 2nd Edition Lippincott Williams & Wilkins www.innerbody.com Medical
Surgical Nursing by Suzzane C. Smeltzer and Brenda G. Bare Vol.1
Pediatric Nephrology 5th Edition Lippincott Williams and Wilkins, 2004 Vol. 1
Black, J. M., & Hawks, J. H. (2009). Medical-Surgical Nursing: Clinical Management for
Positive Outcomes. 8th Edition. Missouri: Saunders.
Porth, C.M. (2005). Pathophysiology: Concepts of Altered Health States. 7th Edition. Lippincott
Williams & Wilkins.
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths
Textbook of Medical-Surgical Nursing. 13th Edition. Volume 2. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Black, J. M., & Hawks, J. H. (2009). Medical-Surgical Nursing: Clinical Management for
Positive Outcomes. 8th Edition. Missouri: Saunders.
Porth, C.M. (2005). Pathophysiology: Concepts of Altered Health States. 7th Edition.Lippincott
Williams & Wilkins
Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner & Suddarths
Textbook of Medical-Surgical Nursing. 13th Edition. Volume 2. Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.

115