A CASE SHARING ON SYSTEMIC LUPUS ERYTHEMATOSUS

Presented to the Faculty of the School of Nursing

Adventist Medical Center College

Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Abdullah, Asniah
Amano,Amirah

Bughaw, Alvin Miko

Bulado, Annielyn

Chinchuntic, Joan

Cornell, Nur Mohammad

Espera, Leslie

Medina, RobelynnMaye

Pagasian, Lady Bee

Rangiris, Johainah

Sabdula, Haide

March 12, 2018

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 TABLE OF CONTENTS

I. TITLE PAGE 1
II. TABLE OF CONTENTS 2
III. LIST OF TABLE 3
IV. LIST OF FIGURES 4
V. OBJECTIVES 5
General Objective
Specific Objectives

VI. DEFINITION OF TERMS 6-7

VII. INTRODUCTION 8-9
VIII. NURSING HEALTH HISTORY

Physical Examination and Review of Systems 10-12

IX. DIAGNOSTIC TEST 13-15

X. NORMAL ANATOMY AND PHYSIOLOGY 16-17

XII. PATHOPHYSIOLOGY 18-20

XIII. NURSING MANAGEMENT 21
XIV. NURSING CARE PLANS 22-30

XV. HEALTH EDUCATION PLAN 31-33

XVI. DISCHARGE PLAN 49-59

XVII. MEDICAL MANAGEMENT 60
XVIII. PROGNOSIS 61
XIX. REFERENCE 62

2
 LIST OF TABLES

TABLES PAGES

1 Physical Examination and Review of System (PEROS) 10-12

2 Diagnostic Test 13-15

3 Normal Anatomy and Physiology 16-17

4 Nursing Care Plan 22-30

3
 LIST OF FIGURES

FIGURES PAGE

1 Pathophysiology 18-20

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 OBJECTIVES

General Objectives:

At the end of one and a half hour of case presentation, the participants will be able to learn about
the disease process of Systemic Lupus Erythematosus

Specific Objectives:

At the end of one and a half hour of case sharing, the participants will be able to:

1. Explain the medical terms related to Systemic Lupus Erythematosus;

2. Summarize the pathophysiology, risk factors and manifestation Systemic Lupus

Erythematosus;

3. Categorize the physical examination and review of systems;

3. Discuss the anatomical structure and functions involved in Systemic Lupus Erythematosus;

5. List the nursing and medical management for Systemic Lupus Erythematosus;

6. Formulate appropriate nursing process and discharge plan for the client with Systemic Lupus
Erythematosus;

7. Organize a health education and discharge plan.

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 DEFINITION OF TERMS

Anemia.Is a condition that develops when your blood lacks enough healthy red blood cells or
haemoglobin. As defined by Brunner and Suddarth (2014), “a condition in which the haemoglobin
concentration is lower than normal; it reflects the presence of fewer than the normal number of
erythrocytes within the circulation.”

Arthralgias.It means a joint pain; it is a symptoms of injury, infections, illnesses, or an allergic

reaction to medication. According to Lewis, Dirksen, and Heitkemper (2013), “an involvement of
multiple pain in the joints and may be accompanied by myalgias.”

Butterfly rash.is a medical sign consisting of a characteristic form of facial rash; a sign of lupus
that is a butterfly-shapedrash across the cheeks and bridge of the nose. As stated by Zaman (2017),
“It is a type of condition of the skin, which is denoted by the appearance of spots/skin eruptions
over the cheekbones and also over the bridge of the nose.”

Discoid lupus.It is a chronic skin condition of sores with inflammation and scarring favoring the
face, ears, and scalp and at times on other body areas; thelesions develop as a red, inflamed patch
with a scaling and crusty appearance. According to Hargrove-Huttel (2005), “results in skin
involvement that may be provoked by sunlight or artificial ultraviolet light.”

Drug-induced lupus.Is caused by a chronic use of medications. As stated by Kauffman (2017),

“is a variant of lupus erythematosus that resolves within days to months after withdrawal of the
culprit drug in a patient with no underlying immune system dysfunction.”

Erythematous rash.It is a red rash in the skin or mucous membrane. As defined by Dewit,
Stromberg, and Dallred (2016), it is a “presence of red rash.”

Leukopenia.It is a decrease in the number of white blood cells found in the blood, which places
individuals at increased risk of infection. According to Fellin (2008), “is usually an indicator of an
underlying inflammatory, infectious, or neoplastic process.”

Neonatal lups.It is the occurrence of systemic lupus erythematosus (SLE) symptoms in an infant
born from a mother with SLE, most commonly presenting with a rash resembling discoid lupus
erythematosus, and sometimes with systemic abnormalities such as complete heart block or
hepatosplenomegaly. As stated by Lee (2004), “is an uncommon autoimmune disease manifested
primarily by cutaneous lupus lesions and/or congenital heart block. Its lesions tend to resolve in a
few weeks or months without scarring.”

Nephrotic lupus. It is inflammation of the kidney that is caused by systemic lupus erythematous
(SLE). As defined by Lee (2004), “When the kidneys are inflamed, they can't function normally and
can leak protein. If not controlled, lupus nephritis can lead to kidney failure.”

Nephrotic syndrome.It is a collection of symptoms due to kidney damage; this includes protein
in the urine, low blood albumin levels, high blood lipids, and significant swelling. As defined by
As defined by Dewit, Stromberg, and Dallred (2016), “occurs after the glomeruli have been
damaged by glomerulonephritis or some other diseases. This damage results in increased
membrane permeability and excretion of protein and decreased serum albumin.”

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Pericarditis.Inflammation of the lining around the heart (the pericardium) that causes chest pain
and accumulation of fluid around the heart (pericardial effusion). As stated by Moses (2018),
“inflammation of the pericardium from various origins, such as infection, neoplasm, autoimmune
process, injuries, or drug-induced.”

Photosensitivity.It is an extreme sensitivity to ultraviolet rays from the sun and other light
sources. As defined by Lagner and Maier (2010), “an abnormal cutaneous reaction to solar
ultraviolet radiation. This reaction may clinically manifest as greater propensity toward sunburn
or development of rash upon exposure to solar radiation.”

Thrombocytopenia. It is a condition characterized by abnormally low levels of thrombocytes,

also known as platelets, in the blood.According to George (2017), “a platelet count below the lower
limit of normal (<150,000/microL [150 x 109/L] for adults).

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 INTRODUCTION

Systemic Lupus Erythematosus, also known simply as lupus, is an autoimmune disorder where
the body’s immune system mistakenly attacks the healthy tissues and affects nearly every organ
in the body. It occurs 6-10 times more frequently in women than in men and occurs more in
African-American populations than among Caucasians.

The disease has been called the great imitator because it has the capacity for affecting many
different body systems, including the musculoskeletal system, the skin, the cardiovascular system,
the lungs, the kidneys, the central nervous system (CNS), and the red blood cells and platelets.
Systemic symptoms include fever, malaise, weight loss and anorexia. Arthralgias and arthritis are
among the most commonly occurring early symptoms of SLE; approximately 90% of all the
persons with this disease complain of joint pain. The most familial skin manifestation is an acute
cutaneous lesion consisting of a butterfly-shaped erythematous rash across the bridge of the nose
and cheeks. Renal involvement occurs in approximately 50% of persons with SLE. Nephrotic
syndromes causes proteinuria with resultant edema in the legs, abdomen, and around the eyes.
Pulmonary involvement of SLE occurs in 40%-50% of patients and is manifested by pleural
effusions or pleuritis. Pericarditis also occurs in 6% to 45% of patients with SLE and is the most
common cardiac manifestation. Neuropsychiatric presentations of SLE are now widely recognized
and include psychosis, cognitive impairment, seizures, transverse myelitis and stroke.
Hematologic disorders may manifest as hemolytic anemia, leukopenia, lymphopenia, or
thrombocytopenia. Other forms of lupus include: discoid lupus (which primarily affects the skin
and the face), drug-induced lupus (which rarely includes some brain or kidney effects and has a
clearer pathophysiology), and neonatal lupus (which is passed to the newborn during childbirth
and usually resolved by 6 months of age). SLE can cause damage to many parts of the body,
potentially leading to the following complications: kidney failure, blood problems such as anemia
(low red blood cell count), bleeding or clotting, high blood pressure, vasculitis (inflammation of
the blood vessels), memory problems, behavior changes or hallucinations, seizures, stroke, heart
disease or heart attack, lung conditions such as pleurisy (inflammation of the chest cavity lining),
and avascular necrosis (death of bone tissue due to a lack of blood supply).

The cause of SLE is unknown. It is characterized by the formation of autoantibodies and immune
complexes. The development of autoantibodies in SLE can result from a combination of factors,
including genetic, hormonal, immunologic, and environmental factors. Genetic predisposition is
evidenced by the occurrence of familial cases of SLE, especially among identical twins. Studies
also suggest that an imbalance in sex hormone levels may play a role in the development of the
disease, especially because the disease is so prevalent among women. Androgens appear to protect
against the development of SLE, whereas estrogens seem to favor its development. It has been
suggested that an imbalance in sex hormone levels may lead to heightened helper T-cell and
weakened suppressor T-cell immune responses, which could lead to the development of
autoantibodies. Certain drugs may provoke a lupus-like disorder in susceptible persons,
particularly the elderly. The most common of these drugs are hydrazine and procainamide.

The pathogenesis starts with the body’s immune system inaccurately recognizing one or more
components of the cell’s nucleus as foreign, seeing it as an antigen. The immune system then starts
to develop antibodies to the nuclear antigen. In particular, B cells begin to overproduce antibodies
with the help of multiple cytokines such as B-lymphocyte stimulator (BLyS), which is
overexpressed in SLE. The antibodies and antigens form antigen-antibody complexes and have the

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propensity to get trapped in the capillaries of visceral structures. The antibodies also act to destroy
host cells.

The reported prevalence of systemic lupus erythematosus (SLE) in the United States is 20 to 150
cases per 100,000. In women, prevalence rates vary from 164 (white) to 406 (African American)
per 100,000. Due to improved detection of mild disease, the incidence nearly tripled in the last 40
years of the 20th century. Estimated incidence rates are 1 to 25 per 100,000 in North America,
South America, Europe, and Asia. SLE was identified as the underlying cause of death for an
average of 1,034 deaths from 2010–2014. SLE was identified as a contributing cause of death (one
of multiple causes of death, including underlying cause of death) for an average of 1,803 deaths
during that 4-year-period.

In the Philippines, women made up the majority of the 2,273 patients with SLE who consulted
with various rheumatology centers around the country from 1995 to 2010, according to the
Philippine-based Lupus Inspired Advocacy (LUISA) Project. The average age of women, reported
LUISA, was 29. Around 90 percent of lupus sufferers experience fatigue and about 50 percent of
patients have this rash, which is usually triggered by exposure to sunlight.

Advancements in lupus research

Treatment Success can be Determined by Imbalanced B Cells

A recent study conducted by researchers at University College London, has made an interesting
discovery that could impact the way we determine individual treatments for people with lupus.
The study focused on the role of B cells, highly important in the body’s immune response, in
patients with lupus. The study found that lupus patients have an unbalanced level of B cells
compared to people without lupus. This could prove to be one of the factors that lead to people
developing lupus. On top of having imbalanced B cells, the B cells in lupus patients also behave
differently from those of healthy people.

The imbalance of B cells caused by the overproduction of interferon-alpha causes lupus patients
to react differently to administered treatments. These treatments often aim to suppress the immune
response, but the effectiveness of treatment could be determined by the interferon-alpha signature
of the patient. Testing for interferon-alpha levels in patients could allow for better personalized
treatment.

The Development of a New Immunosuppressant Treatment

Immunosuppressants are a common form of lupus treatment used that works to suppress the
immune response in patients. The problem faced by immunosuppressant therapy is that this
treatment can also weaken your immune system. However, there may be a new form of
immunosuppressant therapy that reduces your immune response without weakening your immune
system. The drug, called LupuzorTM, is being developed by a research team at the CNRS
Immunopathologie et Chimie Thérapeutique labs in Strasbourg. While LupuzorTM still needs to
undergo more testing before it can be approved for market, the treatment has made it through phase
I and phase II clinical trials with success and shows great promise.

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 Physical Examination and Review of Systems of SLE

Areas Examined Subjective Findings Objective Findings Problems Identified

General Health Survey

 Fatigue related
 Weak appearance
to disease

 Butterfly rash process

”  Impaired skin
 Oral ulcer
integrity

 Discoid skin rash  Disturbed body

 Alopecia image

1. Integumentary  Skin rash (butterfly  Disturbed

System rash) body image
 Oral and naso ulcers related to

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  Alopecia  Impaired
 Mucosal ulcer skin integrity
 Palmar rash
 Photosentivity

2. Respiratory System  Pleural effusion  Ineffective

breathing
 Pneumonitis
pattern
3. Cardiovascular  Pericarditis  Acute pain
System  Chest pain
 Raunaud’s
phenomenon
 Myocarditis
 Hypertension
 Dysrhythmias

4. Gastrointestinal  Ulceration in mouth  Imbalanced

nutrition less
System and  Serositis
than body
Abdomen  Nausea and vomiting requirements
 Diarrhea
 Anorexia
5. Genitourinary/Repr  Glomerular nephritis
oductive Tract  Hematuria
 Proteinuria
6. Musculoskeletal  . Joint pain and  Acute pain
System stiffness early in  Impaired
physical
morning mobility
 Myositis
 Polyarthralgia
 Synovitis
 Boutonnier
deformity
 Ulnar deviation
 Swan neck deformity
7. Neurologic System  Pychosis  Ineffective
intravascular
 Cognitive
perfusion
impairement  Risk for
seizures
 Seizures

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  Peripheral and
cranial neuropathies
 Transverse myelitis
 Strokes
8. Lymphatic/Hemato  Anemia  Risk for
spread of
logic System  Thrombocytopenia
infection
 Leukocytosis, or related to
inadequate
leukopenia.
primary
 Spleenomegaly
9. Reproductive  Abnormal or
system irregular
menstruation

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 CBC

Component Interpretation Normal Value

Red blood cell Decreased Female 4.2-5.4 million/mm3

(RBC)
Male 4.7-6.1 million/mm3

White blood cell Decreased 5,000-10,000/mm3

(WBC)

Hemoglobin (Hgb) Decreased Female 12-16 g/dl

Male 14-18 g/dl

Hematocrit (Hct) Decreased Female 37-47%

Male 14 – 18 g/dl

Platelet count Decreased 150,000-400,000/mm3

Neutrophils Decreased 55-70%

Lymphocytes Decreased 20-40%

Monocytes Normal 2-8%

Eosinophils Normal 1-4%

Basophils Normal 0.5-1.0%

Chemistry Profile

Component Interpretation Normal Value

Alkaline phosphatase Normal 13-39 U/ml

Aspirate amino transferase Normal 5-40 U/ml

(AST)

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 Alanine amino transferase Normal Female 5-35 U/ml
(ALT)

Blood urine nitrogen (BUN) Increased 8.0-25.0 mg/dl

Creatinine Increased 0.7-1.5 mg/dl

Sodium Normal 137-147 mEq/L

Chloride normal 100-106 mEq/L

Potassium Increase 3.5-5 mEq/L

Carbon dioxide (CO2) Normal 24-29 mEq/L

Calcium Normal 8.5 10.3 mg/dl

Phosphate Normal 3-4.5 mg/dl

Uric acid Normal 2.6-7.2 mg/dl

pH normal 7.35-7.45

Biopsy

The sample can be obtained with a needle or through a small incision

Skin biopsy is sometimes performed to confirm a diagnosis of lupus affecting the skin

Autoantibody test

Test Description

ANA Measure abnormal antibodies that react with a

variety of nuclear antigens

Anti-dsDNA Titer measurement of anti body to double stranded

DNA

Serum Immunology

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 Test Normal value Result

Complement levels C3, C4 C3: 80 -170 mg/dL Decreased

C4: 18-51 MG/DL

C- reactive protein <1mg/dL Positive

Show presence of
glycoprotein due to
inflammatory process

Rheumatoid Factor negative Positive

Determine the presence of

abnormal antibodies seen in
connective tissue disease

Urinalysis

Color Normal

Trasparency Normal

Protein Proteinuria due to patient’s lupus nephritis

pH Normal

Specific Gravity Normal

Pus Cells May reveal some destructive or healing process in the urinary
tract anywhere from the kidney to the bladder

RBC Can be due to infection, trauma, or any kidney disease that

alters its permeability

Squamous Normal

Bacteria Normal

Mucus thread Normal

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 Normal Human Anatomy and Physiology

System Function

 Lymphoid tissue Like macrophages, lymphocytes are formed from stem

cells in the bone marrow and then circulated in the
blood to the lymphoid tissue. Lymphoid tissue has
several different structural organizations related to its
particular function in the immune response.

The most highly organized lymphoid tissues are in the

thymus and lymph nodes, which are well-
defined encapsulated organs with easily identifiable
architectures. The most diffuse lymphoid tissue is
found in the loose connective-tissue spaces beneath
most wet epithelial membranes, such as those that line
the gastrointestinal tract and the respiratory system.

These cells mature in the thymus, which is a small

organ in the upper chest, just behind the sternum
(breastbone). T-cells help B-cells make antibodies
against invading bacteria, viruses, or other microbes.
Unlike B-cells, T-cells engulf and destroy pathogens
directly, after binding to the antigen on the surface of
- T cell the microbe.

These cells originate in the bone marrow. They make

proteins called antibodies which attach onto the
surface of infection-causing microbes. Generally,
these are Y or T shaped. Each type of antibody reacts
to different microbes by sticking to molecules, called
antigens, which sit on the surface of the microbe. It is
this antibody-antigen binding that triggers B-cells to
grow and produce more antibodies, which fight
infection.
- B cell
Thymus gland The thymus is an organ that is secretory in pre-
pubescence, which earns its status as a gland. The
thymus gland has an important role in immune
function. One of its main secretions is the
hormone thymosin. Thymosin stimulates the
maturation of T cells, which are derivatives of the
white blood cells that circulate our system. T cells

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 “kill” or are cytotoxic to damaged cells. The damaged
cells may be cancerous cells that have lost the ability
to stop proliferating, or even cells infected with
viruses. T cells will be able to bind the T receptor on
the target cell’s surface that will initiate its eventual
death. The T cell’s cytotoxicity comes from the
cytokines it produces.
Bone marrow Bone marrow is the soft, flexible connective
tissue within bone cavities. A component of
the lymphatic system, bone marrow functions
primarily to produce blood cells and to store fat. Bone
marrow is highly vascular, meaning that it is richly
supplied with a large number of blood vessels. There
are two categories of bone marrow tissue: red
marrow and yellow marrow. From birth to early
adolescence, the majority of our bone marrow is red
marrow. As we grow and mature, increasing amounts
of red marrow is replaced by yellow marrow. On
average, bone marrow can generate hundreds of
billions of new blood cells every day.

The major role of bone marrow is to generate blood

cells. Bone marrow contains two main types of stem
cells. Hematopoietic stem cells, found in red marrow,
are responsible for the production of blood cells. Bone
marrow mesenchymal stem cells (multipotent
stromal cells) produce the non-blood cell components
of marrow, including fat, cartilage, fibrous connective
tissue (found in tendons and ligaments), stromal cells
that support blood formation, and bone cells.
Spleen The spleen is the largest organ of the lymphatic
system. Located in the upper left region of the
abdominal cavity, the spleen's primary function is to
filter blood of damaged cells, cellular debris, and
pathogens such as bacteria and viruses. Like
the thymus, the spleen houses and aids in the
maturation of immune system cells
called lymphocytes. Lymphocytes are white blood
cells that protect against foreign organisms that have
managed to infect body cells. Lymphocytes also
protect the body from itself by controlling cancerous
cells. The spleen is valuable to the immune response
against antigens and pathogens in the blood.

The major role of the spleen is to filter blood. The

spleen develops and produces mature immune cells
that are capable of identifying and destroying
pathogens. Contained within the white pulp of the
spleen are immune cells called B and T-lymphocytes.

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 PATHOPHYSIOLOGY
Predisposing Factor: Precipitating Factor:

o Age(14-45) o Environmental
UNKNOWN ETIOLOGY
o Gender  Extreme stress
(Female)  Exposure to
o Hereditary sunlight
o Childbearing Alteration of body system  Infections
stage  Hormonal
Activation of ANA changes

Ribonucleic- smith antigen

Hyperactivity

Production of Injury to tissue and

abnormal vascular lesion
antibodies by B cells

Decreased or missing
CRP and glycoproteins

Abnormal reaction of
body against its own
cells and serum protein

Increased level of anti ds DNA

antibodies results to engulfed LE
bodies in the LE cells

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 ANA and nuclear antigen found
in serum, small blood vessels,
skin & glomelular basement
membrane

Immune complexes initiate the

complement reaction & serum
complement level are decreased
during attack of SLE

Degeneration of connective
tissue, glomeruli, blood vessels

Specific antigen in
Increases in
joints (T Lymphocytes)
self and non-
self antigen

RH Factor(IgM, IgG) on
antigen in synovial
Hyperactivity cavity
of B cells

Immune complex deposition, RF IgG complexes

Antineurral,anitibody activity activate complement

Acute attack of RA

Polymorphonuclear
leukocytes is being
attacked 19
 Liposomal enzymes
released by this cells

Pannus formation

Joint space is Scarring

destroyed

Bleeding and
thrombus in area

Swelling pain and warm

skin during RA attacks

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 NURSING MANAGEMENT

 Collaboration with other department such as physical and nutrtion therapy

 Assess patient’s general fatigue level.
 Assess for the presence of depression, anxiety, and other stressors.
 Conduct assessment to determine patient’s daily activities that contribute to fatigue.
 Help patient to develop an energy-conserving plan for completing daily and other activities and work.
 Suggest planning for rest periods as needed throughout the day to conserve energy.
 Encourage patient to get 8-10 hours of sleep at night.
 Encourage exercise as tolerated.
 Assess patient’s prescription and non-prescription drug regimen and dosages.
 Assess the patient’s usual daily dietary intake by asking her or him to keep a food diary.
 Develop a dietary plan with the patient that encourages healthful eating. If the patient has nutrition-
related lupus complications, refer her or him to a registered dietitian for specialized counseling.
 Encourage exercise as tolerated.
 Record patient’s weight at each visit.
 Instruct patient to weigh herself or himself at home once a week and record it.
 Monitor patient’s WBC count.
 Teach patient to monitor temperature during a lupus flare.
 Teach patient to look for signs and symptoms of infection, particularly urinary and respiratory
infections. (Note: The cardinal signs of infection may be masked because of corticosteroids and
antipyretic medications.)
 Instruct patient to call physician if signs and symptoms of an infection appear or if a fever is elevated
above normal baseline.
 Explore possible ways of concealing skin lesions and hair loss.
 Allow patient to express feelings and needs.
 Assess patient’s usual coping mechanisms.
 Acknowledge that feelings of denial and anger are normal.

Reference: Hinkle, Cheever (2014) Medical Surgial Nursing (13th edition)

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ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE Acute Pain related to Short term: Independent: Independent: After 8 hours of nursing
inflammation intervention thee
Patient may complaints of secondary to tissue At the end of 1  Carry out a number of  To provide comfort and patient was able to
stiffness and pain early in actions that divert report pain is controlled
injury from lesions hour nursing
morning provide comfort (heat / attention from painbeing
intervention tha experienced.
cold; massage, position
patient will be able changes, break; foam  Expressinx`g feelings
to report decrease mattresses, pillows sometimes reduces
OBJECTIVE: d pain intensity buffer, splints; anxiety.
from 6/10 to 4/10 relaxation techniques,  Review patient's understa
 Joint pain and activity that distracts) nding of disease process.
Long Term;  Encouraged the patient  Providing health teachings
stiffness early in
to express his feelings to the patient and family
morning about the nature of aids in coping with
At the end of 8 hrs
chronic pain and illness. disease condition and
 Myositis nursing
 Educate patient the could help prevent further
 Polyarthralgia intervention patient pathophysiology of pain complication.
will be able to and helping patients to  Provides baseline informa
 Synovitis
report pain is realize that pain is often tion for formulating
 Boutonnier controlled or brought him to the appropriate treatment.
deformity decreased method of unproven
therapies.
 Ulnar deviation  Assisted in identifying a Collaborative:
 Swan neck person's life 1. Anti-
deformity that brings pain to the inflammatory medicati
patient cases using ons help to relieve
unproven therapies. many of the symptoms
 Perform of lupus by
an assessment of the reducing inflammation
subjective changes in and pain.
pain.

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 2. Analgesics: site and
Collaborative: mechanism of action
 Administered anti- unclear.
inflammatory
ASSESSMENT NURSING PLANNING NURSING INTERVENTION
preparations, analgesics a RATIONALE EVALUATION
DIAGNOSIS s prescribed by the
physician.
SUBJECTIVE: Fatigue related to Short Term:  Azathioprine
Independent: Independent: Short Term:
immune suppression tablets- 25, 50, 100 mg
PQRST After 8 hours of nursing  Assist patient with 1. To protect the After 8 hours of nursing
intervention the patient will be  activities.
Mycophenolic patient from intervention the patient will be
able to:  Promote comfort
agents Tablets- injury. able to:
measures
500mg such as deep 2. To enhance the
a. Report measurable  breathing and safe
Paracetamol patient’s ability a. Report measurable
increase activity environment.
Tablets- 80m to participate in increase activity
OBJECTIVE:  Provide positive activities.
tolerance as evidenced tolerance as evidenced
by ability to ambulate atmosphere while 3. Helps minimize by ability to ambulate
 Irritability
to comfort room as acknowledging frustrations and to comfort room as
 Thrombocytope difficulty of the rechannels
tolerated. tolerated.
nia situation for patient. energy.
 Leukopenia  Increase 4. To assess level
 Anemia Long Term: exercise/activity levels of activity Long Term:
gradually. tolerance.
After 2 days of nursing  Involve significant 5. To encourage After 2 days of nursing
intervention the patient others in planning and on-going intervention the patient will
will be able to: doing activities. support for the be able to:
Collaborative patient.
a. Perform activities of  Nutrition diet ( high b. Perform activities of
daily living with in protein, low in daily living with
minimal limitations fat) minimal limitations due
due to pain.  Calcium lactate to pain
 Multivitamins

23
24
ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

SUBJECTIVE: Impaired tissue After 3 days of nursing Independent: Independent: After 3 days of nursing intervention, the
integrity related intervention, the patient patient was able :
PQRST to will be able  Inspected skin on daily  Promotes timely
basis, describing wound intervention and a. Verbalized understanding of
inflammation,alte revision of plan of
a. Verbalize lesions and rashes and condition and causative factors.
red circulation as characteristics observed. care. b. Demonstrated progressive
understanding of
evidence by condition and  Encouraged adequate  To limit metabolic improvement in wound or lesion
malar rash on causative factors. periods of sleep and rest demands, maximize healing through behavior and
OBJECTIVE:
face,discoid skin b. Demonstrate  Assisted client in energy available for lifestyle changes and prevent
understanding and healing and meet complications occur
 Malar or butterfly rashes,oral progressive
improvement in following medical comfort need c. Maintained optimal and nutrition
rash on face mucous
wound or lesion regimen and developing  Help in coping and physical well-being.
 Discoid skin rash on membrane ulcers
healing through program of preventive stress d. Identified measures and
hands, thighs and and presence of
behaviour and care.  Inhibits cell wall preventing treatment regimens
scalp alopecia lifestyle changes and  Use of wig, sunblocks, synthesis , to enhance healing.
 Photosensitivity
prevent moisturizer, long promoting cell wall
 Oral mucous instability
complications occur sleeves, hat and
membrane ulcers ,bactericidal
c. Maintain optimal umbrella
and nutrition and Collaborative:  Inhibits DNA
physical well-being. synthesis of
 Presence of alopecia
d. Identify measures  Cefuroxime sodium specific unaerobes
and preventing 750 mg, IVTT Q8h causing cell death :
treatment regimens mechanism of
to enhance healing. action as
antiprotozoal and
 Metronidazole amebical are not
500 mg, IVTT, Q9h known

25
26
SUBJECTIVE: Disturbed body image After 3 days of nursing Independent: Independent: After 3 days of nursing
related to disease intervention, the patient rash intervention, the patient rash
PQRST process will be able  Assessed for an  The classic “butterfly” rash was able to:
erythematous rash, may appear across the bridge
a. Minimized and which may be present of the nose and on the a. Minimized and
prevented by: on the face, neck, or cheeks and is prevented
 Wearing extremities. characteristically displayed  Wearing protective
protective  Advised to wear in the configuration of a eyewear.
OBJECTIVE: butterfly. This is evident in
eyewear. protective eyewear,  Wearing a wide-
wide-brimmed hat and about 50% of clients.
 Butterfly rash  Wearing a brimmed hat and carry
wide-brimmed carry an umbrella. A  The sun can exacerbate a an umbrella.
on face
maximum protection skin rash or precipitate a
 Alopecia hat and carry an  Wearing maximum
umbrella. sunscreen (SPF 15 or disease flare. Special lotions,
protection sunscreen
above) in the sun. glasses, and other items may
 Wearing (SPF 15 or above) in the
Sunbathing is be required to protect the
maximum sun. Sunbathing is
contraindicated, and skin from sunlight exposure.
protection contraindicated.
Avoid ultraviolet ray.  This antimalarial drug is a
sunscreen (SPF  Avoided ultraviolet ray.
15 or above) in  Introduced or reinforce slow-acting medicine used to
information about the relieve or reduce
the sun.
use of inflammation and rash. It
Sunbathing is
hydroxychloroquine. may take 8 to 12 weeks for
contraindicated.
 Avoid  Instructed the client that effect. A potential side effect
scalp hair loss may be is retinal toxicity. The client
ultraviolet ray.
caused by high-dose must follow up with an
corticosteroids ophthalmologist every 6
(prednisone) and months. Topical cortisone
immunosuppressant medication may likewise be
drugs. used. To reduce the chance
 Encouraged good of exacerbations.
nutrition, sleep habits,  Hair will regrow as the dose
decreases.

27
 exercise, rest and  To improve general health
relaxation technique. and help prevent infection.

Collaborative:

1. To enhance pain relief

Collaborative:

1. Administered
analgesics as
prescribed.

28
 Assessment Nursing diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient knowledge Short term: Independent: The client was able to
related to self care understand the disease
At the end of 30  Encourage good oral  To enhance appetite
hygiene and oral intake process and identify how to
minutes of nursing
Objective: manage the condition
intervention, the
 To provide conducive
- patient will be able
environment for eating
to identify ways on  Ensure a pleasant
environment for eating by
how to improve
covering the wound with
nutritional status dressing an closing the
and how to manage door for comfort
the condition
 Suggest food sources that  To provide information
are rich in protein, iron, on nutritious and
and potassium such as affordable foods
Long term:
fish, beans, and banana
that are within financial
At the end of 8
benefits
hours nursing
intervention, the
 Instruct to adhere low fat,
patient will be  To ensure intake of
high protein, high
needed nutrients and
motivate in potassium diet as tolerated
prevent complications

29
modifying her  Provide health teaching on
lifestyle importance of well
balanced and nutritious
intake.
Collaborative:
 Prepare tolerable diet
specific to the needs of
the patient (DAT)
 Calcium lactate Tablets-
250 mg
 To provide knowledge
on what foods to take
 To provide for lacking
nutrients and ensure
adequate intake of such
 Essential element of
the body; helps
maintain the functional
integrity of the nervous
and muscular systems;
helps maintain cardiac
function, blood
coagulations; is an
enzyme cofactor and
affects the secretory
activity of endocrine
and exocrine glands;
neutralize or reduces
gastric acidity (oral
use).
30
 HEALTH EDUCATION PLAN
Objectives:
1.Summarizes a simple and productive health education plan;
2.Verbalizes the alternative methods to be provided ;
3.Gains knowledge in managing the progression of condition;
4. Enumerate at least 5 general and specific health teachings

MATERIALS NEEDED:
1. Time and effort

GENERAL HEALTH TEACHING SPECIFIC HEALTH TEACHING

1.Nutrition  Instruct the patient to eat foods that

contains with low fat and low
cholesterol diet because it may
produced significant reduction in
LDL cholesterol in patients with

 Recommend a high fiber diet

 Encourage the patient to have a diet

with moderate protein, rich in
vitamins and minerals
(antioxidants)

 Instruct patient to limit their dietary

intake of sodium

 Recommend a high fiber diet

2.Medication  Take your medicine as directed per

physician's order.

 Advice the patient not to stop taking

medication without the physician's
consent.

 Avoid medication that can increase

your uric acid level

 Keep or carry the list of your

medicines in case of emergency

3.lifestyle  Smoking cessation

31
  Regular physical activity are
important measures.

 Avoid alcoholic beverages

4.Applying sunblock  Avoidance of sun exposure must be

done or the patient can use sun
block that contains with high SPF.

 The patient must be taught that the

sun exposure may cause flare-ups in
organ system,not only in the skin.

5.Exercise  Instruct the patient to plan his/her exercises

appropriately or try and perform exercise
on a day/time when they can get an
adequate rest afterwards.

 When doing exercises outside instruct the

patient to cover up by wearing a hat, long-
sleeved shirts, and long pants, and use
sunscreens with a sun protection.

 The patient can do aerobic exercises or

simple stretching at home, it is effective
and suitable for reducing fatigue.

 Advice the patient not to overly or do some

hard exercises, simple exercises is fine.

Rest  8-10 hours a night for restful rest , naps and

time outs.

 Encourage patient to plan for additional

rest periods throughout the day , as
needed. Emphasize the need for avoidance
or exhaustion.

 Discuss to family members on the issue of

avoding stressful situation by providing
them with information regarding patient’s
condition .

Spirituality  Encourage patient to hear masses

regularly to strengthen her spiritual life

 Encourage patient to pray constantly

and surrender all her worries to God
especially her present condition to
lesson anxiety and promote presence of
mind

32
Social  Encourage patient to verbalize feelings
(e.g husband) and to participate in
other support groups which can provide
disease information, daily management
tips and social support

33
DISCHARGE PLAN

Name of Client: Patient X Age: 45 Gender: F

Religion: Roman Catholic Diagnosis: Systemic Lupus Erythematosus

Hospital: Adventist Medical Center Iligan Room/Ward Bed No.

Attending Physician/s:

A. OBJECTIVES
1. Describe the normal anatomy of the Systemic Lupus Erythematosus;
2. Recognize the normal physiologic functions of the SLE;
3. Discuss the pathophysiology, and diagnosis of specific pathologic conditions that affect the SLE; and
4. Recognize the importance of the prescribe medications for SLE religiously.

A. METHODS
1. Medication

2. Exercise/Activity and Home Environment

Type of Activity Allowed/To be continued:

a. Exercise at least 30 minutes daily

b. Should be promoted in away by stretching all body parts every morning. Patients should be encouraged to keep active through light exercises.

34
 c. Maintain rest periods in between activities

Restrictions: Strenuous activities

Home Environmental Hazards:

a) Exposure to smoke

2. Treatments/Therapies
a. Steroid creams for rashes.
b. anti-inflammatory medications for joint pain and stiffnes

4.Health Teaching/Education

Health Prevention/Promotion

 Rest: Rest when you feel it is needed. Slowly start to do more each day. Return to your daily activities as directed.
 Protect your skin from UV light: Sunlight can make your lupus symptoms worse. Avoid the sun between 10 am and 4 pm, when the rays are strongest. Apply sunscreen
with a SPF of 30 or more every 2 hours when you are outside. Do this even on cloudy days. Wear pants and long sleeves to cover your body. A hat with a wide brim can
protect your face, head, and neck.
 Heat: Heat helps decrease joint pain or swelling. Apply heat on the painful joint for 20 to 30 minutes every 2 hours for as many days as directed.
 Ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a towel and place it on
the painful area for 15 to 20 minutes every hour as directed.
 Avoid others who are sick: You are at increased risk of a severe infection.
 Treat flares quickly: This will help prevent serious illness.Manage your stress. Stress may slow healing and lead to illness. Learn ways to control stress, such as relaxation,
deep breathing, and music. Talk to someone about things that upset you.

5.OPD Visit

35
 Clinic Appointment Schedule:

a. Diet
a. Prescribed Diet: DAT

3-Day Sample Menu

Day 1 Day 2 Day 3

Breakfast Breakfast • Peas
• 1 Whole grain breads • Warm milk • Rice
• 1 pieces of banana • Raisins • Warm milk
• 1 glass of milk • fish

Lunch Lunch Lunch

• 1 lean meat • Rice • Friend vegetarian tocino
• Rice • Whole grains • Soyamilk
• black-eyed beans • 1 slice of apple • Rice
• 1 bottle of yogurt • 1 served of salmon

Dinner Dinner Dinner

• Ginataang vegemeat  Sauteed monggo beans • Bland beans
• Avocado  Yogurt • Rice
• Rice  Rice • Orange
• 1 glass lactose-free milk • almond milk

b. Diet Restrictions:

36
  Root crops
 Low in protein

b. Spiritual Care and Psychological or Sexual Needs (Give special consideration to religious and cultural practices)
Spiritual and Psychological Needs
( ) Spiritual Counseling
( ) Grief Work
( ) Anger Management
(-) Confession
(-) Family Therapy
( ) Reconciliation of Conflicted Relationships
(-) Supportive Counseling
( ) Join Church Organizations/Activities
( -) Prayer
( ) Meditation, Reflection, and Spiritual Devotion
( ) Religious Rituals
( ) Religious/Spiritual Materials

Sexual Needs
( ) Marriage Counseling
( ) Sex Therapy
( ) Sexual Violence
( ) Referral to Appropriate Agencies

37
 Medical Management

 Periodic monitoring and recognition of meaningful clinical changes requiring adjustments in therapy
 The goals of treatment include preventing progressive loss of organ function, reducing the likelihood of
acute disease, minimizing disease-related disabilities, and preventing complications from therapy.
 Regular monitoring to assess disease activity and therapeutic effectiveness
 Corticosteroids are used topically for cutaneous manifestations, in low oral doses for minor disease
activity
 Antimalarial medications are effective for managing cutaneous, musculoskeletal, and mild systemic
features of SLE
 NSAIDs used for minor clinical manifestations are often used to minimize corticosteroid requirements
 Immunosuppressive agents are reserved for patients with serious forms of SLE and does not respond to
conservative therapy
 Anti-TNF therapy has been considered in refractory SLE but still controversial

38
 PROGNOSIS

Systemic lupus erythematosus (SLE) is still a disease with significant mortality. Although 5 yr
after diagnosis 92% of patients are alive, the prognosis falls to 82% survival at 10 yr, 76% at
15 yr and only 68% at 20 yr in Toronto .There has been improvement in survival, with the
standardized mortality ratio in patients recruited to the Toronto cohort in 1970–1977 being 10.1
(95% CI 6.5–15.0), compared with 3.3 (95% CI 1.8–5.7) for those recruited between 1986 and
1994 .Data from other centres in the USA and Europe has been similar. Studies published around
1980 found that about 80% of patients survived 5 yr and about 60% of patients survived 10 yr.
More recent studies have shown that 5‐yr survival is now nearer 90–95% and that 70–85% of
patients survive 10 yr.In most studies, patients with renal involvement have had a poorer
prognosis than those without renal disease. Nevertheless, survival has shown improvement in
those with renal disease presenting to a UK centre between 1976 and 1986 (81% 10‐yr survival),
compared with those presenting between 1963 and 1975 (56% 10‐yr survival) .

The commonest cause of death has been infection, both in early and late deaths. Active SLE
contributes to about a third of early deaths but less commonly to late deaths. However, deaths
related to acute and chronic vascular disease including sudden death are more common in those
dying more than 5 yr after diagnosis. However, there is more to prognosis than just death. There
is considerable morbidity associated with more prolonged survival after the diagnosis of SLE.
Most physicians caring for lupus patients will be familiar with patients in whom active disease
has resolved but the patients have suffered from symptoms related to the accumulation of chronic
damage .Both active disease and damage can be associated with impaired quality of life and
reduced functional ability, although other factors such as the psycho‐social background of the
patient will affect a patient's perception of their disease as well .Having improved therapy for
active lupus disease, the challenge is now to understand and prevent the long‐term complications
of this disease, whether they are due to effects of the disease itself, the therapies used, or co‐
morbid disease (perhaps with associated underlying disease mechanisms or linked genetic
predisposition).

https://academic.oup.com/rheumatology/article/41/10/1095/1784099

39
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