24

XIII. NURSING CARE PLAN

Assessment
Abnormal cues:
>Malar or "butterfly"
rash on the face
>Discoid skin rash
on hands, thighs and
scalp
>Photosensitivity
>oral mucous
membrane ulcers
>joint pain
>Patient is not
oriented to time and
place, forgetful
-sunken eyes
-Fatigue and
weakness
-poor appetite
-dependent in her
ADL
-presence of alopecia
Vital signs:
RR=24 cpm
Temp= 36.5C
Laboratory results:
-Antinuclear Anti
Body result is 7.
-HGB, HCT, RBC,
platelet are decreased
-WBC is increased
-serum sodium

Nursing diagnosis

Rationale
Predisposing
Nursing diagnosis:
Gender: Female
Race: Asian
Impaired tissue
Precipitating
integrity related to
Infection: UTI ,
inflammation, altered
Pneumonia
circulation as
evidence by malar
rash on the face,
Unknown etiology
discoid skin rashes
on hands, scalp and
defective immune
thighs, oral mucous
regulatory
membrane ulcers and
mechanism
presence of alopecia.
Nanda definition:
Damage to mucous
membranes, corneal,
integumentary or
subcutaneous tissues

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

Desire outcome

Nursing intervention

After 32 hours of
nurse-client
interaction the client
will be able to:

excess T cell,
defective B cell
suppression and
shifting of T helper 1
to Th2 immune
responses
b cell hyperactivity
production of
pathogenic

Evaluation
After 32 hours of
nurse-client
interaction the client
will be able to:

Independent:
1. Verbalize
understanding of
condition and
causative factors.

1.
a. identify underlying
condition or
pathology involved
in tissue injury

Loss of immune
tolerance
increase antigenic
load

Justification

b. note poor hygiene

and health practices
2. Demonstrate
progressive
improvement in
2.
wound or lesion
a. Assess blood
healing through
supply and sensation
behavior and
on affected area by
lifestyle changes and checking the site for
prevent
redness, discharges,
complications or
temperature and
recurrence
doing sensory tests.
b. Note skin color,
texture, and turgor

-serves as baseline
data and will
suggests treatment
options, as well as
clients desire and
ability to protect self,
and potential for
recurrence of tissue
damage

1. Goal met. The

patient was able to
understand and
identify her present
condition.

- this could have an

impact in tissue
health

-to evaluate actual/or

potential impairment
in circulation

-determines the
extent or

2. Goal met. The

patient takes
medication to
minimize itching.
The patient also
verbalizes gakatol
pa sa dyapon pero
indi na grabe.

25
slightly decreased
>history of
Rheumatoid Arthritis
(2004)
>history of UTI
(March2011)
Weakness:
>Poor immune
system
>gender: female
>poor hygiene
>does not cooperate
in treatment
>does not exercise
Strengths/wellness:
>strong support
system
>strong financial
support

autoantibodies

and assess areas of

pigmentation of
color changes

involvement of
injury

immune complexes
complement
activation

c. inspect skin on
daily basis,
describing wound
lesions and rashes
characteristics
observed

-promotes timely
intervention and
revision of plan of
care

d. encourage
adequate periods of
rest and sleep

-to limit metabolic

demands, maximize
energy available for
healing and meet
comfort needs

tissue injury and

damage
Impaired tissue
integrity related to
inflammation, altered
circulation as
evidence by malar
rash on the face,
discoid skin rashes
on hands, scalp and
thighs, oral mucous
membrane ulcers and
presence of alopecia.
Source:
Smeltzers S.C, et,al.
Brunner &
Suddarths Textbook
of Medical
Surgical Nursing.
Lippincott Williams
and Wilkins. 12th ed.

3. Maintain optimal
nutrition and
physical well-being.

3.
a. maintain
appropriate moisture
environment for
particular wound

-to minimize
condition and
promote healing

b. reposition client,
-to enhance
involving client in
understanding and
reasons for and
cooperation
decisions about times
and positions
c. encourage early
ambulation or
mobilization

-promotes circulation
and reduces risk
associated with
immobility and
prevent excessive
tissue pressure

3. Goal met. The

patient cooperates
measures to improve
nutrition and
physical well-being.
At the first day,
patient was observe
to have poor appetite
but during the fourth
day patient can be
seen eating her meals
gradually with the
help of her folks.

26
4. identify measure
in preventing and
treatment regimens
to enhance healing

d. provide optimum
nutrition and
increased protein
intake

4.
a. emphasize
importance of
adequate nutritional
and adequate fluid
intake

-to provide a positive

nitrogen balance to
aid in skin and tissue
healing and to
maintain a general
good health.
-to maintain general
good health and skin
turgor

b. assist client in
understanding and
following medical
regimen and
developing program
of preventive care.

-enhances
cooperation and
optimizing outcomes

c. discuss importance
of health as well as
measures to maintain
proper skin
functioning

- for changes
indicative of healing
or presence of
infection,
complications.

5. Review laboratory
results pertinent to
causative factors
Collaborative:

-to determine and

assess the
contributing factors

1. Monitor and
administer
medications as

-to be aware of all

the medication client
is taking, noting
possible interaction

4. Goal met. The

patient was able to
know the appropriate
regimen and
prevention with
regards to her disease
condition. Through
incidental health
teaching she was able
to understand more
about the treatment
given to her
especially the
medications and
procedures.

27
Ordered such as,
Lasix, Predisone,
Cozar, Norvasc,
Merrem, Calvit and
KCl.

or cumulative effects

3. Assist with
diagnostic
procedures

-May be necessary to
determine extent of
impairment.

4. Assist in
identifying ongoing
treatment needs and
rehabilitation for the
individual like
physical and
occupational therapy.

-to maintain gains

and continue of
progress

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

28
ASSESSMENT

NURSING
DIAGNOSIS

Actual Abnormal Cues:

Appears very tired and
weak
Lethargic
Compromised
concentration and
mentation changes like
disorientation to place,
incoherent responses,
and focusing on the
feelings of weakness
of her whole body
Inability to perform
activites of daily living
independently
Poor muscle stregth
Hgb result of 115 g/L
and 104 g/L (normal:
120-160 g/L) last
November 15 and
November 17 lab
results
Hct result of 0.32 L/L
and 0.30 L/L(normal:
0.40-0.54 L/L) on
November 15 and 17
lab results repectively
Serum sodium results
of 130 (normal: 137143 mEq/dL) and
serum potassium result

Fatigue related to
immune system
pathology as
evidenced by
patients appearance
of weakness and
tiredness, lethargy,
inability to perform
activities
independently, poor
muscle strength, Hgb
result of 115 g/L and
104 g/L (normal:
120-160 g/L) last
November 15 and
November 17 lab
result, Serum sodium
results of 130
(normal: 137-143
mEq/dL) and serum
potassium result of
2.60 (normal: 3.6-5.1
mg/dL) on November
15 lab result

Definition: An
overwhelming
sustained sense of
exhaustion and
decreased capacity
for physical and

RATIONALE

Predisposing
Gender: Female
Race: Asian
Precipitating
Infection: UTI ,
Pneumonia
Unknown etiology
Female estrogen
hormones
Manifestations of
heightened levels of
estrogen during
puberty and
pregnancy
Unknown cause of
estrogen influencing
the immune
response of the HLA
system in
chromosome 6
Human Leukocyte

DESIRED
OUTCOME/
NURSING GOALS
After 32 hours of
nursing interventions,
the client will be able
to:

NURSING
INTERVENTIONS

JUSTIFICATION

Independent Nursing
Interventions:

EVALUATION
After 32 hours of nursing
interventions, the client was
able to:

1. Report improved
sense of energy
a. Note patients
belief of what is
causing the fatigue
and what relieves it

-to assess
contributing factors

b. Evaluate aspect of
learned
helplessness that
may be manifested
by giving up

-can perpetuate a
cycle of fatigue,
impaired functioning,
and increased anxiety
and fatigue

c. Accept reality of
patients report of
fatigue and do not
underestimate effect
on the quality of life
the client
experiences

-to assist patient in

coping with fatigue

d. Instruct methods
to conserve energy
(e.g. plan steps of
activity before
beginning so that all

-to reduce energy

expenditure

1. Goal met. When asked if

patient still feels extremely
tired, she was able to claim,
kapoy e, pero lain gid ya
sang sadto nga week,
comparing the fatigue she
has felt last week, which was
more severe. Practices to
conserve energy were done
through the help of her
significant others by assisting
her to do activities of daily
living. She also sleeps most
of the time on our duty hours
to conserve energy. Then at
the last day of duty, she was
already able to stand and able
to hold conversations longer
than the conversations she
had upon first admission.

29
of 2.60 (normal: 3.6mental work at usual
5.1 mg/dL) on
work level
November 15 lab
result
Vebal reports of Indi
ko pagsamuka anay,
nakapoy ko.
With health history of
easy fatigability and
body weakness 7
months prior
admission and with
decreased Hgb, Hct,
potassium and sodium
results of lab tests after
consultation to
physician.
Source: Doenges, et
al. Nurses Pocket
th
Risk Factors/Weaknesses: Guide (9 ed.). F.A.
Davis
Poor appetite
Episodes of joint pain Company.2004. p
232.
Noncompliance to
some medical
interventions and
laboratory tests
Hospital environment
(too warm and noisy)
Sleep deprivation
Poor financial support
Knowledge deficit of
disease process and
treatment

Antigen Class 1 and

2 in chromosome 6
possess multiple
genes influenced in
acquiring SLE

Fewer or defective
macrophages in the
body

needed materials are

at hand)

2. Perform activities
of daily living and
desired activities at
level of ability

Defective clearance
of early apoptotic
cells
Secondary necrosis
of the cells
Release of nuclear
fragments as
potential
autoantigens
Impaired membrane
integrity of dendritic
cell
Induced maturation
of dendritic cells

3. Participate in
recommended
treatment program

e. Provide
environment
conducive to relief
of fatigue
( e.g.provide electric
fan, etc.)

-temperature and
level of humidity are
known to affect
exhaustion

f. Provide means to
decrease
environmental noise
(e.g. earplugs, etc.)
g. Provide
diversional
activities. Avoid
overstimulation/und
erstimulation
(cognitive and
sensory)

-when sleep
deprivation is
present, it adds to
fatigue
-impaired
concentration can
limit ability to block
competing
stimuli/distractions

h. Discuss routines
to promote restful
sleep (e.g.
uninterrupted
periods of rest,
longer sleep periods
at night, etc.)

-to assist patient to

establish a sleep
pattern

a. Determine ability
to participate in
activities/ level of
mobility

-to provide baseline

data for the nurses
plan of activities

b. Note daily energy

-helpful in

2. Goal partially met. Patient

was able to perform her
activities of daily living
through the help of her
significant others. The
greatest feat that the patient
made during our duty week
was that she was able to
stand on the last day,
although her basic daily
activities were still done with
assistance.

3. Goal met. Patient was able

to show participation through

30
Wellness/strengths:
Good emotional
support for the family
Willingness to
follow nursing
interventions
Have strong faith
in God

Various
autoantibody
productions

patterns

determining
pattern/timing of
activity

c. Interview
significant others
regarding specific
changes observed on
patient

-to assess
contributing factors

d. Establish realistic
activity goals with
the patient

-enhances
commitment to
promoting optimal
outcomes

e. Plan care to allow

adequate rest
periods. Schedule
activities for periods
when patient has the
most energy

-to maximize
participation

f. Involve patient
and significant
others in schedule
planning

-to increase
awareness of the
treatment and
rehabilitation to
patient and
significant others
-to manage patient
within their limits of
ability

Fatigue

g. Encourage to do
whatever is possible
(e.g.self-care, sit up,
etc.)

Appearance of
tiredness and

h. Assist with selfcare needs; keep bed

in low position and

-to assist patient with

limited mobility

Production of
antinuclear antibody,
anti-phospholipid
and other specific
autoantibodies
Anti-erythrocyte
antibody activation
Formation of
defective immune
complex
Hemolysis
Reduced RBC count
Decrease in oxygen
available for cellular
uptake

listening while the student

nurse gives accidental and
prepared health teachings
about the disease and its
treatment. Although they had
troubles with their finances,
most of the highly needed
medical interventions were
followed. Significant others
also assisted with the patient
as evidenced by their
willingness to accept
information given by the
student nurse. They also able
to give simple examples of
how to conserve the patients
energy like not disturbing her
in her sleep and keeping their
voices down to make her
rest. They also did their part
in assisting her with her
activities of daily living.

31
inability to perform
activities of daily
living independently
Source:
Smeltzers S.C, et,al.
Brunner &
Suddarths Textbook
of Medical
Surgical Nursing.
Lippincott Williams
and Wilkins. 12th ed.

assist in ambulation
as indicated
a. Discuss the
disease process
relevant to patient

-understanding the
disease can help the
client understand the
treatment regimen

b. Discuss therapy
regimen relating to
individual causative
factors

-to help patient and

significant others
understand the
relationship of
disease and treatment
and to elicit their
cooperation on the
treatment regimen

c. Assist patient and

significant others to
develop a plan of
activity and exercise
within the
individuals
capability

-to encourage
participation of
patient and
significant others in
health management
of patient

d. Instruct patient in
ways to monitor
responses to activity
and significant signs
and symptoms

-indicates the need to

alter the activity level

e. Promote overall
health measures (e.g.
nutrition(High CHO,
Normal CHOn, low
Fat), adequate fluid

-presence of
anemia/hypoxemia
reduces oxygen for
available cellular
uptake and

32
intake of 1.5-2L/day, contributes to fatigue
appropriate intake of
vitamins and
minerals as
prescribed especially
iron, etc.)

Collaborative
interventions:
a. Administer
-to promote wellness
medications related
of patient
to patients condition
(e.g. pain relievers,
antimalarials, etc.)
b. Assist with
medical procedures
as indicated
c. Administer blood
transfusions properly
as indicated. Report
any allergic
reactions.
Source: Doenges, et
al. Nurses Pocket
Guide(9th ed.). F.A.
Davis
Company.2004. pp
232-234.
RISK NCP

-to assist in measures

to relieve patients
condition
-to supplement blood
components and
increase oxygen for
cellular uptake

33
Assessment
Abnormal cues:
>easy fatigability and
weakness
>Patient is not oriented to
time and place, forgetful
>Photosensitivity
>presence of alopecia
>Malar or "butterfly" rash
on the face
>Discoid skin rash on
hands, thighs and scalp
>oral mucous membrane
ulcers
>joint pain
>sunken eyes
>poor appetite
>dependent in her ADL
>poor muscle tone
Vital signs:
RR=24 cpm
Temp= 36.5C

Nursing diagnosis
Nursing diagnosis:

Predisposing
Gender: Female
Risk for injury
Race: Asian
related to tissue
Precipitating
damage, autoimmune Infection: UTI ,
dysfunction,
Pneumonia
abnormal blood
profile ,
disorientation and
Unknown etiology
altered mobility as
evidence by malar
immune system
rash on the face,
activation
discoid skin rashes
on hands, scalp and
thighs, oral mucous
altered immune
membrane ulcers and
response
presence of alopecia,
weakness,
disoriented to time
soluble mediators
and place,
(cytokines)
photosensitivity.
Nanda definition:

Laboratory results:
-Antinuclear Anti Body
result is 7.
-HGB, HCT, RBC, platelet
are decreased
-WBC is increased
-serum sodium slightly
decreased

Rationale

At risk of injury as a
result of
environmental
conditions
interacting with the
individuals adaptive
and defensive
resources.

Desire outcome

Justification

After 32 hours of
nurse-client
interaction the client
will be able to:

Evaluation
After 32 hours of
nurse-client
interaction the client
will be able to:

Independent:
1. Verbalize
understanding of
individual factors
that contribute to
possibility of injury

Endothelial / cellular
response
Autoimmunity
Tiisue or organ
involvement

Nursing intervention

2. Modify
environment as
indicated to enhance

1.
a. Perform thorough
assessment regarding
safety issues when
planning for client
care and/or preparing
for discharge from
care.

-failure to accurately
assess and intervene
or refer these issues
can place the client
at needles risk and
creates negligence
issues for the
healthcare
practitioner.

b. note clients age,

gender,
developmental stage,
decision making
ability and level of
cognition

-affects clients
ability to protect self
and/or others, and
influences choice of
interventions and
teaching

c. assess clients
muscle strength,
gross and fine motor
coordination

-to identify risk for

falls

2.
a. provide healthcare
within culture of
safety

-to prevent errors

resulting in client
injury, promote client
safety and model

1. Goal met. The

patient was able to
gain information
about factor that may
contribute to place
patient at risk for
injury.

2. Goal met.
The patient was able
to encourage how to
protect herself and
enhance her

34
>history of Rheumatoid
Arthritis (2004)
>history of UTI
(March2011)
Weakness:
>Poor immune system
>gender: female
>lack of patients
cooperation
>poor hygiene
>does not cooperate in
treatment
>does not exercise
.poor environmental
sanitation

Strengths/wellness:
>strong support system
>strong financial support
>strong religious belief

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

Risk for injury

safety.
related to tissue
damage, autoimmune
dysfunction,
abnormal blood
profile ,
disorientation and
altered mobility as
evidence by malar
rash on the face,
discoid skin rashes
on hands, scalp and
thighs, oral mucous
membrane ulcers and
presence of alopecia,
weakness,
disoriented to time
and place,
photosensitivity.
Source:
Smeltzers S.C, et,al.
Brunner &
Suddarths Textbook
of Medical
Surgical Nursing.
Lippincott Williams
and Wilkins. 12th ed.

3. Display behaviors,
lifestyle changes to
reduce risk factors
and protect self from
injury.

safety behaviors for

patient.
b. monitor
environment for
potentially unsafe
conditions and
modify as needed. ty

-to assist patient to

reduce or correct
individual risk
factors.

c. inform client
regarding all
treatment and
medication

-in order for the

patient to be aware
of all the treatment
that the patient is
receiving and to gain
patients cooperation

d. encourage use of
techniques to reduce
or manage stress and
vent emotions

-to alleviate stress

and anxiety in order
to prevent further
harm to patient.

3.
a. encourage and
assist in frequent
range-of-motion
exercises

b. check vital sign

every 4 hours
c. position patient to
a comfortable
position and side
rails up

-exercises promote
good circulation to
the body. Thus,
improving the body
to be more health
and prevent from
further injury
-to monitor patients
condition.
-to prevent patient
from at risk for falls.

awareness and
knowledge about
safety things and
necessary precaution
to be done to prevent
her to be at risk for
injury.

3. Goal met. The

patient demonstrate
lifestyle changes
such as having
exercises even while
in bed with
assistance. Patient
was able to be aware
of safety precautions
in order to protect
herself.

35
d. stress importance
of monitoring
conditions and risk
that may contribute
to occurrence of
injury

-in order that patient

may be aware in that
she may also be able
to protect herself.

Collaborative:
1. Assist in
treatments and
provide information
regarding clients
disease/condition.

-to provide proper

information about
the disease and
treatments that
would help the client
achieve
independence as well
being.

2. Administer
medications such as;
Lasix, Predisone,
Cozar, Norvasc,
Merrem, Calvit and
KCl as ordered using
the 10 rights to
medication

-to alleviate
itchiness, and to
correct fluid and
electrolyte balance
and also to regulate
blood pressure.

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

Source:
Doenges, et al.
Nurses Pocket
Guide (12 Ed.). F.A.
Davis company.
2010

36

Generic Name: Amlodipine

besylate
Brand Name: Norvasc
Classification: Cardiovascular
agent; calcium channel blocker;
antihypertensive agent
Inhibits calcium ion influx
across cardiac and smooth
muscle cells, thus decreasing
myocardial contractility and
oxygen demand; also dilates

Treat hypertension

Not affected by meals. It is

given once a day.

Tell patient to report

significant swelling of face or
extremities.

Monitor for signs and

symptoms of dose-related
peripheral or facial edema that
may not be accompanied by
Report shortness of breath,
weight gain; rarely, severe
palpitations, irregular heartbeat, edema may cause
discontinuation of drug.
nausea, or constipation to
physician
Monitor BP with postural
changes. Report postural
hypotension.
Monitor heart rate; doserelated palpitations (more

37
coronary arteries and arterioles.
XIV. DRUG STUDY

common in women) may occur.

38

Generic Name: Furosemide

Brand Name: Lasix
Classification: Loop diuretic
Inhibits sodium and chloride
reabsorption at proximal and
distal tubules and ascending
loop of Henle. Promotes water
and sodium excretion.

Treat hypertension

Not affected by meals. It is

given every twelve hours
(q12h) IVTT.

Advise patient to stand

slowly to prevent dizziness, not
to drink alcohol and to
minimize strenuous exercise in
hot weather.

Assess patients underlying

condition before starting
therapy.

Instruct patient to report

ringing in ears, severe
abdominal pain or sore throat
and fever because they may
indicate toxicity.

Monitor weight, peripheral

edema, breath sounds, blood
pressure, fluid intake and
output, and electrolyte, glucose,
BUN, and carbon dioxide
levels.
Monitor uric acid level,
especially if patient has a
history of gout.
Be alert to adverse reactions
and drug interactions.

39

40

Generic name: Losartan

potassium
Brand name: Cozaar
Classification: Antihypertensive drug
Inhibits vasoconstrictive and
aldosterone-secreting acion of
angiotensin II receptor on the
surface of vascular smooth
muscle and other tiaaue cells.

Lowers high blood pressure

Not affected by meals. It is

given once a day (OD).

Tell patient to avoid salt

substitutes; these products may
contain potassium, which can
cause high potassium level.
Notify healthcare provider if
these serious side effects occur:
swelling of face, eyes, lips or
tongue and difficulty of
breathing.

Monitor patients blood

pressure to evaluate effectives
of drug therapy. When used
alone, drug has less of an effect
on blood pressure.
Assess patients renal
function (BUN and creatinine
levels) regularly.
Monitor for signs of allergic
reaction.
Closely monitor patient
especially during first few
weeks of therapy.

41

Generic name: Prednisone

Brand name: Prelone
Classification: Corticosteroids
Decreases inflammation,
mainly by stabilizing leukocyte
lysosomal membranes; and
influences protein, fat and
carbohydrate metabolism.

Suppresses immune
response; stimulates bone
marrow

Given orally with food if

possible to reduce GI irritation.
It is given once a day every am
and once every pm.

Tell patient to take drug

with food or milk.
Teach patient signs and
symptoms of adrenal
insufficiency: fatigue, muscle
weakness, joint pain, fever,
anorexia, nausea, shortness of
breath, dizziness, fainting.
Instruct patient not to stop
drug abruptly or without
prescribers consent.

Determine whether patient

is sensitive to other
corticosteroids.
Weigh patient daily; report
sudden weight gain to
prescriber.
Monitor for Cushingoid
effects: moon face, buffalo
hump, central obesity, thinning
hair, hypertension and
increased susceptibility to
infection.
Watch for depression or
psychotic episodes.

42
C

Generic name: Meropenem

Brand name: Merrem IV
Classification: Miscellaneous
anti-infectives
Inhibits cell wall synthesis
in bacteria. It readily penetrates
cell wall of most gram positive
and gram negative bacteria to
reach penicillin-binding protein
targets.

Prevent complicated skin

and skin structure infections

Not affected by meals. It is

given every eight hours (Q8h).

Tell patient to report adverse Obtain specimen for culture

effects if drug or signs and
and sensitivity before giving
symptoms of superinfection.
first dose.
Advise patient to report
loose stools to prescriber.

Monitor patient for signs of

superinfection. Drug may cause
overgrowth of non susceptible
bacteria or fungi.
Periodic assessment of organ
system functions including
renal, hepatic and
hematopoietic function is
recommended.

43

Generic name: Tramadol +

Paracetamol
Brand name: Ultram
Classification: Opioid
analgesics; central nervous
system drugs
Centrally acting synthetic
analgesic compound not
chemically related to opioids.
Thought to bind to opiate
receptors and inhibit reuptake
of norepinephrine and serotonin
levels.

Relieve moderate to
moderately severe pain

Not affected by meals. It is

given thrice a day (TID).

Tell patient to avoid driving

or other hazardous activities
that require mental alertness
until drugs CNS effects are
known.
Advise patient to check with
prescriber before taking OTC
drugs because drug interactions
can occur.
Instruct patient not to stop
drug abruptly or without
prescribers consent.

Reassess patients level of

pain at least 30 minutes after
administration.
Monitor patients
cardiovascular and respiratory
status. Withhold dose and
notify prescriber if respiration
is below 12cpm.
Monitor bowel and bladder
function. Anticipate need for
laxative.

44

45

C
Generic name:
levofloxacin
Brand name:
Levaquin
Classification:
Antibiotic, florquinolone
Bactericidal: interferes with
DNA by inhibiting DNA gyrase
replication in susceptible gramnegative and gram-positive
bacteria, preventing cell
reproduction

H
treats bacterial infection

E
Administer without regards to
meals with a glass of water;
given twice a day per Orem

C
Instruct patient to drink plenty
of fluids while taking this drug
Instruct to report rash, visual
changes, severe GI problems,
weakness, tremors

K
Arrange for culture and
sensitivity tests before
beginning therapy
Ensure patient is well hydrated
Administer oral drug without
regard to meals with a glass of
water; separate oral drug from
other cation administration,
including antacids by at least 2
hours
Discontinue at any sign of
hypersensitivity (rash,
photophobia) or at complaint of
tendon pain, inflammation or
rupture

46

47

K
C

Generic name:
Potassium Chloride
Brand name:
Potassium Chloride
Classification:
Electrolyte
Principal intracellular cation of
most body tissues, participates
in a number of physiologic
processesmaintaining
intracellular tonicity,
transmission of nerve impulses,
contraction of cardiac, skeletal
and smooth muscle,
maintenance of normal renal
function; also plays a role in
carbohydrate metabolism and
various enzyme reaction

prevent and correct potassium

deficiency

Not affected by meals

Caution patient not to use salt

substitutes

Agitate prepare IV solution to

prevent of potassium, do not
add potassium to an IV bottle in
Report toughing of the hands or
the hanging position
feet unusual tiredness or
weakness, feeling of heaviness Monitor IV injection sites
in legs, severe nausea,
regularly for necrosis, tissue
vomiting, abdominal pain,black sloughing and phlebitis
or tarry stools, pain at IV
injection site
Monitor cardiac rhythm
carefully during IV
administration

48

49

C
Generic name:
Eperisone
Brand name:
Eperisone
Classification:
Antispasmodic
Eperisone acts by relaxing both
skeletal muscles and vascular
smoothmuscles, and
demonstrates a variety of
effects such as reduction
of myotonia, improvement of
circulation, and suppression of
the pain reflex.The drug
inhibits the vicious cycle of
myotonia by decreasing
pain,ischaemia, and hypertonia
in skeletal muscles, thus
alleviating stiffnessand
spasticity, and facilitating

H
Treats muscle spasm

E
Should be taken with food;
given three times a day per
Orem

C
Report fever, erythema,
blistering, itching, ocular
congestion or stomatitis

In the event of symptoms such

as redness, itching, urticaria, or
edema of the face and other
parts of the body,dyspnoea etc,
treatment should
be discontinued and appropriate
measures taken
Patients should be carefully
observed, treatment
Discontinued and approriate
measures taken, in the event of
symptomssuch as fever,
erythema, blistering, itching,
ocular congestion or stomatitis,
etc

50
muscle movement.

51

C
Generic name:
Multivitamins with Buclizine
Brand name:
Multivitamins with Buclizine
Classification:
Multivitamins supplement
Buclizine is a piperazine
antihistamine with
antimuscarinic and moderate
sedative properties. It is used
mainly for its antiemetic action
and in the treatment of
migraine in combination with
analgesics.

H
Treats nausea, vomiting and
dizziness

E
Should be taken with food.
(Take within hr before
meals.) Given once a day

C
Avoid over the counter drugs;
may contain ingredients that
cause serious reactions with
drug
Avoid alcohol; serious sedation
could occur
Report difficulty breathing;
hallucinations, remors, loss of
coordination; visual
disturbances, irregular heart
beat

K
Assess orientation, reflexes,
affects; visual examinations; P,
BP;RR, adventitious sounds;
bowel sounds, normal GI
output, normal urinary output

52

C
Generic name:
Potassium Chloride
Brand name:
Potassium Chloride
Classification:
Electrolyte
Principal intracellular cation of
most body tissues, participates
in a number of physiologic
processesmaintaining
intracellular tonicity,
transmission of nerve impulses,
contraction of cardiac, skeletal
and smooth muscle,
maintenance of normal renal
function; also plays a role in
carbohydrate metabolism and
various enzyme reaction

H
prevent and correct potassium
deficiency

E
Not affected by meals

C
Caution patient not to use salt
substitutes

Agitate prepare IV solution to

prevent of potassium, do not
add potassium to an IV bottle in
Report toughing of the hands or
the hanging position
feet unusual tiredness or
weakness, feeling of heaviness Monitor IV injection sites
in legs, severe nausea,
regularly for necrosis, tissue
vomiting, abdominal pain,black sloughing and phlebitis
or tarry stools, pain at IV
injection site
Monitor cardiac rhythm
carefully during IV
administration

53

54

X.V HEALTH TEACHING PLAN

Medication
1. Generic name:
Furosemide
Brand name: Lasix

Exercise
Exercise plays its part in
the treatment of lupus. It
is very important to keep
muscles & joints active
C: Loop Diuretic
for a variety of reasons.
Muscles need to be
H: Treat hypertension
toned in order to
function adequately. The
E: Not affected by meals. size of the muscle & its
blood circulation depend
It is given every twelve
on its function (where
hours (q12h) IVTT.
the muscle is & what it
C: Advise patient to stand does). Physical therapy
is very beneficial to the
slowly to prevent
patient who is trying to
dizziness, not to drink
maintain muscle
alcohol and to minimize
integrity & tone. Joints
strenuous exercise in hot
depend on tendons & the
weather
calcification of bones.
These in turn depend on
K: Monitor weight,
continued movement.
peripheral edema, breath
Significant bone loss
sounds, blood pressure,
through osteoporosis
fluid intake and output,
occurs when bones are
and electrolyte, glucose,
not used regularly.
BUN, and carbon dioxide Encourage significant
levels.
other to do passive ROM
(Range of motion)
exercises for the client.
2. Generic name:

Treatment
Hygiene
The goal for the treatment For maintaining skin
of systemic lupus
integrity:
erythematosus
1. Keep skin clean while
relieving itching and
1.Dietary regulationdryness.
alcohol restriction.
2. Treatment of associated
condition.
Monitor intake and
output to identify the
output and fluid
replacement needs.
Vital signs taking every
hour to assess any
changes on health
status
Encourage fluid intake
to replace fluid and
blood loss and to
maintain blood
pressure and renal
function
Administer medications
as ordered to prevent
infections
Encourage and assist
significant other to turn

Sponge bath
Mild soap added to
water to moisturize the
skin.
2. Keep nails short and
trimmed to prevent
excoriation.
3. Keep hair clean and
moisturized.

Outpatient
Adherence to
pharmacological and
non-pharmacological
interventions.
Stress to patient and
family the importance of
follow-up examinations
and treatment because of
changing physical status.
Allowing monitoring of
symptoms, disease
activities, and treatment
of side effects.
Refer patient for
continuous physical
therapy for the
improvement of the
condition..

Diet
Suggested diet is
DASH diet (high in
fruits and
vegetables,
moderate in low-fat
dairy products, and
low in mimimal
protein, has a
substantial amount
of plant protein from
legumes and nuts
Promote intake of
vegetable-value
protein foods: soy
protein, broccoli

The client must have

a high fiber
4. Provide or encourage
vegetable diet, such
oral hygiene to
as a medium-size
minimize dryness of oral
piece of fruit (an
mucous membranes.
Refer patient to a
orange, small
Preventive dental
nutritionist because of the
banana, mediumhygiene care in
dietary changes required.
size apple).
Lupus patients is
very important.
Get enough sleep and Advice client to
Chlorhexidine
mouthwashes could rest.
avoid foods or
help contain
drinks that contain

55
Prednisone
Brand name: Prelone
C: Corticosteroids
H: Suppresses immune
response; stimulates bone
marrow

1. Musculoskeletal
activity (designed to
enhance flexibility &
mobility)
Types of Activities:
Passive ROM Exercises

and move the patient to

prevent bed sores and
immobility
Avoid sun exposure.
Sunscreens and
clothing covering the
extremities can be
helpful to prevent
flares.

Duration:
E: Given orally with food 10-15 minutes
if possible to reduce GI
irritation. It is given once Frequency:
Prescribed medications:
Everyday, 2-4 hours
a day every am and once
NSAIDs: For people
every pm.
with joint or chest pain
2. Stretching Exercises
or fever, drugs that
(to specifically target
C: Teach patient signs and
joint weakness)
decrease inflammation,
symptoms of adrenal
called nonsteroidal
insufficiency: fatigue,
Types of Activities:
anti-inflammatory
muscle weakness, joint
Chin-to-chest. Raise the
pain, fever, anorexia,
drugs (NSAIDs), are
back of the person's head
nausea, shortness of
often used. Although
up from the bed. Gently
breath, dizziness, fainting.
some NSAIDs, such as
tip his chin toward his
ibuprofen and
chest. Try to rest the
K: Monitor for
person's chin on his
naproxen, are available
Cushingoid effects: moon chest if possible.
over the counter, a
face, buffalo hump,
doctors prescription is
Head turns. Put one hand
central obesity, thinning
necessary for others.
on each side of the
hair, hypertension and
NSAIDs may be used
increased susceptibility to person's face. Turn the
alone or in
person's head toward the
infection.
right as if he were
combination with other
looking over his right
types of drugs to
shoulder.
Then
slowly
3. Generic name: losartan
control pain, swelling,
turn the person's head so
Brandname: Cozaar
and fever. Even though
he is looking over his
some NSAIDs may be
left shoulder. Turn the

periodontal disease.
Mucous membrane
ulcers can be treated
with hydrogen
peroxide gargle,
buttermilk gargle, or
steroid impregnated
gel.
5. Proper food
preparation

Avoid too much sun

exposure and wear
protective clothing to
prevent direct sunlight.
Use sunsceen and
suunblocks to protect the
skin.
Use sunglasses for
cases of photosensitivity.

alcohol, alcohol
restriction is a must
because of clients
condition.
The client should
consume amounts of
necessary calories to
maintain moderate
body weight. Fat
intake should be
limited to 30% of
the total calories
Instruct patient to
limit fluid intake to
500-600 ml/day.
Include foods rich in
zinc. These foods
include oysters,
meats, seafood,
poultry and eggs.
Include rich sources
of iron in your diet.
To increase
absorption, consume
with an acidcontaining food or
one with vitamin C.
Sources of iron

56
C: antihypertensives,
angiotensin II receptor
antagonists, Management
of hypertension

head only far enough so

that the person's nose is
lined up above their
shoulder.

Head tilts. Put one of

H: the blood pressure of
your hands on each side
the patient will be
of the person's face. Tilt
lowered.
the head to the side,
bringing the right ear
E: Medication usually
toward the right
given once a day, the
shoulder. Then slowly
same time per day.
tilt the person's head to
bring the left ear toward
C: Tell patient to avoid
the left shoulder.
salt substitutes; these
products may contain
Intensity:
potassium, which can
Start with minimal
cause high potassium
stretching, gradually
level.
increasing
K: Monitor patients
blood pressure to evaluate
Duration:
effectives of drug therapy.
15-20 minutes
When used alone, drug
has less of an effect on
Frequency:
blood pressure.
2-4 times a week

4. Generic name:
Amlodipine besylate
Brandname: Norvasc

3.Ankle & Foot

Exercises
Types of Activities:
How to start: Hold the
right ankle with one
hand. Put your other
hand on the bottom of

purchased without a
prescription, it is
important that they be
taken under a doctors
direction.
Antimalarials:
Antimalarials are
another type of drug
commonly used to treat
lupus. These drugs
were originally used to
treat malaria, but
doctors have found that
they also are useful for
lupus. A common
antimalarial used to
treat lupus is
hydroxychloroquine
(Plaquenil1). It may be
used alone or in
combination with other
drugs and generally is
used to treat fatigue,
joint pain, skin rashes,
and inflammation of
the lungs.
Corticosteroids: The
mainstay of lupus
treatment involves the
use of corticosteroid

include cream of
wheat, liver, beef,
lamb, pork, chicken,
turkey, eggs, fish,
beans baked with
molasses, prunes,
prune juice, apricots,
green peas, enriched
breads, and cereals
Take medications
with food to
decrease the
irritating effect on
the stomach and
small intestine.
Foods and drugs
taken together also
increase the time
available for the
absorption of the
drug.
Include foods rich in
Vitamin D. These
include foods
primarily of animal
origin: eggs, butter,
milk, fish oils,
cereals, margarines
and breads. This

57
C: Cardiovascular agent;
calcium channel blocker;
antihypertensive agent
H: Treat hypertension
E: Not affected by meals.
It is given once a day.
C: Report shortness of
breath, palpitations,
irregular heartbeat,
nausea, or constipation to
physician
K: Special Precautions for
patients w/ impaired
hepatic & renal function,
CHF. Elderly. Pregnancy
& lactation.
5. Generic name:
Meropenem
Brand name: Merrem IV
C: Miscellaneous antiinfectives
H: Prevent complicated
skin and skin structure
infections
E: Not affected by meals.
It is given every eight
hours (Q8h).

the foot.
Ankle bends. Push the
person's foot so his toes
point up toward the
ceiling. Then put your
hand on top of the foot
and push the foot down
again.
Ankle rotation. Hold the
ankle with one hand.
Hold the person's upper
foot with your other
hand. Gently turn the
foot and ankle in circles.
Toe bends. With your
palm on top of the
person's foot, curl the
toes down toward the
sole (bottom) of the foot.
Then straighten and
stretch the toes.
Toe spreads. Use your
fingers to spread the toes
apart one at a time. Then
bring them together
again.
Intensity:
Gradually increasing
from soft to moderate
pressure.
Duration:
2-3 Sessions, 15-20
minutes a day

hormones, such as
prednisone
(Deltasone),
hydrocortisone,
methylprednisolone
(Medrol), and
dexamethasone
(Decadron, Hexadrol).
Corticosteroids are
related to cortisol,
which is a natural antiinflammatory hormone.
They work by rapidly
suppressing
inflammation.
Immunosuppressives:
For some patients
whose kidneys or
central nervous
systems are affected by
lupus, a type of drug
called an
immunosuppressive
may be used.
Immunosuppressives,
such as
cyclophosphamide
(Cytoxan) and
mycophenolate mofetil
(CellCept), restrain the
overactive immune

along with calcium

decreases the risk of
osteoporosis.
Include foods rich in
Vitamin B6
(Pyridoxine). These
foods include whole
grain cereals,
breads, liver,
avocados, spinach,
green beans,
bananas, fish,
poultry, meats, nuts,
potatoes, green leafy
vegetables.
Increase your intake
of foods high in
Vitamin C. These
foods include
broccoli, oranges,
strawberries,
cauliflower,
cantaloupe, cabbage
and green peppers.

58
C: Tell patient to report
adverse effects if drug or
signs and symptoms of
superinfection.
K: Obtain specimen for
culture and sensitivity
before giving first dose.
6. Generic name:
Tramadol + Paracetamol
Brand name: Ultram
C: Analgesic
H: Relieve moderate to
moderately severe pain
E: Not affected by meals.
It is given thrice a day
(TID).

Frequency:
2-4 times a week.
Consultation must be
done first before
engaging to any exercise
programs. This is to
ensure the safety and
limitations of exercises
intended for end stage
renal disease patients.
Encourage significant
other (wife) to do ROM
(range of motion)
exercises on the time
required to prevent
immobility of the patient.

Instruct significant other

to perform proper
stretching and warm up
activities before
C: ell patient to avoid
driving or other hazardous engaging patient to a
higher intensity ROM
activities that require
exercises.
mental alertness until
Aerobic conditioning
drugs CNS effects are
exercise is the best
exercise for lupus
K: Reassess patients
level of pain at least 30
patients.
minutes after
administration.
7. Generic name: Calcium

system by blocking the

production of immune
cells. These drugs may
be given by mouth or
by IV infusion.
BLyS-specific
inhibitors: Belimumab
(Benlysta), a Blymphocyte stimulator
(BLyS) protein
inhibitor, was approved
by the U.S. Food and
Drug Administration
(FDA) in March 2011
for patients with lupus
who are receiving other
standard therapies,
including those listed
above. Given by IV
infusion, it may reduce
the number of
abnormal B cells
thought to be a
problem in lupus.
Alternative and
complementary therapies:
Because of the nature and
cost of the medications
used to treat lupus and the
potential for serious side

59
+Vit D
Brandname: Calvit
C: Dietary supplements
H: improve and
strengthen bones and
joints
E: Should be taken with
food, swallow whole and
do not chew.
C: Monitor blood
pressure, ECG, renal
function, magnesium,
phosphate, potassium,
serum, and urine calcium
concentrations.
K: Avoid using two (2)
hours prior to or until four
(4) hours after taking
other medications
8. Generic name:
Levofloxacin
Brand name:
C: Antibiotic,
florquinolone
H: treat fatigue, joint pain,
skin rashes, and
inflammation of the lungs.
E: With or without meals

effects, many patients seek

other ways of treating the
disease. Some alternative
approaches people have
tried including special
diets, nutritional
supplements, fish oils,
ointments and creams,
chiropractic treatment, and
homeopathy.
Diagnostic tools for lupus:
Medical history
Complete physical
examination
Laboratory tests:
Complete blood
count (CBC)
Erythrocyte
sedimentation rate
(ESR)
Urinalysis
Blood Chemistries
Complement levels
Antinuclear antibody
tests (ANA)
Other autoantibody
tests (anti-DNA, antiSm, anti-RNP, anti-Ro
[SSA], anti-La [SSB])
Anticardiolipin
antibody test

60
with a glass of water

Skin Biopsy

C: Report rash, visual

changes, severe GI
problems, weakness,
tremors

Kidney Biopsy

K: Discontinue at any
sign of hypersensitivity
(rash, photophobia) or at
complaint of tendon pain,
inflammation or rupture
9. Generic name: KCL
Brand name:
C: Electrolyte
H: Replaces potassium
and maintains potassium
level
E: Taken with or after
meals with full glass of
water or fruit juice
C: Report toughing of the
hands or feet unusual
tiredness or weakness,
feeling of heaviness in
legs, severe nausea,
vomiting, abdominal
pain,black or tarry stools,
pain at IV injection site
K: Monitor IV injection
sites regularly for

61
necrosis, tissue sloughing
and phlebitis
10. Generic name:
Eperisone
Brand name:
C: antispasmodic
H: Relaxation of
hypertonic skeletal
muscles, Improves
intramuscular blood flow,
Reduction of muscle
spindle sensitivity via
motor neurons,
Vasodilatation and
augmentation of blood
flow.
E: After meals
C: Report symptoms such
as fever, erythema,
blistering, itching, ocular
congestion or stomatitis,
etc
K: Monitor symptoms
such as redness, itching,
urticaria, or edema of the
face and other parts of
the body,dyspnoea etc,
treatment should
be discontinued and
appropriate measures

62
taken
11. Generic name:
Multivitamins with
Buclizine
Brand name:
Multivitamins with
Buclizine
C: Antihistamines &
Antiallergics
H: Relieved Motion
sickness, migraine,
nausea, pruritic skin
disorders
E: Should be taken with
food. (Take within hr
before meals.)
C: Report signs of
hypersensitivity.
K: Make sure it is taken
after meals to prevent GI
disturbances.

63