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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= 36.5˚C Laboratory results: -Antinuclear Anti Body result is 7. -HGB, HCT, RBC, platelet are decreased -WBC is increased -serum sodium 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. Loss of immune Nanda definition: tolerance Damage to mucous membranes, corneal, increase antigenic integumentary or load subcutaneous tissues excess T cell, defective B cell suppression and Source: shifting of T helper 1 to Th2 immune Doenges, et al. responses Nurse’s Pocket Guide (12 Ed.). F.A. b cell hyperactivity Davis company. 2010 production of pathogenic Nursing diagnosis Desire outcome 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 -serves as baseline data and will suggests treatment options, as well as client’s desire and ability to protect self, and potential for recurrence of tissue damage - this could have an impact in tissue health 2. Goal met. The patient takes medication to minimize itching. The patient also verbalizes “gakatol pa sa dyapon pero indi na grabe”. 1. Goal met. The patient was able to understand and identify her present condition. Nursing intervention Justification Evaluation After 32 hours of nurse-client interaction the client will be able to:
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
-to evaluate actual/or potential impairment in circulation
-determines the extent or
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 c. inspect skin on daily basis, describing wound lesions and rashes characteristics observed 3. Maintain optimal nutrition and physical well-being. d. encourage adequate periods of rest and sleep involvement of injury -promotes timely intervention and revision of plan of care
immune complexes complement activation 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 & Suddarth’s Textbook of Medical – Surgical Nursing. Lippincott Williams and Wilkins. 12th ed.
-to limit metabolic demands, maximize energy available for healing and meet comfort needs -to minimize condition and promote healing
3. a. maintain appropriate moisture environment for particular wound
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 -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 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.
4. a. emphasize importance of adequate nutritional and adequate fluid intake b. assist client in understanding and following medical regimen and developing program of preventive care. c. discuss importance of health as well as measures to maintain proper skin functioning 5. Review laboratory results pertinent to causative factors Collaborative: 1. Monitor and administer medications as
-enhances cooperation and optimizing outcomes
- for changes indicative of healing or presence of infection, complications.
-to determine and assess the contributing factors -to be aware of all the medication client is taking, noting possible interaction
). Merrem. Nurse’s Pocket Guide (12 Ed. Lasix. Source: Doenges.). et al. Cozar. F. 2010 Source: Doenges. Davis company. Norvasc. Nurse’s Pocket Guide (12 Ed. 4. F.A. Calvit and KCl.A. Davis company.27 Ordered such as. Predisone. 2010 . et al. Assist with diagnostic procedures or cumulative effects -May be necessary to determine extent of impairment. 3. Assist in -to maintain gains identifying ongoing and continue of treatment needs and progress rehabilitation for the individual like physical and occupational therapy.
Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and -to reduce energy expenditure . pero lain gid ya sang sadto nga week”. Goal met.1 mg/dL) on November 15 lab result RATIONALE DESIRED OUTCOME/ NURSING GOALS After 32 hours of nursing interventions. Then at the last day of duty.60 (normal: 3. Report improved sense of energy a. Practices to conserve energy were done through the help of her significant others by assisting her to do activities of daily living. she was able to claim. Accept reality of patient’s report of fatigue and do not underestimate effect on the quality of life the client experiences d. inability to perform activities independently. the client was able to: Predisposing • Gender: Female • Race: Asian Precipitating • Infection: UTI . plan steps of activity before beginning so that all -to assist patient in coping with fatigue 1.54 L/L) on November 15 and 17 lab results repectively • Serum sodium results of 130 (normal: 137143 mEq/dL) and serum potassium result of 2.6NURSING DIAGNOSIS Fatigue related to immune system pathology as evidenced by patient’s appearance of weakness and tiredness. 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 -can perpetuate a cycle of fatigue.32 L/L and 0. She also sleeps most of the time on our duty hours to conserve energy. 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. Note patient’s belief of what is causing the fatigue and what relieves it b. poor muscle strength.30 L/L(normal: 0. “kapoy e. she was already able to stand and able to hold conversations longer than the conversations she had upon first admission.28 ASSESSMENT Actual Abnormal Cues: • Appears very tired and weak • Lethargic • Compromised concentration and mentation changes like disorientation to place.40-0.60 (normal: 3. When asked if patient still feels extremely tired. lethargy. the client will be able to: 1. Instruct methods to conserve energy (e.g. Serum sodium results of 130 (normal: 137-143 mEq/dL) and serum potassium result of 2.6-5. which was more severe. incoherent responses. Hgb result of 115 g/L and 104 g/L (normal: 120-160 g/L) last November 15 and November 17 lab result. impaired functioning. and increased anxiety and fatigue c. comparing the fatigue she has felt last week. Evaluate aspect of “learned helplessness” that may be manifested by giving up -to assess contributing factors NURSING INTERVENTIONS Independent Nursing Interventions: JUSTIFICATION EVALUATION After 32 hours of nursing interventions.
etc. Antigen Class 1 and 2 in chromosome 6 possess multiple genes influenced in acquiring SLE 2. longer sleep periods at night. Goal met. Nurse’s Pocket Guide (9th ed. Participate in recommended treatment program -to provide baseline data for the nurses plan of activities -helpful in 3. Hct. Davis Company.” • With health history of easy fatigability and body weakness 7 months prior admission and with decreased Hgb. uninterrupted periods of rest.A.g. nakapoy ko. potassium and sodium results of lab tests after consultation to physician. Perform activities of daily living and desired activities at level of ability needed materials are at hand) e.) g.provide electric fan.) a. Risk Factors/Weaknesses: Poor appetite • Episodes of joint pain • 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 Wellness/strengths: • Good emotional Source: Doenges. Discuss routines to promote restful sleep (e.1 mg/dL) on mental work at usual November 15 lab work level result • Vebal reports of “Indi ko pagsamuka anay. et al. Goal partially met. F. etc.29 5. Patient was able to show participation through . Provide environment conducive to relief of fatigue ( e. earplugs. Provide means to decrease environmental noise (e. -to assist patient to establish a sleep pattern 3. Determine ability to participate in activities/ level of mobility b. etc. Note daily energy -temperature and level of humidity are known to affect exhaustion Fewer or defective macrophages in the body 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 -when sleep deprivation is present.2004. The greatest feat that the patient made during our duty week was that she was able to stand on the last day.) f. it adds to fatigue -impaired concentration can limit ability to block competing stimuli/distractions 2.). Avoid overstimulation/und erstimulation (cognitive and sensory) h. Patient was able to perform her activities of daily living through the help of her significant others. p 232. although her basic daily activities were still done with assistance. Provide diversional activities.g.g.
Encourage to do whatever is possible (e. Assist with selfcare needs. sit up. etc. Significant others also assisted with the patient as evidenced by their willingness to accept information given by the student nurse.) h.self-care. They also able to give simple examples of how to conserve the patient’s energy like not disturbing her in her sleep and keeping their voices down to make her rest. Although they had troubles with their finances. Schedule activities for periods when patient has the most energy -enhances commitment to promoting optimal outcomes -to maximize participation g.g. 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 Fatigue Appearance of tiredness and f. Plan care to allow adequate rest periods. keep bed in low position and . Interview significant others regarding specific changes observed on patient d. 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 -to assist patient with limited mobility patterns determining pattern/timing of activity -to assess contributing factors listening while the student nurse gives accidental and prepared health teachings about the disease and its treatment. c.30 support for the family • Willingness to follow nursing interventions • Have strong faith in God Various autoantibody productions Production of antinuclear antibody. Establish realistic activity goals with the patient e. most of the highly needed medical interventions were followed. They also did their part in assisting her with her activities of daily living.
Instruct patient in ways to monitor responses to activity and significant signs and symptoms e.g. low Fat). 12th ed. Normal CHOn. Assist patient and significant others to develop a plan of activity and exercise within the individual’s capability d. Lippincott Williams and Wilkins. Brunner & Suddarth’s Textbook of Medical – Surgical Nursing. Discuss the disease process relevant to patient b. et. Promote overall health measures (e.al.31 inability to perform activities of daily living independently Source: Smeltzers S.C. adequate fluid -indicates the need to alter the activity level -presence of anemia/hypoxemia reduces oxygen for available cellular uptake and . nutrition(High CHO. Discuss therapy regimen relating to individual causative factors -understanding the disease can help the client understand the treatment regimen -to help patient and significant others understand the relationship of disease and treatment and to elicit their cooperation on the treatment regimen -to encourage participation of patient and significant others in health management of patient c. assist in ambulation as indicated a.
A.5-2L/day.) b.2004. pain relievers. Report any allergic reactions. Nurse’s Pocket Guide(9th ed.g.) Collaborative interventions: a. Administer blood transfusions properly as indicated. Administer medications related to patient’s condition (e. pp 232-234. etc. etc. Source: Doenges. Davis Company. Assist with medical procedures as indicated c. et al. contributes to fatigue appropriate intake of vitamins and minerals as prescribed especially iron. antimalarials. F.32 intake of 1.). -to promote wellness of patient -to assist in measures to relieve patient’s condition -to supplement blood components and increase oxygen for cellular uptake .
Perform thorough assessment regarding safety issues when planning for client care and/or preparing for discharge from care. autoimmune • Infection: UTI . RBC. decision making ability and level of cognition c. a. forgetful >Photosensitivity >presence of alopecia >Malar or "butterfly" rash on the face >Discoid skin rash on hands. HCT. Nanda definition: Endothelial / cellular response Autoimmunity Tiisue or organ involvement b. weakness. disorientation and Unknown etiology altered mobility as evidence by malar immune system rash on the face. Pneumonia abnormal blood profile . developmental stage. The patient was able to encourage how to protect herself and . -HGB.5˚C Nursing diagnosis Nursing diagnosis: Rationale Desire outcome After 32 hours of nurse-client interaction the client will be able to: Independent: 1. gross and fine motor coordination 2. assess client’s muscle strength. oral mucous altered immune membrane ulcers and response presence of alopecia. disoriented to time soluble mediators and place. provide healthcare within culture of safety Laboratory results: -Antinuclear Anti Body result is 7. promote 2. dysfunction. Verbalize understanding of individual factors that contribute to possibility of injury 1. -affects client’s ability to protect self and/or others. -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. a. Modify environment as -to prevent errors resulting in client injury. scalp and thighs. Goal met. The patient was able to gain information about factor that may contribute to place patient at risk for injury. gender.33 RISK NCP Assessment Abnormal cues: >easy fatigability and weakness >Patient is not oriented to time and place. activation discoid skin rashes on hands. (cytokines) photosensitivity. Goal met. platelet are decreased -WBC is increased -serum sodium slightly decreased At risk of injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources. and influences choice of interventions and teaching -to identify risk for falls 1. 2. 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. note client’s age. Nursing intervention Justification Evaluation After 32 hours of nurse-client interaction the client will be able to: Predisposing • Gender: Female Risk for injury • Race: Asian related to tissue Precipitating damage.
-in order for the patient to be aware of all the treatment that the patient is receiving and to gain patient’s cooperation -to alleviate stress and anxiety in order to prevent further harm to patient.A. check vital sign every 4 hours c. -exercises promote good circulation to the body. et. Source: Smeltzers S. Display behaviors. monitor environment for potentially unsafe conditions and modify as needed. 2010 Risk for injury related to tissue damage. encourage use of techniques to reduce or manage stress and vent emotions 3. enhance her awareness and knowledge about safety things and necessary precaution to be done to prevent her to be at risk for injury. autoimmune dysfunction. Brunner & Suddarth’s Textbook of Medical – Surgical Nursing. encourage and assist in frequent range-of-motion exercises 3.). disoriented to time and place. disorientation and altered mobility as evidence by malar rash on the face. ty c. The patient demonstrate lifestyle changes such as having exercises even while in bed with assistance. indicated to enhance safety. 12th ed.poor environmental sanitation Source: Doenges. a.al. photosensitivity. abnormal blood profile . scalp and thighs. discoid skin rashes on hands. et al. -to prevent patient from at risk for falls. Davis company. Strengths/wellness: >strong support system >strong financial support >strong religious belief d. oral mucous membrane ulcers and presence of alopecia. inform client regarding all treatment and medication client safety and model safety behaviors for patient. Nurse’s Pocket Guide (12 Ed.C. improving the body to be more health and prevent from further injury -to monitor patients condition. b. Goal met.34 >history of Rheumatoid Arthritis (2004) >history of UTI (March2011) Weakness: >Poor immune system >gender: female >lack of patient’s cooperation >poor hygiene >does not cooperate in treatment >does not exercise . 3. Patient was able to be aware of safety precautions in order to protect herself. b. Thus. Lippincott Williams and Wilkins. -to assist patient to reduce or correct individual risk factors. lifestyle changes to reduce risk factors and protect self from injury. weakness. position patient to a comfortable position and side rails up . F.
35 d. Predisone.). Administer medications such as. -to provide proper information about the disease and treatments that would help the client achieve independence as well being. F. Lasix. and to correct fluid and electrolyte balance and also to regulate blood pressure. 2010 . Assist in treatments and provide information regarding client’s disease/condition. Nurse’s Pocket Guide (12 Ed. Merrem.). et al.A. -in order that patient may be aware in that she may also be able to protect herself. Source: Doenges. Davis company. 2. Davis company. Calvit and KCl as ordered using the “10 rights to medication” Source: Doenges. Norvasc. stress importance of monitoring conditions and risk that may contribute to occurrence of injury Collaborative: 1. et al. F.A. Nurse’s Pocket Guide (12 Ed. Cozar. 2010 -to alleviate itchiness.
Tell patient to report significant swelling of face or extremities. edema may cause discontinuation of drug. Treat hypertension Not affected by meals. severe Report shortness of breath. . Monitor for signs and symptoms of dose-related peripheral or facial edema that may not be accompanied by weight gain. DRUG STUDY C H E C K Generic Name: Amlodipine besylate Brand Name: Norvasc Classification: Cardiovascular agent. irregular heartbeat. Monitor heart rate. palpitations. Report postural hypotension. or constipation to physician Monitor BP with postural changes. It is given once a day. also dilates coronary arteries and arterioles.36 XIV. doserelated palpitations (more common in women) may occur. nausea. calcium channel blocker. thus decreasing myocardial contractility and oxygen demand. rarely. antihypertensive agent Inhibits calcium ion influx across cardiac and smooth muscle cells.
Assess patient’s underlying condition before starting therapy. fluid intake and output. Monitor weight. Treat hypertension Not affected by meals. severe abdominal pain or sore throat and fever because they may indicate toxicity. Instruct patient to report ringing in ears. . Promotes water and sodium excretion.37 C H E C K Generic Name: Furosemide Brand Name: Lasix Classification: Loop diuretic Inhibits sodium and chloride reabsorption at proximal and distal tubules and ascending loop of Henle. Monitor uric acid level. BUN. Be alert to adverse reactions and drug interactions. especially if patient has a history of gout. peripheral edema. Advise patient to stand slowly to prevent dizziness. not to drink alcohol and to minimize strenuous exercise in hot weather. It is given every twelve hours (q12h) IVTT. breath sounds. blood pressure. and carbon dioxide levels. and electrolyte. glucose.
which can cause high potassium level. When used alone. lips or tongue and difficulty of breathing.38 C H E C K 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. Notify healthcare provider if these serious side effects occur: swelling of face. drug has less of an effect on blood pressure. . Closely monitor patient especially during first few weeks of therapy. Tell patient to avoid salt substitutes. Monitor for signs of allergic reaction. these products may contain potassium. It is given once a day (OD). Assess patient’s renal function (BUN and creatinine levels) regularly. eyes. Lowers high blood pressure Not affected by meals. Monitor patient’s blood pressure to evaluate effectives of drug therapy.
39 Generic name: Prednisone Brand name: Prelone Classification: Corticosteroids Decreases inflammation. muscle weakness. buffalo hump. fever. thinning hair. and influences protein. anorexia. stimulates bone marrow Given orally with food if possible to reduce GI irritation. . hypertension and increased susceptibility to infection. fainting. fat and carbohydrate metabolism. central obesity. Monitor for Cushingoid effects: moon face. mainly by stabilizing leukocyte lysosomal membranes. joint pain. shortness of breath. Weigh patient daily. dizziness. Suppresses immune response. Teach patient signs and symptoms of adrenal insufficiency: fatigue. report sudden weight gain to prescriber. nausea. Watch for depression or psychotic episodes. Instruct patient not to stop drug abruptly or without prescriber’s consent. Tell patient to take drug with food or milk. It is given once a day every am and once every pm. Determine whether patient is sensitive to other corticosteroids.
hepatic and hematopoietic function is recommended. Obtain specimen for culture and sensitivity before giving first dose. Prevent complicated skin and skin structure infections Not affected by meals.40 C H E C K Generic name: Meropenem Brand name: Merrem IV Classification: Miscellaneous anti-infectives Inhibits cell wall synthesis in bacteria. Tell patient to report adverse effects if drug or signs and symptoms of superinfection. Periodic assessment of organ system functions including renal. Drug may cause overgrowth of non susceptible bacteria or fungi. It is given every eight hours (Q8h). Monitor patient for signs of superinfection. It readily penetrates cell wall of most gram positive and gram negative bacteria to reach penicillin-binding protein targets. . Advise patient to report loose stools to prescriber.
Instruct patient not to stop drug abruptly or without prescriber’s consent. . Anticipate need for laxative. Monitor patient’s cardiovascular and respiratory status. It is given thrice a day (TID). Reassess patient’s level of pain at least 30 minutes after administration. Thought to bind to opiate receptors and inhibit reuptake of norepinephrine and serotonin levels. central nervous system drugs Centrally acting synthetic analgesic compound not chemically related to opioids. Relieve moderate to moderately severe pain Not affected by meals. 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. Monitor bowel and bladder function.41 Generic name: Tramadol + Paracetamol Brand name: Ultram Classification: Opioid analgesics. Withhold dose and notify prescriber if respiration is below 12cpm.
photophobia) or at complaint of tendon pain.43 C Generic name: levofloxacin Brand name: Levaquin Classification: Antibiotic. weakness. severe GI problems. preventing cell reproduction H treats bacterial infection E Administer without regards to meals with a glass of water. including antacids by at least 2 hours Discontinue at any sign of hypersensitivity (rash. 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. given twice a day per Orem C Instruct patient to drink plenty of fluids while taking this drug Instruct to report rash. inflammation or rupture . separate oral drug from other cation administration. visual changes. florquinolone Bactericidal: interferes with DNA by inhibiting DNA gyrase replication in susceptible gram-negative and gram-positive bacteria.
maintenance of normal renal function. skeletal and smooth muscle. also plays a role in carbohydrate metabolism and various enzyme reaction H prevent and correct potassium deficiency E C Not affected by meals Caution patient not to use salt substitutes K Agitate prepare IV solution to prevent “” of potassium. abdominal pain.black sloughing and phlebitis or tarry stools. tissue vomiting. feeling of heaviness Monitor IV injection sites in legs. pain at IV injection site Monitor cardiac rhythm carefully during IV administration . participates in a number of physiologic processes—maintaining intracellular tonicity. regularly for necrosis. do not add potassium to an IV bottle in Report toughing of the hands or the hanging position feet unusual tiredness or weakness. transmission of nerve impulses. contraction of cardiac. severe nausea.44 C Generic name: Potassium Chloride Brand name: Potassium Chloride Classification: Electrolyte Principal intracellular cation of most body tissues.
itching. H Treats muscle spasm E Should be taken with food. treatment Discontinued and approriate measures taken. given three times a day per Orem C Report fever. thus alleviating stiffnessand spasticity. ocular congestion or stomatitis. itching. erythema. and suppression of the pain reflex. erythema.ischaemia. improvement of circulation. etc . blistering. blistering. and facilitating muscle movement. ocular congestion or stomatitis K In the event of symptoms such as redness.45 C Generic name: Eperisone Brand name: Eperisone Classification: Antispasmodic Eperisone acts by relaxing both skeletal muscles and vascular smoothmuscles. and hypertonia in skeletal muscles. treatment should be discontinued and appropriate measures taken Patients should be carefully observed. or edema of the face and other parts of the body. urticaria. in the event of symptomssuch as fever.The drug inhibits the vicious cycle of myotonia by decreasing pain.dyspnoea etc. and demonstrates a variety of effects such as reduction of myotonia. itching.
serious sedation could occur Report difficulty breathing. It is used mainly for its antiemetic action and in the treatment of migraine in combination with analgesics.) Given once a day C Avoid over the counter drugs. visual disturbances. reflexes. P. normal urinary output .46 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. bowel sounds. irregular heart beat K Assess orientation. loss of coordination. normal GI output. affects. remors. hallucinations.RR. adventitious sounds. visual examinations. H Treats nausea. vomiting and dizziness E Should be taken with food. may contain ingredients that cause serious reactions with drug Avoid alcohol. (Take within ½ hr before meals. BP.
black sloughing and phlebitis or tarry stools. contraction of cardiac. transmission of nerve impulses. maintenance of normal renal function. skeletal and smooth muscle. severe nausea. 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 K Agitate prepare IV solution to prevent “” of potassium. abdominal pain. pain at IV injection site Monitor cardiac rhythm carefully during IV administration . participates in a number of physiologic processes—maintaining intracellular tonicity.47 C Generic name: Potassium Chloride Brand name: Potassium Chloride Classification: Electrolyte Principal intracellular cation of most body tissues. regularly for necrosis. tissue vomiting. 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.
Lupus patients is very important. Stress to patient and family the importance of follow-up examinations and treatment because of changing physical status. and carbon dioxide levels. Exercise Exercise plays its part in the treatment of lupus. blood pressure. peripheral edema. breath sounds. BUN. size apple). glucose. C: Advise patient to stand slowly to prevent dizziness. These in turn depend on continued movement. Provide or encourage vegetable diet. 2. 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 Hygiene For maintaining skin integrity: 1. not to drink alcohol and to minimize strenuous exercise in hot weather K: Monitor weight. Get enough sleep and Advice client to Chlorhexidine mouthwashes could rest. moderate in low-fat dairy products. mediumhygiene care in dietary changes required. such oral hygiene to as a medium-size minimize dryness of oral piece of fruit (an mucous membranes. and low in mimimal protein. It is very important to keep muscles & joints active for a variety of reasons. Keep nails short and trimmed to prevent excoriation. disease activities. Joints depend on tendons & the calcification of bones. Encourage significant other to do passive ROM (Range of motion) exercises for the client. and treatment of side effects. Keep hair clean and moisturized. Allowing monitoring of symptoms. Physical therapy is very beneficial to the patient who is trying to maintain muscle integrity & tone. Outpatient Adherence to pharmacological and non-pharmacological interventions.V HEALTH TEACHING PLAN Medication 1. Monitor intake and output to identify the output and fluid replacement needs. 3. small Preventive dental nutritionist because of the banana. Sponge bath Mild soap added to water to moisturize the skin. Muscles need to be toned in order to function adequately. Keep skin clean while relieving itching and dryness.Dietary regulationalcohol restriction.. broccoli 2. Generic name: Furosemide Brand name: Lasix C: Loop Diuretic H: Treat hypertension E: Not affected by meals. It is given every twelve hours (q12h) IVTT. The size of the muscle & its blood circulation depend on its function (where the muscle is & what it does). 2. avoid foods or help contain drinks that contain . fluid intake and output. Treatment of associated condition. Refer patient for continuous physical therapy for the improvement of the condition. Refer patient to a orange. Treatment The goal for the treatment of systemic lupus erythematosus 1. Significant bone loss through osteoporosis occurs when bones are not used regularly. Diet Suggested diet is DASH diet (high in fruits and vegetables. Generic name: The client must have a high fiber 4. has a substantial amount of plant protein from legumes and nuts Promote intake of vegetable-value protein foods: soy protein. and electrolyte.48 X.
To increase absorption. Then slowly Brandname: Cozaar and fever. anti-inflammatory muscle weakness. buttermilk gargle. Turn the infection. swelling. Musculoskeletal activity (designed to enhance flexibility & mobility) Types of Activities: Passive ROM Exercises Duration: 10-15 minutes Frequency: Everyday. stimulates bone marrow E: Given orally with food if possible to reduce GI irritation. Use sunsceen and suunblocks to protect the skin. fainting. such as up from the bed. periodontal disease. Even though turn the person's head so some NSAIDs may be he is looking over his . joint Types of Activities: pain. Put one hand hair. a face. symptoms of adrenal joint weakness) called nonsteroidal insufficiency: fatigue. some NSAIDs. Try to rest the naproxen. Fat intake should be limited to 30% of the total calories Instruct patient to limit fluid intake to 500-600 ml/day.49 Prednisone Brand name: Prelone C: Corticosteroids H: Suppresses immune response. dizziness. Raise the nausea. Include foods rich in zinc. consume with an acidcontaining food or one with vitamin C. Sunscreens and clothing covering the extremities can be helpful to prevent flares. Proper food preparation Avoid too much sun exposure and wear protective clothing to prevent direct sunlight. or steroid impregnated gel. alcohol restriction is a must because of clients’ condition. thinning necessary for others. chest if possible. anorexia. The client should consume amounts of necessary calories to maintain moderate body weight. Gently ibuprofen and tip his chin toward his K: Monitor for chest. Use sunglasses for cases of photosensitivity. It is given once a day every am and once every pm. Generic name: losartan control pain. 1. are Chin-to-chest. 2-4 hours and move the patient to prevent bed sores and immobility Avoid sun exposure. drugs (NSAIDs). are available Cushingoid effects: moon person's chin on his over the counter. 5. alcohol. These foods include oysters. Mucous membrane ulcers can be treated with hydrogen peroxide gargle. Include rich sources of iron in your diet. Although back of the person's head breath. Head turns. poultry and eggs. shoulder. fever. drugs that 2. seafood. Stretching Exercises C: Teach patient signs and (to specifically target decrease inflammation. doctor’s prescription is central obesity. hypertension and NSAIDs may be used increased susceptibility to on each side of the alone or in person's face. buffalo hump. shortness of often used. meats. person's head toward the combination with other right as if he were types of drugs to looking over his right 3. Sources of iron Prescribed medications: NSAIDs: For people with joint or chest pain or fever.
which can Intensity: cause high potassium Start with minimal level. and cereals Take medications with food to decrease the irritating effect on the stomach and small intestine. stretching. drug 15-20 minutes has less of an effect on blood pressure.Ankle & Foot Exercises Types of Activities: How to start: Hold the right ankle with one hand. Then slowly tilt the person's head to C: Tell patient to avoid bring the left ear toward salt substitutes. Corticosteroids: The mainstay of lupus treatment involves the use of corticosteroid include cream of wheat. This H: the blood pressure of Head tilts. milk. green peas. it is important that they be taken under a doctor’s direction. beans baked with molasses. enriched breads. butter. apricots. cereals. fish. joint pain. fish oils. lamb. Generic name: Amlodipine besylate Brandname: Norvasc . liver. Antimalarials: Antimalarials are another type of drug commonly used to treat lupus. Management of hypertension left shoulder. these the left shoulder. beef. prunes. turkey. margarines and breads. Foods and drugs taken together also increase the time available for the absorption of the drug. shoulder. These drugs were originally used to treat malaria. Put one of the patient will be your hands on each side lowered. and inflammation of the lungs. Duration: When used alone. E: Medication usually bringing the right ear given once a day.50 C: antihypertensives. These include foods primarily of animal origin: eggs. Turn the head only far enough so that the person's nose is lined up above their shoulder. purchased without a prescription. pork. eggs. angiotensin II receptor antagonists. Include foods rich in Vitamin D. It may be used alone or in combination with other drugs and generally is used to treat fatigue. skin rashes. A common antimalarial used to treat lupus is hydroxychloroquine (Plaquenil1). Tilt the head to the side. gradually increasing K: Monitor patient’s blood pressure to evaluate effectives of drug therapy. of the person's face. products may contain potassium. chicken. the toward the right same time per day. prune juice. Frequency: 2-4 times a week 3. Put your other 4. but doctors have found that they also are useful for lupus.
These foods include whole grain cereals. a type of drug called an immunosuppressive may be used. palpitations. These foods include broccoli. It is given every eight hours (Q8h). breads. calcium channel blocker. Ankle rotation. Then straighten and stretch the toes. or constipation to physician K: Special Precautions for patients w/ impaired hepatic & renal function. strawberries. They work by rapidly suppressing inflammation. poultry.51 C: Cardiovascular agent. Include foods rich in Vitamin B6 (Pyridoxine). CHF. C: Report shortness of breath. meats. hydrocortisone. fish. Duration: 2-3 Sessions. Immunosuppressives. hand on the bottom of the foot. cauliflower. restrain the overactive immune along with calcium decreases the risk of osteoporosis. With your palm on top of the person's foot. such as cyclophosphamide (Cytoxan) and mycophenolate mofetil (CellCept). potatoes. Hold the ankle with one hand. bananas. green beans. such as prednisone (Deltasone). liver. which is a natural antiinflammatory hormone. Toe bends. cantaloupe. nausea. Gently turn the foot and ankle in circles. Generic name: Meropenem Brand name: Merrem IV C: Miscellaneous antiinfectives H: Prevent complicated skin and skin structure infections E: Not affected by meals. avocados. Hexadrol). 15-20 hormones. curl the toes down toward the sole (bottom) of the foot. and dexamethasone (Decadron. It is given once a day. . Ankle bends. Increase your intake of foods high in Vitamin C. Intensity: Gradually increasing from soft to moderate pressure. irregular heartbeat. methylprednisolone (Medrol). Toe spreads. oranges. Pregnancy & lactation. antihypertensive agent H: Treat hypertension E: Not affected by meals. green leafy vegetables. Then bring them together again. Corticosteroids are related to cortisol. Hold the person's upper foot with your other hand. Immunosuppressives: For some patients whose kidneys or central nervous systems are affected by lupus. Push the person's foot so his toes point up toward the ceiling. spinach. Elderly. nuts. Then put your hand on top of the foot and push the foot down again. Use your fingers to spread the toes apart one at a time. 5. cabbage and green peppers.
Alternative and complementary therapies: Because of the nature and cost of the medications used to treat lupus and the potential for serious side Instruct significant other to perform proper stretching and warm up C: ell patient to avoid driving or other hazardous activities before engaging patient to a activities that require higher intensity ROM mental alertness until exercises. Consultation must be done first before engaging to any exercise programs. 6. K: Obtain specimen for culture and sensitivity before giving first dose. These drugs may be given by mouth or by IV infusion. It is given thrice a day (TID). This is to ensure the safety and limitations of exercises intended for end stage renal disease patients. including those listed above. it may reduce the number of abnormal B cells thought to be a problem in lupus. Encourage significant other (wife) to do ROM (range of motion) exercises on the time required to prevent immobility of the patient. Generic name: Tramadol + Paracetamol Brand name: Ultram C: Analgesic H: Relieve moderate to moderately severe pain E: Not affected by meals. a Blymphocyte stimulator (BLyS) protein inhibitor.52 C: Tell patient to report adverse effects if drug or signs and symptoms of superinfection. Food and Drug Administration (FDA) in March 2011 for patients with lupus who are receiving other standard therapies. 7. system by blocking the production of immune cells.S. Generic name: Calcium Aerobic conditioning exercise is the best exercise for lupus patients. . minutes a day Frequency: 2-4 times a week. BLyS-specific inhibitors: Belimumab (Benlysta®). Given by IV infusion. was approved by the U. drugs CNS effects are K: Reassess patient’s level of pain at least 30 minutes after administration.
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. Generic name: Levofloxacin Brand name: C: Antibiotic. and urine calcium concentrations. ECG. renal function. Some alternative approaches people have tried including special diets. ointments and creams. joint pain. fish oils. phosphate. anti-La [SSB]) • Anticardiolipin antibody test . chiropractic treatment. antiSm. florquinolone H: treat fatigue. skin rashes. serum. many patients seek other ways of treating the disease. swallow whole and do not chew. nutritional supplements.53 +Vit D Brandname: Calvit C: Dietary supplements H: improve and strengthen bones and joints E: Should be taken with food. anti-RNP. anti-Ro [SSA]. magnesium. C: Monitor blood pressure. and inflammation of the lungs. E: With or without meals effects. potassium. and homeopathy. K: Avoid using two (2) hours prior to or until four (4) hours after taking other medications 8.
pain at IV injection site K: Monitor IV injection sites regularly for Skin Biopsy Kidney Biopsy . severe nausea. feeling of heaviness in legs. 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. vomiting. visual changes. tremors K: Discontinue at any sign of hypersensitivity (rash.54 with a glass of water C: Report rash. severe GI problems. abdominal pain. photophobia) or at complaint of tendon pain.black or tarry stools. weakness. inflammation or rupture 9.
treatment should be discontinued and appropriate measures .55 necrosis. Generic name: Eperisone Brand name: C: antispasmodic H: Relaxation of hypertonic skeletal muscles.dyspnoea etc. Reduction of muscle spindle sensitivity via motor neurons. itching. blistering. urticaria. Improves intramuscular blood flow. Vasodilatation and augmentation of blood flow. or edema of the face and other parts of the body. tissue sloughing and phlebitis 10. erythema. itching. etc K: Monitor symptoms such as redness. E: After meals C: Report symptoms such as fever. ocular congestion or stomatitis.
. (Take within ½ hr before meals. migraine. pruritic skin disorders E: Should be taken with food.) C: Report signs of hypersensitivity. Generic name: Multivitamins with Buclizine Brand name: Multivitamins with Buclizine C: Antihistamines & Antiallergics H: Relieved Motion sickness.56 taken 11. nausea. K: Make sure it is taken after meals to prevent GI disturbances.
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