GORDON COLLEGE

COLLEGE OF ALLIED HEALTH STUDIES

OLONGAPO CITY

PULMONARY EFFUSION SYSTEMATIC LUPUS ERYTHOMATOSUS POST

DEBRIDEMENT FOURNIER’S GANGRENE

In Partial Fulfillment for the

The Subject NCM116a

Submitted by:

Abdon, Princess Mildred

Dataylo, Arlelie Fae
Espejo, Vivien Rose
Moreno, Darwin
Valencia, Airrah

Submitted to:
Mr. Romer Dumlao, RN
Clinical Instructor

MARCH, 2022

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 TABLE OF CONTENTS

Introduction……………………………………………………………………………3

I. Patient’s Profile……………………………………………………..……………….4

A. Biographic Data....……………………………………….…………...…………….4

B. Past Health History …………………………………………………………………6

II. Gordon’s Pattern of Functioning................................................................................6

1. Health Perception-Health Management Pattern………………………………..6

2. Nutritional-Metabolic Pattern………………………………………………….7
3. Elimination Pattern …………………………………………………………….7
4. Activity-Exercise Pattern……………………………………………………….8
5. Sleep and Rest Pattern………………………………………………………….9
6. Cognitive-Perceptual Pattern…………………………………………………...9
7. Roles-Relationship Pattern ……………………………………………………9
8. Sexuality-Reproductive Pattern ……………………………………………….9
9. Coping-Stress Tolerance Pattern………………………………………………9

III. Physical Assessment......................................................................................... .......10

IV. Laboratory and Diagnostic Examination Results.....................................................11

V. Course in the Ward....................................................................................................13

VI. Drug Study................................................................................................................13

VII. Anatomy and Physiology.........................................................................................26

VIII. Pathophysiology.....................................................................................................28

IX. Prioritization..............................................................................................................29

X. Nursing Care Plan........................................................................................................30

XI. Discharge Plan...........................................................................................................44

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Introduction

Systemic Lupus Erythematosus is an autoimmune disease in which the immune system

attacks its own tissues, resulting in extensive inflammation and tissue damage throughout the body.
It can affect the joints, skin, brain, lungs, kidneys, and blood vessels. The diagnosis of SLE is based
on a complete history, physical examination, and blood tests. The causes of SLE are unknown, but
are believed to be linked to environmental, genetic, and hormonal factors. Lupus is most likely
caused by a mix of your genetics and your environment. People who have a hereditary
susceptibility to lupus may get the condition if they come into contact with something in the
environment that can cause lupus.

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. Treatment of SLE includes management of acute and chronic disease. Although SLE
can be life-threatening, advances in its treatment have led to improved survival and reduced
morbidity. SLE is managed by assessing disease activity and therapy effectiveness on a regular
basis. SLE can have both short- and long-term effects on a person’s life. Early detection and
treatment can help lessen the negative consequences of SLE and increase the chances of improved
function and quality of life.

The reported prevalence of systemic lupus erythematosus (SLE) in the United States is 20
to 150 cases per 100,000. In one meta-analysis, the prevalence was 73 out of 100,000. In women,
prevalence rates vary from 164 (White individuals) to 406 (African American individuals) 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.

The chosen patient for this case study is a 19 year old female who was admitted last
February 02, 2022, with the chief complaint of edema. The patient’s admitting diagnosis is
probable SLE secondary to Fournier’s gangrene. Physical examination was done, and it revealed
positive bipedal edema & negative murmur.

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I. PATIENT’S PROFILE

A. Biographic Data

Patient’s name: Danie Gurl

Marital Status: Single

Address: Palauig, Zambales

Age: 19 y/o

Sex: F

Date of birth: March 02,

Nationality: Filipino

B. PAST HEALTH HISTORY

A. Childhood Illnesses

“Madalas syang lagnatin nung bata sya” as verbalized by the client’s mother

Interpretation:

Based on the mother, the patient often had a fever when she was young.

Analysis:

According to Bartels (2021), SLE-specific fatigue or fever generally occurs in concert with
other clinical markers. Fever may reflect active SLE, infection, and reactions to medications

B. Immunization

“Kumpleto naman ang bakuna nya simula nung bata sya” as verbalized by the client’s
mother

Interpretation:

According to the data, the patient is complete on her immunization since she was young.

Analysis:

According to Goodman (2020), Immunizations, or vaccines as they're also known, safely

and effectively use a small amount of a weakened or killed virus or bacteria or bits of lab-made
protein that imitate the virus in order to prevent infection by that same virus or bacteria.
Immunizations protect us from serious diseases and also prevent the spread of those diseases to
others.

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C. Allergies

“Wala naman syang allergy sa kahit anong gamot at pagkain” as verbalized by the client’s
mother

Interpretation:

By conducting an interview with the patient, we asked if she had any allergy on food and
medication. according to her, she had no known food and medication allergies.

Analysis:

According to National Library of Medicine, Allergic disorders commonly occur in patients

with systemic lupus erythematosus (SLE) and allergies to some drugs may occasionally be related
to disease flares.

D. Accidents

“Makulit sya nung bata sya pero di naman sya naaaksidente, siguro nadadapa lang” as verbalized
by the client’s mother.

Interpretation:

The patient had no past accidents even if she was playful according to her mother.

Analysis:

Psychological stress associated with exposure to trauma appears to boost the odds of
women developing lupus, according to a study by Harvard T.H. Chan School of Public Health and
Brigham and Women’s Hospital researchers. Lupus is an autoimmune disease in which skin, joints,
and internal organs become inflamed.

E. Hospitalization

“Simula noon wala pa, ni hindi pa sya naoospital. Ngayon lang talaga” as verbalized by the
client’s mother.

Interpretation:

The patient has no past history of hospitalizations.

Analysis:

According to The Journal of Rheumatology August 2017, Hospitalization occurs in about 10% of
patients with systemic lupus erythematosus (SLE) each year and accounts for most of the direct cost of SLE
patient care.

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F. Medications used or taken

“Kapag nilalagnat sya, masakit ang ulo nagpaparacetamol sya” as verbalized by the client’s
mother.

Interpretation:

According to the data given, the patient takes paracetamol for headache and fever.
Analysis:

Hospitalization occurs in about 10% of patients with systemic lupus erythematosus (SLE)
each year and accounts for most of the direct cost of SLE patient care.

II. GORDON’S PATTERN OF FUNCTIONING

1. Health Perception Health Management Pattern

History

a. How has general health been? “I only experience discomfort and heavy feeling in
the private part” as verbalized by the client.
b. Any colds in past year? – N/A; When appropriate: absences from work? – N/A
c. Most important things you do to keep healthy? – “I’m just taking vitamins” as
verbalized by the client; Think these things make a difference to health? – “yes”
as verbalized by the client.; Use of cigarettes, alcohol, drugs? – “Di naman ako
umiinom talaga, occasional lang” as verbalized by the client..; Breast self-
examination? – N/A
d. Accidents? – N/A
e. In past, been easy to find ways to follow suggestions from physicians or nurses? –
“hindi ako nagpapacheck up agad” as verbalized by the client
f. When appropriate: what do you think caused this illness? Actions taken when
symptoms perceived? Results of action? – N/A
g. When appropriate: things important to you in your health care? How can we be
most helpful? – N/A

Examination

h. General health appearance – weakness, fatigue were noted.

Interpretation:
By conducting an interview with the patient, we asked her about her health. The patient
was doing well but felt uncomfortable and heavy in her private part. She also had no colds for the
past year and barely drinking. When sick, she is only drinking medicine and taking a rest. The
patient is also at rest but awake and alert.

Analysis:
Patients with SLE shall be well educated on the disease pathology, potential organ involvement
including brochures, and the importance of medication and monitoring compliance. Stress

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reduction techniques, good sleep hygiene, exercises, and use of emotional support shall be
encouraged.

2. Nutritional-Metabolic Pattern
History

a. Typical daily food intake? – “Sabi ng doctor bawal daw sya sa matamis, maalat at
matatabang pagkain pero pwede naman kahit ano wag lang mga yon” as
verbalized by the client’s mother. Supplements (vitamins, type of snacks)? –
“naimon sya vitmains lang” as verbalized by the client’s mother
b. Typical daily fluid intake? – “nakalimit ang pag-inom nya e. Tapos nagbabasa
lang ako ng bulak para punasan yung bibig nya” as verbalized by the client’s
mother.
c. Weight loss or gain? (Amount) Height loss or gain? (Amount)
d. Appetite?
e. Food or eating: Discomfort? Swallowing? Diet restrictions? “limitado ang tubig
nya tapos bawal daw sya sa matamis, maalat at matatabang pagkain sabi” as
verbalized by the client’s mother.
f. Heal well or poorly? N/A
g. Skin problems: Lesions? Dryness? “manas lang sya talaga” as verbalized by the
client’s mother.
h. Dental problems? N/A

Examination
a. Skin: Bony prominences? Lesions? Color changes? Moistness? – presence of edema
b. Oral mucous membranes: Color? Moistness? Lesions? -Normal findings
c. Teeth: General appearance and alignment? Dentures? Cavities? Missing teeth? - Normal
findings
d. Actual weight, height. -N/A
e. Temperature- Normal finding
f. Intravenous feeding–parenteral feeding (specify)? N/A

Interpretation:
The patient is currently taking vitamins and is having a limited fluid intake. She
also had diet restrictions to salty foods, sweets and fatty. She doesn’t have any skin lesions
but is having an edema due to fluid congestion.

Analysis:
Peripheral edema is a common manifestation of multiple disease entities ranging
from advanced heart failure, liver disease to localized swelling from an allergic reaction. It
may be a warning sign for many systemic diseases and if not treated early leads to high
morbidity and mortality. Patients should be educated regarding healthy lifestyles such as
exercise, diet, and routine check-ups to diagnose underlying disease entities early and
prevent long-term complications.

3. Elimination Pattern
History
a. Bowel elimination pattern? (Describe) Frequency? Character? Discomfort?
Problem in control? Laxatives? “dumudumi sya every other day” as verbalized by
the client’s mother

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 b. Urinary elimination pattern? (Describe.) Frequency? Problem in control? “Di
naman sya hirap umihi pero hindi lang comfortable talaga kasi nga may ano sa
puwerta nya” as verbalized by the client’s mother
c. Excessive perspiration? Odor problems? N/A
d. Body cavity drainage, suction, and so on? (Specify.) N/A

Interpretation:
According to the data gathered, the patient’s bowel elimination is every other day and
urination is not painful just a little discomfort.

Analysis:
Some researchers indicate that anywhere from three bowel movements a day to three a week
can be normal. Sometimes the consistency of a person’s stool can be a more significant indicator
of bowel health than frequency.

4. Activity-Exercise Pattern

Feeding: Level 2
Bathing: Level 2
Toileting: Level 2
Home maintenance: N/A
Dressing: Level 2
Grooming: Level 2
General mobility: Level 2
Cooking: N/A
Shopping: N/A
Bed mobility: Level 2

Interpretation:
The patient is in the Level 2 of the functional level codes in which she requires assistance
or supervision from another person. She can’t do things on her own except on changing bed
position but she sometimes need assistance on it so that she can be comfortable as she wants. She
also told that before the operation, she can walk within 74.5 ft. but now, she can barely walk.

Analysis:
Patients expressed fears about getting injured during exercise, but they thought physical
activity would be beneficial if it were managed appropriately. Fatigue, exposure to sunlight, joint
pain, hematologic and bony abnormalities predisposing patients to bleeding and fracture were
among the patient-reported physical activity barriers cited to be specific to SLE

5. Sleep-Rest Pattern
“Dalawang oras lang na tulog, pinakamahaba na yun tapos wala naman na gaanong
magawa pa di tulad dati” as verbalized by the client

Interpretation:
Patient is not well-rested and can’t do daily activities like she used to do before.

Analysis:
Studies have shown that 53–80% of SLE patients have identified fatigue as one of their primary
symptoms. One of the major causes of morbidity in SLE patients is chronic, debilitating fatigue,

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decreasing quality of life, and increasing risk of work disability with associated cumbersome
healthcare costs.

6. Cognitive-Perceptual Pattern
“wala namang nagbago, ganun parang ganun parin naman pagdating sa memory” as
verbalized by the client.

Interpretation:
Patient is alert and was able to answer questions, aware of the time, place and person.

Analysis:
Lupus and its treatments can impair mental & emotional health. Neuropsychiatric lupus
describes feelings of depression, headaches, and lupus fog — trouble thinking or remembering due
to lupus.

7. Roles-Relationship Pattern
“huminto sya sa pag-aaral dahil sa kondisyon nya. Itinago pa nga nyang buntis sya sa amin
kaya siguroo nagkaganyan sya, nawala din tuloy yung anak nya” as verbalized by the
mother.

Interpretation:
Patient stopped going to school when she knew that she was pregnant. Her family felt down
especially her mother because they didn’t know the cause of her condition and why miscarriage
happened.

Analysis:
First-trimester miscarriages in women with lupus either have no known cause or are considered
the possible result of active lupus.

8. Sexuality-Reproductive Pattern
“Hindi naman ako gumagamit ng mga contraceptives na yan” as verbalized by the client
Interpretation:
The patient was not using any contraceptives and no problems faced.

Analysis:
Safe and effective contraception is important for all women, including women with systemic
lupus erythematosus. The best contraceptive for a woman with lupus will depend on whether she
tests positive for antiphospholipid antibodies, her level of disease activity, her medical history,
current medications, and her personal preference.

9. Coping-Stress Tolerance Pattern

“Para syang nadepress nung naghiwalay sila ng boypren nya tas panay nalang ang
cellphone nya” as verbalized by the client’s mother.

Interpretation:
The patient had changes in her life for the past year or two when her partner broke up with
her before he knew that she was pregnant. She was also using her phone to cope up with the
situation and to entertain herself. Patient was tensed because of the discomfort and heavy feeling.

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Analysis:
The quality of life of patients with SLE is impaired compared with that of controls.
Fibromyalgia adversely affects the quality of life of SLE patients. This reduced sense of coherence
in SLE women represents impaired adaptive coping and is independently associated with reduced
quality of life in women with SLE.

III. PHYSICAL ASSESSMENT

ASSESSMENT ACTUAL NORMAL INTERPRETATION

FINDINGS FINDING
A. VITAL SIGNS
TEMPERATURE 35.3 C 36-37.5 °C Lower than the normal
range
HEART RATE 90 bpm 60-100 BPM NORMAL

RESPIRATORY 15 bpm 14-20 BPM NORMAL

RATE
B. GENERAL APPEARANCE
PHYSICAL Patient is at rest. Sitting, walking NORMAL
ACTIVITY Awake and alert or at rest. Awake
and alert.
C. SKIN
COLOR No jaundice or No jaundice or NORMAL
cyanosis or cyanosis or
discoloration discoloration
TEXTURE Smooth or moist Smooth or moist NORMAL
NAILS Nail bed is pale, Nail bed is pink, Due to low red blood
Capillary refill Capillary refill cell
test is normal test is normal
D. ABDOMEN
SKIN INTEGRITY unblemished unblemished NORMAL
skin, uniform skin, uniform
color color
CONTOUR AND (+) abdominal abdomen is flat, Abdomen is distended
SYMMETRY distention rounded due to edema
PRESENCE OF No presence of No abdominal NORMAL
ABDOMINAL PAIN abdominal pain pain or
OR TENDERNESS or tenderness tenderness
E. MENTAL STATUS
ORIENTATION Able to answer Able to answer NORMAL
question; aware question; aware
of time , place of time, place,
and person and person.

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Interpretation:

Almost all results from the physical assessment were all normal. The deviations found were
the presence of pale nail bed due to lack of red blood cell, abdominal distention and presence of
multiple diseases

Analysis:

Pail nails could mean you have a low red blood cell count. A swollen abdomen occurs when
your stomach area is larger than normal. This is sometimes known as a distended abdomen or
swollen belly. A swollen abdomen is often uncomfortable or even painful. A swollen abdomen has
a number of potential causes and is a common occurrence.

IV. LABORATORY AND DIAGNOSTIC EXAMINATION RESULTS

Complete Blood Count

Date: 03/07/2022

Examination Result Ref. value

Hemoglobin 89 120-150

Hematocrit .28 0.30-0.40

WBC 5.68 5.0-10.0x10^9/L

Neutrophils 0.88 0.30-0.70

Lymphocytes 0.11 0.20-0.40

Monocytes 0.01 0.02-0.10

Eosinophils 0.00 0.01-0.06

Platelet 149 150-350x1-^9/L

RBC 2.84 4.6-5.0x10^12/L

Serum Potassium

Date: 03/07/2022

Serum Potassium 6.80 3.5-5.0 mEq

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Serum Electrolytes

Creatinine 180.1 µmol/L 0.6 to 1.1 mg/dL (53 to 97.2

µmol/L)

Sodium 144.5 mEq/L 135- 145 milliequivalents per liter

(mEq/L).

Potassium 6.08 mEq 3.5-5.0 mEq

Calcium 1.14 mg/dl 8.5 - 10.5 mg/dL

Magnesium 0.52 mg/dl 2-3 mg/dl

Culture & Sensitivity

Findings: No growth

Gram Stain

Findings: No organism

Serology ANA

Date: 02/28/2022

Findings:

(+) at 1.10 dilution

2D echocardiogram doppler

Normal 2 ventricle w/ segmental wall motion abnormality as described

Overall systolic function is distressed.

Moderate pericardial effusion

Fused mitral E/A

Incidental finding of left side pleural effusion.

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 Interpretation:

The above laboratory works are essential in diagnosing and monitoring the client’s
condition in ruling out the possible complications in order to prevent them.

Analysis:

According to national resource center on lupus, many different laboratory tests

are used to detect changes or conditions in your body that can occur with lupus. Each
test result adds more information to the picture your doctor is forming of your illness.
The most common types of tests you may be asked to get are blood and urine tests.

V. COURSE IN THE WARD

Patient Danie gurl was admitted on Feb. 2. 2022 with the chief complaint of edema. Her physical
examination revealed a (+) bipedal edema and (-) murmur. Her admission diagnosis is Probable SLE sec to
Fournier’s gangrene. Serology ANA made on Feb.28, 2020 revealed (+) at 1.10 dilution. Her final diagnosis
was pulmonary effusion systematic lupus erythomatosus post debridement fournier’s gangrene.

The ordered medication for patient Danie gurl are:San Zinc, furosemide 40 mg with BP precaution,
prednisone 20 mg, spironolactone 25 mg, calcium carbonate, omeprazole 40 mg, enalapril, carvedilol 25
mg, ferrous sulfate + folic, potassium chloride 3 tab, ketoanalogues, paracetamol as needed, stat human
albumin 20.25% 1 vial q/2 and GI solution d5050 1 vial.

She is for monitoring of I&O, VS, and lab works such as K, Creatinine, Na, Ca and Mg as per
doctor’s order. In addition, TPAG was also ordered after 4 doses of albumin as prescribed. Blood transfusion
was ordered too.

There is a repetitive order on the physician’s note for primary closure. It starts on March 1 and the
ordered was delayed primary closure on March 18,2022 followed by for primary closure on March 4,2022
and the lastly, please follow up primary closure on March 14,2022.

VI. DRUG STUDY

NAME OF DOSAGE/FREQU MECHANISM OF CLASSIFIC CONTRA ADVERSE NURSING

DRUG: ENCY/ TIME ACTION ATION INDICATION EFFECT RESPONSIBILITIES
&ROUTE
• Albumin is • Volume Albumin • edema, • Monitor BP,
GENERIC Route: normally Expand hypersensitiv • increase pulse and
NAME: Intravenous present in the ers ity d heart respiration,
blood and Use of rate, and IV
Albumin • Individualiz constitutes albumin is • headach albumin flow
(human) e dosage 50% to 60% contraindicat e rate. Adjust
based on of the plasma ed in patients • nausea flow rate as
careful proteins and
with a history • vomitin needed to
monitoring 80% to 85% g, avoid too
of albumin
of clinical of the

13
 parameters oncotic hypersensitiv • flushing rapid a rise in
in all patient pressure. ity or , BP.
BRAND populations. Exogenously hypersensitiv • itching, • Lab tests:
NAME: In general, administered ity to any of chills. Monitor
do not albumin the dosage of
Albuminar exceed 2 increases the excipients. albumin using
Albuked, g/kg/day. oncotic plasma
Discontinue
Albuminar, pressure of albumin
administratio
Albuminex, Adjust infusion the (normal): 3.5–
n
Alburex, rate to the intravascular 5 g/dL; total
immediately serum protein
Alburx, patient's system,
pulling fluids and institute (normal): 6–
Albutein, individual
from the appropriate 8.4 g/dL;
Flexbumin, requirements.
interstitial medical Hgb; Hct; and
Hizentra, Do not exceed 1
space, treatment if a serum
Human to 2 mL/minute
thereby hypersensitiv electrolytes.
Albumin for patients with
Grifols, decreasing ity reaction is • Observe
normal blood closely for
Kedbumin, edema and suspected.
volume. More increasing S&S of
Octalbin,
rapid the circulatory
Plasbumin,
administration circulating overload and
Plasmanate
can cause blood pulmonary
circulatory volume. This edema (see
overload and increase in Appendix F).
pulmonary volume If S&S
edema. reduces the appear, slow
concentration infusion rate
and viscosity just
of blood in sufficiently to
patients with keep vein
decreased open, and
circulating report
blood immediately
volume and to physician.
also • Observe for
maintains bleeding
cardiac points that did
output in not bleed at
shock. In lower BP with
dehydrated injuries or
patients, surgery and as
albumin has BP rises.
little or no • Monitor I&O
clinical effect ratio and
on pattern.
circulating Report
blood changes in
urinary

14
 volume. output.
Albumin is Increase in
also used to colloidal
replace osmotic
protein in pressure
patients with usually causes
hypoproteine diuresis,
mia until the which may
cause of the persist 3–20
deficiency h.
can be • Withhold
determined. fluids
completely
during
succeeding 8
h, when
albumin is
given to
patients with
cerebral
edema.

NAME OF DOSAGE/FREQUE MECHANISM OF CLASSIFIC CONTRA ADVERSE NURSING

DRUG: NCY/ TIME ACTION ATION INDICATION EFFECT RESPONSIBILITIES
&ROUTE

Adults • known as a • Diureti • Contraind • Dizzines • As with any

GENERIC • The usual initial diuretic cs ications s, medication,
NAME: dose of LASIX (like a ('water to lighthea it’s important
for "water pills') furosemi dedness, for nurses to
hypertension is
Furosemide 80 mg, usually
pill"). It de use headach be familiar
divided into 40 helps your include e, or with the
mg twice a day. body get rid patients blurred specific
Dosage should of extra with vision diuretic(s) a
then be adjusted water by document may patient is
according to
response. If increasing ed allergy occur as taking,
response is not the amount to your including
satisfactory, add of urine you furosemi body indication,
other make. de and adjusts dosage and
antihypertensiv Getting rid patients to the administration
e agents.
of extra with medicati ,
BRAND water anuria. on. contraindicati
NAME: Geriatric
decreases ons,
Patients
the strain on interactions,
Lasix • In general, your heart and adverse
dose and blood effects. Below

15
 selection and vessels, Side effects are some
dose thereby of Lasix general
adjustment lowering include: considerations
for the high blood related to
elderly pressure and • increase diuretics.
patient reducing durinati Assess patients
should be your risk of on, for sulfa allergies,
cautious, strokes, • thirst as some diuretics
usually heart
• muscle are sulfonamide
starting at the attacks, and
cramps, derivatives.
low end of kidney
• itching Monitor weight,
the dosing problems.
or rash, intake, output, and
range This effect
• weaknes serum electrolyte
can also
s, levels.
improve
symptoms • dizzines Monitor blood
Adult and
such as s, glucose levels
Pediatric
trouble • spin (some agents may
Dosage Forms
breathing • sensatio cause
and Strengths
and swelling n, hyperglycemia).
(edema). • diarrhea Follow blood urea
• Injectable , nitrogen and
solution • stomach creatinine levels
pain, regularly.
10mg/mL and Administer
Oral solution constipation diuretics in the
morning to
10 mg/mL
prevent nocturia.
Tablet
Educate patients
-20 mg on the agent(s)
-40 mg they are
-80 mg prescribed and
review adverse
effects of therapy.

NAME OF DOSAGE/FREQUE MECHANISM CLASSIFICA CONTRA ADVERSE NURSING

DRUG: NCY/ TIME OF ACTION TION INDICATION EFFECT RESPONSIBILITIES
&ROUTE
• 5-60 mg/day • decreases • Glucoco • Prednison • blurred • Administer
GENERIC PO in single inflammati rticoids e is vision, once-a-day
NAME: daily dose or on via contraind • eye doses before
divided q6- suppression icated in pain, or 9AM to mimic
Prednisone 12hr of the patients seeing normal peak
migration with halos corticosteroid
around blood levels.
of document
lights;
polymorph ed

16
 Dosing onuclear hypersens • swelling • Increase
considerations leukocytes itivity to , dosage when
When converting and the drug • rapid patient is
reversing or weight subject to
from immediate-
increased compone gain, stress.
release to • feeling
capillary nts of the • WARNING:
delayed-release short of
permeabilit formulati Taper doses
formulation, note breath;
y. It also on. when
BRAND that delayed- • Severe
suppresses Contraind discontinuing
NAME: release depressi
the ications on, high-dose or
formulation long-term
immune to the • feelings
Rayos, takes about 4 system by administr therapy to
of
Sterapred, hours to release reducing ation of extreme avoid adrenal
Deltasone active substances the activity prednison happine insufficiency.
Note that and the e include ss or • Do not give
exogenous volume of the sadness, live virus
steroids suppress the presence • changes vaccines with
adrenal cortex immune of in immunosuppr
system. systemic personal essive doses
activity least
ity or of
during maximal fungal
behavior corticosteroid
natural adrenal infections ,
. s.
cortex activity • seizure
Teaching points
(between 4:00 (convuls
and 8:00 AM) ions);
▪ Do not stop
• bloody
or tarry taking the
• usually taken drug without
with food one stools,
to four times a • coughin consulting
day or once g up your health
every other day. blood; care provider;
• pancreat take once-
itis daily doses at
The main routes of • low about 9 AM.
administration of potassiu ▪ Avoid
corticosteroids are m
:
exposure to
dangerously infections.
high blood ▪ Report
• Oral (by
ingestion
pressure unusual
through the weight gain,
mouth). swelling of the
extremities,
• Parenteral
(intravenous or
muscle
intramuscular). weakness,
black or tarry
stools, fever,
prolonged
sore throat,
colds or other

17
 infections,
worsening of
the disorder
for which the
drug is being
taken.

DRUG ROUTE/D CLASSIFICA ACTION INDICATI CONTRADI ADVERSE NURSING

NAME OSAGE TION OF ON CTIONS EFFECTS CONSIDER
DRUGS ATIONS

GENERI ROUTE: THERAPE Inhibitis • Sympt • Contrai CNS: • False-

C P.O UTIC proton omatic ndicate positive
NAME: CLASS: pump GERD d in • Asthenia results
DOSAG Antiulcer activity withou patients • Dizziness in
• Ome E: drugs by t hyperse • Headache diagnos
prazo binding esopha nsitive tic
le • Capsu PHARMAC to geal to drug GI: investig
• Ome les OLOGIC hydroge lesions and its ations
prazo (delay CLASS: n- • Erosiv compo • Abdominal for
le ed PPIs potassiu e nents. pain neuroen
magn releas m esopha • Use • Constipati docrine
esiu e): adenosin gitis cautiou on tumors
m 10, e • Pathol sly in • Diarrhea may
20, 40 triphosp patients occur
ogic • Flatulence
BRAND mg hatase, hypers with due to
• Nausea
NAME: • Powd located ecretor hypoka increase
at • Vomiting
er for y lemia d CgA
• Acid
• Lose delay secretor conditi and level.
y regurgitati Tempor
c ed- ons respirat
on
• Prilo releas surface (such ory arily
sec e oral of as alkalosi stop
gastric MUSCULOS omepra
OTC suspe Zolling s in
parietal KELETAL: zole
nsion: er- patients
2.5 cells, to Ellison on a treatme
mg/pa suppress low- • Back pain nt at
syndro
cket, gastric me) sodium least 14
RESPIRATO
10 acid • Duode diet, days
mg/pa secretio and in RY: before
nal
cket n. ulcer breastfe assessin
• Table eding • Cough g CgA
(short-
ts term women. • URI level
(delay treatm • Long- and
ed- ent) term SKIN: conside
Rash
releas • Helico adminis r
e): 20 bacter tration repeatin
mg pylori of g the
infecti bicarbo test if

18
 on and nate initial
duoden with CgA
al calcium level is
ulcer or milk high. If
disease can serial
, to cause tests are
eradica milk- perform
te H. alkali ed (e.g.,
pylori syndro for
with me. monitor
clarithr \ ing), the
omyci same
n (dual commer
therap cial
y) laborato
• H. ry
pylori should
infecti be used
on and for
duoden testing,
al as
ulcer referenc
disease e ranges
, to between
eradica tests
te H. may
pylori vary.
with • Long-
clarithr term
omyci therapy
n and may
amoxic cause
illin vitamin
(triple B12
therap absorpti
y) on
• Short- problem
term . Assess
treatm patient
ent of for
active signs nd
benign sympto
gastric ms of
ulcer cyanoco
• Freque balamin
nt deficien
heartb cy
urn (2 (weakn
or ess,
more heart
palpitati

19
days a ons,
week) dyspnea
,
paresthe
sia, pale
skin,
smooth
tongue,
CNS
changes
, and
loss of
appetite
).
• Dosage
adjustm
ents
may be
necessa
ry in
Asians
and
patients
with
hepatic
impair
ment.
• Periodic
ally
assess
patient
for
osteopo
rosis.
• Drug
increase
s its
own
bioavail
ability
with
repeate
d doses.
Drug is
unstable
in
gastric
acid;
less
drug is
lost to

20
 hydroly
sis
because
drug
increase
s gastric
pH.
• Gastrin
level
rises in
most
patients
during
the first
2 weeks
of
therapy.
• ALERT
:
Prolong
ed use
of PPIs
may
cause
low
magnesi
um
levels.
Monitor
magnesi
um
levels
before
starting
treatme
nt and
periodic
ally
thereaft
er.
• ALERT
:
Monitor
patients
for
signs
and
sympto
ms of
low
magnesi

21
 um
level,
such as
abnorm
al HR
or
rhythm,
palpitati
ons,
muscle
spasms,
tremors
or
seizures
. In
children
, an
abnorm
al HR
may
present
as
fatigue,
upset
stomach
,
dizzines
s, and
light-
headedn
ess.
Magnes
ium
supple
mentati
on or
drug
disconti
nuation
may be
required
.
• Look
alike-
sound
alike:
Don’t
confuse
Prilosec
OTC
with

22
 Prozac,
prilocai
ne or
Prinivil.

DRUG ROUTE/DO CLASSIFI ACTION INDICATIO CONTRADI ADVERSE NURSING

NAME SAGE CATION OF DRUGS N CTIONS EFFECTS CONSIDER
ATIONS

GENER ROUTE: Bronchodi Salbutamo • Acute IV (in the SIGNIFICAN • Drug

IC P.O lators l is a bronch treatment T: may
NAME: direct- ospasm of decreas
Salbuta DOSAGE: acting • Prophy premature • Hypersensi e
mol sympatho laxis of labor): Pre- tivity sensitiv
• Inhalat mimetic exercis existing or reactions ity of
BRAND ion that acts e- risk factors (e.g., spirom
NAMES aerosol on B2- induce for urticaria, etry
: : 100 receptors d ischaemic angioedem used
mcg/ac to relax bronch heart a, rash, for
• Airo tuation bronchial ospasm disease, bronchosp diagno
mir , 108 smooth • Chroni gestational asm, sis of
• Com mcg/ac muscle c age <22 oropharyn asthma.
bive tuation with less bronch weeks, geal • Syrup
nt • Inhalat prominent ospasm conditions edema), contain
• Proai ion effect on • Severe in which hypokalem s no
r powder the heart. bronch prolongatio ia. alcohol
• Prov : 108 ospasm n of or
entil mcg/ac • Uncom pregnancy CARDIAC sugar
• Vent tuation plicate is DISORDERS: and
olin • Oral d hazardous, may be
• Xop solutio premat intrauterine • Tachycardi taken
enex n: 0.4 ure fetal death, a by
mg/mL labor known • Palpitation childre
• Solutio lethal s n as
n for congenital • Chest pain young
inhalati or lethal • Cardiac as age
on: chromoso arrhythmia 2.
0.021 mal s (rare) • In
% malformati • Myocardia childre
(0.63 on, l ischaemia n,
mg/3 pulmonary syrup
mL), hypertensio GASTROINT may
0.042 n. Non-IV ESTINAL rarely
% formulatio DISORDERS: cause
(1.25 n is not erythe
indicated ma
mg/3m • Nausea
for use in multifo
L), 0.5 • Vomiting
mg/mL uncomplica rme or

23
 ,1 ted • Mouth and Steven
mg/mL premature throat s-
,2 labor or irritation Johnso
mg/mL threatened n
, 0.5% abortion. GENERAL syndro
(5 DISORDERS me.
mg/mL AND • Monito
) ADMINISTR r
• Syrup: ATION SITE patient
2 CONDITION for
mg/5m S: effectiv
L eness.
• Tablets • Weakness Using
: 2 mg, drug
4 mg METABOLIS alone
• Tablets M AND may
(extend NUTRITION not be
ed- DISORDERS: adequa
release te to
): 4 • Hyperglyc control
mg, 8 emia asthma
mg in
MUSCULOS some
KELETAL patient
AND s.
CONNECTIV Long-
E TISSUE term
DISORDERS: control
medica
• Muscle tions
cramps may be
needed.
NERVOUS • ALER
SYSTEM T:
DISORDERS: Drug
may
• Tremor acuse
• Headache parado
• Dizziness xical
bronch
• Drowsines
ospasm
s
.
• Restlessne
Monito
ss
r
patient
PSYCHIATRI
closely
C
;
DISORDERS:
discont
inue
• Nervousne drug
ss immedi

24
• Irritability ately
• Insomnia and use
alternat
RESPIRATO ive
RY, therapy
THORACIC if
AND parado
MEDIASTIN xical
AL bronch
DISORDERS: spasm
occurs.
• Pharyngiti Bronch
s ospasm
• Rhinitis with
• Pulmonary inhaled
edema formul
ations
VASCULAR frequen
DISORDERS: tly
occurs
• Peripheral with
vasodilatio first
n use of
new
• Flushing
caniste
r or
vial.
• ALER
T:
Patient
may
use
tablets
and
aerosol
togethe
r.
Monito
r these
patient
s
closely
for
signs
and
sympto
ms of
toxicity
.
• Look
alike-

25
 sound
alike:
Don’t
confus
e
albuter
ol with
atenolo
l or
Albutei
n.
Don’t
confus
e
Salbuta
mol
with
salmete
rol.

VII. ANATOMY AND PHYSIOLOGY

Immunity is the body’s specific protective response to a foreign agent or organism.

Immune system functions as the body’s defense mechanism against invasion and allows a rapid
response to foreign substances in a specific manner.

Apoptosis, or programmed cell death, is the body’s way of destroying worn-out cells such as blood
or skin cells or cells that need to be renewed.

Diffuse connective tissue disease refers to a group of systemic disorders that are chronic in nature
and are characterized by diffuse inflammation and degeneration in the connective tissues. These disorders
share similar clinical features and may affect some of the same organs. The characteristic clinical course is
one of exacerbations and remissions. Although diffuse connective tissue diseases have unknown causes,
they are thought to be the result of immunologic abnormalities.

Systemic Lupus Erythematosus is an inflammatory, autoimmune disorder that affects nearly

every organ in the body. The overall incidence of SLE is estimated to be 1.8 to 7.6 per 100,000 persons.
The lifetime risk of developing SLE is 0.91% for women and 0.21% for men. It occurs 6 to10 times more
frequently in women than in men and occurs more in African American populations than among Caucasians.
It 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 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 propensity to get trapped in the capillaries of visceral structures.
The antibodies also act to destroy host cells. It is thought that those two mechanisms are responsible for the
majority of the clinical manifestations of this disease process. It is hypothesized that the immunoregulatory
disturbance is brought about by some combination of four distinct factors: genetic, immunologic, hormonal,
and environmental

26
 The mucocutaneous, musculoskeletal, renal, nervous, cardiovascular, and respiratory systems are
most commonly involved in SLE. Less commonly affected are the gastrointestinal tract and liver as well as
the ocular system. The most familiar skin manifestation (occurring in less than 50% of patients with SLE)
is an acute cutaneous lesion consisting of a butterfly shaped erythematous rash across the bridge of the nose
and cheeks.

Joint symptoms, with arthralgias and/or arthritis (synovitis), occur in more than 90% of patients
with SLE and are commonly the earliest manifestation of the disease process. Joint swelling, tenderness,
and pain on movement are also common. Frequently, these are accompanied by morning stiffness.

The cardiac system is also commonly affected in SLE. Pericarditis is the most common cardiac
manifestation, occurring in 6% to 45% of patients. Patients may present with substernal chest pain that is
aggravated by movement or inspiration. Symptoms can be acute and severe or last for weeks at a time.
Other cardiac symptoms may involve myocarditis, hypertension, cardiac dysrhythmias, and valvular
incompetence.

Nephritis as a result of SLE, also referred to as lupus nephritis, occurs due to a buildup of antibodies
and immune complexes that cause damage to the nephrons. Serum creatinine levels and urinalysis are used
in screening for renal involvement. Early detection allows for prompt treatment so that renal damage can
be prevented.

Central nervous system involvement is widespread, encompassing the entire range of neurologic
disease. These are generally demonstrated by subtle changes in behavior patterns or cognitive ability.

27
 VII. PATHOPHYSIOLOGY
PREDISPOSING FACTORS
Age: Most people are diagnosed with lupus between the ages
of 15 and 45, although it can occur at any time.
Sex: Nine out of 10 people diagnosed with lupus are female
PRECIPITATING FACTORS
Sunlight: Exposure to the sun may bring on lupus skin lesions or
trigger an internal response in susceptible people.
Infections: Having an infection can initiate lupus or cause a relapse in
some people.

Family history: Most people with SLE do not have family
members with the disease; however, some people with SLE
do have a family history of the disease. Men and women with
an immediate family member with SLE have only a slightly
higher risk for the disease.
Medications: Lupus can be triggered by certain types of blood
pressure medications, anti-seizure medications and antibiotics. People
who have drug-induced lupus usually get better when they stop taking
the medication. Rarely, symptoms may persist even after the drug is
stopped.

DISEASE PROCESS SIGNS AND SYMPTOMS

Environmental triggers  apoptosis  a lot of nuclear antigens release  General symptoms: Fever, weight loss
immune response antinuclear antibodies bind with nuclear antigen 
deposits in tissues  inflammation  symptoms of lupus Specific symptoms depend on the organ/ tissue.

COMPLICATIONS
• Kidneys. Lupus can cause serious kidney damage, and kidney failure is one of the leading causes of death
among people with lupus.
• Brain and central nervous system. If your brain is affected by lupus, you may experience headaches,
dizziness, behavior changes, vision problems, and even strokes or seizures. Many people with lupus experience
memory problems and may have difficulty expressing their thoughts.
• Blood and blood vessels. Lupus may lead to blood problems, including a reduced number of healthy red blood
cells (anemia) and an increased risk of bleeding or blood clotting. It can also cause inflammation of the blood
vessels.
• Lungs. Having lupus increases your chances of developing an inflammation of the chest cavity lining, which
can make breathing painful. Bleeding into lungs and pneumonia also are possible.
• Heart. Lupus can cause inflammation of your heart muscle, your arteries or heart membrane. The risk of
cardiovascular disease and heart attacks increases greatly as well.
• Infection. People with lupus are more vulnerable to infection because both the disease and its treatments can
weaken the immune system.
• Cancer. Having lupus appears to increase your risk of cancer; however, the risk is small.
• Bone tissue death. This occurs when the blood supply to a bone decline, often leading to tiny breaks in the
bone and eventually to the bone's collapse.
• Pregnancy complications. Women with lupus have an increased risk of miscarriage. Lupus increases the risk
of high blood pressure during pregnancy and preterm birth. To reduce the risk of these complications, doctors
often recommend delaying pregnancy until your disease has been under control for at least six months.

28
IX. PRIORITIZATION

PRIORITIZED NURSING DIAGNOSIS JUSTIFICATION

1. Fluid volume excess r/t compromised Fluid volume excess is the first priority nursing
regulatory mechanism aeb (+) bipedal edema diagnosis that needs to be addressed
immediately. Maintenance of an adequate fluid
balance is vital to health. Excessive fluid intake
can lead to over dehydration, which in turn can
affect cardiac and renal function and electrolyte
management. Fluid management is an essential
part for any patient admitted to the hospital. In
critically ill patients, fluid overload is related to
increased mortality and lead to several
complications.
2. Ineffective airway clearance sec to pleural This falls under the second priority even if it is
effusion aeb RR of 29bpm airway related because what we need is to
address first the cause of the ineffective airway
clearance which is the excess fluid or the edema
that the pt had due to accumulation of fluid in
the pleural spaces.
3. Acute pain Acute Pain is the third priority nursing
diagnosis since pain interferes with many daily
activities. Pain does not have to be tolerated but
can be treated to improve the comfort and
quality of life. When treated early, pain is easier
to control.
4. Fatigue Fatigue is the 4th priority nursing diagnosis and has
to be solved for the patient to willingly participate
with the treatment regimen. Managing of fatigue
can be perform after prioritizing the top 3 nursing
diagnosis.
5. Deficient knowledge Deficient knowledge is the least prioritize
nursing diagnosis since it does not require
immediate attention and may be done later as
health teaching to the patient.

29
X. NURSING CARE PLAN
Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Excess fluid Short term Independen Independent Short term

volume r/t goal: t nursing: nursing: goal:
“Nagmamana compromise
s yung After 2hrs of 1. Review 1. Such Goal met.
d regulatory
katawan nya, nursing patient’s information
mechanism
nung pipindot interventions history to can assist to After 2hrs of
aeb (+)
the client determine direct nursing
yung balat nya bipedal
will be able the probable management. interventions
lumulubog” as edema
to verbalize cause of the History may the client
verbalized by
at least 2 fluid include was able to
the client’s imbalance. increased verbalize at
measures
mother. fluids or least 2
that can be
taken to treat sodium intake. measures
or prevent that can be
Objective fluid volume taken to treat
Cues: excess. 2.Monitor 2. Sudden or prevent
weight weight gain fluid volume
• Positive regularly may mean fluid excess as
bipedal Long term using the retention. evidenced by
edema goal: same scale Different scales verbalization
• Edema all and and clothing of I&O and
over the After 5 days preferably at may show false elevation of
body of nursing the same weight edematous
• Distended interventions time of day inconsistencies extremity.
stomach , the client wearing the .
• Hgb: 89 will be able same amount
• Hct: .28 to have a of clothing. Long term
• I: 875ml balanced goal:
• O: 3 intake and
soiled output. 3. Monitor 3. Dehydration Goal met.
diapers input and may be the
After 5 days
output result of fluid
of nursing
closely shifting even if
interventions
overall fluid
, the client
intake is
was able to
adequate.
have a
balanced
intake and
4. Assess 4. In some output aeb
weight in patient with
relation to heart failure, • I:500ml
nutritional the weight may • O:500ml
status. be a poor
indicator of
fluid volume

30
 status. Poor
nutrition and
decreased
appetite over
time result in a
decrease in
weight, which
may be
accompanied
by fluid
retention even
though the net
weight remains
unchanged.

5. Monitor 5. Sinus
and note BP tachycardia
and HR. and increased
BP are evident
in early stages.

6. Note for 6. Edema

presence of occurs when
edema by fluid
palpating accumulates in
over the the
tibia, ankles, extravascular
feet, and spaces. Pitting
sacrum. edema is
manifested by
a depression
that remains
after one’s
finger is
pressed over an
edematous area
and then
removed.

7. Assess for 7. These signs

crackles in are caused by
the lungs, an
changes in accumulation
respiratory

31
pattern, of fluid in the
shortness of lungs.
breath, and
orthopnea.

8. All are
8. Review
indicators of
serum
fluid status and
electrolytes,
guide therapy
urine
osmolality,
and urine
specific
gravity.

9. Elevate 9. Elevate
edematous edematous
extremities, extremities,
and handle and handle
with care. with care.

10. Aid with 10.

repositioning Repositioning
every 2 hours prevents fluid
if the patient accumulation
is not in dependent
mobile. areas.

Health Health
education: education:
11. Instruct 11.
patient, Information
caregiver, and knowledge
and family about condition
members are vital to
regarding patients who
fluid will be co-
restrictions, managing
as fluids.
appropriate.

12. 12. Restriction

Emphasize of sodium aids

32
 limitation in in decreasing
sodium fluid retention
intake as
prescribed.

13. Information
13. Educate
is key to
patient and
managing
family
problems.
members
regarding
fluid volume
excess and
its causes.

Dependent Dependent
nursing: nursing:
14. 14. Diuretics
Administer aids in the
diuretics as excretion of
prescribed. excess body
fluids.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Ineffective Short term 1. Assess LOC 1.To identify Short term
“Nahihirapan na airway clearance goal: and ability to potential goal:
akong huminga sec to pleural After 2 hours protect own airway
kaya minsan nagne- effusion of nursing airway. problems, After 2 hours
nebulizer ako.” As interventions, providing of nursing
verbalized by the the patient will baseline level interventions,
patient. be able to of care needed the patient
and maintained
maintain
influencing airway
Objectives: airway
choices of patency.
patency.
interventions.
• Restlessness
• Use of
accessory Long term 2.Elevate head Long term
2.To take
muscles goal: of the bed, goal:
advantage of
• Edema all over After 8 hours encourage early
gravity
the body of nursing ambulation or After 8 hours
decreasing
change client’s
• Hooked in o2 interventions, pressure on of nursing
the patient will position every 2
• Cyanosis the diaphragm interventions,
be able to hours. the patient has
• RR: 26 and enhancing
ventilation to

33
 improve clear differed lung improved clear
airway. segments. airway.

3.Keep
environment 3.To avoid
allergen free. allergens that
trigger
symptoms.

4.Mobilize the 4.This reduces

client as the risk or
frequently as effects of
possible. atelectasis,
enhancing
lung
expansion and
drainage of
differed lung
segments. It
also prevents
bed sores.
5. Position
appropriately.
5.For lung
expansion.
Dependent:

6. Administer Dependent:
analgesics.
6. To improve
cough when
pain is
inhibiting
7. Administer effort.
medications
(bronchodilators,
expectorants, 7. To relax
mucolytics). smooth
respiratory
musculature.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Acute pain Short term Independent Independent Short term

Cue: related to goal: nursing: Nursing: goal:
inflammation After 2 hours of 1. Note client’s 1. Impacts ability to Goal met,
“Sobrang sakit associated with nursing age, report pain
After 2 hours of
ng ari ko halos increased intervention the developmental parameters.
di na ako diseases patient will be level, and current nursing
makalakad” as activity able to report a condition intervention the
verbalized by decreased level (infant/child, patient was
the patient of pain scale critically ill, able to report a
ventilated,

34
Objective cue: from 8 over 10 sedated, or decreased level
to 3 over 10 cognitively of pain scale
• Facial impaired). from 8 over 10
grimace to 3 over 10
• Moaning Long term
or other goal:
pain After 4 hours of 2. Assess pain
nursing reports, noting Long term
associated
interventions, location, 2. Pain is a goal:
sounds
the patient characteristics, subjective Goal met,
will and severity (0 to experience.
Ongoing assessment After 4 hours of
demonstrate 10 [or similar]
is needed for nursing
use of scale).
relaxation Investigate and evaluating interventions,
skills, other report changes in effectiveness of the patient
methods to pain, as medication and will be able to
promote appropriate. progression of demonstrate
comfort healing. Changes in
use of
characteristics of
pain may indicate relaxation
developing abscess skills, other
or peritonitis, methods to
requiring prompt promote
medical evaluation comfort
and intervention.

3. Observe
nonverbal cues 3. Nonverbal cues
and pain may or may not
behaviors (e.g., support client’s pain
how client holds intensity, but may
body, facial be the only indicator
expressions such if client is unable to
as grimacing, verbalize.
withdrawal,
narrowed focus,
crying).

4. Monitor skin 4. May be related by

color and acute pain.
temperature, as
well as vital
signs (e.g., heart
rate, blood
pressure,
respirations).

5. Encourage
early
ambulation.
5. Promotes
normalization of
organ function;
stimulates
peristalsis and
passing of flatus,
reducing abdominal
6. Provide discomfort.
comfort
measures (e.g.,
touch,

35
repositioning, 6. To promote
quiet nonpharmacological
environment, pain management
focused
breathing).

7. Provide
diversional
activities.
7. Refocuses
Simple,
attention, promotes
everyday
relaxation, and may
activities like
enhance coping
walking,
abilities.
swimming,
gardening and
dancing can ease
some of the pain
directly by
blocking pain
signals to the
brain. Activity
also helps lessen
pain by
stretching stiff
and tense
muscles,
ligaments and
joints.

8. Encourage the
client to assume
an anatomically
correct position
with all joints. 8. To promote
Suggest that the nonpharmacological
client uses a pain management
small flat pillow
under the head
and not use a
knee gatch or
pillow to prop
the knee.

9. Encourage the
client to perform
range-of-motion
(ROM) exercises
after the shower 9. These exercises
or bath, two help reduce stiffness
repetitions per and maintain joint
joint mobility.

10. Instruct the

client to take
anti-
inflammatory
medications as 10. The sooner the
client takes the

36
 prescribed. medication, the
Explain the need sooner the stiffness
for taking the will abate. Anti-
first dose of the inflammatory drugs
day as early in should not be taken
the morning as on an empty
possible with a stomach
small snack.

Collaborative
nursing:

11. Administer
Collaborative
analgesics, as
nursing:
indicated, to
maximum 11. Promotes
dosage needed to comfort and
maintain facilitates
comfort. cooperation with
other therapeutic
interventions, such
as ambulation.

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective Cues: Fatigue STG: Independent: STG:

related to After 3-4 hours Goal met.
“Nahihirapan disease of nursing 1. Identify the 1. Important After 3-4
akong makatulog condition as intervention, presence of physical information can hours of
at paputol putol evidenced by the patient will and /pr psychological be obtained nursing
ang tulog ko. difficulty be able to conditions. from knowing if intervention,
Dalawang oras na sleeping. verbalize fatigue is a the patient
result of an
yata ang reduction in was able to
underlying
pinakamatagal fatigue level, as verbalize
condition or
kong tulog tapos evidenced by reduction in
disease process
magigising na uli improved sense and/or whether fatigue level,
ako” as verbalized of energy. fatigue has been as evidenced
by the patient. present for a by improved
long period of sense of
LTG: time without any energy.
Objective Cues: After 10- identifiable
12hours of cause. LTG:
• Lethargy nursing 2. Obtain patient/SO Goal met.
• Muscle intervention, descriptions of 2. To assist in After 10-
weakness the patient will fatigue. evaluating the 12hours of
be able to impact on the nursing
participate in client’s life. intervention,
recommended the patient
treatment was able to
program. 3. Ask client to rate participate in
fatigue using a 0-10 3. Fatigue may
recommended
scale. vary in intensity
and is often
accompanied by

37
 irritability, lack treatment
of program.
concentration,
difficulty
making
decisions and
relationship
difficulties that
can add to stress
level and
aggravate sleep
patterns.

4. Assess the patient’s

emotional reaction to 4. The common
fatigue. emotional
responses
associated with
fatigue are
anxiety and
depression.
These emotional
conditions can
increase the
person’s fatigue
level and
produces a
vicious cycle.

5. Determine the
client’s nighttime 5. The
sleep pattern. discomfort
associated with
systemic lupus
erythematosus
(SLE) may
obstruct sleep.

6. Restrict
environmental stimuli, 6. Vivid
especially during lighting, noise,
planned times for rest visitors,
and sleep. numerous
distractions, and
litter in the
patient’s
physical
surroundings
can limit
relaxation,
disturb rest or
sleep, and
contribute to
fatigue.

38
 7. Aid the patient
develop habits to
promote effective 7. Promoting
rest/sleep patterns. relaxation
before sleep and
providing for
several hours of
uninterrupted
sleep can
contribute to
energy
restoration.
8. Encourage the
client to sleep in an
anatomically correct 8. Good body
position and not to alignment will
prop up affected result in muscle
joints. relaxation and
comfort.

9. Encourage the client

to frequently change
position at night. 9. Repositioning
promotes
comfort.
10. Encourage the use
of progressive muscle-
relaxation techniques. 10. These
techniques
promote
relaxation and
Dependent nursing: rest.
11.Administer a
Dependent
nighttime analgesic
nursing:
and/or a long-acting
11.The relief of
anti-inflammatory
pain can
drug as prescribed.
facilitate rest
and sleep.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

“Bata pa kasi “Deficient Short term 1. Identify the 1. Some patients Short term
kaya wala pa Knowledge goal: learner: the patient, especially older goal:
family, significant adults or the
masyadong r/l to Goal met
alam” condition, After 2-3 other, or caregiver. terminally ill view After 2-3
themselves as
treatment hours of
dependent on the hours of
As verbalized and nursing caregiver, nursing
by the procedure intervention therefore will not intervention

as the patient allow themselves

the patient

39
patient’s evidenced will be able to be part of the understands
mother. by to know and educational the disease
process.
Expressing understand process and
frustration the disease treatment
or process and regimen.
2. Learning
confusion treatment requires energy.
OBJECTIVE: when regimen. 2. Assess
Patients must see a
motivation and
performing need or purpose
-Anxious willingness of
task” patient to learn.
for learning. They
also have the right
-Nervousness to refuse
educational
- Restlessness Long term services. Long term
goal: goal:

After 1-2 Goal met

3. Determine 3. Knowing what
days the
priority of learning to prioritize will
patient will After 1-2
needs within the help prevent
be able to overall care plan. wasting valuable
days the
initiate time. patient
necessary initiated
lifestyle 4. Allow the patient necessary
changes to open up about 4. They learn best lifestyle
previous when teaching changes and
and
experience and builds on previous participates in
participates health teaching. knowledge and
in treatment treatment
experience.
regimen. regimen.

5. Observe and note

existing 5. Assessment
misconceptions provides an
regarding material important starting
to be taught. point in education.
Knowledge serves
to correct faulty
ideas.

6.
6. Acknowledge
Acknowledgement
racial/ethnic
of racial/ethnicity
differences at the
issues will enhance
onset of care.
communication,
establish rapport,
and promote
treatment
outcomes.

40
 7. Interventions
need to be specific
7. Identify cultural to each patient
influences on considering their
health teaching. individual
differences and
backgrounds.

8. Matching the
8. Consider the learner’s preferred
patient’s learning style with the
style, especially if educational
the patient has method will
learned and facilitate success
retained new in mastery of
information in the knowledge.
past.

9. Self-efficacy
9. Determine the refers to a person’s
patient’s self- confidence in his
efficacy to learn or her own ability
and apply new to perform a
knowledge. behavior.

10. The patient

brings to the
10. Assess barriers learning situation a
to learning unique
(perceived change personality,
in lifestyle, established social
financial concerns, interaction
cultural patterns, patterns, cultural
lack of acceptance norms and values,
by peers or and environmental
coworkers). influences.

11. Ensuring
physical comfort
11. Render allows the patient
physical comfort to concentrate on
for the patient. what is being
discussed or
demonstrated.

12. Conveying
respect is
especially

41
12. Provide an important when
atmosphere of providing
respect, openness, education to
trust, and patients with
collaboration. different values
and beliefs about
health and illness.

13. Goal setting

allows the learner
13. Include the
to know what will
patient in creating
be discussed and
the teaching plan,
expected during
beginning with
the session.
establishing
objectives and
goals for learning
at the beginning of
the session.
14. Allowing the
patient to identify
the most
14. Consider what significant content
is important to the to be presented
patient. first is the most
effective.

15. Assessment
assists the nurse in
15. Explore understanding how
reactions and the learner may
feelings about respond to the
changes. information and
possibly how
successful the
patient may be
with the expected
changes.

16. Enhances
16. Conduct Health
patient and
Teaching about the
family’s
disease process,
knowdlege.
treatments and
procedures to be
done.

17. Patients are

17. Provide clear, better able to ask
thorough, and questions when
understandable they have basic

42
explanations and information about
demonstrations. what to expect.

18. When 18. This method

presenting a allows the patient
material, start with to understand new
the basics or material in relation
familiar, simple, to familiar
and concrete material.
information to less
familiar, complex
ones.

19. Encourage
19. Questions
questions
facilitate open
communication
between patient
and health care
professionals and
allow verification
of understanding
of given
information.

20. Note progress 20.

of teaching and Documentation
learning. allows additional
teaching to be
based on what the
learner has
completed.

21. Help patient 22. Learning

identify occurs through
community imitation, so
resources for persons who are
continuing currently involved
information and in lifestyle changes
support. can help the
learner anticipate
adjustment issues.

43
XI. DISCHARGE PLAN

• Medication prescribed to the patient must be taken

appropriately and on time
• Take vitamins to boost immune system
• Encourage patient to report any adverse side effects of
the drugs
• Steroids: These decrease inflammation. They may be
given as a pill or ointment. Emphasize the need to follow
the schedule of medication when to take and not to
MEDICATION
continuous take it because it can increase the risk for
infection due to immunosuppression.
• Take your medicine as directed.
• Contact your healthcare provider if you think your
medicine is not helping or if you have side effects. Tell
him or her if you are allergic to any medicine. Keep a list
of the medicines, vitamins, and herbs you take. Include
the amounts, and when and why you take them. Bring
the list or the pill bottles to follow-up visits. Carry your
medicine list with you in case of an emergency.
• If patient is going out encourage to wear mask
• Ensure patient is always safe from hazards
ENVIRONMENT • Maintain a clean and quiet environment to promote
relaxation
• Provide clean and comfortable environment
• Continue home medications
TREATMENT • Encourage patient to take multivitamins for immunity

• 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.
HEALTH TEACHINGS
• Avoid others who are sick: You are at increased risk of
a severe infection.
• Treat flares quickly: This will help prevent serious
illness.
• Emphasize to prioritize strengthening the immune
system by eating healthy foods and taking vitamin
supplements.
• Encourage not to have many visitors if possible.

If ever joint pain develops:

44
 • 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.
• Patient will be advised to go back in the hospital in a
specific date to have a follow up check up
OPD
• Consult with doctor if any problems occurred or
complications encountered
• Diet as tolerated as possible with restriction of fluid and
sodium intake.
• Eat a nutritious, well-balanced, and varied diet that
contains plenty of fresh fruits and vegetables, whole
DIET grains and moderate amounts of meats, poultry, and fish.
• Increase albumin level by eating foods rich in albumin
such as egg white.
• Eat foods that will boost the immune system to prevent
infections/diseases.

• Support client religious practices

SPIRITUAL • Take time to go to church
• Strengthen faith and communicate with God

References:

• Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (10th ed., Vol. 1). (n.d.). .
• Systemic Lupus Erythematosus (SLE). (n.d.). Center for Disease Control & Prevention.
Retrieved August 9, 2022, from https://www.cdc.gov/lupus/facts/detailed.html#sle
• Temitope, H. (2020, September 8). Excess fluid volume – nursing diagnosis & care plan.
Nurseslabs. Retrieved March 9, 2022, from https://nurseslabs.com/excess-fluid-volume/
• Gardner, Stephanie. “Why Do My Nails Look Weird? Nail Changes That Signal Illness.”
WebMD, 6 Mar. 2021, www.webmd.com/skin-problems-and-treatments/nails-look-
weird#:~:text=Do%20they%20look%20pale%20or.
• Sethi, Saurabh. “What You Need to Know about Abdominal Swelling.” Healthline, 10
Sept. 2012, www.healthline.com/health/abdomen-swollen.+
• 5 Facts about Lupus & Mental Health. (n.d.). Lupus Research Alliance.
https://www.lupusresearch.org/5-facts-about-lupus-mental-health/
• Abu-Shakra, M. (2016). Quality of Life, Coping and Depression in Systemic Lupus
Erythematosus. The 4th Israel-Italy Meeting.
https://www.ima.org.il/FilesUploadPublic/IMAJ/0/193/96903.pdf

45
• Ahn, G. E., & Ramsey-Goldman, R. (2012). Fatigue in systemic lupus erythematosus.
International journal of clinical rheumatology, 7(2), 217–227.
https://doi.org/10.2217/IJR.12.4
• Goyal, A., Cusick, A., & Bhutta, B. (2022, February 9). Peripheral Edema. NCBI.
https://www.ncbi.nlm.nih.gov/books/NBK554452/
• Jewett-Tennant, J. (2020, January 31). Does Lupus Cause Miscarriages? Very Well
Health. https://www.verywellhealth.com/lupus-and-miscarriage-2249978
• Koenig H. G. (2012). Religion, spirituality, and health: the research and clinical
implications. ISRN psychiatry, 2012, 278730. https://doi.org/10.5402/2012/278730
• Macejová Z, Záriková M, Oetterová M. Systemic lupus erythematosus--disease impact on
patients. Cent Eur J Public Health. 2013 Sep;21(3):171-3. doi: 10.21101/cejph.a3818.
PMID: 24344545.
• Nall, R. (2018, September 17). How Many Times Should You Poop a Day? Healthline.
https://www.healthline.com/health/how-many-times-should-you-poop-a-day
• Sammaritano, L. (n.d.). Lupus and Contraception: Essentials for Patients. HSS.
https://www.hss.edu/conditions_lupus-contraception-essentials-patients.asp
• Systemic Lupus Erythematosus. (2022, February 12). NCBI.
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• Lab tests for lupus. Lupus Foundation of America. (n.d.). Retrieved March 10, 2022, from
https://www.lupus.org/resources/lab-tests-for-lupus
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2022, from https://www.youtube.com/watch?v=0junqD4BLH4

46