SYSTEMIC LUPUS

ERYTHEMATOSUS,
COMMUNITY ACQUIRED
PNEUMONIA
• PATIENT’S PROFILE
 
• Name: MS. C.M.
• Age: 28
• Sex: Female
• Civil Status: Single
• Address: Bitoon, Dumanjug Cebu
• Occupation: None
• Nationality: Filipino
• Religion: Roman Catholic
• Date and Time: February 08, 2020
• Hospital # : Ward and Bed # : C-846
• Admitting Diagnosis: Systemic Lupus Erythematosus in Flare, Community
• Acquired Pneumonia, Myositis
• Chief Complaints: Malar rash and weakness of U/L Extremities
• Attending Physician: Dr. Ronald N. Eullaran M.D., FPCP, FPRA
Internal Medicine & Rheumatology
• PERTINENT NURSING HEALTH HISTORY
• History of present illness:
• A case of patient C.B.M. 28 years old, female, single, Filipino,
• Roman Catholic from Bitoon Dumanjug Cebu was admitted for the first time in Chung Hua
Hospital for a chief complaint of severe weakness of upper and lower extremities and malar rash.
• January 2019 patient delivered a live baby boy in CHH, 3 days postpartum patient
experienced tolerable weakness in upper and lower extremities no check-up done, instead they
went to a HILOT and eventually weakness vanished. August 2019 patient noticed small red itchy
scratched in her right check and U/L extremities weakness. September 2019 another small red
itchy scratched in her left check and still weakness was noted. October 2019 first week she
noticed that the scratch in her right check becomes bigger that why she went to a dermatologist
and she was given unrecalled liquid wash and lotion moisturizer and rashes vanished away.
Middle of December they went to the beach, when they went home she noticed redness in her
both checks and pain in her joints, still no check-up done then by 2nd week of January patient
had mouth sores and the lips are swelling, productive cough but unable to expectorate and
alopecia, rashes in the body thus prompted her to seek medical advice and was admitted in St.
Vincent General Hospital for 4 days and was diagnosed as Rubella and unconfirmed SLE. One
week prior to admission in CHH patient noted severe weakness of both upper and lower
extremities and malar rash, hence consult with attending physician.
• Previous Hospitalization:
• January 13, 2020 – St. Vincent General Hospital – Rubella, SLE
• Past Health History:
• Patient experienced minimal tolerable joint pains
• Family History:
• Patient has a family history of hypertension in his paternal side
• Others:
• Non-smoker
• Non-alcoholic drinker
• No food and drug allergies
GENERAL SURVEY
Received patient lying flat on bed with venoclysis #1 PNSS 1liter @___

Anatomical Area Normal Findings Abnomal Findings

SKIN ,HAIR & NAIL    Malar rash noted and rash in the trunk
 Hairloss noted
 

HEAD AND NECK  Head is moist ,small round ,face is symmetric , no  

lesions noted ,
 Neck no swollen lymphnodes
 

Mouth, Nose, Sinus  Pink lips,moist tonge, no tonsilopharyngeal  Mouth sores are present in the bucal cavity
congestion  Lips are swollen
 No nasal flaring, no colds
 Sinus not tender

Eye and Ear  Aninteric scleria,pink palpebral conjunctivae, 20/20  

vision
 With enough serumen, no hearing problem

Thoracic and Lung  Equal chest expansion, equal tactile fremitus, clear  With productive cough
breath sounds
 No difficulty of breathing
1. Self Perception & Self Concept Patient taught of not acquiring the disease of they don’t Although weak, still manages to be calm and relaxed,
have family hx of SLE hopeful and positive, major concern is her fast recovery

1. Roles & Relationship The patient serves as bread-winner in their family, she has The patients lie-in partner and her family takes care of her
live-in partner, they have 1 son

1. Stress Tolerance & Coping She said that she easily got stressed and her coping She keeps on praying , make a video call to her son, watch tv,
mechanism is just to browse internet browse internet
 

1. Values & Belief Pt. is a Roman Catholic and she used to go to church Pt said that she’s faith become stronger, she make God as her
every Sunday when she stayed here in the city strength
 
 Admission_________________
Agency: ________________________Ward and Bed No. _____________ Medical Diagnosis:
_________________________________________________
Name of Student:______________________________________ Name of Physician: ____________________________________ Case Number
______________
NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE NSG. RESPONSIBILITIES
REACTIONS
Generic Name General Classification     Contraindicated in: Active Adverse rxn/side Before
Corticosteroids corticosteroids PREDNISONE: have minimal PREDNISONE: used untreated infections; effects are much . Check doctor's order
    mineralocorticoid activity systemically and locally in lactation; known alcohol, more comon with . check pt's hx of
    a wide variety of chronic bisulfite, or tartrazine high-dose /long term hypersensitivity
Trade Name   diseases including: hypersensitivity or intolerance therapy . explain the MOA of the
hydrocortisone   inflammatory, allergic, Use Cautiously in: Chronic CNS: Depression, medication
prednisone   hematologic,neoplastic, treatment; hypothyroidism; euphoria, headache, . do handwashing
    autoimmune disorders Cirrhosis; increase ICP, . Assess patient for signs of
      Pedi: Children ( chronic use wil psychoses, adrenal insufficiency
      result in decrease growth; use restlessness During:
      lower possible dose for ENT: Cataracts, . Assist pt to a.comfortable
Patient’s Dose     shortest period of time) stress increase intra ocular position
      (surgery, infections) pressure . Check pt's identity
5 mg/day     OB: Pregnancy (safety not CV: hypertension . Assess pt for s/s of adrenal
  Functional Classification   established) GI: peptic ulceration, insufficiency
  corticosteroids   anorexia, n/v After:
Maximum Dose   DERM: acne, . Document medication
    decrease wound administration
  Patient’s Indication healing . Observe patient 30 to 1 hour
5 mg/day allergy after taking and document any
  usualities and report to the
  doctor
Minimum Dose
5mg/day
DRUG STUDY
Client’s Name:____________________________________________Age:_______Gender:_________Ht._____Wt:_____Date of Admission_________________
Agency: ________________________Ward and Bed No. _____________ Medical Diagnosis: _________________________________________________
Name of Student:______________________________________ Name of Physician: ____________________________________ Case Number ______________
NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE REACTIONS NSG. RESPONSIBILITIES

Generic Name General Classification     Hyper- CNS: anxiety, dizziness, Before

Mycophenolate immunosuppressants Inhibits the enzyme Prevention of rejection Sensitivity to polysorbate headache, insomnia, . Check doctor's order
mofetil   inosine monophosphate in allogenic renal , OB: pregnancy mor tremor, CV: edema, . check pt's hx of
    de-hydrogenase, which hepatic, and cardiac lactation hypertension, tachycardia hypersensitivity
    is involved in purine transplantation. Use cautiously in: active Derm: rashes . explain the MOA of the
Trade Name   synthesis. This medication
Cellcept   serious pathology of the Endo: hyperglycemia, . monitor hepatic and
    inhibitions results in GI tract, phenylketonuria, hyperkalemia, renal status
    suppression of T and B severe renal impairement hypocalcemia, . monitor CBC with
    lymphocyte Geri: increased risk of hypomagnesemia differential
    proliferation adverse reaction GI: GI bleeding, anorexia, During:
Patient’s Dose     constipation, diarrhea . Instruct patient to
      GU: renal dysfunction take medication exactly
500mg tab OD pc   HEMAT: leukocytocis, as directed and
breakfast Functional Classification leukopenia,
  continue full course of
thrombocytopenia, therapy
  anemia RESp: cough,
Maximum Dose After:
  dyspnea . Document medication
  Misc: fever, infection, administration
  increased malignancy . Observe patient after
  taking and document any
  usualities and report to
Minimum Dose the doctor
 
Client’s Name:____________________________________________Age:_______Gender:_________Ht._____Wt:_____Date of Admission_________________
Agency: ________________________Ward and Bed No. _____________ Medical Diagnosis: _________________________________________________
Name of Student:______________________________________ Name of Physician: ____________________________________ Case Number ______________

NAME OF DRUG CLASSIFICATION MECHANISM OF ACTION INDICATION CONTRAINDICATION ADVERSE NSG. RESPONSIBILITIES
REACTIONS
Generic Name General Classification     Hyper- CNS: Before
Hydroxy-chloroquine Anti-malarials, Inhibits protein synthesis in Suppression/ Sensitivity to hydroxy- Seizures, . Check doctor's order
  Anti-rheumatics susceptible organisms by Chemo- chloroquine; Anxiety, . check pt's hx of
    inhibiting DNA an RNA Prophylaxis Previous visual Confusion, hypersensitivity
    polymerase. Of malaria. Damage from Headache . explain the MOA of the
Trade Name:     Treatment of severe medication
hydroxy-chloroquin Irritability . do handwashing
PLAQUENIL   Therapeutic rheumatoid
  Use cautiously EENT: . Assess deep
  Effects: Arthritis/
    In concurrent Visual Tendon reflex periodically
    Death of plasmodia Systemic lupus Use of hepatotoxic Distur-bance,
respnsible for causing Eryth-ematous to determine muscle
    Drugs, history ototoxicity, weakness
Patient’s Dose   malaria. Also has anti- Of liver dse, Retino- During:
    inflammatory properties. Alcoholism or Pathy . Instruct patient to take
200MG OD pc breakfast   Renal impairement; CV: medication exactly as
    Severe neuro- Hypo-tension
  directed and continue full
Functional Classification Logical disorder GI:
Maximum Dose   course of therapy even if
n/v feeling better
  anorexia
  After:
  diarrhea . Document medication
  administration
Minimum Dose . Observe patient 30 to 1 hour
  after taking and document
any usualities and report to
the doctor
MEDICATION  Instructed patient not to take medication that are not prescribed by the doctor
 Instructed to continue administering the prescribed home medication at the right
time ,dosage and route
 Encourage to administer medication religiously

ENVIRONMENT  Instructed pt to have house cleaned everyday

 Instructed pt to wash hands before and after contact with contaminated objects
 Instructed S.O to maintained cool and pleasant environment

TREATMENT  Advise SO to notify the nurse/physician on arrangements for ff-up check-up

 Encourage to seek regular consultations for monitoring on health conditions
 Instructed to have a regular laboratory monitoring as indicated by the pohysician
HEALTH TEACHING
OBSERVATION OF SIGN AND SYMPTOMS
 Advise pt to have proper hygiene
 Avoid gastric irritants foods
 Be aware of signs and symptoms of different organ impairement
 Advise patient not expose to sunlight
 Advise patient to avoids foods that exacerbate her conditions
 Advise patient to engage any divertional activities for coping And to avoid episodes
of stress
 Instructed patient to report to the nearest health care facility, or to her private
physician of any of the following signs observed :
 Dyspnea
 Decreased urine output
 Jaundice, pallor
 Confusions
 Or any s/s concerning effects of SLE
OBSERVATION OF SIGN AND SYMPTOMS  Instructed patient to report to the nearest health care facility, or to her private
physician of any of the following signs observed :
 Dyspnea
 Decreased urine output
 Jaundice, pallor
 Confusions
 Or any s/s concerning effects of SLE

DIET  Encouraged pt to follow prescribed diet by the doctor

 Encouraged pt to drink 2000 to 3000 ml of water

SPIRITUALITY  Advise pt to always have faith in GOD strengthen and deepen spiritual relationship
with the latter