V.

Medical Management

A. General Management

Ideal Management

1. Optimize the Use of Immunosuppressives

• Corticosteroids, such as prednisone, are a mainstay of lupus therapy because
they suppress the immune system and reduce inflammation..

• Cyclophosphamide also suppresses the immune system and has

antiinflammatory properties. Treatment with cyclophosphamide improves many
severe manifestations of lupus. Unfortunately, cyclophosphamide can produce
serious toxicities.

• Mycophenolate mofetil (CellCept®) is another immunosuppressant used to treat

severe lupus.

2. Tests for Blood Cell Abnormalities

Blood cell abnormalities often accompany SLE. People suspected of having
lupus are usually tested for anemia, leukopenia, and thrombocytopenia.

• Anemia
Tests for anemia include those for
1. hemoglobin,
2. hematocrit
3. red blood cell (RBC) counts
In addition, the levels of iron, total iron-binding capacity, and ferritin may be
tested.
The anemia may be caused by iron deficiency, gastrointestinal (GI) bleeding,
medications, and autoantibody formation to RBCs, or “chronic disease.”

• Leukopenia and Thrombocytopenia

Abnormalities in the white blood cell (WBC) and platelet counts are an important
indicator of SLE. Leukopenia, a decrease in the number of WBCs, is very common in
active SLE and is found in 15 to 20 percent of patients. Leukopenia can occur from
lupus or from prednisone. Thrombocytopenia, or a low platelet count, occurs in 25 to 35
percent of patients with SLE. This can be serious problem when platelet count is very
low.

3. Measurements of Autoimmunity
When certain autoantibodies are present, this provides valuable diagnostic information
for SLE. The most specific tests are those that detect high levels of these
autoantibodies. These are the most common and specific tests for autoantibodies and
other elements of the immune system:

53
 • Antinuclear Antibody (ANA)
A screening test for ANA is standard in assessing SLE because it is positive in close to
100 percent of patients with active SLE. Patients with SLE tend to have high titers of
ANA. False-positive results are found during the course of chronic infectious diseases,
such as subacute bacterial endocarditis, tuberculosis, hepatitis, and malaria. The
sensitivity and specificity of ANA determinations depend on the technique used.

• C-reactive protein test

CRP is a protein found in serum or plasma at elevated levels during a inflammatory
processes. The protein can be measured via a variety of methods for the quantitative or
semiquantitative determination of C-reactive protein in human serum. CRP binds to part
of the capsule of Streptococcus pneumoniae. It is a sensitive marker of acute and
chronic inflammation and infection, and in such cases is increased several hundred-fold.

• Anti-Sm
Anti-Sm is an immunoglobulin specific against Sm, a ribonucleoprotein found in the cell
nucleus. This test is highly specific for SLE. However, only 30 percent of patients with
SLE have a positive anti-Sm test.

• Anti-dsDNA
Anti-dsDNA is an immunoglobulin specific against native (double-stranded) DNA. This
test is highly specific for SLE. Fifty percent of patients with active SLE have a positive
anti-dsDNA test. For many patients with anti-dsDNA, the titer is a useful measure of
disease activity. The presence of antidsDNA is associated with a greater risk of lupus
nephritis.

• Anti-Ro(SSA) and Anti-La(SSB)

These immunoglobulins, commonly found together, are specific against RNA proteins.
Anti-Ro is found in 30 percent of SLE patients. Anti-La is found in 15 percent of people
with lupus. Anti-Ro is highly associated with photosensitivity.

• Complement
Complement proteins constitute a serum enzyme system that helps mediate
inflammation. Complement components are triggered into an activated form by such
immunologic events as interaction with immune complexes. Complement components
are identified by numbers (C1, C2, etc.). Genetic deficiencies of C1q, C2, and C4,
although rare, are commonly associated with SLE. A test to evaluate the entire
complement system is called CH50. The most commonly measured complement
components are the serum levels of C3 and C4.

• Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP)

Tests for ESR and CRP are nonspecific tests to detect generalized inflammation. Levels
are generally increased in patients with active lupus and decline when corticosteroids or
nonsteroidal anti-inflammatory drugs are used to reduce inflammation. However, they

54
do not directly reflect disease activity.

• Antiphospholipid Antibodies (APLs)

APLs are autoantibodies that react with phospholipids. Recent data indicate that APLs
recognize a number of phospholipid-binding plasma proteins (e.g., prothrombin, ß2
glycoprotein I) or protein-phospholipid complexes rather than phospholipids alone. APLs
are present in 50 percent of people with lupus. Most lupus anticoagulant antibodies are
directed against ß2 glycoprotein I or prothrombin.

• Anticardiolipin antibodies (ACA).

Sensitive enzyme-linked immunoabsorbent assays (ELISAs) using cardiolipin as the
putative antigen are commonly performed to detect APLs. In patients with
antiphospholipid syndrome, most antibodies detected in anticardiolipin ELISAs are
directed against cardiolipin-bound ß2 glycoprotein I.

• Anti-ß2 glycoprotein I.
Because ELISAs do not recognize cardiolipin unless ß2 glycoprotein I is present, anti-
ß2 glycoprotein detection assays have been developed. These assays have revealed
that anti-ß2 glycoprotein I antibodies may be more strongly associated with
antiphospholipid syndrome than are anticardiolipin antibodies.

4. Tests for Kidney Disease

Several tests can be done to assess a patient for kidney disease.

• Measurement of Glomerular Filtration Rate and Proteinuria

The glomerular filtration rate is a measure of the efficiency of kidneys in filtering blood to
excrete metabolic products. Typically this is done by collecting a 24-hour urine sample
for measurement of creatinine clearance. Impairment of renal function by lupus nephritis
results in reduced levels of creatinine clearance. The 24-hour urine sample can also
quantify protein loss.
• Protein/Creatinine Ratio
Performed on a one-time voided specimen, rather than from a 24hour collection, this
test is useful as a measure of protein loss and is more convenient for patients.
• Urinalysis
Urinalysis can indicate the presence or extent of renal disease. For example, proteinuria
can be a reliable indicator of renal disease. The presence of RBCs,
WBCs, and cellular casts, particularly red cell casts, in the urine also indicates renal
disease.
• Measurement of Serum Creatinine Concentration
Creatinine is a waste product of muscle metabolism that is excreted by the kidneys.
Loss of renal function as a consequence of lupus nephritis causes increases in serum
levels of creatinine. The concentration of creatinine in the serum can be used to assess
the degree of renal impairment.
• Kidney Biopsy
Kidney biopsy can be used to determine the presence of immune complexes and the

55
presence, extent, and type of inflammation in the glomeruli. Diagnosing the extent and
type of inflammation may help to determine a treatment program for lupus.
5. Medications

• NSAIDs
Comprise a large and chemically diverse group of drugs that possess analgesic, anti-
inflammatory, and antipyretic properties. Pain and inflammation are common problems
in patients with SLE, and NSAIDs are usually the drugs of choice for patients with mild
SLE and little or no organ involvement. Patients with serious organ involvement may
require more potent anti-inflammatory and immunosuppressive drugs.

• Corticosteroids
SLE patients with symptoms that do not improve or who are not expected to respond to
NSAIDs may be given a corticosteroid. Although corticosteroids have potentially serious
side effects, they are highly effective in reducing inflammation, relieving muscle and joint
pain and fatigue, and suppressing the immune system. They are also useful in
controlling major organ involvement associated with SLE.

• Immunosuppressive agents
Used in serious, systemic cases of lupus in which major organs such as the kidneys are
affected or in which there is severe muscle inflammation or intractable arthritis. Because
of their steroid-sparing effect, immunosuppressives may also be used to reduce or
sometimes eliminate the need for corticosteroids, thereby sparing the patient from
undesirable side effects of corticosteroid therapy.

• Intravenous Immunoglobulins (IVIGs)

This drug is thought to reduce antibody production or promote the clearance of
immune complexes from the body.

Actual Management
 TPR every shift
 DAT
 Problem: Lupus nephritis
 IVF: D5 0.3% NaCl @ KVO rate
 Urinalysis
 CBC with platelet count
 ESR
 ECG 12 leads
 FBS
 Blood Chemistry: Creatinine, Sodium, Potassium
Daily Dressing of wound at lower extremities
C-reactive Protein Laboratory Test
ANA determination test

56
MEDICATIONS:
• Cefuroxime 750mg IVTT q8 (-)ANST
• Cloxaccillin 500 mg IVTT q6 ANST (-)
• Cyclophosphoride 1.5 gm
• Dexamethasone 10 mg amp
• Metoclopramide 1 tab P.O. PRN
• Metronidazole 500 mg IVTT q8 ANST (-)
• Paracetamol 500mg 1 tab q4 PO (for temp. above 38C)
• Gentamycin 80mg IVTT

57
 B. DRUG STUDY

Generic Name: Cefuroxime Sodium

Classification: Second Generation Cephalosporin Antibiotic Dosage/ Administration/ Route: 750mg IVTT q8h
ANST(-)

PHARMACO
INDICATION THERAPEU MECHANISM CONTRA- KINETICS/ SIDE ADVERSE NURSING
TIC OF ACTION INDICATION PHARMACO EFFECTS EFFECTS CONSIDERATION
EFFECTS DYNAMICS
Skin or skin- Absence or Inhibits cell Hypersensitiv Metabolized Nausea Pseudom • Check patient for
structure minimized wall ity to in the liver; Vomiting embranou hypersensitivity
infection signs and synthesis, Cephalospori excreted in Diarrhea s colitis to cephalosporins
caused by symptoms promoting ns or the urine. Anorexia Bloody and penicillins
Streptococcu of infection osmotic Penicillins Abdominal diarrhea • For P.O., give
s instability; pain Nephrotox drug with
Pneumoniae bactericidal Flatulence icity food. Crush
and S. Superinfe tablet if patient
pyogenes, ction has difficulty with
Haemophilus swallowing
influenza, S. • Advise patient to
aureus, E. take drug as
coli, prescribed , even
Moraxella after patient feels
catarrhalis better
• Instruct patient to
notify prescriber if
rashes or
superinfection
occurs
• Frequent small
feedings
• Comfort
58
 measures for pain
relief
• Advise to report
discomfort at IV
insertion site
• Notify prescriber if
loose stools/
diarrhea occurs

59
Generic Name: Metronidazole
Classification: Antiprotozoal Dosage/ Administration/ Route: 500mg IVTT
q8 ANST (-)

60
 THERAPE CONTRA PHARMACOKIN
INDICATION UTIC MECHANISM INDICATI ETICS/ SIDE ADVERSE NURSING
EFFECTS OF ACTION ON PHARMACODY EFFECTS EFFECTS CONSIDERATION
NAMICS
Acute Resolutio Inhibits DNA Hypersen Metabolized in Dizziness Headache • Arrange for
infection n of synthesis of sitivity to the liver; Weakness Fever appropriate
caused by infection specific drug excreted in the Nausea Chills culture and
susceptible anaerobes, Pregnanc urine. Vomiting sensitivity test
strains of causing cell y Metallic before beginning
anaerobic death; taste therapy to ensure
bacteria mechanism of Darkening proper drug for
action as of urine susceptible
anitprotozoal organisms
and amebical • Administer the
are not known complete course
of the drug to get
full beneficial
effects
• Monitor hepatic
function before
and periodically
during treatment
to arrange to
effectively stop
the drug if signs
of failure or
worsening liver
function occurs
• Provide comfort
and safety
measures if CNS
effects occur such
as side rails and
assistance with
ambulation if
dizziness and
weakness are
present
• Provide small
61
frequent ,
nutritional meals if
GI upset is severe
to ensure proper
nutrition
62
 Generic Name: Gentamicin
Classification: Aminoglycosides / Antibiotic Dosage/ Administration/ Route: 80mg IVTT q8h
ANST(-)

THERAPE CONTRA PHARMACOKIN

INDICATION UTIC MECHANISM INDICATI ETICS/ SIDE ADVERSE NURSING
EFFECTS OF ACTION ON PHARMACODYN EFFECTS EFFECTS CONSIDERATION
AMICS
Treatment of Resolution Inhibits Hypersen Distribution: Dizziness Rash •Check culture and
Pseudomon of protein sitivity to extracellular Sinusitis Fever sensitivity reports
as infection bacterial synthesis in aminogly fluids, crosses Nausea Nephrotoxi to ensure that this
and a wide infection susceptible cosides placenta, poorly Vomiting city is the drug of
variety of strains of Renal distributed in CSF Diarrhea Sinusitis choice for the
gram gram-negative disease Palpita- Neuro patient
negative bacteria, Pre- Metabolized in tions toxicity •Ensure that the
infection disrupting existing the liver; excreted Hypo- Bone patient receives
functional hearing in the urine. tension marrow the full course of
integrity of the loss Numbess suppressio aminoglycoside as
cell which Tingling n prescribed, divided
membrane could be Confusion Ototoxicity around the clock,
and causing intensifie to increase
cell death d by toxic effectiveness and
drug decrease risk for
effects on development of
the resistant strain of
auditory bacteria
nerve •Monitor patient for
Active signs of bone
infection marrow
with suppression,
herpes or nephrotoxicity, and
mycobact neurotoxicity to
erial effectively arrange
63
 infections dosage, as
Myasthen appropriate, if any
ia gravis of these toxicity
or occurs
Parkinso •Provide safety
nism measures to
Lactation protect patient if
CNS effects occur
•Ensure that the
patient is hydrated
at all times during
drug therapy to
minimize renal
toxicity from drug
exposure.
•Evaluate patient’s
hearing before and
during therapy.
Notify prescriber if
patient complains
of tinnitus, vertigo
or hearing loss
•Watch out for signs
and symptoms of
superinfection
•Encourage
increase fluid
intake.

Generic name: Cyclophosphamide

64
Classification: Antineoplastic Dosage/Route/Administration: 1.5 gms

65
 THERA- PHARMACOKIN
INDICA- PEUTIC MECHANISM CONTRA ETICS/ SIDE ADVERSE NURSING
TIONS EFFECTS OF ACTION INDICATI PHARMACODYN EFFECTS REACTION RESPONSIBILTIES
ONS AMICS
Treatment of Death of Interferes with Hyper Inactive parent Anorexia, Pulmonary • Instruct patient to
immune rapidly DNA and RNA sensitivity drug is absorbed nausea Fibrosis take dose early in
system replicating Transcription, from the and Myocardial the morning
disorders cells, ultimately Gastrointestinal vomiting Fibrosis • Monitor BP, pulse,
particularl disrupting tract. Converted Hematuria Hemorrhagi respiratory rate, and
y protein to active drug by Alopecia c cystitis temperature
malignant synthesis the liver. Leukopenia frequently during
ones Widely administration.
distributed. Report significant
Limited changes
penetration of the •Monitor urinary
blood-brain output frequently. To
barrier. reduce the risk of
Converted to hemorrhage cystitis,
active drug by the fluid intake should
liver; 30% be at least 3000
eliminated ml/day.
unchanged by the •Monitor for bone
kidneys marrow suppression
•asses cardiac and
respiratory status for
dyspnea,
rales/crackles,
weight gain, edema
• monitor for signs
and symptoms of
cystitis. If occurs,
stop the drug and
notify prescriber
•provide adequate
hydration
•warn patient that
hair loss is
reversible
•instruct to void by66
the clock (q1-2hrs)
•watch for infection
or bleeding
•small frequent
 Generic Name: Metoclopramide
Classification: GI stimulants Dosage/Route/Administration: 1 tab PO

PRN

PHARMACO
THERAPE MECHANISM CONTRA- KINETICS/ SIDE ADVERSE NURSING
INDICATION UTIC OF ACTION INDICATIONS PHARMACO EFFECTS REACTION RESPONSIBILITIES
EFFECTS DYNAMICS

67
Prevention Decreas- Blocks Hypersensi- Well Drow- Anxiety, •Administer at least
of ed nausea dopamine tivity absorbed siness depression, 15mins ac meal and
chemotherap and receptors in GI obstruction from the GI Extrapyra irritability, at HS
y-induced vomiting chemorecept Hemorrhage tract, from midal tardive •Instruct patient to
emesis or trigger History of rectal reactions dyskinesia medication at the
zone of the depression mucosa and Restlessn Arrythmias, same time each day.
CNS from IM ess Hyperten-
sites. Widely Constipati sion, • Instruct patient to
distributed on hypotension monitor weight
into body diarrhea Gynecomas biweekly
tissues and tia
fluids. •Caution patient to
Crosses change position
blood brain slowly to minimize
barrier. orthostatic
Partially hypotension.
metabolized
by the liver, •Safety precaution
25% when performing
eliminated activities that require
unchanged alertness especially
in the urine. 2 hrs after dose

Generic Name: Cloxacillin

Classification: Penicillin Dosage/Route/Administration: 500mg IVTT q 6hrs
ANST (-)

PHARMACO
INDICATION THERAPE MECHANISM CONTRAIN KINETICS/ SIDE ADVERSE NURSING
UTIC OF ACTION DICATION PHARMACOD EFFECTS REACTION RESPONSIBILITIES
EFFECTS YNAMICS
68
Skin and Bactericid Bind to Hypersensi Moderately Diarrhea, Seizures •Administer
skin al action bacterial cell tivity to absorbed nausea Pseudome medication around
structure wall, leading penicillins following oral and mbranous the clock on an
infections to cell death. administration vomiting, colitis, drug- empty stomach at
Resist the Widely phlebitis, induced least 1 hr before or 2
action of distributed; rashes hepatitis hours after meals.
penicillinase , penetration Interstitial Take with a full glass
an enzyme into CSF is nephritis of water; acidic juices
capable of minimal Anaphylaxis may decrease
inactivating Some and serum, absorption.
penicillin metabolism by sickness, •Instruct patient to
the liver 9- superinfecti notify health care
22% and on professionals if fever
some renal and diarrhea develop,
excretion of especially if stool
unchanged contains blood pus,
drug 30-45% or mucus
•Advise patient to
report signs of
superinfection

Generic Name: Dexamethasone

Classification: Coticosteroids Dosage/Route/Administration: 10mg 1 ampule
IVTT

THERAPE PHARMACOKI
INDICATION UTIC MECHANISM CONTRA- NETICS/ SIDE ADVERSE NURSING
EFFECTS OF ACTION INDICATION PHARMACOD EFFECTS REACTION RESPONSIBILTIES
YNAMICS
69
•Autoimmun •Suppress Suppress Hypersensiti Well absorbed Headache Depression, •Administer
e disorders ion of inflammation vity after oral restlessne Euphoria medication in the
•Diagnostic inflammati and the Active administration. ss insomnia morning to coincide
agent in on and normal untreated Widely Nausea cataracts with the body’s
adrenal modificati immune infections distributed. and Peptic normal secretion of
disorders on of the response of Tartrazine Metabolized by vomiting ulceration cortisol.
•Short term normal the body hypersensitiv the liver. Hypertensio •Discuss possible
treatment of immune Block action ity or n effects on body
inflammation response of intolerance Adrenal image
disorders •Anti- arachidonic suppression •Instruct patient to
inflammat acid which hyperglyce inform health care
ory and leads to a mia professional promptly
immunosu decrease in fluid if severe abdominal
ppressive prostaglandin retention pain or tarry stool
effects to and potential occurs
allow the leukotriene CHF •Do not give
body to production Increased vaccination when
heal from Impair ability appetite patient is
effects of of Weight gain immunosuppressed
inflammati phagocytes Hair loss •Protect patient from
on to leave the increased unnecessary
blood stream susceptibilit exposure to infection
and move to y to
injured infection
tissues
Blocks
antibody
production
Inhibit
lymphocyte
activity in
immune
system
70
 Generic Name: Paracetamol
Classification: Anti-inflammatory Dosage/Route/Administration: 500mg 1 tab q 4hrs PRN temp =
>38oC PO

THERAPE PHARMACOKI
INDICATION UTIC MECHANISM CONTRAIN NETICS/ SIDE ADVERSE NURSING
EFFECTS OF ACTION DICATION PHARMACOD EFFECTS REACTION RESPONSIBILITIES
YNAMICS
Fever Antipyretic Acts directly Hypersensiti Rapidly Nausea Rash •instruct patient that
on the vity Absorbed in and Fever drug is for short term
thermoregulat the GIT vomiting Chest pain use only; consult
ory cells in extensively Drowsines Liver prescriber if given
71
 the metabolized in s toxicity for more than 10
hypothalamu the liver and dizziness failure days
s to cause excreted in the Bone •use only when
sweating and urine marrow temperature is >
vasodilatation depression 38.5C or for
; analgesic recurrent fever or as
effects are ordered
thought to be
a result of
blocking pain
impulses,
probably
inhibiting
prostaglandin
release

VI. NURSING MANAGEMENT

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Fluid volume Short term: Independent: Independent: Short term:
“Nanghupong man ko excess related to At the end of 30 1. Weigh 1. To provide At the end of 30
adtong pagka-admit decreased minutes of regularly. comparative minutes of
nako. Dani sa akong oncotic pressure nursing baseline and nursing
nawong og tiil. Naa pa secondary to intervention evaluate intervention
gani sya hantud Lupus Nephritis patient will be degree of patient was able
karun,” as verbalized as evidenced by able to excess. to demonstrate
by the patient. proteinuria of +3 demonstrate 2. Measure 2. To note for behaviors to
and manifested behaviors to abdominal girth changes that monitor fluid
72
Objective: by non-pitting monitor fluid daily. may indicate status, reduce
• Non-pitting facial and bipedal status, reduce increasing recurrence of
facial and edema. recurrence of fluid retention fluid excess and
bipedal edema fluid excess and or edema. verbalize
• Proteinuria= +3 verbalize 3. Record 3. To understanding of
• Weight gain understanding of intake and calculate fluid individual dietary
(from 65-70kgs individual dietary output balance. and fluid
in 2weeks and fluid regularly. restrictions.
time) restrictions. 4. Evaluate 4. To reduce
edematous tissue Long Term:
Long Term: extremities and pressure and At the end of 2
At the end of 2 change risk of skin days of nursing
days of nursing position breakdown. intervention
intervention frequently as patient did not
patient will be tolerated. have an
able to display 5. Place in 5. To appropriate
appropriate semi-Fowler’s facilitate urinary output but
urinary output, position. movement of vital signs are
vital signs within diaphragm within patient’s
patient’s normal improving normal range
range and respiratory and progression
minimized 6. Promote effort. of edema was
edema. early 6. To minimized.
ambulation. promote
mobilization of
7. Discus excess fluids.
importance of 7. To
fluid and facilitate
sodium understanding
restrictions. and promote
wellness.
Collaborative:
1. Restrict
73
 water and
sodium intake. 1. To reduce
excessive
water
retention.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute pain Short term: Independent: Independent: Short term:
“Lisod kayo ko related to tissue At the end of 1 1. Develop a 1. This facilitates At the end of 1
maglihok tungod injury from hour of nursing therapeutic patient’s expression hour of nursing
sa hubag ug lesions in the left intervention, relationship with of feelings about pain. intervention,
samad sa akong lower leg as patient will be the patient. 2. Helps improve patient was able
tiil, dapat evidenced by able to report 2. Provide a clean mental and physical to report
alalayan pajud ko pain score of decreased pain and soothing health. decreased pain
aron dli kaau 6/10, 10 as the intensity from environment by intensity from 6
sakit, lisod na most painful. 6/10 to 4/10. keeping the to 4/10.
74
matumba palang bedside free from
ko” as verbalized Long term: unnecessary Long term:
by the patient. At the end of 8 trash and clutter At the end of 8
“Gakatulog ko’g hrs of nursing by arranging hrs of nursing
12 sa gabii dayon intervention, linens. 3. Provide pain intervention,
mata2x jud ko patient will be 3. Administer cold reduction and reduce patient was able
permi … tungod able to report application for 15 swelling and to report pain is
kay sakit akong pain is controlled minutes. inflammation. controlled.
tiil.” as verbalized if not relieved. 4. Provide 4. Provides cutaneous
by the patient. backrub. stimulation, blocks
“Sukad sa pain so as to promote
pagkasamad comfortable sleep and
nako ani na relaxation.
burot, sakit jud 5. Facilitate deep 5. Deep breathing is
ako gakabatiun breathing as both a relaxation and
unya dili mawala tolerated by the distraction technique
ang sakit,” as patient. by stimulating
verbalized by baroreceptors in the
patient. atria and carotid
“Dili ko ganahan sinuses.
mag-lihok2x kay
musakit ug samot 6. Assist the 6. To provide comfort
akong tiil. patient to a and prevent
Pagmusakit tolerable position complications.
akong tiil musakit every two hours.
pud akong ulo”,
as verbalized by
the patient.
Objective: Dependent:
• Pain scale = 1. Collaborate in 1. To assist client to
6/10, 10 being treatment of explore methods for
the most painful underlying the alleviation/control
• Reduced hours condition/disease of pain.
75
 of sleep = 4 process causing
hours pain and
• Swollen lower proactive
left leg management of
• Sighing pain such as
• Limping assisting in
• Guarding wound dressing.
behavior
• Avoids physical
activity
• Requesting
help with
walking
• Lying down
during the day
• Moving very
slowly
• Reduced
interaction with
people
NURSING
CUES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Hyperthermia Short term: Independent: Independent: Short term:
“Init akong related to At the end of 30 1. Provide 1. To promote heat At the end of 30
paminaw. Tan- inflammatory minutes of tepid sponge loss by evaporation minutes of
awa daw kung process as nursing bath. & conduction. nursing
gihilantan ba ko,” manifested by intervention, 2. To promote heat intervention,
as verbalized by increased body patient will have 2. Ensure loss by convection. patient had
the patient. temperature stable vital signs proper room reduced body
beyond 37.8 °C, reduced body ventilation by temperature from
Objectives: warm skin, temperature from opening 38 °C to 37.5 °C
• Temperature = increased heart 37.9 °C to 37.5 windows or and normal vital

76
 37.9 C rate and °C turning the signs.
• Skin warm to respiration rate. ceiling fan on. 3. To promote heat
touch Long term: 3. Let the loss by conduction. Long term:
• Heart rate= 94 At the end of 8 client wear At the end of 8
bpm hours of nursing non- hours of nursing
• Respiratory intervention, constrictive intervention,
rate= 25 cpm patient will be and light 4. To maintain patient was able
able to maintain a clothing. hydration since to maintain a
body temperature 4. Provide fluid loss body
ranging from 36.5 ample fluids contributes to temperature from
C to 37.4 C and per orem. fever. 36.5 °C to 37.2
experience no 5. To reduce °C and
further metabolic demand experienced no
complications. 5. Provide and oxygen further
adequate consumption. complications.
rest.
6. To note for
changes in vital
6. Monitor signs and maintain
temperature it within normal.
and note for
chills or
profuse
diaphoresis.
1. Pharmacologic
Dependent: intervention to
1. Administer reduce fever
Paracetamol
500 mg 1 tab
q4° for T≥ .
38°C as 2. To support
ordered. circulating
2. Provide volume.
77
 ample fluids
via
intravenous
route.
Administer
D50.3%NaCl
500cc and
regulate at
KVO rate. 1.To meet
Collaborative: increased metabolic
1.Provide a demands of the
high calorie body.
diet, as
advised by
dietician.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS

78
Subjective: Imbalanced Short term: Independent: Independent: Short term:
“Mahilig jud ko ug nutrition less than At the end of 30 1. Encourage 1. To enhance At the end of 15
karne labin nag body minutes of nursing good oral appetite and minutes of nursing
baboy. Usahay requirements intervention, hygiene. oral intake. intervention,
related to patient will be able 2. Ensure a 2. To provide a patient was able
pag walay kwarta,
increased to identify ways on pleasant conducive to identify ways on
isda nalang. Dili glomerular how to improve environment for environment for how to improve
kayo ko hingaon permeability nutritional status. eating by eating. nutritional status
ug gulay, secondary to covering the by enumerating
makabuot man lupus nephritis as Long term: wound with foods she is
pud ko kay ako manifested by At the end of 8 dressing and advised to eat .
man ang galuto. presence of hours of nursing closing the door
protein in the intervention, of the comfort Long term:
Dili pud kaau ko
urine, increased patient will be able room. At the end of 8
makakaon ug level of RBCs in to consume full 3. Suggest food 3. To provide hours of nursing
prutas kay wala the urine and share with good sources that are information on intervention,
may kwarta”as reduced serum appetite. rich in protein, nutritious and patient was able
verbalized by the potassium level. iron, and affordable food to consume full
patient. potassium such to take. share with good
as fish, beans appetite.
“Dili pud ko and banana
mahilig ug gatas, that are within
Kape nuon kaisa patients
sa usa ka adlaw. financial
Usahay pud juice capabilities.
kung wala jud, 4. Instruct to 4. To ensure
tubig akong adhere to low- intake of
ga.imnon” as fat, high-protein needed
verbalized by the and high- nutrients and
patient. potassium diet prevent
Objective: as tolerated. complications.
• Proteinuria 5. Provide 5. To provide
= +3 patient teaching knowledge on
79
 • RBC in on importance what foods to
urine = 13- of well balanced take.
15/hpf and nutritious
• Pale intake.
conjunctiva
Collaborative:
1. Prepare 1. To provide for
tolerable diet lacking
specific to the nutrients and
needs of the ensure
patient. adequate
intake of such.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Impaired skin Short term: Independent: Independent: Short term:
“Tulo mani ka integrity related to At the end of 30 1. Clean, dry and 1. To keep skin At the end of 30
80
burot, isa ka dako lesions at left minutes of nursing moisturize intact. minutes of nursing
ug duha ka lower leg. intervention, intact skin. Use intervention,
gagmay, sa patient will be able warm water. patient was able
pagka-admit nako to identify means 2. Encourage 2. To promote to identify means
dani nibuto ni ang on how to prevent adequate healing and on how to prevent
pinakadako…,” as further skin nutrition and prevent further skin
verbalized by the integrity hydration. infection. impairment.
patient. impairment such Serve foods
as skin care. rich in calories Long term:
“Lisod kayo ko such as beans. At the end of 8
maglihok tungod Long term: 3. Instruct to 3. To prevent hours of nursing
sa hubag ug At the end of 8 avoid harsh skin irritation. intervention
samad sa akong hours of nursing chemicals e.g. Alcohol dries patient was able
tiil…,” as intervention detergents and the skin which to demonstrate
verbalized by the patient will be able not to use exacerbates the proper skin care
patient. to demonstrate soaps or lotions condition. and prevent
proper skin care with alcohol. further skin
Objective: and prevent 4, Protect self 4. To prevent impairment.
further skin form exposure exacerbations
• Lesions at left integrity to sunlight such since rashes are
lower leg impairment. as using sun also triggered
block and long- by sunlight
sleeved exposure.
clothing.

Dependent: Dependent:
1. Administer 1. To treat
medications as underlying
ordered: cause and
-Cefuroxime IVTT prevent infection
q8° (-) ANST. thus facilitating
-Cloxacillin 500 wound healing.
mg IVT q6°
81
 ANST (-)
-Gentamycin 80
mg IVTT q8°
ANST (-)
-Metronidazole
500 mg IVTT
q8° ANST (-)
-Dexamethsone
10 mg amp
2. Assist in 2. To promote
everyday healing and
wound prevent
dressing. infection.

CUES NURSING OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Sleep pattern Short term: Independent: Independent: Short term:
“Gakatulog ko’g disturbance At the end of 20 1. Minimize the 1. To provide At the end of 20
82
12 sa gabii dayon related to pain at minutes of nursing environmental an environment minutes of nursing
mata-mata jud ko left lower leg and intervention, noise by conducive for intervention,
permi tungod sa environmental patient will be able closing the sleeping. patient was able
saba ug sa mga factors such as to identify door properly to initiate sleep.
tao dani sa akong noise and methods on how always and
palibot ug tungod temperature as to improve quality maintain Long term:
kay sakit akong manifested by of sleep. comfortable At the end of 16
tiil.” as verbalized reduced number temperature hours of nursing
by the patient. of hours of sleep. Long term: and proper intervention,
“Pangbawi sa At the end of 16 ventilation as patient was be
akong tulog hours of nursing much as able to improve
matulog ko ug intervention, possible. sleep pattern as
ginagmay sa patient will be able 2. Assist in 2. To provide evidenced by
buntag ug hapon” to increase in the wearing comfort and increase in the
as verbalized by number of hours comfortable freshness. number of hours
the patient. of sleep and clothes and of sleep and
Objective: feeling rested on washing her feeling rested on
• Decreased awakening. face awakening.
number of 3. Assist patient 3. To promote
hours of sleep in performing relaxation.
= 4 hours bedtime rituals
• Sleep during and provide
the day, at most sleeping aids
2 hours. such as
pillows.

4. Provide 4. To promote
comfort rest and
measures by relaxation.
doing back rub
and placing
patient flat on
bed with head
83
 elevated by a
pillow.
5. Organize 5. To promote
nursing care. minimal
interruption in
sleep/rest.

6. Limit fluids 6. To reduce

before need for
bedtime. voiding during
the night.

Dependent: Dependent:
1. Administer 1. To treat
medications as underlying
ordered: cause and
-Cefuroxime IVTT prevent
q8° (-) ANST. infection thus
-Cloxacillin 500 facilitating
mg IVT q6° ANST wound
(-) healing.
-Gentamycin 80
mg IVTT q8°
ANST (-)
-Metronidazole
500 mg IVTT q8°
ANST (-)
-Dexamethsone
10 mg amp
-Cyclophospha-
mide 1.5 g
2. Assist in 2. To promote
84
 everyday healing and
wound prevent
dressing. infection.

CUES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

85
Subjective: Activity intolerance Short term: Independent: Independent: Short term:
“Lisod kayo ko related to local At the end of 8hrs 1. Assist patient 1. To protect At the end of 8hrs
maglihok tungod inflammatory of nursing with activities. the patient from of nursing
sa hubag ug process at lesions intervention, injury. intervention,
samad sa akong on left lower leg patient will be able 2. Promote 2. To enhance patient was able to
tiil, dapat alalayan and surrounding to report comfort measures the patient’s report increased
pajud ko aron dli areas as measurable such as deep ability to activity tolerance
kaau sakit, lisod manifested by increase in activity breathing and safe participate in as evidenced by
na matumba avoiding physical tolerance as environment. activities. ability to ambulate
palang ko” as activity, lying down evidenced by 3. Provide positive to comfort room
verbalized by the during the day and ability to ambulate atmosphere while 3. Helps with minimal
patient. reduced to comfort room as acknowledging minimize assistance.
“Galisod jud ko ug interaction with tolerated. difficulty of the frustrations and
lakaw unya people. situation for the rechannels Long term:
mahadlok pud ko Long term: patient. energy. At the end of 16hrs
musakit ug samot At the end of 4. Increase of nursing
akong tiil mao 16hrs of nursing exercise/activity intervention,
nang gapatabang intervention, the levels gradually. 4. To assess patient was able to
ko sa akong bana patient will be able 5. Involve level of activity perform activities
sa pag.cr,” as to perform significant others tolerance. of daily living with
verbalized by the activities of daily in planning and 5. To reports of minimal
patient. living with minimal doing activities. encourage limitations caused
“Dili ko ganahan limitations due to ongoing by pain.
mag-lihok2x kay pain. Collaborative: support for the
musakit ug samot 1. Administer patient.
akong tiil. medications as
Pagmusakit akong ordered:
tiil musakit pud -Cefuroxime IVTT 1. To prevent
akong ulo”, as q8° (-) ANST. infection thus
verbalized by the -Cloxacillin 500 facilitating
patient. mg IVT q6° ANST wound healing.
Objective: (-)
• Avoiding -Gentamycin 80
86
 physical activity mg IVTT q8°
• Lying down ANST (-)
during the day -Metronidazole
• Reduced 500 mg IVTT q8°
interaction with ANST (-)
people 2. Assist in
everyday
wound
dressing. 2. To promote
healing and
prevent
infection.

87
 ASSESSMENT NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Disturbed body Short term: Independent: Independent: Short Term:
“Dili nako ganahan image related to At the end of 1 1. Establish a 1. To develop a At the end of
na mag.gawas2x presence of malar hour of nursing therapeutic nurse- sense of trust. nursing
sa balay kai pangit rash at the bridge intervention, client relationship intervention,
na kaau ko ” as of the nose as patient will conveying an patient was able to
verbalized by the evidenced by verbalize attitude of caring. verbalize
patient. change in social understanding that understanding that
“Gusto ko ako ra involvement and changes in 2. Acknowledege 2. To assist client the change in
isa dili ko ganahan verbalizations of physical and accept in issues of self- physical
makit-an sa uban social withdrawal. appearance are feelings of grief concept. appearance is part
na inani akong part of the disease and hostility by of the disease
nawong Sakit pud process. encouraging process as
akong tiil maypag verbalization of evidenced by
magpuyo, arang2x Long term: feelings and by beginning to care
pa kung ako At the end of 32 listening and accept self by
nalang isa.” as hours of nursing attentively. grooming and
verbalized by the intervention, looking at the
patient. patient will be able 3. Encourage 3. To promote mirror.
to talk to family client to look at acceptance of
Objective: about the changes and touch affected body changes. Long Term:
• Change in in self-concept body parts. At the end of
social without negative nursing
involvement self-esteem and 4. Give 4. To boost the intervention,
• Not looking at develop realistic complements and clients self- patient was able to
self in the goals and plans appraisals such as esteem. talk to family about
mirror for the future. praising her for the changes in
• Behaviors of positive traits. self-concept
avoidance without negative
• Presence of 5. Provide holistic 5. To recognize self-esteem and
malar rash at care such as patient’s positive develop realistic
the bridge of providing body traits than focusing goals and plans for
88
the nose care and good on negative ones. the future.
grooming.

6. Involve the 6. To minimize

family in patient’s self
increasing the belittling.
patient’s self-
esteem by
avoiding negative
comments about
her and non-verbal
cues of
discrimination.

89
 ASSESSMENT NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Risk for spread Short term: Independent: Independent: At the end of 1hr
“Akong gabutangan of infection At the end of 1 1. Observe for 1. To assess of nursing
ug botelya na naai related to hour of nursing localized causative/ intervention,
bugnaw na tubig inadequate intervention, signs of contributing patient was able
ang ibabaw sa primary defense patient will be infection. factors. to identify and
akong samad aron as evidenced by able to 2. Wash hands 2. Washing demonstrate
mahubsan ang ka- broken skin and demonstrate ways before contact between ways of
sakit.” –as traumatized in preventing and with patient procedures preventing and
verbalized by client. tissue in the reducing the risk and between reduces risk reducing risk for
lower left leg of of infection procedures of infection.
Objective: the patient. through proper with patient. transmitting
• Increased use of aseptic pathogens At the end of 8hrs
temperature techniques. from one of nursing
= 38 C area of the intervention,
• WBC count Long term: body to patient has a
= At the end of 8hrs another. stable
13,720mm3 of nursing 3. Maintain 3. To minimize temperature
• Open wound intervention, proper environment noting to be
at left lower patient will environmental al afebrile.
leg with achieve stable sanitation pathogens.
moist temperature through
dressing. noting to be cleaning
• Swollen and afebrile and will patient’s bed
warm area not manifest and bedside.
around the further signs and 4. Emphasize 4. To minimize
wound. symptoms of importance of acquiring
infection. proper infections.
hygiene
especially
proper hand
washing.

5. Limit access 5. To prevent

to the open introduction
site. of
microorgani
sms 90
6. Prepare a 6. To maintain
calorie- and optimal
protein- rich nutritional
diet. status.
VII. DISCHARGE PLANNING

o Encourage strict adherence to the

medication regimen to attain
therapeutic effects.
o Instruct patient to strictly follow
orders for take home medications
upon discharge as prescribed by
physician.
o Instruct patient to take medications
as prescribed such as:
Medications • Cyclophosphoride 1.5 gm
• Metoclopramide 1 tab
• Paracetamol 500mg 1 tab q4 PO
(for temp. above 38C)
• Prednisolone 5mg 3-0-3
• Calcium lactate 300mg 1-1-1
• Chloroquinine 150 mg 1 tab OD
• Diphenhydramine 10 mg TID For 3
days
o Instruct patient to follow right dose
and timing of medications, and not
to stop taking them abruptly without
physician’s order.
o Report any adverse effects and
drug-drug interactions/drug-food
interactions of the medications to
the physician.
o Warn patient about the increased
risk towards superinfections and
immunosuppression; Observe
aseptic technique and proper
sanitation and hygiene to prevent
spread of microorganisms.

o Encourage patient to individualized

exercise program (e.g. active or
active-self assisted ROM exercises)
Exercise is recommended for patients with
SLE to prevent joint stiffness
(especially on the affected leg) and
increase mobility.
91
 o Mild analgesic may be suggested
before exercise.
o Encourage deep breathing
exercises to decrease feelings of
pain and discomfort.

Physical Rest:
o Eight to 10 hours a night of restful
sleep, naps, and “timeouts” during
the day are basic guidelines.
Health Teachings Physical activity should be
encouraged as the patient can
tolerate it.
o Encourage patient to plan for
additional rest periods throughout
the day, as needed. Emphasize the
need for avoidance of exhaustion.
Emotional Rest:
o Discuss to family members on the
issue of avoiding stressful situations
by providing them with information
regarding patients condition and
obtaining their support. Advocate
counseling for both the patient and
the family.
Protection from direct sunlight:
o Inform patient that all people with
lupus should avoid direct, prolonged
exposure to the sun especially
between 10 a.m. and 4 p.m., and
wear protective clothing, such as
wide-brimmed hats and long
sleeves.

o Advocate appropriate follow-up in

collaboration with the healthcare
team.
o Make use of health care resources
Out-patient/Follow-up in the community and instruct
patient to have a visit to their health
center from time to time.
o Instruct patient to recognize the
warning signals of a flare(increased
fatigue, a new or higher fever,
92
 increased pain, development or
worsening of a rash and
development of symptoms you
haven’t had before and swollen
joints) and to seek medical help.
o Instruct patient to consult physician
before receiving any immunization.
Routine immunizations, including
those for the flu and pneumonia.

o A low-fat, low-cholesterol diet is

recommended, given the increased
Diet risk of heart disease in SLE.
o Instruct patient to limit their dietary
intake of sodium.
o Recommend a high-fiber diet.
o Increase protein intake.
o Use flavoring agents (e.g. lemon
and herbs) to enhance food
satisfaction and stimulate appetite.

o Encourage the patient to hear

masses regularly to strengthen her
spiritual life.
o Encourage patient to pray
Spirituality constantly and surrender all her
worries to God especially her
present condition to lessen
anxiety and to promote presence of
mind.
o Have her join in prayer groups and
meeting offered by the church or
community.

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

93
 seek out other supportive
mechanisms, such as: in local
support groups an in educational
and self-management programs.
o Develop a support system
that includes family, friends, medical
or nursing professionals, community
organizations, and support groups.

VIII. PROGNOSIS

94
 CRITERIA GOOD POOR
Health Seeking Behavior √

Late Diagnosis √

Frequent Exposure to UV light √

Experiences extreme stress √

Defective Organs:

• Kidney √

• Heart √

• Brain (CNS and PNS) √

√
• Skin
√
• Lungs
√
• Liver

Compliance to medical regimen such as:

• Chemotherapy
√
• Steroid Therapy

• Antibiotic Therapy
4/11 7/11

Basing on the above criteria, the patient’s prognosis is poor. At present, there is

no cure for her disease. Death usually results from complications such as organ

failures. The patient already has defective organs – kidney, heart and skin. She also

experiences extreme stress and frequent exposure to UV light, such as the sunlight –

which are known factors that could exacerbate the disease. The medical treatment she

is undergoing are only palliative and are only given to treat the signs and symptoms.
95
IX. CONCLUSION

In conclusion, the group was able to come up with a comprehensive case

presentation on Systemic Lupus Erythematosus (SLE), especially concerning our client,
Patient X. Information presented here were factual, basing on our actual assessments
by interview and by using available secondary sources, such as her chart. The group
was able to work together to surface this case study in the best way that we can, using
every resource we can find useful in making every part of this write up.

In the process, we were able to enhance our knowledge about SLE, its signs and
symptoms and treatment modalities, as well as on how we, future nurses, can care for
patients similar to Patient X. Moreover, we have taken our grand case presentation
enactment to the next level, owing this to our extensive learning from our experiences
this semester as well as our previous wisdom acquired in the classroom and hospital
settings. Lastly, the group has developed a better working relationship with one another,
especially through this challenging and demanding stretch of our student life.

X. RECOMMENDATION

Recommendations are necessary for patient X to be able to minimize signs and

symptoms and prevent further complications as possible. This, in turn, will consider
having a better health status – be it physically, emotionally, mentally, and spiritually.

96
 For Patient X, recommendations would include but not limited to the following:
First, patient X should be able to develop an optimistic attitude towards the situation in
order to promote a positive inclination of mental and emotional dimension of health.
Second, she should strictly comply with the medication regimen since personal
adherence is a determinant of willingness and eagerness to recover. Third, she should
also be able to verbalize feelings, especially regarding pain to prompt the support
persons to take emotional care and actions. This is essential when associated health
seeking behavior. She should also be able to express any discomfort in order for the
health care provider to carry out certain measures. Patient X should be able to establish
a direct open communication with her husband and health care practitioner to link care
and needs. Thus, the proponents of this case study are able to understand the
significance of a good health seeking behavior and medical treatment. Fourth, she
should be able to strengthen or maintain strong faith since spiritual health is an
important factor to be considered in achieving a healthy status. Patient X must be willing
to follow low salt low fat, and low protein diet having known that she has a lupus
nephritis. She should eat foods high in vitamins D & E and calcium such as liver, milk,
cheese, fish and others. She should be advised to avoid gas-irritant foods such as
cabbage, beans, spinach, garlic, tea, and coffee.

Patient X’s husband and support persons can prove functional when they are
able to provide comfort, care measures, and assistance. They can encourage patient X
to follow care provider’s instruction particularly on medication adherence. Patient X
should be encouraged to avoid exposure of sunlight. She should use umbrella and
sunscreen to prevent production of rashes.
As health care providers, we should be able to provide quality health care
services to patient X. As nurses and physicians, individualized care should be carried
out. Open and welcome approach should be initiated to the patient, and most especially
by showing empathy and recognizing that there is no enough words to overrule her
feelings of heaviness and despondency. Sensitivity to the patient X has verbalized is

97
also necessary for us to consider in planning care. Physical, social, spiritual, emotional,
and mental feedbacks and motivations can also be considered in imparting to the client.

XI. BIBLIOGRAPHY

Black, JM., and Hawks, JH. Medical-Surgical Nursing Clinical Management for Positive
Outcomes volume 1 &2. 7th edition, El Sevier Saunders, Singapore, 2004

98
Doenges, Marilynn E et al. Nurse’s Pocket Guide Diagnosis, Prioritized Interventions &
Rationales. 10th edition, F.A. Davis Company, 2006

Karch, Amy M. Focus on Nursing Pharmacology. 3rd edition, Lippimcott Williams and
Wilkins, 2006

Karch, Amy M. Lippincott’s Nursing Drug Guide Lippincott Williams and Wilkins, 2007

Kozier, B., Erb, G., and Berman, A. Fundamentals of Nursing: Concepts, Process and
Practice. 6th edition, Upper Saddle River, NJ: Prentice-Hall Inc., 2000

Pillitteri, Adele. Maternal and Child Health: care of the Childbearing and Childrearing
Family. 5th edition, Lippincott Williams and Wilkins, 2006

Brunner , Sudarth . Textbook of Medical-Surgical Nursing volume 1 & 2. 11th edition,

Lippincott Williams and Wilkins, 2007

XII. APPENDIX

A. HISTORY OF PRESENT ILLNESS:

 2002

Patient X verbalized she had her prenatal check ups at Tabique Clinic,
18th-1st Street, Brgy. Nazareth, CDO and was advised to maintain an intake of
99
Ferrous Sulfate (FeSO4) during her pregnancy. Last November 9, 2002, the
patient gave birth to a healthy full term baby boy through a normal spontaneous
vaginal delivery (NSVD) at Northern Mindanao Medical Center (NMMC) and was
admitted for 3 days for safe recovery. After a week, patient returned to NMMC for
a consultation regarding her sensations of pain during urination and was given
medications for 1 week, but no progress was noted. She then referred to
Polymedic Hospital and was submitted for urine culture. Results showed bacteria
present in her urine and was given another set of medications to be taken for the
next week. After completing the full medication regimen, patient reported relief of
pain in urination. While she was experiencing these, she was also breastfeeding
her baby for 6 months before she changed to bottle formula.

 2003 - 2007

Patient only recalled instances of weakness in the lower extremities in

prolonged standing accompanied by “palpitations”.

 2007

For a year, patient worked as a housekeeper for a 2-storey house, where

she experienced inadequate rest periods for she reported 6 am everyday, went
home by 10pm, then slept at 12 midnight. She looked after 6 children with
minimal assistance and did the laundry under the heat of the sun for 2 – 3 hours
for 3 days in a week.

 2008

Early January, patient X manifested alopecia and observed a metallic

taste in her saliva, both manifestations lasted more than a month. She went to
Sabal Hospital for a check up having complaints of urinary retention and frequent
urination in small amounts. The resident doctor then ordered for urinalysis which

100
resulted to high bacterial infection in urine. She was then prescribed a set of
medications to be maintained for a week to treat the infection, but this showed no
progress. She returned to the doctor to report the same problems, the doctor
recommended her to take another set of medications, yet still there was no sign
of progress evident. She returned to the doctor for 4 times taking different sets of
medications, but still, there was no improvement in her condition. She then
stopped seeing the doctor in Sabal Hospital, and sought medical help to another
physician in Polymedic Hospital. There, she was submitted for hematology and
an ultrasound of the kidney which showed normal results. With this, the doctor
decided not to issue her medication. Unfortunately, this didn’t help in the relief of
her manifestations.
In February, small rashes started to show by the side of her cheeks along
with painless oral ulcers, but she didn’t consult any medical help regarding these
abnormal findings. A few weeks after, she was admitted to Maria Reyna Hospital
(MRH) due to persistent vomiting for 4 days. The resident doctor diagnosed her
with ulcer, but the patient could not recall the specifics of the diagnosis. She was
then given IVTT meds and stayed in the hospital for 3 days. Yet the patient didn’t
complain about her rashes for she thought it was of no significance.
By the 2nd week of April, patient consulted her doctor in Tabique Clinic
because she was confused about her condition and the manifestations she
experienced. The patient was referred by Dr. Tabique to Dr. Fabia, who is a
specialist at MRH. The doctor suspected for Systemic Lupus Erythematosus
(SLE) basing on the actual symptoms then encouraged the patient to undergo an
anti-nuclear antibody (ANA) assay, which showed positive results and confirmed
the diagnosis. Dr. Fabia said the disease was genetic but the patient didn’t know
anyone in her family who had the disease. As recalled by the patient, she was
then given medications, such as: Prednisone (5mg OD), Godex (OD), Imuran
(1/2 tab OD), Isoniazid (OD), and lastly Chloroquine (OD), with varying dosages
based on her condition, to be taken every month and followed by monthly check
ups and laboratory tests such as: complete blood count (CBC), urinalysis (UA),
erythrocyte sedimentation rate (ESR) and serum glutamic-pyruvic transaminase

101
(SGPT). Due to financial concerns, patient often missed taking her daily
medications. Because of this, she tried seeking help at J.R. Borja City Hospital
hoping to access free medical assistance. To her dismay, the doctors available
didn’t specialize in her disease condition which left her the option to seek medical
attention at MRH for 6 months.
When September came, she had her last check up under Dr. Fabia then
stopped seeking treatment due to serious financial constraints. She finally
decided to go to German Doctor’s Hospital, also known as Xavier University
Community Health Care Center (XU-CHCC), and was under the care of Dr.
Gabatan, who advised her to come back with laboratory test taken at JR Borja
City Hospital such as erythrocyte sedimentation rate (ESR), C-reactive protein
(CRP), urinalysis (UA), Na+, K+, creatinine, FBS and liver profile. She was then
given medications to take such as hydroxychloroquine, Godex (OD), INH(1tab
OD) Azathioprine (1/2tab OD) and Prednisone. She was then subject to monthly
checkups from then on until January of 2009. While at home care, the patient at
times experienced edema in her face, as well as in her extremities, but the doctor
explained to her that these were just side effects of the drugs she is taking.
Around December, patient X verbalized that with constant movement of
the hands (like doing the laundry) both her thumbs would adduct and would
stiffen which lasted for 5 minutes. She never reported this to the doctor.
For the entire year of 2008, the major abnormalities the patient noticed
were the occurrences of 5 missed menses, but she never reported this to her
doctor, along with her other manifestations (the adducting of the fingers,
alopecia, and palpitations).

 2009

On January 10, 2009 patient was admitted at German Doctor’s Hospital

under the care of Dr. Gabatan due to worsening of the symptoms of her SLE and
was referred to Dr. Saavedra in Cagayan de Oro Medical Center (COMC). By
January 12, 2009, Dr. Saavedra referred her back to Dr. Gabatan for an advised
102
 chemotherapy to be done monthly in a span of 6 months. He also confirmed the
diagnosis of Lupus Nephritis. During her chemotherapy (Cyclophosphamide
therapy), the patient’s alopecia was not as worse as that of the first encounter.
The same medications were given with an additional dose of Calcium to be
maintained until the first week of February. On January 27, 2009 patient was
referred back to Dr. Saavedra and was advised to take Ciprofloxacin for a week
to treat her UTI and a repeat chemotherapy on February 10, 2009 at German
Doctors Hospital.
By first week of February, patient noticed 3 swollen lesions on her left leg.
Thus, the supposed chemotherapy for the month was postponed due to the
found lesions. On the morning of February 13, 2009, the largest lesion burst but
the other two remained small and swollen. By mid-February, we had our duty, the
lesions were still present and she was wearing a diaper since she was not
ambulatory.

B. DOCTORS ORDER

Patient’s Name: Patient X Age: 25 y.o.

Diagnosis: Systemic Lupus Erythematosus (SLE) Attending Physician: Dr. Gabatan
Date/time DOCTOR’S ORDER
2/10/09 >please admit under the service of me
>consent to care
>DAT
>TPR q shift
>problem Lupus Nephritis
>IVF: D5 0.3% NaCl at KVO rate
>labs. FBS, creatinine, Na+ K+, CBC with platelet count, ESR, ECG
12 leads
>meds.:
1. Cloxacillin 500mg IVTT q6o ANST
2. Paracetamol 500mg 1 tab q4o for temp. > 38oc
>please prepare:
Metoclopramide tab #1
103
 Dexamethasone 10mg ampule
Cyclophosphamide 1.5gm
>Dr. Saavedra informed
>refer for any unusualities
>refer accordingly
Dr. Gabatan (Signed)
> daily dressing of wound at LE
Dr. Gabatan (signed)
+ +
2/11/09 > FBS, creatinine, Na K - error
>please follow up results
Dr. Gabatan (Signed)
0
2/12/09 >Cefuroxime 750g IVTT q8 ANST
10:45am
Dr. Gabatan (Signed)
2/13/09 >repeat UA tomorrow
4:45pm
Dr. Gabatan (Signed)
2/16/09 >D/C Cefuroxime
11:25pm
>Gentamycin 80g IVTT q8o ANST
>Metronidazole 50g IVTT q8o ANST
Dr. Gabatan (Signed)
2/17/09 >continue medications
9:35am
2/18/09 >CBC with Platelet count
10:55am Dr. Gabatan (Signed)
C. NURSES NOTES

Patient’s Name: Patient X Age: 25 y.o.

Diagnosis: Systemic Lupus Erythematosus (SLE) Attending Physician: Dr. Gabatan
Date/time NURSE`S NOTES
2/10/09 >Admitted a 25y.o. female with chief complaint of facial lesions
>afebrile
>due labs. Requested
3-11
2/10/09 >Received awake ambulatory from ER with ongoing IVF of D5NaCl
500cc at 500cc level regulated at KVO rate infusing well at left arm
3:30pm >placed on bed safely
>conscious and coherent
>with pale conjunctiva
>with verbal report of throbbing pain on left leg with a pain scale of
5/10 with 10 as the most painful
>with edematous face and upper and lower extremities- non pitting
>with purulent, open wound on left ankle
>initial vital signs taken and recorded= T: 37oc, RR:28cpm, PR: 98bpm,
104
 BP: 120/70mmHg
>legs kept elevated
>deep breathing exercises initiated
>placed on moderate high back rest
DAT >served and consumed whole of share with fair appetite
>health teaching imparted with emphasis on:
a. Proper hygiene ex. handwashing
b. Medication compliance
c. Precautionary measures to protect self from infection
11:00pm >endorsed with latest vital signs of :T=37.1oc, RR=25cpm, PR=95bpm,
BP=110/70mmHg
XUSN3 (signed)
11-7
11:00pm >Received awake on bed with IVF of D5NaCl 500cc regulated at KVO
rate
>vital signs taken and recorded
>anasarca noted
>due meds. given
>intake and output measured and recorded
>cared for
>endorsed
Signed by NOD
2/11/09 7-3
>Received awake on bed with IVF D5 0.3%NaCl 500cc at 80cc level
regulated at KVO rate
>with facial and bipedal edema-noted
>for blood chemistry today-taken
>daily dressing- done
>vital signs taken and recorded
>endorsed
Signed by NOD
3-11
3pm >Received lying on bed with ongoing IVF of #2 D5 0.3% NaCl 500cc at
490cc level regulated at 10 gtts/min. infusing well at right arm
>anasarca noted
>with dry and intact dressing on lower left leg
>with complaints of throbbing headache
>with initial vital signs of T=38.7oc, RR=14cpm, PR=98bpm,
BP=110/80mmHg
2pm >febrile, T=38.7oc
>tepid sponge bath done
3pm >paracetamol 500mg 1 tab PO PRN given for fever T=38.7oc
>back massage provided
>adequate rest given
3:30pm >temp. Rechecked T=38.5oc
105
 >continuous tepid sponge bath done
>afternoon and bedside care done
DAT >served and consumed whole amount of share of 1 cup of rice and 1
serving of chopsuey with good appetite
>health teachings rendered with emphasis on:
a. Strict medication compliance
b. Adequate nutrition
c. Proper hygiene to prevent infection
>intake and output monitored and recorded
>kept watched for any unusualities
>endorsed with latest vital signs of T=37.6oc, PR=92bpm, RR=21cpm,
BP=110/80mmHg
XUSN3(Signed)
2/11/09 11-7
>Receivewd awake on bed with D5 0.3%NaCl at KVO rate at 200cc
level
>with wound dressing at left lower leg- dry and intact
>with complaints of pain at wound area
>due medications given
>intake and output measured and recorded
>needs attended
>endorsed
Signed by NOD
2/12/09 7-3
7am >Received awake on bed with ongoing D5 0.3% NaCl at 100cc level
regulated at KVO rate infusing well at right arm
>with wound dressing at left lower extremity-slightly soaked but intact
>with open wound at left lower extremity with diameter of 2cm
>with complaints of throbbing pain at wound site with pain scale of 8/10
with 10 as most painful
>verbalized feelings of generalized body weakness
>generalized non pitting edema noted
>swelling on left lower extremity and around the IV site noted
>with initial vital signs of T=37.4oc, PR=107bpm,RR=23cpm,
BP=110/80mmHg
>morning care done: bed linens changed, tucked, and well pressed
>turned to sides at frequent intervals to prevent pressure ulcer
>placed on moderate high back rest position
>encouraged deep breathing exercises and tolerated for 30 seconds
>kept left lower extremity elevated with towel
>back rub done
>environmental stimuli restricted
DAT >consumed full share with good appetite
9:15am >daily dressing aseptically done at wound by NOD
10:25am >seen and examined by Dr. Gabatan with new orders carried out by
106
 NOD
10:40am >febrile with T=38.2oc
10:45am >Paracetamol 500mg given
>continuous TSB done
10:50am >above IVF consumed and followed up with same IVF and regulated at
same rate
11:15am >temperature rechecked: T=37.8oc
>health teachings given with emphasis on:
a. Medication compliance
b. Adequate nutrition
c. Proper hygiene such as bathing and frequent handwashing to
prevent infection
d. Proper wound care
e. Turning to side at frequent intervals
>intake and output measured and recorded
>kept watched for any unusualities-none noted
>endorsed with latest vital signs: T=37.8oc, PR=93bpm,
RR=24cpm,BP=100/70mmHg
,XUSN3(signed)
2/12/09 3-11
2pm >Received awake lying on bed with ongoing IVF of #3 D5 0.3% NaCl at
500cc level regulated at 10gtts/min infusing well on right arm
>with complaints of pain at left leg with a pain scale of 9/10 with 10 as
most painful
>with dressing on lower left leg- dry and intact
>non-pitting edema noted on left leg
>with initial vital signs of
T=37.8oc,PR=90bpm,RR=24cpm,BP=120/80mmHg
2pm >febrile T=37.8oc
>tepid sponge bath done
>adequate rest given and provided
3pm >temperature rechecked T=34.4oc
>continuous tepid sponge bath done
>lower extremities elevated with towel
>encourage to do deep breathing exercise and relaxation techniques
>afternoon and bedside care done
DAT >served and consumed whole of share with good appetite
>health teachings reinforced
>intake and output taken and recorded
10pm >endorsed with latest vital signs of
T=37.6oc,PR=91bpm,RR=22cpm,BP=110/80mmHg
XUSN3 (signed)
2/12/09 11-7
11pm >received asleep on bed with D5 0.3%NaCl at 400cc level regulated at
KVO rate
107
 >with wound dressing at left lower leg- dry and intact
>vital signs taken and recorded
>due medications given
>needs attended
>endorsed
Signed by NOD
2/13/09 7-3
7am >received awake lying on bed with IVF of D5 0.3% NaCl regulated at
KVO rate
>vital signs taken and recorded
>due medications given
>kept comfortable on bed
>cared for
>endorsed
Signed by NOD
2/13/09 11-7
>Received asleep on bed with ongoing IVF of #3 D5 0.3% NaCl
regulated at 10gtts/min infusing well on right arm
>afebrile
>due medications given
>kept comfortable
>needs attended
>endorsed
Signed by NOD
2/14/09 7-3
>Received with D5 0.3% NaCl regulated at 10gtts/min infusing well on
right arm
>vital signs taken and recorded
>daily dressing done
>due medications given
>kept comfortable
>endorsed
Signed by NOD
2/14/09 3-11
>on bed with D5 0.3% NaCl regulated at KVO rate
>vital signs taken and recorded
>due medications given
>needs attended
>endorsed
Signed by NOD
2/14/09 11-7

108
 >Received with D5 0.3% NaCl regulated at KVO rate
>vital signs taken and recorded
>due medications given
>cared for
>endorsed
Signed by NOD
2/15/09 7-3
>Received with D5 0.3% NaCl regulated at KVO rate
>vital signs taken and recorded
>due medications given
>cared for
>endorsed
Signed by NOD
2/15/09 3-11
>Received with D5 0.3% NaCl at 400cc level regulated at KVO rate
>with wound dressing at left lower leg-dry and intact
>afebrile
>due medications given
>needs attended
>cared for
>endorsed
Signed by NOD
2/15/09 11-7
>Received with D5 0.3% NaCl at 220cc level regulated at KVO rate
>due medications given
>vital signs taken and recorded
>needs attended
>endorsed
Signed by NOD
2/16/09 7-3
>Received awake on bed with D5 0.3% NaCl regulated at KVO rate
>vital signs taken and recorded
>dressing changed
>IVF site changed
>due medications given
>cared for
>endorsed
Signed by NOD
2/16/09 3-11
>Received with D5 0.3% NaCl 500cc at 100cc level regulated at KVO

109
 rate
>vital signs taken and recorded
>due medications given
>cared for
>endorsed
Signed by NOD
2/16/09 11-7
>Received awake on bed with IVF of D50.3 NaCl @ 50cc level
regulated at KVO rate
>due meds on time given
>above IVF consumed and followed up with D50.3 NaCl 500cc at
same rate
>vital signs taken and recorded
>endorsed
Signed by NOD
2/17/09 7-3
>Received lying on bed with ongoing IVF of D50.3% NaCl 500cc @
450cc level regulated @ KVO rate infusing well on left arm
>conscious and coherent
>with wound dressing at left lower extremity slightly soaked but intact
>inflammation at left lower extremity around the wound noted
>with complaints of throbbing pain at wound site with pain scale of
6/10 with 10 as most painful
> generalized non-pitting edema noted
>with initial vital signs of T=37.30C , PR=79bpm, RR=25cpm,
BP=120/80mmHg
>morning care done; bed linens changed, tucked and well pressed
9:35am >seen and examined by Dr. Gabatan with new orders carried out by
NOD
9:40am >daily dressing aseptically done at wound site by Dr. Gabatan
>placed on comfortable position
>turned to sides at frequent intervals to prevent pressure ulcers
>encouraged deep breathing exercises as tolerated for 30 seconds
>kept left lower extremity elevated with towel
>back rubbing done
>diversional activities provided
>adequate rest periods provided
>consumed full share with good appetite
>health teachings given with emphasis on:
a. Medication compliance
b. Adequate nutrition with food low in sodium and potassium
content
c. Proper hygiene to prevent infection
d. Proper wound care
>input and output recorded
110
>kept watched for other unusualities-none noted

111
112
113
 >endorsed with latest vital signs T=37.70C, PR=90bpm, RR=25cpm,
BP=110/70mmHg
XUSN3 (signed)
3-11
3pm >Received awake lying on bed with ongoing IVF of D50.3 NaCl 500ml
at 460cc level regulated @ KVO infusing well at left arm
>pale and dry lips noted
>weakness noted
>with sanguinous, open wound at left ankle
>with presence of wound at lower left extremity
>with complaint of pain at wound area, with pain score of 7 out of 10
with 10 as the most painful
>initial vital signs taken and recorded with HR: 94bpm; RR:25cpm;
temp: 37.90C; BP:110/70mmHg
>afternoon care done
>placed in a dorsal recumbent position
>tepid sponge bath done
4:00pm >rechecked temperature: 37.50C
>continuous tepid sponge bath done
DAT >served and consumed share with fair appetite
>health teachings imparted with emphasis on:
a. Proper hygiene
b. Proper nutrition such as eating foods high in vitamin C, limiting
fluid intake to 1000ml
c. Oral care to deviate oral discomfort
d. Strict medication compliance
>intake and output measured and recorded
>endorsed with latest vital signs: HR: 98bpm; RR: 27cpm; temp:
37.80C; BP: 110/70 mmHg
XUSN3 (signed)
2/17/09 11-7
>Received on bed awake with IVF of D50.3% NaCl at 300cc level
regulated KVO rate
>with wound dressing- dry, intact
>vital signs taken and recorded
>due meds given
>needs attended
>endorsed
Signed by NOD
2/18/09 7-3
7:00am > Received awake sitting on bed with newly hooked IVF of D50.3 NaCl
500cc regulated at KVO rate infusing well at right arm
>conscious, responsive and coherent
>with presence of wound at left lower leg with diameter of 2cm-with
dressing and wrapped elastic bandage-dry and intact
114
 >with redness and swelling at left lower leg
> with complaints of throbbing pain at left lower leg rated as 5/10 in the
pain scale 0-10, 10 as most painful
> generalized pitting edema noted
>with numerous dark skin lesions on the face and darker at anterior
portion of the nose
>initial vital signs taken and recorded, T=36.80C; HR=110bpm;
RR=26cpm; BP=110/70mmHg
>morning care done, bed linen changed, tucked and well-pressed
>place on supine position
>left lower extremity kept elevated with rolled towel
>deep breathing exercises initiated and tolerated for 1-2minutes
>turned to sides at frequent intervals
>diversional activities offered such as socialization
>adequate rest period provided
>environmental stimuli restricted
DAT >served and consumed share with poor appetite
9:55am >seen and examined by Dr. Gabatan with new orders carried out by
NOD
10:05am >daily dressing at wound site aseptically done by Dr. Gabatan
>health teachings given with emphasis on:
a. Compliance of medication and treatment regimen
b. Adequate nutrition
c. Proper hygiene; handwashing; daily bathing
d. Proper wound care
e. Pain management
>for CBC with platelet count-requested
>kept watched for any unusualities-none noted
3:00pm >endorsed with latest vital signs of temp:37.30C; HR:99bpm;
RR:25cpm; BP:110/70mmHg
2/18/09 3-11
3pm >Received awake lying flat on bed with IVF#8 of D5 0.3%NaCl
@450cc level, regulated at 10gtts/min.-infusing well at left arm
>conscious, coherent and oriented to time, date, place
>noted to be calm and neatly dressed
>with complaints of pain on left leg with a pain scale of 6 in a 1-10 pain
scale- 10 as the most painful
>with newly dressed wound on left leg-dry and intact
>with initial vital signs of: Temp= 37.70C; PR=87bpm; RR=28cpm;
BP=100/70mmHg
>tepid sponge bath continuously done
>left leg elevated with pillows
>bedside care and nail care done
>diversional activities given
DAT > served and consumed whole share with good appetite
115
 >health teachings imparted with emphasis on:
a. Relaxation and deep breathing exercise – for pain management
b. Increased oral fluid intake
c. Proper environmental sanitation- to prevent infection
7:20pm >above IVF-kept set sterile
9:45pm >above IVF regulated at left arm-infusing well
>intake and output monitored and recorded
10pm >endorsed with latest vital signs of: T=37.70C; PR=88bpm; RR=28cpm;
BP=100/70mmHg
XUSN3 (signed)
2/18/09 11-7
>Received asleep lying on bed with IVF of D50.3% NaCl, regulated at
10gtts/min, infusing well at left arm
>dressing at left leg kept dry and intact
>vital signs taken and recorded
>due meds given
>provided with adequate rest
>cared for
>endorsed Signed by NOD
2/19/09 7-3
7:00am >Received awake sitting on bed with IVF of D5 0.3%NaCl 500cc @
90cc level,at KVO rate-infusing well at left arm
>alert and responsive
>still with redness and swelling on left lower leg
>generalized pitting edema noted
>still with numerous dark skin lesions on the face and darker at
anterior portion of the nose
>initial vital signs taken and recorded T=37.20C, HR=98bpm,
RR=26cpm, BP=110/70mmHg
>morning care done
>placed on modified high back rest
>left leg extremity kept elevated with rolled towel
>deep breathing exercises measured for 1-2 minutes
>turned to sides at frequent intervals
>adequate rest period provided
>environmental stimuli restricted
DAT > served and consumed full share with good appetite
>above IVF consumed and followed up with D5 0.3NaCl 500cc
regulated at same rate
9:00am > seen and examined by Dr. Gabatan
10:00am > daily dressing at wound site aseptically done by Dr. Gabatan
>health teachings given-endorsed
>kept watched for other unusualities-none noted
> endorsed with latest vital signs of temp:37.30C; HR:97bpm;
RR:29cpm; BP:110/70mmHg XUSN3 (signed)
116
2/19/09 3-11
>Received with IVF of D5 0.3NaCl @ 280cc level regulated at KVO
rate
>vital signs taken and recorded
>with wound dressed; dry and intact
>cared for
>due meds given
>low-salt /DAT-consumed with good appetite
>endorsed Signed by NOD
2/19/09 11-7
>Received with IVF of D5 0.3NaCl regulated at KVO rate, infusing well
>vital signs taken and recorded
>due meds given
>wound dressing kept dry and intact
>endorsed Signed by NOD
2/20/09 7-3
>Received awake on bed with IVF of D5 0.3NaCl 500cc at KVO rate
>with wound dressing at left lower leg-dressing done
>vital signs taken and recorded
>due meds given
>adequate rest provided
>endorsed
Signed by NOD

117
D. ECG STRIP

Figure 1

118
Figure 2

119
120