The patient is Mary, a 35-year old female who works as an electrical engineer. She arrived with the rash that has been on her face and the bridge of her nose for one week. According to Mary, her rash first became noticeable during the hiking trip in the Appalachians. The accompanying symptoms are fatigue, loss of weight, and high fever, muscle pains (in particular, in her hand and wrist), BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F.
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Presumptive nursing diagnosis
According to the symptoms, it is possible to establish a presumptive nursing diagnosis is lupus. Mayo Clinic’s definition of this condition states that “the most distinctive sign of lupus — a facial rash that resembles the wings of a butterfly unfolding across both cheeks” (2016). Mary has the butterfly rash and most of the other symptoms typical for lupus – fatigue, weight loss, and painful joints (Pietrangelo & Cherney, 2015). Most importantly, according to Mary, she noticed that spending time outdoors made her condition worse. This observation indicates that the patient has been experiencing photosensitivity, one of the most significant signs of lupus (Bartels, 2015). In addition, the patient has reported oral ulcers – another diagnostic criterion for lupus (Bartels, 2015). The final diagnosis requires lab tests because the symptoms of lupus are not easy to distinguish as they may be similar to the signs of many other diseases and conditions.
Education and treatment plan
First of all, the patient needs to be educated about her condition and its management. Since Mary reported that this is the first time she is experiencing these symptoms, she requires full and detailed information about what lupus is and how it is caused. My plan is to deliver the information about the disease in several sections such as the background and mechanics of the disease; or to be more comprehensive, what happens in the patient’s body when it is affected by lupus. Further, I plan to inform Mary about the possible developments of the disease and that its symptoms and signs can be rather individual and vary from one person so another. Besides, I plan to educate the patient about the management of the disease and the necessary treatment so that she is prepared to follow through with the doctors’ prescription and instructions. It is crucial to make sure that the patient is very clear about the seriousness of the condition and the importance of the consistent treatment.
As for the treatment, Mary needs to be informed about the medications that are usually prescribed for lupus; namely, anti-inflammatory of nonsteroidal characters to relieve the joint pain (some of such drugs are Ibuprofen and naproxen sodium they can be purchased over the counter. Mary also needs to be informed that she would have to see her doctor on a regular basis in order to ensure that the treatment is conducted under observation and with professional advice. In case if the patient’s symptoms get worse, she would have to be hospitalized for further tests. Lupus tends to develop and affect many different systems and organs. However, there are cases with rather mild symptoms. Such patients do not require hospitalization and at times, may even recover without taking drugs. In other words, at the initial stages of her condition, Mary requires a lot of professional attention and information in order to be able to manage the disease and cooperate with the medical professionals.
Bartels, C. M. (2015). Systemic Lupus Erythematosus (SLE). Web.
Mayo Clinic. (2016). Lupus. Web.
Pietrangelo, A. & Cherney, K. (2015). 10 Early Signs of Lupus. Web.
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