History and Physical Examination
The patient under analysis is a female, thirty-five years old. The woman has a rash on the face for approximately one week. The allergic reaction to soap, lotion, or food is excluded. The rash is over the face and is itchy and painful. The woman did not take any medicaments to get rid of the rash. She stressed that the rash is worse when she goes outside. The rash on the face was first noticed after hiking in the mountains.
The major symptoms are the following ones, namely fatigue, weight loss, and fever from time to time. The patient does not have a headache, chest pain, pain with urination, and sore throat. According to the words of the woman, she has mouth soreness and pain in wrists. The patient did not notice the increased appetite and thirst. Because of regular throat infections, she had a tonsillectomy at the age of nine. However, being an adult the patient was healthy and was never taken to the hospital.
According to family history, the mother of the patient has rheumatoid arthritis, whereas her father does not have any diseases.
The patient does not smoke and does not take any drugs. The woman can have a glass of wine, however, she does not drink too much. The patient is a master’s in engineering. At the moment, she lives with her boyfriend.
The patient is a young woman. After the analyses, certain conclusions can be drawn. The blood pressure is low, namely 112/66 mm Hg. The heart rate is normal, namely 62 BPM, the temperature is 100.3°F, the respiratory rate is 12 breaths per minute. Erythematous plaques over the face (cheeks and nose) were detected. The sclera is white with clear conjunctivae. Pupils are equal and constrict from four millimeters to two, react to the light change. Also, erythema is found in the posterior pharyngeal wall. There are shallow ulcers in the buccal mucosa. There is no swelling; the patient feels comfortable while moving.
Presumptive Nursing Diagnosis
According to the stated above symptoms, the presumptive diagnosis is systemic lupus erythematosus.
In the vast majority of cases, the disease begins gradually. Patients complain concerning fatigue, weight loss, fever, and pain in wrists. The primary symptoms of the disease are the following ones, namely, rash on face, erythematous plaques, and shallow ulcers in the buccal mucosa. Patients also note that they have symmetrical pain in joints and pain in muscles.
Although there are a lot of symptoms that match, it should be pointed out that further investigations and analyses are needed to prove the presumptive diagnosis.
Teaching and Nursing Care Plan
The nursing care plan involves assessment, diagnosis, inference, planning, intervention, and evaluation.
Assessment: the patient has facial rash, fatigue, pain in wrists, and hands. The following information is essential to be taken into consideration:
- Temperature: 100.3°F;
- BP: 112/66 mm Hg;
- HR: 62 BPM;
- R 12: breaths per minute.
Diagnosis: rash, lesions.
Inference: diffuse connective tissue disease characterized by systemic lesions of the connective tissue and its derivatives, which affects microvessels (Kyttaris 1115). The disease is more common for young women than men (Lateef and Petri 507).
Planning: after the nursing interventions the amount of rash and pain will be reduced to a minimum within a week.
Intervention: good nutrition, rest, sleep, good hygiene. It is essential to teach the patient deep relaxation techniques. The patient should avoid being on the direct sun rays and should be protected with clothes. The patient should take prescribed medicine.
Rationale: it is vital to teaching the patient how to prevent infections and try to improve the immune system. Moreover, stress contributes to the fact that the symptoms become more severe. That is, stress should be eliminated. It is worth highlighting that the patient should be aware of possible risks and drawbacks of the treatment process.
Evaluation: After a week of intervention, the overall condition of the patient’s health was improved. However, further treatment is needed.
Requirements
The diagnosis of systemic lupus erythematosus is commonly determined by a dermatologist based on the patient’s complaints regarding weight loss, fever, facial rash, and pain in muscles and joints (Lahita 45). In SLE the blood count, a blood test for lupus, the study of immunity, clinical urine analysis, an x-ray of the lungs, echocardiography (ultrasound of the heart) are commonly prescribed (Schur and Massarotti 73). The doctor must not only identify the disease but also understand the negative effects of it. Patients with systemic lupus erythematosus need long-term continuous monitoring and comprehensive treatment by a physician or rheumatologist. The sooner the treatment process has started the better outcomes the patient will have.
SLE Treatment starts with hormonal drugs (corticosteroids) (Traczewski and Rudnicka 177). To mitigate immune reactions, immunosuppressants are commonly used during the process of treatment (Borba et al. 215). The disease demands professional treatment, and that is, the patient should consult the doctor as soon as the first symptoms are evident. The patient from the case study consulted the specialists in time. After further analyses, the treatment will be prescribed.
Works Cited
Borba, Helena, Astrid Wiens, Thais Souza, Cassyano Correr, and Roberto Pontarolo. “Efficacy and Safety of Biologic Therapies for Systemic Lupus Erythematosus Treatment: Systematic Review and Meta-Analysis.” Bio Drugs 28.2 (2013): 211-228. Web.
Kyttaris, Vasileios. “Biologic Agents in the Treatment of Systemic Lupus Erythematosus.” Systemic Lupus Erythematosus (2011): 1109-1117. Web.
Lahita, Robert. Systemic Lupus Erythematosus. San Diego: Academic, 2011. Print.
Lateef, Aisha, and Michelle Petri. “Biologics in the Treatment of Systemic Lupus Erythematosus.” Current Opinion in Rheumatology 22.5 (2010): 504-509. Web.
Schur, Peter, and Elena Massarotti. Lupus Erythematosus: Clinical Evaluation and Treatment. New York: Springer, 2012. Print.
Traczewski, Pawel, and Lidia Rudnicka. “Treatment of Systemic Lupus Erythematosus with Epratuzumab.” British Journal of Clinical Pharmacology 71.2 (2010): 175-182. Web.