Presumptive Nursing Diagnosis
Although the information provided by the patient is rather brief, it can be supposed that Mary suffers from a case of Systemic Lupus Erythematosus (SLE). SLE is typically defined as an autoimmune disease that causes adverse effects to most organ systems. The pathology implies the release of antibodies triggering an immediate reaction with the regular nuclear components.
The so-called “butterfly rash” (Adams, 2012, p. 930) is the primary symptom of SLE. In addition, the development of fatigue and fever can be attributed to SLE. Similarly, muscle aches and lesions are listed among typical symptoms of SLE. It should also be brought up that the exposure to the outside environment, especially to sunlight, often becomes the trigger for lupus onset and further progress.
It could be argued that SLE typically manifests itself in swelling, which Mary currently does not have. One must keep in mind, though, that the disease may occur at a rather slowly pace, with only the butterfly rash as the primary symptom. For instance, the absence of swelling, which the patient declared very distinctly, is not quite typical for SLE, which traditionally manifests itself in large swelling. Similarly, the mouth soreness that the patient has been experiencing cannot be deemed as the exact symptom of SLE (Suki & Massry, 2012). However, the comorbid symptoms such as fatigue and pain, particularly, muscle aches, point quite clearly to the fact that the patient has developed SLE.
Further Course of Actions
Along with providing the patient with the necessary treatment, the nurse will also have to offer Mary extensive information on the disease and its management. Specifically, it will be crucial to make sure that the patient should not be overly alarmed about the problem as it may eventually lead to depression. Instead, the nurse will have to warn Mary about the essential threats that she may face. For instance, the patient should not expose her skin to UV light. In addition, Mary should consider using ice to reduce the swelling. Finally, the patient must be aware of the significance of regular rest.
Nursing Care Plan
To address the needs of the patient, a nurse must provide the environment, in which the patient could be relieved of the discomfort that she is currently experiencing. Specifically, the relaxation techniques, as well as the activities that may distract the patient from the pain in muscles could be viewed as the primary options to consider. To reduce the pain, NSAIDs should be prescribed (Chernecky & Berger, 2012).
In order to manage the rash and fever issue, the nurse should consider the provision of the anti-inflammatory medicine. In addition, the patient must be provided with the medicine that will help relieve the pain. However, it would be wrong to expect that the medicine will help Mary get rid of the discomfort complete; therefore, it will also be required to carry out an intervention informing her on the experiences that she is likely to have in the course of treatment. It will also be necessary to encourage the patient to express her emotions about the subject matter so that the emotional state could be controlled by the nurse and that the threat of depression development could be avoided successfully. Finally, the schedule for providing the necessary treatment will have to be shaped so that Mary’s personal, professional, and social life should not be disrupted.
Adams, J. G. (2012). Emergency medicine: Clinical essentials. New York, NY: Elsevier Health Sciences.
Chernecky, C. C., & Berger, B. J. (2012). Laboratory tests and diagnostic procedures. New York, NY: Elsevier Health Sciences.
Suki, W. N., & Massry, S. G. (2012). Therapy of renal diseases and related disorders. New York, NY: Springer Science & Business Media.