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    Clinical Portrait

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    Dann Francis Sarnillo
    This nursing care plan summarizes a 14-year-old female patient with a diagnosis of Systemic Lupus Erythematosus. The patient presents with rashes, scarring, oral sores, joint pain, edema, and abnormal lab results. A review of her medical history reveals an 8 month history of hair loss and recent onset of fever, vomiting, and joint pain. Laboratory tests confirm positive ANA and anti-DSDNA antibodies.

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    Clinical Portrait

    Uploaded by

    Dann Francis Sarnillo
    130 views6 pages
    This nursing care plan summarizes a 14-year-old female patient with a diagnosis of Systemic Lupus Erythematosus. The patient presents with rashes, scarring, oral sores, joint pain, edema, and abnormal lab results. A review of her medical history reveals an 8 month history of hair loss and recent onset of fever, vomiting, and joint pain. Laboratory tests confirm positive ANA and anti-DSDNA antibodies.

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    This nursing care plan summarizes a 14-year-old female patient with a diagnosis of Systemic Lupus Erythematosus. The patient presents with rashes, scarring, oral sores, joint pain, edema, and abnormal lab results. A review of her medical history reveals an 8 month history of hair loss and recent onset of fever, vomiting, and joint pain. Laboratory tests confirm positive ANA and anti-DSDNA antibodies.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    130 views6 pages

    Clinical Portrait

    Uploaded by

    Dann Francis Sarnillo
    This nursing care plan summarizes a 14-year-old female patient with a diagnosis of Systemic Lupus Erythematosus. The patient presents with rashes, scarring, oral sores, joint pain, edema, and abnormal lab results. A review of her medical history reveals an 8 month history of hair loss and recent onset of fever, vomiting, and joint pain. Laboratory tests confirm positive ANA and anti-DSDNA antibodies.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    NURSING CARE PLAN

    Patients Name : Tumongha, G.A.A. Hospital No : 432997


    Age : 14 years old Room No/Bed No : M2 49
    Impression/Diagnosis : Systemic Lupus Erythematosus Physician : Dr. Ralph John T. Noval
    CLINICAL PORTRAIT PERTINENT DATA
    1. Assessment:
    A case of patient G.A.T., 14 years old, female, Roman Catholic, from
    Tugbongan, Consolacion Cebu. The patient is seen lying on bed ,
    conscious , responsive, coherent, afebrile not in respiratory distress, with
    ongoing intravenous fluid of #2 D5NM1 L @25gtts/min infusing well on
    the patients left arm. With the following vital signs:
    T-36.1
    0
    C PR-72 bpm RR-19 cpm BP-90/60mmHg
    2.Significant Findings:
    Review of Systems
    Skin: The patients skin is light brown with presence of rashes, petechiae/
    popular scars. Skin is warm & has good turgor. Nail reveals to be pale
    that cant be able to perform capillary refill test.
    Head: Head is symmetric, round, & in the midline. Alopecia & scars are
    noted.
    Eyes: Eyeballs are symmetrically aligned in sockets without protruding
    or sinking.
    Ears: Presence of scars & rashes are noted over the pinna.
    1. History of Present Illness
    8 months prior to admission- Patient noted sudden abnormal hair loss.
    One month prior to admission- Patient came from school and had an
    onset of fever, & dysuria, arrived with facial swelling, edema in both
    feet, associated with pain on a pain scale of 5 out of 10. Patient was then
    brought to private physician for consultation. Patient was given
    ciprofloxacin. Edema subsided however pain persisted.
    2 days after, patient had fever and had two constant episodes of vomiting
    per day, went back to the physician and requested an ultrasound test. This
    revealed a complex structure at the right lower quadrant. The patient
    complains of body pain and also joint pain especially in the extremities.
    Patients condition worsened, patient noted fatigue, generalized body
    pallor, positive stiffness, joint pain. Consult physician, ultrasound done,
    revealed cystitis. Was admitted to Eversley, and was given ceftriazone.
    Patient noted paleness of fingerbeds, stiffening of fingers, tightening of
    extremities with pain, dry lips, oral sores, appearance of purpuric rashes
    and hematoma, with evident malar rashes. Menses usually noted at the
    Nose & sinuses: Nasal structure is smooth &symmetric. No tenderness
    noted on the sinuses.
    Throat: Presence of oral sores noted.
    Respiratory: The patient is not in respiratory distress with the respiratory
    rate of 19 cpm.
    Gastrointestinal: Patient eats small amount of food.
    Genitourinary: presence of oliguria noted.
    Musculoskeletal: Tenderness noted in joints.
    Psychiatric: The patient is mentally-oriented.

    Laboratory Results:
    Test Name Result Range/ Reference
    ANA

    Positive (+2)@1:320
    Dilution
    Negative
    Urine Creatinine 300.00 L 1000-2000
    Total Protein 1028 H 10-150
    WBC Count 2.50 L 4.8-10.8
    Hemoglobin 103 L 120-160
    Hematocrit 0.32 L 0.37-0.47
    Platelet Count 129 L 150-400
    Protein +3
    Albumin 2.63 L 3.5-5.0
    end of the month. However, patient had no menses for one month and
    noted browness vaginal discharge. Laboratory tests done. Thus, condition
    prompted referral to Vicente Sotto Memorial Medical center for further
    examination.
    2. Chief Complains:
    Generalized body pain and weakness, edema, neck stiffness, pale
    fingerbeds.
    3. Laboratory Results:
    Ultrasound Report
    ( February 15, 2013)

    UTERUS: 6.3 x 3.1 x 3.7 cm (L x AP x T) Anteverted. No focal solid or cystic
    masses demonstrated.
    Endometrial echo: 0.2 cm

    OVARIES:
    Right: 1.2 x 2.3 cm
    Left: 1.8 x 3.1 cm

    CERVIX: 1.9 x 1.8 x 2.1 cm
    Nabothian Cysts: NONE
    Posterior cul-de-sac: No significant fluid collection

    IMPRESSION:
    1. NORMAL SIZED ANTEVERTED UTERUS WITH THIN
    ENDOMETRIUM.
    2. BOTH ADNEXAE ARE NEGATIVE.
    3. NO SIGNIFICANT FLUID COLLECTION WITHIN THE POSTERIOR
    CUL-DE-SAC.

    3. Vital signs taken during the nurse first contact with the patient.
    T-36.1
    0
    C PR-72 bpm RR-19 cpm BP-90/60mmHg


    5 Problems Identified:
    Alteration in Comfort related to inflammation of joints and juxta-
    articular structure
    Impaired oral mucosa related to oral lesions/ oral sores.
    Fluid volume excess related to edema.
    Body image disturbance
    Knowledge deficit







    Ultrasound Report
    (February 27, 2013)

    EXAMINATION WHOLE ABDOMEN
    REPORTS
    GB intraluminal diameter: 1.3 cm (N= <4.0 cm) GB wall thickness: 0.3
    cm (N= <0.4 cm)
    Common duct: 0.2 cm (N= <0.6 cm?)
    Pancreas: 1.6 x 1.7 x 2.3 cm (Head, Body, Tail) Pancreatic duct: 0.2 cm
    Liver Span: 14.9 cm
    Spleen: 10.9 cm x 6.2 cm (LH)
    Right Kidney: 10.6 x 6.2 x 4.8 cm (LWH) Cortical thickness: 1.9 cm
    Left Kidney: 10. X 7.3 x 5.5 cm (LW) Cortical thickness: 2.0 cm
    Uterus: 7.7 x 5.0 x 3.2 cm (LWH)
    Right Ovary: 3.1 x 2.2 cm; Left ovary: 3.1 x 2.5 cm
    Elaborations: (Abnormal findings/ Areas of Concern)

    The urinary bladder is physiologically distended. Its wall is thickened at 1.0 cm.
    No abnormal intraluminal echoes are seen.

    *****IMPRESSION****
    Unremarkable GB, CBD & intrahepatic biliary radicles.
    Essentially normal kidneys, liver, pancreas & spleen.
    Normal sized uterus with physiologic endometrium;
    Physiologic appearance of the ovaries.
    Thickened UB wall, consistent with cystitis.
    Structurally unremarkable abdominal aorta

    Clinical chemistry report
    (March 02, 2013)

    TEST RESULT REFERENCE UNIT
    COMPLEMENT C3 1.10 0.9-1.9 G/L

    IMMUNOLOGY REPORT
    (March 05, 2013)

    TEST RESULT REFERENCE UNIT
    ANA
    (immunofluorence)
    POSITIVE (+2)
    @ 1:320
    DILUTION
    Negative
    Anti-DSDNA
    (immunofluorence)
    POSITIVE Negative


    HEMATOLOGY
    (March 5, 2013)

    COMPLETE BLOOD
    COUNT
    RESULT RANGE
    WBC Count 2.50 10^9/L 4.8-10.8
    Hemoglobin 103 g/L 120-160
    Hematocrit 0.32 L/L 0.30-0.47
    MCV 76.50 fl 81-99
    MCH 24.90 pg 27-31
    RBC Count 4.13 10^12/L 4.20-5.40
    MCHC 326 g/L 320-370
    RDW 15.50 11-15
    Platelet Count 129 10^9/L 150-400
    Neutrophil 49.20 % 40-74
    Lymphocytes 38.80 % 19-48
    Monocyte 12.00 % 3-9
    Eosinophil 0.00 % 0-7
    Basophil 0.00 % 0-2
    Stab 0 % -
    Atypical Lymphocyte 0 % -
    Metamyelocytes 0 -
    Myelocytes 0 -
    Blast 0 -


    X-RAY REPORT
    (March 3, 2013)

    Procedure: CHEST PA/LAT- PEDIA

    Findings:
    Both injury fields are clear. Heart is normal in size & shape. The trachea
    is at the midline. Both hemidiaphragms are sharp & distinct. The osseous
    thoracic cage showed no significant bony abnormality.

    IMPRESSION;

    = NORMAL CHEST


    CLINICAL MICROSCOPY
    (March 03, 2013)

    URINALYSIS RESULT UNIT
    Color YELLOW
    Transparency SLCLDY
    Specific Gravity 1.025
    PH 6.0
    Glucose NEG (-)
    Protein +3
    RBC 1-3 /hpf
    WBC 3-5 /hpf
    CAST
    >10 /hpf
    CRYSTALS
    A. Urates FEW
    MISCELLANEOUS
    STRUCTURES

    Squamous E. Cells FEW
    Bacteria FEW


    CHEMISTRY (LIPID EXAMINATION)
    (March 03, 2013)

    LIPID PROFILE RESULT UNIT REFERENCE
    Cholesterol 148.0 mg/dL 0.0-200.0
    Triglycerides 226.4 mg/dL 0.0-200.0
    HBL-cholesterol 23.51 mg/dL >60.0-


    DENGUE NS1 ANTIGEN, IgM & IgG ANTIBODIES TEST
    (March 01, 2013)

    TESTS RESULTS
    DENGUE NS1 ANTIGEN NEGATIVE
    DENGUE IgM ANTIBODY NEGATIVE
    DENGUE IgG ANTIBODY NEGATIVE

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