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