CHAPTER 1

INTRODUCTION

Systemic Lupus Erythromatosus (SLE) is a multisystem inflammatory

autoimmune disease. It is a complex disorder of multi-factorial origin via genetic,
hormonal, environmental, and immunologic factors. SLE affect the skin, joints,
and serous membranes (pleura, pericardium), along with the renal, hematologic,
and neurologic systems. It is characterized by a chronic unpredictable course
marked by alternating periods of exacerbation and remission. (Lewis, Dirksen,
Heitkemper & Butcher, 2014)
According to the Centers for Disease Control and Prevention, there is a
prevalence of 161,000 with definite SLE and 322,000 with probable SLE. An
estimated annual prevalence from 2002–2004 was much higher for blacks than
whites in Michigan (Washtenaw and Wayne Counties) with 111.6 per 100,000
people and in Georgia (DeKalb and Fulton Counties) with128.0 per 100,000
people. Annual prevalence from 2007–2009 for American Indians/Alaska Natives
was 178 per 100,000. Annual prevalence estimates were much higher among
women than men in Michigan with 9.3 per 100,000 people, in Georgia with 145.8
per 100,000 people, and in the American Indian/Alaska Native population with
271 per 100,000 people. (CDC.gov, 2017)
SLE incidence estimates are available from the CDC-funded lupus
registries. Annual incidence for different racial/ethnic groups from 2002–2004
was much higher for blacks than whites in Michigan with 7.9 per 100,000 people5
and in Georgia with 9.4 per 100,000 people. Annual incidence from 2007–2009
for American Indians/Alaska Natives was 7.4 per 100,000. Annual incidence
estimates were much higher for women than men in Michigan with 9.3 per
100,000, Georgia with 10.6 per 100,000, and the American Indian/Alaska Native
population with 8.4 per 100,000. (CDC.gov, 2017)
According to Dr. Sandra Navarra, a rheumatologist and the president of
Rheumatology Educational Trust Foundation Inc. (RETFI) and the records of the
Lupus Inspired Advocacy (Luisa) Project, there were 2,273 SLE patients from

1
1995 to 2010 seen in various rheumatology training institutions and private
rheumatology clinics in the Philippines. The average age of the patients was 29,
while children and adolescents accounted for 408 cases. Patients were
predominantly females with a ratio of 15 to one. (Crisostomo, 2012)
For 4 days, the members of Group 1, under Mrs. Anabel Bauzon., R.N.,
M.N., were assigned in the Emergency Department of Southern Philippines
Medical Center. The group chose a case of a 28-year old patient with SLE. The
group chose this case for it is their first encounter with the said disease, would
like to gain more knowledge and understanding of it, and be able to conduct a
research about the case since there are no available local statistics published.
This study will enable the group to be aware about the disease and be able to
educate the people with SLE that would help boost up awareness in the
community. Lastly, the group would want to apply the concept they learned last
academic year.

2
 CHAPTER 2
PROCESS AND MECHANICS

J.P. was diagnosed of SLE last march 2016 and had undergone pulse
therapy. She was admitted last April 2017 however; no therapy was done. She
was discharged and improved conditions. Unfortunately, 3 days prior to
admission, she had onsets of mild dyspnea and recurrence of edema with
hemoglobin of 66, which forced her for admission and for another pulse therapy.
Patient came in for cyclophosphamide therapy for her condition and there
were initial findings of UTI upon urinalysis in this institution, which decided to be
referred to Internal Medicine Department in the Emergency Department.
Patient came in to the Emergency Room on July 12, 2017 and was triaged
at 3:37pm as an ambulatory patient. Chief complaint of non-traumatic epigastric
pain and categorized as Category 3, meaning that the patient seeks immediate
care and services and condition is potentially life-threatening. She was then sent
to the IM Department for consultation after registration. Patient was assessed
with dyspnea, bipedal edema grade 3, rigid abdomen, non-tender and with striae,
butterfly rash and rashes on lower and upper extremities. She was then
diagnosed with Systemic Lupus Erythromatosus in flare and for IDS clearance
prior to pulse therapy.
After the consultation, she transferred to the nurse’s station to start her
IVF Therapy of PNSS 1L at 80 cc/hour.

3
 CHAPTER 3
PERSONAL DATA
Patient’s Profile
Patient’s Code Name: J.P.
Age: 28 years old
Sex: Female
Birth Date: June 26, 1989
Birth Place: Sultan Kudarat
Civil Status: Married
Occupation: Housekeeper
Nationality: Filipino
Ethnic Background: Ilonggo
Religion: Iglesia Ni Kristo
Source of Information: Patient’s chart

Clinical Data
Date of Admission: July 12, 2017, 3:37 pm
Chief Complaint: Epigastric Pain
Presenting Signs and Symptoms
 Dysuria
 Hypertension
 Rigid abdomen
 Rash (on lower and upper extremities)
 Striae on the abdomen
 Bipedal edema
 Butterfly rash
Weight: 60 kg
Height: 5 ft. 1 inch
Admitting Physician: Dr. Ahmad M. Domado
Admitting Diagnosis: Systemic Lupus Erythematosus in Flare
Health Care Institution: Southern Philippines Medical Center (SPMC)

4
 CHAPTER 4
DEVELOPMENTAL DATA
Development is an increase in the complexity of function and skill
progression. Development is the behavioral aspect of growth. Growth and
development are continuous, orderly, sequential processes influenced by
maturational, environmental and genetic factors. Components of growth and
development are generally categorized as physiologic, psychosocial, cognitive,
moral and spiritual. Normally, an individual cannot have growth without
development. Only the person himself can contribute a lot in her own growth and
development. This highly includes the way how an individual’s lifestyle, the way
he handles different life situations and also the way he manages life difficulties.

Psychosocial Theory of Development by Erik Erikson

Erik Erikson’s theory of psychosocial development, a theory that stresses
the importance of culture and society in development of the personality, states
that a person’s social view of self is more important than instinctual drives in
determining behavior, allows for a more optimistic view of the possibilities for
human growth. Erikson looked at actions that lead to mental health. Erikson
describes eight developmental stages covering the entire life span and at each
stage, there is a conflict between two opposing forces. The resolution of each
conflict, or accomplishment of the developmental task of that stage, allows the
individual to go on to the next phase of development. (Pillitteri, 2010)

Stage Age Characteristics Result Justification

Young 28 INTIMACY Intimacy J.P. current civil status, and

Adulthood - relate well with other Achieved reflected in the patient’s
people, both with members chart, is married with a guy
Intimacy vs. of the opposite sex and named “Rostom”.
Isolation one’s own sex to form
(20-39 years long-lasting friendships. When asked about having

5
old) - A sense of intimacy grows group of friends with lasting
out of earlier relationship, she mentioned
developmental tasks, that she still kept in touch
because people need a her group whenever her
strong sense of identity condition doesn’t occur.
before they can reach out
fully and offer deep
friendship or love.
ISOLATION
- When individuals were
rejected and do not have
the confidence to cope
with it.
- Did not develop a sense of
trust in an infant.
- Parents without a sense of
intimacy may have more
difficulty than others
accepting a pregnancy and
beginning to love a
newborn child.
(Pillitteri, 2010)

6
 Robert Havighurst’s Developmental Tasks Theory
Havighurst’s main assertion is that development is continuous throughout
the entire lifespan, occurring in stages, where an individual move from one stage
to the next by successful resolution of problems or performance of
developmental tasks. These tasks are typically encountered by most people in
the culture where the individual belongs. When a person successfully
accomplishes and masters these tasks, he/she feels the pride and satisfaction,
and consequently earns the approval of society. This success provides a good
foundation which allows to accomplish developmental tasks that he/she will
encounter at later stages. On the other hand, if a person fails, he/she will become
unhappy and is not accorded the desired approval by society, which makes
him/her feel the experience of difficulty when faced with succeeding
developmental tasks. (Psychologynoteshq.com, 2017)

Stage Age Characteristics Result Justification

Early 28  Choose a partner Partially Reflected in her charts that

Adulthood  Establish a family Achieved she has chosen a partner
(18-35 years  Manage a home and married, and she
old)  Establish a career mentioned that she currently
(Psychologynoteshq.com, 2017) has one child. They were a
able to establish a family
and have their own home,
however, as reflected on her
charts that she is a
Housekeeper, meaning that
she has not establish yet a
career that is acceptable to
the society and considered
to be successful.

7
John H. Westerhoff’s Faith Development Theory
Westerhoff presented two separate theories of faith development in his
writings. The first, a four-stage theory where faith grows like the rings of a tree,
with each ring adding to and changing the tree somewhat, yet building on that
which has grown before. Our lives as people of faith can best be understood as a
pilgrimage that moves slowly and gradually through ever-expanding expressions.
(Westerhoff, 1976)

Stage Age Characteristics Result Justification

Searching 28 - One becomes aware Achieved J.P.’s religion is Iglesia

Faith that personal beliefs
(Adolescent or experience may no
to Early longer be exactly the
Adulthood) same as those of the
group.
- Beginning to question
some of the
commonly held
beliefs or practices.
- Naturally recognizes
that his or her faith is
formed more by
others than by
personal conviction.
- Discerning whether or
not to develop,
express, and accept
responsibility for a
personal
interpretation of one's
religion as over
ni Kristo and mentioned
that it has been her
religion ever since she
was a kid. She said that
she appreciates her
religion since she was a
kid and there were times
that she questioned the
beliefs and practices but
did not came to the point
of doubting it. She
personally accepts her
religion despite of being
aware of the influences
of others because she
was already used to it.

8
 against accepting that
which may be viewed
as a group's
interpretation.
- Often there is
experimentation in
which persons try out
alternatives or
commit themselves to
persons or causes
which promise help in
establishing personal
conviction and active
practice of one's faith.
(Westerhoff, 1976)

9
 CHAPTER 5
PATIENT’S DIAGNOSIS

PATIENT’S DIAGNOSIS:
 Systemic Lupus Erythematosus in Flare

1. Systemic Lupus Erythematosus (SLE) is a chronic, inflammatory

autoimmune collagen disease resulting from disturbed immune regulation
that causes an exaggerated production of autoantibodies.
(Handbook for Brunner and Suddarth’s Text Book of Medical Surgical
Nursing 13th Edition)

2. SLE is a chronic autoimmune disease that can affect almost any organ
system; thus, its presentation and course are highly variable, ranging from
indolent to fulminant.
(Medscape; September 10, 2016)

3. Lupus is one of many disorders of the immune system known as

autoimmune diseases. In autoimmune diseases, the immune system turns
against parts of the body it is designed to protect. This leads to
inflammation and damage to various body tissues. Lupus can affect many
parts of the body, including the joints, skin, kidneys, heart, lungs, blood
vessels, and brain.
(National Institute of Arthritis and Musculoskeletal and Skin Diseases,
June 2016)

4. Systemic lupus erythematosus, referred to as SLE or lupus, is a chronic

(long-term) disease that causes systemic inflammation which affects
multiple organs.
In addition to affecting the skin and joints, it can affect other organs in the
body such as the kidneys, the tissue lining the lungs (pleura), heart

10
(pericardium), and brain. Many patients experience fatigue, weight loss,
and fever.
Lupus flares vary from mild to serious. Most patients have times when the
disease is active, followed by times when the disease is mostly quiet -
referred to as a remission. Yet, there is much reason for hope.
Improvements in treatment have greatly improved these patients’ quality
of life and increased their lifespan.
(American College of Rheumatology, 2017)

11
 CHAPTER 6
ANATOMY AND PHYSIOLOGY

I. Immune System

The Immune System:

Humoral immunity: Primary response:

The very first time the lymphocytes meet a
particular antigen, plasma cells produce
antibodies to kill the pathogen. Memory B
cells remember how to kill the antigen.
Secondary response: Exposure to the
same antigen later triggers a stronger
immune response, because the system is
already prepared.

Cellular Immunity: T cells kill infected

cells in the cell-mediated response.
Once inside cells, pathogens are harder to
detect. Cell-mediated immunity
recognizes and kills the body’s own
infected cells.

B-cells: Develop in the bone marrow and become antibody-producing plasma cells. Bind
antigens to surface-bound antibodies.

T-cells: Develop in the thymus; differentiate into T-helper cells or T-cytotoxic cells.Antibodies:
Antibodies are soluble proteins that are bound to the surface of cells, as well as unbound in the
circulation. There are 5 types (isotypes) of antibodies: IgA: protects mucosal surfaces, IgD: B-
Cell antigen receptor, IgE: involved in allergy, IgG: majority of antibody-based immunity and IgM:
key to B-Cell immunity.

II. Cardiovascular System

The cardiovascular system is sometimes

called the blood-vascular or simply the
circulatory system. It consists of the heart,
which is a muscular pumping device, and a
closed system of vessels called arteries,
veins, and capillaries. As the name implies,
the heart around a closed circle or circuit of
vessels pumps blood contained in the
circulatory system as it passes again and
again through the various "circulations" of

12
the body.

As in the adult, survival of the developing embryo depends on the circulation of

blood to maintain homeostasis and a favorable cellular environment. In response
to this need, the cardiovascular system makes its appearance early in
development and reaches a functional state long before any other major organ
system. Incredible as it seems, the primitive heart begins to beat regularly early
in the fourth week following fertilization.

The vital role of the cardiovascular system in maintaining homeostasis depends

on the continuous and controlled movement of blood through the thousands of
miles of capillaries that permeate every tissue and reach every cell in the body. It
is in the microscopic capillaries that blood performs its ultimate transport function.
Nutrients and other essential materials pass from capillary blood into fluids
surrounding the cells as waste products are removed.

Numerous control mechanisms help to regulate and integrate the diverse

functions and component parts of the cardiovascular system in order to supply
blood to specific body areas according to need. These mechanisms ensure a
constant internal environment surrounding each body cell regardless of differing
demands for nutrients or production of waste products.

Heart

The heart is a muscular pump that

provides the force necessary to
circulate the blood to all the tissues in
the body. Its function is vital because,
to survive, the tissues need a
continuous supply of oxygen and
nutrients, and metabolic waste
products have to be removed. Deprived
of these necessities, cells soon
undergo irreversible changes that lead
to death. While blood is the transport medium, the heart is the
organ that keeps the blood moving through the vessels. The

normal adult heart pumps about 5 liters of blood every minute throughout life. If it
loses its pumping effectiveness for even a few minutes, the individual's life is
jeopardized.

13
Structure of the Heart

The human heart is a

four-chambered
muscular organ,
shaped and sized
roughly like a man's
closed fist with two-
thirds of the mass to
the left of midline.

The heart is enclosed

in a pericardial sac that
is lined with the parietal
layers of a serous
membrane. The
visceral layer of the
serous membrane
forms the epicardium.

Layers of the Heart Wall

Three layers of tissue form the heart wall. The outer layer of the heart wall is the
epicardium, the middle layer is the myocardium, and the inner layer is the
endocardium.

Chambers of the Heart

The internal cavity of the heart is divided into four chambers:

 Right atrium
 Right ventricle
 Left atrium
 Left ventricle

The two atria are thin-walled chambers that receive blood from the veins. The
two ventricles are thick-walled chambers that forcefully pump blood out of the
heart. Differences in thickness of the heart chamber walls are due to variations in
the amount of myocardium present, which reflects the amount of force each
chamber is required to generate.

14
The right atrium receives deoxygenated blood from systemic veins; the left atrium
receives oxygenated blood from the pulmonary veins.

Valves of the Heart

Pumps need a set of valves to keep the fluid flowing in one direction and the
heart is no exception. The heart has two types of valves that keep the blood
flowing in the correct direction. The valves between the atria and ventricles are
called atrioventricular valves (also called cuspid valves), while those at the bases
of the large vessels leaving the ventricles are called semilunar valves.

The right atrioventricular valve is the tricuspid valve. The left atrioventricular
valve is the bicuspid, or mitral, valve. The valve between the right ventricle and
pulmonary trunk is the pulmonary semilunar valve. The valve between the left
ventricle and the aorta is the aortic semilunar valve.

When the ventricles contract, atrioventricular valves close to prevent blood from
flowing back into the atria. When the ventricles relax, semilunar valves close to
prevent blood from flowing back into the ventricles.

Pathway of Blood through the Heart

While it is convenient to describe the flow of blood through the right side of the
heart and then through the left side, it is important to realize that both atria
contract at the same time and both ventricles contract at the same time. The
heart works as two pumps, one on the right and one on the left, working
simultaneously. Blood flows from the right atrium to the right ventricle, and then is
pumped to the lungs to receive oxygen. From the lungs, the blood flows to the
left atrium, then to the left ventricle. From there it is pumped to the systemic
circulation.

Blood Supply to the Myocardium

The myocardium of the heart wall is a working muscle that needs a continuous
supply of oxygen and nutrients to function with efficiency. For this reason, cardiac
muscle has an extensive network of blood vessels to bring oxygen to the
contracting cells and to remove waste products.

The right and left coronary arteries, branches of the ascending aorta, supply
blood to the walls of the myocardium. After blood passes through the capillaries
in the myocardium, it enters a system of cardiac (coronary) veins. Most of the
cardiac veins drain into the coronary sinus, which opens into the right atrium.

15
Physiology of the Heart

The work of the heart is to pump blood to the lungs through pulmonary circulation
and to the rest of the body through systemic circulation. This is accomplished by
systematic contraction and relaxation of the cardiac muscle in the myocardium.

Conduction System

An effective cycle for productive pumping of blood requires that the heart be
synchronized accurately. Both atria need to contract simultaneously, followed by
contraction of both ventricles. Specialized cardiac muscle cells that make up the
conduction system of the heart coordinate contraction of the chambers.

include the atrioventricular node, atrioventricular bundle, bundle branches, and

conduction myofibers. All these components coordinate the contraction and
relaxation of the heart chambers.

Cardiac Cycle

The cardiac cycle refers to the alternating contraction and

relaxation of the myocardium in the walls of the heart
chambers, coordinated by the conduction system, during
one heartbeat. Systole is the contraction phase of the
cardiac cycle, and diastole is the relaxation phase. At a
The conduction system includes several components. The first part
of the conduction system is the sinoatrial node . Without any neural
stimulation, the sinoatrial node rhythmically initiates impulses 70 to
80 times per minute. Because it establishes the basic rhythm of the
heartbeat, it is called the pacemaker of the heart. Other parts of the
conduction system
normal heart rate, one cardiac cycle lasts for 0.8 second.

Heart Sounds

The sounds associated with the heartbeat are due to vibrations in the tissues and
blood caused by closure of the valves. Abnormal heart sounds are called
murmurs.

Heart Rate

The sinoatrial node, acting alone, produces a constant rhythmic heart rate.
Regulating factors are reliant on the atrioventricular node to increase or decrease

16
the heart rate to adjust cardiac output to meet the changing needs of the body.
Most changes in the heart rate are mediated through the cardiac center in the
medulla oblongata of the brain. The center has both sympathetic and
parasympathetic components that adjust the heart rate to meet the changing
needs of the body.

Peripheral factors such as emotions, ion concentrations, and body temperature

may affect heart rate. These are usually mediated through the cardiac center.

Blood

Blood is the fluid of life, transporting oxygen from the

lungs to body tissue and carbon dioxide from body tissue
to the lungs. Blood is the fluid of growth, transporting
nourishment from digestion and hormones from glands
throughout the body. Blood is the fluid of health,
transporting disease fighting substances to the tissue
and waste to the kidneys. Because it contains living cells,
blood is alive. Red blood cells and white blood cells are
responsible for nourishing and cleansing the body.

Classification & Structure of Blood Vessels

Blood vessels are the channels or conduits through which blood is distributed to
body tissues. The vessels make up two closed systems of tubes that begin and
end at the heart. One system, the pulmonary vessels, transports blood from the
right ventricle to the lungs and back to the left atrium. The other system, the
systemic vessels, carries blood from the left ventricle to the tissues in all parts of
the body and then returns the blood to the right atrium. Based on their structure
and function, blood vessels are classified as either arteries, capillaries, or veins.

Physiology of Circulation

Role of the Capillaries

In addition to forming the

connection between the arteries and
veins, capillaries have a vital role
in the exchange of gases,
nutrients, and metabolic waste

17
products between the blood and the tissue cells. Substances pass through the
capillaries wall by diffusion, filtration, and osmosis. Oxygen and carbon dioxide
move across the capillary wall by diffusion. Fluid movement across a capillary
wall is determined by a combination of hydrostatic and osmotic pressure. The net
result of the capillary microcirculation created by hydrostatic and osmotic
pressure is that substances leave the blood at one end of the capillary and return
at the other end.

Blood Flow

Blood flow refers to the movement of blood through the vessels from arteries to
the capillaries and then into the veins. Pressure is a measure of the force that the
blood exerts against the vessel walls as it moves the blood through the vessels.
Like all fluids, blood flows from a high pressure area to a region with lower
pressure. Blood flows in the same direction as the decreasing pressure gradient:
arteries to capillaries to veins.

The rate, or velocity, of blood flow varies inversely with the total cross-sectional
area of the blood vessels. As the total cross-sectional area of the vessels
increases, the velocity of flow decreases. Blood flow is slowest in the capillaries,
which allows time for exchange of gases and nutrients.

Resistance is a force that opposes the flow of a fluid. In blood vessels, most of
the resistance is due to vessel diameter. As vessel diameter decreases, the
resistance increases and blood flow decreases.

Very little pressure remains by the time blood leaves the capillaries and enters
the venules. Blood flow through the veins is not the direct result of ventricular
contraction. Instead, venous return depends on skeletal muscle action,
respiratory movements, and constriction of smooth muscle in venous walls.

Pulse and Blood Pressure

Pulse refers to the rhythmic expansion of an artery that is caused by ejection of

blood from the ventricle. It can be felt where an artery is close to the surface and
rests on something firm.

In common usage, the term blood pressure refers to arterial blood pressure, the
pressure in the aorta and its branches. Systolic pressure is due to ventricular
contraction. Diastolic pressure occurs during cardiac relaxation. Pulse pressure
is the difference between systolic pressure and diastolic pressure. Blood

18
pressure is measured with a sphygmomanometer and is recorded as the systolic
pressure over the diastolic pressure. Four major factors interact to affect blood
pressure: cardiac output, blood volume, peripheral resistance, and viscosity.
When these factors increase, blood pressure also increases. Arterial blood
pressure is maintained within normal ranges by changes in cardiac output and
peripheral resistance. Pressure receptors (barareceptors), located in the walls of
the large arteries in the thorax and neck, are important for short-term blood
pressure regulation.

Circulatory Pathways

The blood vessels of the body are functionally divided into two distinctive circuits:
pulmonary circuit and systemic circuit. The pump for the pulmonary circuit, which
circulates blood through the lungs, is the right ventricle. The left ventricle is the
pump for the systemic circuit, which provides the blood supply for the tissue cells
of the body.

Pulmonary Circuit

Pulmonary circulation transports oxygen-poor blood from the right ventricle to the
lungs where blood picks up a new blood supply. Then it returns the oxygen-rich
blood to the left atrium.

Systemic
Circuit

The systemic
circulation
provides the
functional
blood supply
to all body
tissue. It
carries
oxygen and nutrients to the cells and picks up carbon dioxide and waste
products. Systemic circulation carries oxygenated blood from the left ventricle,
through the arteries, to the capillaries in the tissues of the body. From the tissue
capillaries, the deoxygenated blood returns through a system of veins to the right
atrium of the heart.

19
The coronary arteries are the only vessels that branch from the ascending aorta.
The brachiocephalic, left common carotid, and left subclavian arteries branch
from the aortic arch. Blood supply for the brain is
provided by the internal carotid and vertebral
arteries. The subclavian arteries provide the
blood supply for the upper extremity. The celiac,
superior mesenteric, suprarenal, renal, gonadal,
and inferior mesenteric arteries branch from the
abdominal aorta to supply the abdominal viscera.
Lumbar

arteries provide blood for the muscles and spinal

cord. Branches of the external iliac artery provide
the blood supply for the lower extremity. The
internal iliac artery supplies the pelvic viscera.

Major Systemic Arteries

All systemic arteries are branches, either directly

or indirectly, from the aorta. The aorta ascends
from the left ventricle, curves posteriorly and to the left, then descends through
the thorax and abdomen. This geography divides the aorta into three portions:
ascending aorta, arotic arch, and descending aorta. The descending aorta is
further subdivided into the thoracic arota and abdominal aorta.

Major Systemic Veins

After blood delivers oxygen to the tissues and picks up carbon dioxide, it returns
to the heart through a system of veins. The capillaries, where the gaseous
exchange occurs, merge into venules and these converge to form larger and
larger veins until the blood reaches either the superior vena cava or inferior vena
cava, which drain into the right atrium.

Fetal Circulation

Most circulatory pathways in a fetus are like those in the adult but there are some
notable differences because the lungs, the gastrointestinal tract, and the kidneys
are not functioning before birth. The fetus obtains its oxygen and nutrients from

20
the mother and also depends on maternal circulation to carry away the carbon
dioxide and waste products.

IV. Urinary System (kidneys)

The principal function of the urinary system is to maintain the volume and
composition of body fluids within normal limits. One aspect of this function is to
rid the body of waste products that accumulate as a result of cellular metabolism,
and because of this, it is sometimes referred to as the excretory system.

Although the urinary system has a major role in excretion, other organs
contribute to the excretory function. The lungs in the respiratory system excrete
some waste products, such as carbon dioxide and water. The skin is another
excretory organ that rids the body of wastes through the sweat glands. The liver
and intestines excrete bile pigments that result from the destruction of
hemoglobin. The major task of excretion still belongs to the urinary system. If it
fails the other organs cannot take over and compensate adequately.

The urinary system maintains an appropriate fluid volume by regulating the

amount of water that is excreted in the urine. Other aspects of its function include
regulating the concentrations of various electrolytes in the body fluids and
maintaining normal pH of the blood.

In addition to maintaining fluid homeostasis in the body, the urinary system

controls red blood cell production by secreting the hormone erythropoietin. The
urinary system also plays a role in maintaining normal blood pressure by
secreting the enzyme renin.

Components of the Urinary System

The urinary system consists of the kidneys, ureters,

urinary bladder, and urethra. The kidneys form the
urine and account for the other functions attributed to
the urinary system. The ureters carry the urine away
from kidneys to the urinary bladder, which is a
temporary reservoir for the urine. The urethra is a
tubular structure that carries the urine from the urinary
bladder to the outside. To learn more

21
Kidneys

The kidneys are the primary organs of the urinary system. The kidneys are the
organs that filter the blood, remove the wastes, and excrete the wastes in the
urine. They are the organs that perform the functions of the urinary system. The
other components are accessory structures to eliminate the urine from the body.

The paired kidneys are located between the twelfth thoracic and third lumbar
vertebrae, one on each side of the vertebral column. The right kidney usually is
slightly lower than the left because the liver displaces it downward. The kidneys
protected by the lower ribs, lie in shallow depressions against the posterior
abdominal wall and behind the parietal peritoneum. This means they are
retroperitoneal. Each kidney is held in place by connective tissue,
calledrenal fascia, and is surrounded by a thick layer of adipose tissue, called
perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal
capsule closely envelopes each kidney and provides support for the soft tissue
that is inside.

In the adult, each kidney is approximately 3 cm thick, 6 cm wide, and 12 cm long.

It is roughly bean-shaped with an indentation, called the hilum, on the medial
side. The hilum leads to a large cavity, called the renal sinus, within the kidney.
The ureter and renal vein leave the kidney, and the renal artery enters the kidney
at the hilum.

22
The outer, reddish region, next to the capsule, is the renal
cortex. This surrounds a darker reddish-brown region called
the renal medulla. The renal medulla consists of a series of
renal

pyramids, which appear striated because they

contain straight tubular structures and blood vessels. The wide bases of the
pyramids are adjacent to the cortex and the pointed ends, called renal papillae,
are directed toward the center of the kidney. Portions of the renal cortex extend
into the spaces between adjacent pyramids to form renal columns. The cortex
and medulla make up the parenchyma, or functional tissue, of the kidney.

The central region of the kidney contains the renal pelvis, which is located in the
renal sinus and is continuous with the ureter. The renal pelvis is a large cavity
that collects the urine as it is produced. The periphery of the renal pelvis is
interrupted by cuplike projections called calyces. A minor calyx surrounds the
renal papillae of each pyramid and collects urine from that pyramid. Several
minor calyces converge to form a major calyx. From the major calyces the urine
flows into the renal pelvis and from there into the ureter.

Each kidney contains over a million functional units, called nephrons, in the
parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle
and a renal tubule.The renal corpuscle consists of a cluster of capillaries, called
the glomerulus, surrounded by a double-layered epithelial cup, called the
glomerular capsule. An afferent arteriole leads into the renal corpuscle and an
efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into
collecting ducts then into the minor calyces.

The juxtaglomerular apparatus, which monitors blood pressure and secretes

renin, is formed from modified cells in the afferent arteriole and the ascending
limb of the nephron loop.

23
Ureters

Each ureter is a small tube, about 25 cm long, that carries urine from the renal
pelvis to the urinary bladder. It descends from the renal pelvis, along the
posterior abdominal wall, behind the parietal peritoneum, and enters the urinary
bladder on the posterior inferior surface.

The wall of the ureter consists of

three layers. The outer layer, the
fibrous coat, is a supporting layer of
fibrous connective tissue. The
middle layer, the muscular coat,
consists of inner circular and outer
longitudinal smooth muscle. The
main function of this layer is
peristalsis to propel the urine. The
inner layer, the mucosa, is
transitional epithelium that is
continuous with the lining of the
renal

Urinary Bladder

The urinary
bladder is a
temporary storage
reservoir for urine.
It is located in the
pelvic cavity,
posterior to the
symphysis pubis,
and below
the parietal
peritoneum. The
size and shape of
the urinary bladder varies with the amount of urine it contains and with pressure it
receives from surrounding organs.

24
The inner lining of the urinary bladder is a mucous membrane of transitional
epithelium that is continuous with that in the ureters. When the bladder is empty,
the mucosa has numerous folds called rugae. The rugae and transitional
epithelium allow the bladder to expand as it fills.

The second layer in the walls is the submucosa that supports the mucous
membrane. It is composed of connective tissue with elastic fibers.

The next layer is the muscularis, which is composed of smooth muscle. The
smooth muscle fibers are interwoven in all directions and collectively these are
called the detrusor muscle. Contraction of this muscle expels urine from the
bladder. On the superior surface, the outer layer of the bladder wall is parietal
peritoneum. In all other regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by three openings in the
floor of the urinary bladder. Two of the openings are from the ureters and form
the base of the trigone. Small flaps of mucosa cover these openings and act as
valves that allow urine to enter the bladder but prevent it from backing up from
the bladder into the ureters. The third opening, at the apex of the trigone, is the
opening into the urethra. A band of the detrusor muscle encircles this opening to
form the internal urethral sphincter.

Urethra

The final passageway for the flow of urine is the urethra, a thin-walled tube that
conveys urine from the floor of the urinary bladder to the outside. The opening to
the outside is the external urethral orifice. The mucosal lining of the urethra is
transitional epithelium. The wall also contains smooth muscle fibers and is
supported by connective tissue.

The internal urethral sphincter surrounds the beginning of the urethra, where it
leaves the urinary bladder. This sphincter is smooth (involuntary) muscle.
Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle
and encircles the urethra where it goes through the pelvic floor. These two
sphincters control the flow of urine through the urethra.

In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The
external urethral orifice opens to the outside just anterior to the opening for the
vagina.

25
In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and
transports both urine and semen. The first part, next to the urinary bladder,
passes through the prostate gland and is called the prostatic urethra. The second
part, a short region that penetrates the pelvic floor and enters the penis, is called
the membranous urethra. The third part, the spongy urethra, is the longest
region. This portion of the urethra extends the entire length of the penis, and the
external urethral orifice opens to the
outside at the tip of the penis.

V. The Integumentary system

covers or protects the body. Its

components are skin, and the skin's
derivatives: hair, nails, sweat glands and
sense receptors.

Beneficial Functions:

1. Protects the body's internal living tissues and organs

2. Lubricates and waterproofs the exterior
3. Protects against invasion by infectious microorganisms
4. Protects the body from dehydration
5. Helps to regulate body temperature
6. Excretes and expels toxins and waste materials
7. Sense receptors for touch, pressure, pain, heat and cold
8. Stores water, fat, and vitamin D

Skin
The skin is the outer covering of the body. It is also the largest organ of the body;
that performs many beneficial functions. For simplicity I have briefly outlined the
two layers of skin:

1. Epidermis: The epidermis is the superficial, thin outer layers of skin containing
many nerve endings and no blood vessels. It is made up of squamous epithelium
tissue, that contain squamous, basal, Langerhan and Granstein cells.

There are many layers to the epidermis, I have briefly outlined two:

26
- Outer stratum corneum is a superficial "horny outer layer that contains the
"dead cells" that are usually sloughed off to expose new cells.

- Basale stratum is the layer that leads to the next layer of skin called the dermis.
It is the only layer that can "push up" new, regenerated cells to the outer stratum
corneum for disposal.

The epidermis contains a dark brown to black pigment called melanin. Melanin
affects the color of skin, hair, and parts of the eye.

2. Dermis: The dermis also called the "corium" is a two fold, thick inner layer of
skin below the epidermis.

The two layers are:

- Upper papillary is the communicator with the Central Nervous System (CNS);
the sense receptors. Sense receptors enable the human to experience touch,
pain, exertion of pressure, temperatures (hot and cold).

- Lower reticular is made up of connective tissue (dense and fibrous). The lower
reticular layer contains nerves, lymph vessels, various glands such as the
sebaceous, sudorferous and ceruminous, hair follicles and hair shafts.

As we age the skin has the tendency to sag, wrinkle, it may contain broke blood
vessels, loose moisture, and become thin. We are not in control of aging
however preventatively we can limit our exposure to harse irritants, moisturize,
limit sun exposure (apply a sunscreen lotion), limit alcohol intake and quit
smoking.

Seek medical attention for such conditions as acne, ezcema, skin tumors
(keratosis) , inflammations and skin cell damage (carcinoma). Good skin starts
with common sense, general nutritional intake (diet), hydration (water) and the
application of natural skin care products.

27
SKIN DERIVATIVES:
SKIN
Hair is present on every part of body (except palms, soles, lips and perhaps other
small areas). Beneath the thin outer layer of skin called the "epidermis", is a
tubular sheath of cells called a " follicle". Attached to the follicles are tiny muscles
called erector or arrector pili.When cold or frightened these muscles tighten
forming 'goose pimples'. Associated with follicles are the sebaceous (oil) glands,
they keep the hair soft and pliable.

If we were to penetrate further into the thick inner layer of skin called the
"dermis", to the bottom of the follicle, inside we would see is a bulb-like root that
expands and tapers upwards. The "root" is the starting point of a hollow,
threadlike appendage filled with keratin. This is called a "hair". The exposed part
of the hair above the skin consists of an outer cuticle or hairshaft. It shrouds a
cortex that contains pigment that gives hair its color, and an inner medulla (a
marrow like substance).

Alopecia or hair loss can strike all ages and genders. Hair loss may occur
through poor diet, surgery shock, illness, hormonal imbalances (thyroid or
pregnancy), too much Vitamin A, chemotherapy, medications (blood thinners),
fungal infections or underlying diseases such as lupus or diabetes.

Many treatments are available from your medical

practitioner for critical hair loss situations, and hair
loss causes and conditions can be easily corrected.
Basic hair care is simple, start with good dietary
intake, proper supplementation and the use of
quality hair care products; avoid harsh chemicals
(alcohol based, perming, colorants) When caring for
your hair avoid restraining, harsh styling or binding
of your hair (dreadlocks, back combing, or elastics).

NAILS
The flattened, horny type structures formed from the protein keratin made from
epidermal tissue located at the end of each finger and each toe are called "finger
nails" and "toe nails" respectively.

28
Each nail is composed of a root, body and a free edge. The root is located and
attached closest to the finger or the toe, with a nail fold overlaying the root. The
body of the nail has a structure underneath it called the nail bed. The area that
the nails are formed or grow out of are called the nail matrix. A lunula or
sometimes referred to as the "moon" is the crescent shaped area at the base of
the nail. It has a lighter colour than that of the nail matrix as it mixes with the
matrix cells and the nail fold. Outward growth of the nails from the tip of the
fingers and toes create a "free" edge as they are not attached.

The condition: Onychomycosis or nail fungus is an organism that attacks and

digests the keratin in the nails of the fingers and toes. The condition is both a
fungus and a yeast infection. It can be destroyed by use of essential oils such as
myrrh or oil of oregano; or probiotics, antibiotic and anti-fungal agents.

Nails need to be well cared for and nourished just as the rest of the body. Start
nail care from the inside, out.

SUDORIFEROUS or SWEAT GLANDS

There are several millions of these structures in the body that produce the by-
product perspiration or more commonly called sweat. The majority of these
structures or glands are by nature "eccrine" glands; they contain waste by-
products of urea and a combination of salts. The fluid associate with the eccrine
gland is light, clear fluid that has a slight odor. The other structures or other
glands are called "apocrine" glands. They are located in the armpits, pubic
regions.They are large, deep exocrine glands that secrete a strong, thicker fluid
and have a distinct odour. The glands are located underneath the dermis.
Sweat is excreted through ducts and expelled at the surface of the skin.
The function of the sudoriferous glands are to regulate the temperature of the
body.

These tissues are not necessarily a specific component of the Integumentary

System such as skin or nails. However, they are categorized as such as their
purpose is to protect, support and bind (connect) . Connective tissues can have
the same or different functions in other locations of the body then those of the
Integumentary System.

Connective tissues are defined as a type of material that supports and binds
other tissues and parts of the body together; it may include skin, ligaments,
tendons, interlacing fibrils and bones. We may not consider cartilage or bone as

29
tissues, but they are. Hyaline, elastic and fibrous cartilages are found in such
locations as the ends of bones, nose, specific parts of the respiratory passages.

Bones provide the support, protection and framework of the skeleton. Some
other examples of a connective tissue is the pigmented tissue; its function is to
store store pigment of the eye. Rheumatoid arthritis and scleroderma are just two
of the diseases that affect a connective tissues

MEMBRANES
A membrane is a thin layer of tissue that covers an organ or lines a cavity or a
part. Membranes consist of two lipid layers, and a globular protein floats in
between.

There are three (3) types of membranes:

1. Mucous: is a thin layer of epithelium tissue overlying a thicker connective

tissue. Its functions are to protect underlying organs, secrete mucous, and
absorb water and solutes.
2. Synovial: this type of membrane secretes synovial fluid (transparent
viscous fluid) and acts as a lubricant for the freely movable joints. The
joints that benefit from the synovial membrane are: ball-and-socket, hinge,
gliding or pivot.
3. Serous: is a smooth, transparent membrane consisting of two layers: the
visceral (covers the organs) and the parietal (lines the cavity wall). The
serous membrane contains fibrous connective tissue within it. Between
the two layers is a serous fluid made up of blood serum, that moistens the
structures and allow them to move in a frictionless manner. Its function is
to line many large cavities of the body. The pleural and pericardial cavities
are just two of such cavities.

VI. Musculoskeletal System

The musculoskeletal system is composed of two systems – the muscular system

and the skeletal system – but is commonly referred to as 'musculoskeletal'
because of the main common functions of the said two systems, which are,
movement and support.

30
The musculoskeletal system is made up of hard and soft tissues. The hard tissue
includes bones and cartilages (articular cartilages), while the soft tissues are the
muscles, tendons, synovial membranes, joints capsule and ligaments.

Primarily, the roles of the musculoskeletal system are movement and support,
but the system also performs the following functions:
Protection of vital structures
Provision of body forms
Stability
Storage of salts (e.g., calcium)
Formation and supply of new blood cells

Essentially the skeletal part of the system pertains to the arrangement of bones,
and how they join to one another to form joints which permit and limit specific
movements. This part also outlines the factors that influence stability of some of
those joints. For example, a joint with good bony congruence (joint with bones
fitting well together) is most likely to be more stable than one with poor bony
congruence. On the other hand, the muscular portion of the musculoskeletal
system primarily describes the movements produced at joints, which as a basic
principle, is based on the location of a muscle in relation to the joint and
attachment to bones forming the joint. For example, a muscle lying anterior to
two or more bones, and also crossing the joint formed by those bones anteriorly
will produce the movement – “flexion” at that joint when it is contracted.

Muscles

Muscles are the largest soft tissues of the musculoskeletal system. The muscle
cells - muscle fibres - produce contractions that move body parts, including
internal organs. Associated connective tissue binds muscle fibres into fascicles
or bundles, and these associated connective tissues also convey nerve fibres
and blood vessels (capillaries) to the muscle cells.

31
Functions include:
Production of movement
Support of the body
Stability of joints
Production of body heat
Provision of form to the body

Types

Muscles can be grouped into the following three types:

 Skeletal muscle, which move bones and other structures (e.g., the eyes)
 Cardiac muscle, which forms most of the walls of the heart and adjacent
great vessels, such as the aorta
 Smooth (Visceral) muscle, which forms part of the walls of most vessels
and hollow organs, move substances through viscera such as the
intestine, and controls movement through blood vessels

However, the basic histological classification of muscles is into two types:

 Striated
 Non-striated

32
Based on this classification, skeletal and cardiac muscles are grouped as striated
muscles, while the visceral muscle is non-striated. This structural characteristic
(striation) is due to the way the filaments of actin and myosin are arranged in
each of the classes of muscles.

Tendons and Ligaments

A tendon is a tough, flexible band of fibrous connective tissue that connects

muscles to bones. The extracellular connective tissue between muscle fibres
binds to tendons at the distal and proximal ends, and the tendon binds to the
periosteum of bones at the muscle’s proximal attachment to bone (origin) and
distal attachment (insertion). As muscle contracts, tendon transmits the force to
the bones, pulling on them and causing movement.

Tendons and ligaments are made of dense fibrous connective tissue (DFCT)
which has an abundance of collagen fibre bundles arranged in parallel, creating a
high tensile strength (resistance to longitudinal force). Tendons and ligaments
appear white because their fibrous connective tissues are made up of collagen,
and collagen is white. They also appear white because they have very poor
blood supply. Nutrients reach those structures by diffusion.

Tendons are generally rounded cords and thick. Ligaments are flatter in shape
than tendons and attach a bone to another bone. They have more elastic fibres
and thus are slightly stretchier than tendons.

33
Joint Capsule and Synovial Membrane

Synovial membranes line the synovial cavity and secrete synovial fluid that
lubricates most joints where they are found (synovial joints) in order to reduce
friction. The fluid secreted by a synovial membrane also serve as a source of
nutrients for tendons and ligaments, as well as to articular cartilages.
Joint capsules are very strong and surround a joint, particularly synovial joints.
They are composed of dense fibrous connective tissue. Ligaments are usually
found by thickenings of the joint capsule, for example, the medial and lateral
thickenings of the joint capsule at the knee joint, forms the medial and lateral
collateral ligaments of the knee joint.

Skeletal System

This system is composed of bones and cartilages, and makes up the hard tissue
of the musculoskeletal system. Functions of the skeletal system include:

 support for the body

 shock absorption
 storage for salts
 production of blood cells
 production of vital organs
 mechanical basis for movement

The skeletal system consists of two main parts, the axial skeleton and the
appendicular skeleton. The axial skeleton consists of the bones of the head, neck
and trunk. The appendicular skeleton consists of the bones of the limbs,
including those forming the pectoral and pelvic girdles.
Hard tissues of the musculoskeletal system will be discussed further under the
headings – bones, cartilages, and joints.

Bones

Bones are made up of a superficial layer, compact bone, and a deeper layer of
spongy bone, except where the latter is replaced by a medullary (marrow) cavity.
Within this cavity in the adult bone, and between the spicules of spongy bones,
blood cells are formed.

A typical bone (especially long bones) has a head, neck and body or shaft. It also
possesses some markings and formations that gives passage and attachments
to soft tissues like ligaments and tendons. Some of those features (markings)
include:

Condyle – rounded articular area (e.g. lateral femoral condyle)

Crest – ridge of bone (e.g. iliac crest)

34
Epicondyle – eminence superior to a condyle
Facet – smooth, flat area, usually covered with cartilage
Foramen – passage through a bone

Classification of Bones

Bones can be classified according to their shapes as follows:

Long bones - These are bones longer than they are wide. They are tubular (e.g.
the humerus in the arm)
Short bones - These bones are roughly cube-like or round. Examples include the
tarsals and carpals
Flat bones - these types of bones are mostly thin, flattened and usually curved.
They mostly serve protective functions. Examples include most of the skull bones
– protecting the brain, and the ribs – protecting the thoracic viscera
Irregular bones - These are bones that do not fit into any of the other types of
bones. Generally, irregular bones will have a foramen through them. A very good
example is the hip bone.

Cartilages

Cartilages line the articulating surfaces of bones. Thus, cartilages are usually
found deep within a joint. They are great for weight bearing and are extremely
slippery to reduce the friction inside a joint (movable joint like synovial joint).
Synovial joints possess hyaline cartilage.

Joints

Joints are formed where two or more bones meet. They promote movements of
body parts, however, movement is not a necessary attribute of a joint as some
joints do not move, e.g. joints between bones of the skull. The integrity or stability
of a joint is guaranteed by several factors including the bony congruence (fit of
bones), and other structures which cross the joint.
Joints can be classified broadly by the connective tissues found between the
bone ends. The following are three categories based on their structures:
Fibrous joints - The tissues between the bone ends of this class of joints is dense
fibrous connective tissue (DFCT). The bones are held together firmly and the
joint allows little or no movement. Examples are the sutures of the skull

Cartilaginous joints - The tissue between the bones forming this category of joints
is cartilage. The bones are firmly held together by these, but movement is also
allowed. An example is the joints between the bodies of the vertebrae

Synovial joints - These joints have the potential to allow movement through a
wide range – far more than fibrous or cartilaginous joints. There are no direct
bone to bone attachment by tissues at the bone ends, instead they are held

35
together by a connective tissue sleeve – the joint capsule, attached at the
margins of the joint.

There is a potential space called synovial cavity between the bone ends, allowing
easy movements. Cartilage is also found on the articular surfaces of the bones.
Synovial membrane is found in this joint, and covers structures within the
synovial cavity other than those covered with articular cartilage. Hence, synovial
membrane is the inner lining of the joint capsule.

Other classification of joints includes:

Based on Axis:
 Uni-axial joints
 Bi-axial joints
 Multi-axial joints
Based on Shape (Synovial joints):
 ball and socket joints (e.g. hip joint)
 condylar joints (e.g. knee joint)
 hinge joints (e.g. elbow joint)
 pivot joints (e.g. radio-ulnar joints)
 ellipsoid joints (e.g. 2nd – 5th metacarpal-phalanx joints)
 plane joints (e.g. joints between the carpal bones)

VII. Nervous System

To carry out its normal role, the nervous system has three overlapping functions.

1. Monitoring changes. Much like a sentry, it uses its millions of sensory

receptors to monitor changes occurring both inside and outside the body;
these changes are called stimuli, and the gathered information is called
sensory input.

2. Interpretation of sensory input. It processes and interprets the sensory

input and decides what should be done at each moment, a process called
integration.

3. Effects responses. It then effects a response by activating muscles or

glands (effectors) via motor output.

4. Mental activity. The brain is the center of mental activity, including

consciousness, thinking, and memory.

5. Homeostasis. This function depends on the ability of the nervous system

to detect, interpret, and respond to changes in the internal and external
conditions. It can help stimulate or inhibit the activities of other systems to
help maintain a constant internal environment.

36
Anatomy of the Nervous System

The nervous system does not work alone to regulate and maintain body
homeostasis; the endocrine system is a second important regulating system.

Organization of the Nervous System

We only have one nervous system, but, because of its complexity, it is difficult to
consider all of its parts at the same time; so, to simplify its study, we divide it in
terms of its structures (structural classification) or in terms of its activities
(functional classification).

Structural Classification

The structural classification, which includes all of the nervous system organs, has
two subdivisions- the central nervous system and the peripheral nervous system.

Central nervous system (CNS). The CNS consists of the brain and spinal cord,
which occupy the dorsal body cavity and act as the integrating and command
centers of the nervous system

Peripheral nervous system (PNS). The PNS, the part of the nervous system
outside the CNS, consists mainly of the nerves that extend from the brain and
spinal cord.

37
Functional Classification

The functional classification scheme is concerned only with PNS structures.

 Sensory division. The sensory, or afferent division, consists of nerves

(composed of nerve fibers) that convey impulses to the central nervous
system from sensory receptors located in various parts of the body.
 Somatic sensory fibers. Sensory fibers delivering impulses from the skin,
skeletal muscles, and joints are called somatic sensory fibers.

 Visceral sensory fibers. Those that transmit impulses from the visceral
organs are called visceral sensory fibers.

 Motor division. The motor, or efferent division carries impulses from the
CNS to effector organs, the muscles and glands; the motor division has
two subdivisions: the somatic nervous system and the autonomic nervous
system.

 Somatic nervous system. The somatic nervous system allows us to

consciously, or voluntarily, control our skeletal muscles.

 Autonomic nervous system. The autonomic nervous system regulates

events that are automatic, or involuntary; this subdivision, commonly
called involuntary nervous system, has two parts: the sympathetic and
parasympathetic, which typically bring about opposite effects.

Nervous Tissue: Structure and Function

Even though it is complex, nervous tissue is made up of just two principal types
of cells- supporting cells and neurons.

Supporting Cells

Supporting cells in the CNS are “lumped together” as neuroglia, literally mean
“nerve glue”.

 Neuroglia. Neuroglia include many types of cells that generally support,

insulate, and protect the delicate neurons; in addition, each of the different
types of neuroglia, also simply called either glia or glial cells,has special
functions.
 Astrocytes. These are abundant, star-shaped cells that account for nearly
half of the neural tissue; astrocytes form a living barrier between the
capillaries and neurons and play a role in making exchanges between the
two so they could help protect neurons from harmful substances that
might be in the blood.

38
  Microglia. These are spiderlike phagocytes that dispose of debris,
including dead brain cells and bacteria.
 Ependymal cells. Ependymal cells are glial cells that line the central
cavities of the brain and the spinal cord; the beating of their cilia helps to
circulate the cerebrospinal fluid that fills those cavities and forms a
protective cushion around the CNS.
 Oligodendrocytes. These are glia that wrap their flat extensions tightly
around the nerve fibers, producing fatty insulating coverings called myelin
sheaths.
 Schwann cells. Schwann cells form the myelin sheaths around nerve
fibers that are found in the PNS.
 Satellite cells. Satellite cells act as protective, cushioning cells.

Neurons

Neurons, also called nerve cells, are highly specialized to transmit messages
(nerve impulses) from one part of the body to another.

 Cell body. The cell body is the metabolic center of the neuron; it has a
transparent nucleus with a conspicuous nucleolus; the rough ER, called
Nissl substance, and neurofibrils are particularly abundant in the cell body.

 Processes. The armlike processes, or fibers, vary in length from

microscopic to 3 to 4 feet; dendrons convey incoming messages toward

39
 the cell body, while axons generate nerve impulses and typically conduct
them away from the cell body.

 Axon hillock. Neurons may have hundreds of the branching dendrites,

depending on the neuron type, but each neuron has only one axon, which
arises from a conelike region of the cell body called the axon hillock.

 Axon terminals.These terminals contain hundreds of tiny vesicles, or

membranous sacs that contain neurotransmitters.

 Synaptic cleft. Each axon terminal is separated from the next neuron by a
tiny gap called synaptic cleft.

 Myelin sheaths. Most long nerve fibers are covered with a whitish, fatty
material called myelin, which has a waxy appearance; myelin protects and
insulates the fibers and increases the transmission rate of nerve impulses.

 Nodes of Ranvier. Because the myelin sheath is formed by many

individual Schwann cells, it has gaps, or indentations, called nodes of
Ranvier.

During embryonic development, the CNS first appears as a simple tube, the
neural tube, which extends down the dorsal median plan of the developing
embryo’s body.

Brain

Because the brain is the largest and most complex mass of nervous tissue in the
body, it is commonly discussed in terms of its four major regions – cerebral
hemispheres, diencephalon, brain stem, and cerebellum.

Cerebral Hemispheres

The paired cerebral hemispheres, collectively called cerebrum, are the most
superior part of the brain, and together are a good deal larger than the other
three brain regions combined.

 Gyri. The entire surface of the cerebral hemispheres exhibits elevated

ridges of tissue called gyri, separated by shallow grooves called sulci.
 Fissures. Less numerous are the deeper grooves of tissue called fissures,
which separate large regions of the brain; the cerebral hemispheres are
separated by a single deep fissure, the longitudinal fissure.
 Lobes. Other fissures or sulci divide each hemisphere into a number of
lobes, named for the cranial bones that lie over them.

40
  Regions of cerebral hemisphere. Each cerebral hemisphere has three
basic regions: a superficial cortex of gray matter, an internal white matter,
and the basal nuclei.

 . Cerebral cortex. Speech, memory, logical and emotional response, as

well as consciousness, interpretation of sensation, and voluntary
movement are all functions of neurons of the cerebral cortex

 Parietal lobe. The primary somatic sensory area is located in the parietal
lobe posterior to the central sulcus; impulses traveling from the body’s
sensory receptors are localized and interpreted in this area.
 Occipital lobe. The visual area is located in the posterior part of the
occipital lobe.
 Temporal lobe. The auditory area is in the temporal lobe bordering the
lateral sulcus, and the olfactory area is found deep inside the temporal
lobe.
 Frontal lobe. The primary motor area, which allows us to consciously
move our skeletal muscles, is anterior to the central sulcus in the front
lobe.
 Pyramidal tract. The axons of these motor neurons form the major
voluntary motor tract- the corticospinal or pyramidal tract, which descends
to the cord.
 Broca’s area. A specialized cortical area that is very involved in our ability
to speak, Broca’s area, is found at the base of the precentral gyrus (the
gyrus anterior to the central sulcus).
 Speech area. The speech area is located at the junction of the temporal,
parietal, and occipital lobes; the speech area allows one to sound out
words.
 Cerebral white matter. The deeper cerebral white matter is compose of
fiber tracts carrying impulses to, from, and within the cortex.
 Corpus callosum. One very large fiber tract, the corpus callosum, connect
the cerbral hemispheres; such fiber tracts are called commisures.
 Fiber tracts. Association fiber tracts connect areas within a hemisphere,
and projection fiber tracts connect the cerebrum with lower CNS centers.
 Basal nuclei. There are several islands of gray matter, called the basal
nuclei, or basal ganglia, buried deep within the white matter of the cerebral
hemispheres; it helps regulate the voluntary motor activities by modifying
instructions sent to the skeletal muscles by the primary motor cortex.

Diencephalon

The diencephalon, or interbrain, sits atop the brain stem and is enclosed by the
cerebral hemispheres.

41
  Thalamus. The thalamus, which encloses the shallow third ventricle of the
brain, is a relay station for sensory impulses passing upward to the
sensory cortex.
 Hypothalamus. The hypothalamus makes up the floor of the diencephalon;
it is an important autonomic nervous system center because it plays a role
in the regulation of body temperature, water balance, and metabolism; it is
also the center for many drives and emotions, and as such, it is an
important part of the so-called limbic system or “emotional-visceral brain”;
the hypothalamus also regulates the pituitary gland and produces two
hormones of its own.
 Mammillary bodies. The mammillary bodies, reflex centers involved in
olfaction (the sense of smell), bulge from the floor of the hypothalamus
posterior to the pituitary gland.
 Epithalamus. The epithalamus forms the roof of the third ventricle;
important parts of the epithalamus are the pineal body (part of the
endocrine system) and the choroid plexus of the third ventricle, which
forms the cerebrospinal fluid.

Brain Stem

The brain stem is about the size of a thumb in diameter and approximately 3
inches long.

 Structures. Its structures are the midbrain, pons, and the medulla
oblongata.
 Midbrain. The midbrain extends from the mammillary bodies to the pons
inferiorly; it is composed of two bulging fiber tracts, the cerebral
peduncles, which convey descending and ascending impulses.
 Corpora quadrigemina. Dorsally located are four rounded protrusions
called the corpora quadrigemina because they remind some anatomist of
two pairs of twins; these bulging nuclei are reflex centers involved in vision
and hearing.
 Pons. The pons is a rounded structure that protrudes just below the
midbrain, and this area of the brain stem is mostly fiber tracts; however, it
does have important nuclei involved in the control of breathing.
 Medulla oblongata. The medulla oblongata is the most inferior part of the
brain stem; it contains nuclei that regulate vital visceral activities; it
contains centers that control heart rate, blood pressure, breathing,
swallowing, and vomiting among others.
 Reticular formation. Extending the entire length of the brain stem is a
diffuse mass of gray matter, the reticular formation; the neurons of the
reticular formation are involved in motor control of the visceral organs; a
special group of reticular formation neurons, the reticular activating system
(RAS), plays a role in consciousness and the awake/sleep cycles.

42
Cerebellum

The large, cauliflower-like cerebellum projects dorsally from under the occipital
lobe of the cerebrum.

 Structure. Like the cerebrum. the cerebellum has two hemispheres and a
convoluted surface; it also has an outer cortex made up of gray matter and
an inner region of white matter.
 Function. The cerebellum provides precise timing for skeletal muscle
activity and controls our balance and equilibrium.
 Coverage. Fibers reach the cerebellum from the equilibrium apparatus of
the inner ear, the eye, the proprioceptors of the skeletal muscles and
tendons, and many other areas.

Protection of the Central Nervous System

Nervous tissue is very soft and delicate, and the irreplaceable neurons are
injured by even the slightest pressure, so nature has tried to protect the brain and
the spinal cord by enclosing them within bone (the skull and vertebral column),
membranes (the meninges), and a watery cushion (cerebrospinal fluid).

Meninges

The three connective tissue membranes covering and protecting the CNS
structures are the meninges.

43
  Dura mater. The outermost layer, the leathery dura mater, is a double
layered membrane where it surrounds the brain; one of its layer is
attached to the inner surface of the skull, forming the periosteum
(periosteal layer); the other, called the meningeal layer, forms the
outermost covering of the brain and continues as the dura mater of the
spinal cord.
 Falx cerebri. In several places, the inner dural membrane extends inward
to form a fold that attaches the brain to the cranial cavity, and one of these
folds is the falx cerebri.
 Tentorium cerebelli. The tentorium cereberi separates the cerebellum from
the cerebrum.
 Arachnoid mater. The middle layer is the weblike arachnoid mater; its
threadlike extensions span the subarachnoid space to attach it to the
innermost membrane.
 Pia mater. The delicate pia mater, the innermost meningeal layer, clings
tightly to the surface of the brain and spinal cord, following every fold.
 Cerebrospinal Fluid
 Cerebrospinal fluid (CSF) is a watery “broth” similar in its makeup to blood
plasma, from which it forms.
 Contents. The CSF contains less protein and more vitamin C, and
glucose.
 Choroid plexus. CSF is continually formed from blood by the choroid
plexuses; choroid plexuses are clusters of capillaries hanging from the
“roof” in each of the brain’s ventricles.
 Function. The CSF in and around the brain and cord forms a watery
cushion that protects the fragile nervous tissue from blows and other
trauma.
 Normal volume. CSF forms and drains at a constant rate so that its normal
pressure and volume (150 ml-about half a cup) are maintained.
 Lumbar tap. The CSF sample for testing is obtained by a procedure called
lumbar or spinal tap;because the withdrawal of fluid for testing decreases
CSF fluid pressure, the patient must remain in a horizontal position (lying
down) for 6 to 12 hours after the procedure to prevent an agonizingly
painful “spinal headache”.

The Blood-Brain Barrier

No other body organ is so absolutely dependent on a constant internal

environment as is the brain, and so the blood-brain barrier is there to protect it.

 Function. The neurons are kept separated from bloodborne substances by

the so-called blood-brain barrier, composed of the least permeable
capillaries in the whole body.
 Substances allowed. Of water-soluble substances, only water, glucose,
and essential amino acids pass easily through the walls of these
capillaries.

44
  Prohibited substances. Metabolic wastes, such as toxins, urea, proteins,
and most drugs are prevented from entering the brain tissue.
 Fat-soluble substances. The blood-brain barrier is virtually useless against
fats, respiratory gases, and other fat-soluble molecules that diffuse easily
through all plasma membranes.

Spinal Cord

The cylindrical spinal cord is a glistening white continuation of the brain stem.

 Length. The spinal cord is approximately 17 inches (42 cm) long.

 Major function. The spinal cord provides a two-way conduction pathway to
and from the brain, and it is a major reflex center (spinal reflexes are
completed at this level).
 Location. Enclosed within the vertebral column, the spinal cord extends
from the foramen magnum of the skull to the first or second lumbar
vertebra, where it ends just below the ribs.
 Meninges. Like the brain, the spinal cord is cushioned and protected by
the meninges; meningeal coverings do not end at the second lumbar

45
 vertebra but instead extend well beyond the end of the spinal cord in the
vertebral canal.
 Spinal nerves. In humans, 31 pairs of spinal nerves arise from the cord
and exit from the vertebral column to serve the body area close by.
 Cauda equina. The collection of spinal nerves at the inferior end of the
vertebral canal is called cauda equina because it looks so much like a
horse’s tail.
 Gray Matter of the Spinal Cord and Spinal Roots
 The gray matter of the spinal cord looks like a butterfly or a letter H in
cross section.
 Projections. The two posterior projections are the dorsal, or posterior,
horns; the two anterior projections are the ventral, or anterior, horns.
 Central canal. The gray matter surrounds the central canal of the cord,
which contains CSF.
 Dorsal root ganglion. The cell bodies of sensory neurons, whose fibers
enter the cord by the dorsal root, are found in an enlarged area called
dorsal root ganglion; if the dorsal root or its ganglion is damaged,
sensation from the body area served will be lost.
 Dorsal horns. The dorsal horns contain interneurons.
 Ventral horns. The ventral horns of gray matter contain cell bodies of
motor neurons of the somatic nervous system, which send their axons out
the ventral root of the cord.
 Spinal nerves. The dorsal and ventral roots fuse to form the spinal nerves.

White Matter of the Spinal Cord

White matter of the spinal cord is composed of myelinated fiber tracts- some
running to higher centers, some traveling from the brain to the cord, and some
conducting impulses from one side of the spinal cord to the other.

 Regions. Because of the irregular shape of the gray matter, the white
matter on each side of the cord is divided into three regions- the dorsal,
lateral, and ventral columns; each of the columns contains a number of
fiber tracts made up of axon with the same destination and function.
 Sensory tracts. Tracts conducting sensory impulses to the brain are
sensory, or afferent, tracts.
 Motor tracts. Those carrying impulses from the brain to skeletal muscles
are motor, or efferent, tracts.

Peripheral Nervous System

The peripheral nervous system consists of nerves and scattered groups of

neuronal cell bodies (ganglia) found outside the CNS.
Structure of a Nerve

 A nerve is a bundle of neuron fibers found outside the CNS.

46
  Endoneurium. Each fiber is surrounded by a delicate connective tissue
sheath, an endoneurium.
 Perimeurium. Groups of fibers are bound by a coarser connective tissue
wrapping, the perineurium, to form fiber bundles, or fascicles.
 Epineurium. Finally, all the fascicles are bound together by a tough fibrous
sheath, the epineurium, to form the cordlike nerve.
 Mixed nerves. Nerves carrying both sensory and motor fibers are called
mixed nerves.
 Sensory nerves. Nerves that carry impulses toward the CNS only are
called sensory, or afferent, nerves.
 Motor nerves. Those that carry only motor fibers are motor, or efferent,
nerves.

Cranial Nerves

The 12 pairs of cranial nerves primarily serve the head and the neck.

 Olfactory. Fibers arise from the olfactory receptors in the nasal mucosa
and synapse with the olfactory bulbs; its function is purely sensory, and it
carries impulses for the sense of smell.
 Optic. Fibers arise from the retina of the eye and form the optic nerve; its
function is purely sensory, and carries impulses for vision.
 Oculomotor. Fibers run from the midbrain to the eye; it supplies motor
fibers to four of the six muscles (superior, inferior, and medial rectus, and
inferior oblique) that direct the eyeball; to the eyelid; and to the internal
eye muscles controlling lens shape and pupil size.
 Trochlear. Fibers run from the midbrain to the eye; it supplies motor fibers
for one external eye muscle ( superior oblique).
 Trigeminal. Fibers emerge from the pons and form three divisions that run
to the face; it conducts sensory impulses from the skin of the face and
mucosa of the nose and mouth; also contains motor fibers that activate
the chewing muscles.
 Abducens. Fibers leave the pons and run to the eye; it supplies motor
fibers to the lateral rectus muscle, which rolls the eye laterally.
 Facial. Fibers leave the pons and run to the face; it activates the muscles
of facial expression and the lacrimal and salivary glands; carries sensory
impulses from the taste buds of the anterior tongue.
 Vestibulocochlear. fibers run from the equilibrium and hearing receptors of
the inner ear to the brain stem; its function is purely sensory; vestibular
branch transmits impulses for the sense of balance, and cochlear branch
transmits impulses for the sense of hearing.
 Glossopharyngeal. Fibers emerge from the medulla and run to the throat;
it supplies motor fibers to the pharynx (throat) that promote swallowing
and saliva production; it carries sensory impulses from the taste buds of
the posterior tongue and from pressure receptors of the carotid artery.

47
  Vagus. Fibers emerge from the medulla and descend into the thorax and
abdominal cavity; the fibers carry sensory impulses from and motor
impulses to the pharynx, larynx, and the abdominal and thoracic viscera;
most motor fibers are parasympathetic fibers that promote digestive
activity and help regulate heart activity.
 Accessory. Fiber arise from the medulla and superior spinal cord and
travel to muscles of the neck and back; mostly motor fiber that activate the
sternocleidomastoid and trapezius muscles.
 Hypoglossal. Fibers run from the medulla to the tongue; motor fibers
control tongue movements;; sensory fibers carry impulses from the
tongue.
 Spinal Nerves and Nerve Plexuses

Autonomic Nervous System

The autonomic nervous system (ANS) is the motor subdivision of the PNS that
controls body activities automatically.

 Composition. It is composed of a specialized group of neurons that

regulate cardiac muscle, smooth muscles, and glands.
 Function. At every moment, signals flood from the visceral organs into the
CNS, and the automatic nerves make adjustments as necessary to best
support body activities.
 Divisions. The ANS has two arms: the sympathetic division and the
parasympathetic division.

Anatomy of the Parasympathetic Division

The parasympathetic division allows us to “unwind” and conserve energy.

 Preganglionic neurons. The preganglionic neurons of the parasympathetic

division are located in brain nuclei of several cranial nerves- III, VII, IX,
and X (the vagus being the most important of these) and in the S2 through
S4 levels of the spinal cord.
 Craniosacral division. The parasympathetic division is also called the
craniosacral division; the neurons of the cranial region send their axons
out in cranial nerves to serve the head and neck organs.
 Pelvic splanchnic nerves. In the sacral region, the preganglionic axons
leave the spinal cord and form the pelvic splanchnic nerves, also called
the pelvic nerves, which travel to the pelvic cavity.
 Anatomy of the Sympathetic Division
 The sympathetic division mobilizes the body during extreme situations,
and is also called the thoracolumbar division because its preganglionic
neurons are in the gray matter of the spinal cord from T1 through L2.
 Ramus communicans. The preganglionic axons leave the cord in the
ventral root, enter the spinal nerve, and then pass through a ramus

48
 communicans, or small communicating branch, to enter a sympathetic
chain ganglion.
 Sympathetic chain. The sympathetic trunk, or chain, lies along the
vertebral column on each side.
 Splanchnic nerves. After it reaches the ganglion, the axon may synapse
with the second neuron in the sympathetic chain at the same or a different
level, or the axon may through the ganglion without synapsing and form
part of the splanchnic nerves.
 Collateral ganglion. The splanchnic nerves travel to the viscera to synapse
with the ganglionic neuron, found in a collateral ganglion anterior to the
vertebral column.

Physiology of the Nervous System

The physiology of the nervous system involves a complex journey of impulses.

Nerve Impulse

 Neurons have two major functional properties: irritability, the ability to

respond to a stimulus and convert it into a nerve impulse, and
conductivity, the ability to transmit the impulse to other neurons, muscles,
or glands.
 Electrical conditions of a resting neuron’s membrane. The plasma
membrane of a resting, or inactive, neuron is polarized, which means that
there are fewer positive ions sitting on the inner face of the neuron’s
plasma membrane than there are on its outer surface; as long as the
inside remains more negative than the outside, the neuron will stay
inactive.
 Action potential initiation and generation. Most neuron in the body are
excited by neurotransmitters released by other neurons; regardless what
the stimulus is, the result is always the same- the permeability properties
of the cell’s plasma membrane change for a very brief period.
 Depolarization. The inward rush of sodium ions changes the polarity of the
neuron’s membrane at that site, an event called depolarization.
 Graded potential. Locally, the inside is now more positive, and the outside
is less positive, a situation called graded potential.
 Nerve impulse. If the stimulus is strong enough, the local depolarization
activates the neuron to initiate and transmit a long-distance signal called
action potential, also called a nerve impulse; the nerve impulse is an all-
or-none response; it is either propagated over the entire axon, or it doesn’t
happen at all;it never goes partway along an axon’s length, nor does it die
out with distance as do graded potential.
 Repolarization. The outflow of positive ions from the cell restores the
electrical conditions at the membrane to the polarized or resting, state, an
event called repolarization; until a repolarization occurs, a neuron cannot
conduct another impulse.

49
  Saltatory conduction. Fibers that have myelin sheaths conduct impulses
much faster because the nerve impulse literally jumps, or leaps, from node
to node along the length of the fiber; this occurs because no electrical
current can flow across the axon membrane where there is fatty myelin
insulation.

Sympathetic Division

The sympathetic division is often referred to as the “fight-or-flight” system.

 Signs of sympathetic nervous system activities. A pounding heart; rapid,

deep breathing; cold, sweaty skin; a prickly scalp, and dilated pupils are
sure signs sympathetic nervous system activities.
 Effects. Under such conditions, the sympathetic nervous system increases
heart rate, blood pressure, and blood glucose levels; dilates the
bronchioles of the lungs; and brings about many other effects that help the
individual cope with the stressor.
 Duration of the effect. The effects of sympathetic nervous system
activation continue for several minutes until its hormones are destroyed by
the liver.
 Function. Its function is to provide the best conditions for responding to
some threat, whether the best response is to run, to see better, or to think
more clearly.

Parasympathetic Division

The parasympathetic division is most active when the body is at rest and not
threatened in any way.

 Function. This division, sometimes called the “resting-and-digesting”

system, is chiefly concerned with promoting normal digestion, with
elimination of feces and urine, and with conserving body energy,
particularly by decreasing demands on the cardiovascular system.
 Relaxed state. Blood pressure and heart and respiratory rates rate being
regulated at normal levels, the digestive tract is actively digesting food,
and the skin is warm (indicating that there is no need to divert blood to
skeletal muscles or vital organs.
 Optical state. The eye pupils are constricted to protect the retinas from
excessive damaging light, and the lenses of the eye are “set” for close
vision.

50
 CHAPTER 7
PHYSICAL ASSESSMENT

General Survey

Patient is awake, conscious, oriented to time and place. Patient is not in

respiratory distress.

VS
BP 160/120
Temperature 36.7°C

Pulse Rate 85
Respiratory Rate 21

Neurological

Patient is alert. Pupils are equal and constrict briskly to light. The upper
and lower extremities are equal in strength and strong. Speech is clear. Patient
has GCS of 15.

Musculoskeletal

Patient has normal range of motion of extremities.

Respiratory

Patient’s breathing pattern is even with clear breath sounds. No secretions

noted.

Cardiovascular

51
 Patient has regular pulse. Radial pulse and pedal pulse are strong.

Renal

Edema is present on right and left foot with pitting edema of +3.

Gastrointestinal

Oral mucosa is normal. Bowel sounds is normal. Patient has rigid

abdomen. Striae on the abdomen is also noted.

Nutrition

Patient’s general appearance is well nourished. Patient has good appetite.

Diet includes vegetables and sometimes meat.

Genitourinary

Urine is normal. Patient reports of dysuria.

Skin Assessment

Patient’s skin color is normal. Skin turgor is good. Patient has rash on
lower and upper extremities. Patient has butterfly rash on face.

52
 CHAPTER 8

ETIOLOGY

Predisposing Present/ Rationale Justification

Factors Absent
Gender Present About 90% of lupus patients are women, Patient J.P. is a female
most diagnosed when they are in their and a mother of 1. She
childbearing years. Hormones may be an was diagnosed last
explanation. After menopause, women are March 2016, at the
only 2.5 times as likely as men to contract same year, where she
SLE. Flares also become somewhat less had her baby.
common after menopause in women who
have chronic SLE.
Source:
http://www.umm.edu
/health/medical/reports
/articles/systemic-lupus-erythematosus
Genetics Absent Research indicates SLE may have a genetic link. Patient J.P. verbalized
SLE does run in families, but no single causal gene
that she is the first one
has been identified. Instead, multiple genes appear
in the family to ever get
to influence a person's chance of developing lupus
when triggered by environmental factors. The most this kind of disease
important genes are and no other major
located in the HLA region on chromosome 6, history of health
where mutations may occur randomly (de novo) or
conditions other than
may be inherited. HLA class I, class II, and class III
hypertension is present
are associated with SLE, but only classes I and II
contribute independently to increased risk of
in the family.
SLE.[32] Other genes which contain risk variants for
SLE are IRF5, PTPN22, STAT4,[33] CDKN1A,[34]
ITGAM, BLK,[33] TNFSF4 and BANK1.[35] Some of
the susceptibility genes may be population specific.

Source: http://en.wikipedia.org/wiki

53
 /Systemic_lupus_erythematosus
#Genetics
Hormones Absent Oral Contraceptives. Female patients Patient J.P. verbalized
with lupus used to be cautioned against that she has not been
taking oral contraceptives (OCs) due to using any oral
the possibility that estrogen could trigger contraceptives before,
lupus flare-ups. However, recent evidence thus, is not considered
indicates that OCs are safe, at least for as a probable cause to
women with inactive or stable lupus. her underlying
Women who have been newly diagnosed condition.
with lupus should avoid OCs. Lupus can
cause complications in its early stages.
For this reason, women should wait until
the disease reaches a stable state before
taking OCs. In addition, women who have
a history of, or who are at high risk for,
blood clots (particularly women with
antiphospholipid syndrome) should not
use OCs. The estrogen in
OCs increases the risk for blood clots.
Source: http://www.umm.edu/health
/medical/reports/articles/systemic-lupus-
erythematosus

54
Precipitating Present/ Rationale Justification
Factors Absent
Environmental Absent Researchers have sought to find a No documented
connection between certain infectious environmental factors
agents (viruses and bacteria), but no were considered as a
pathogen can be consistently linked to the result of her diagnosis.
disease. Some researchers have found
that women with silicone gel-filled breast
implants have produced antibodies to their
own collagen, but it is not known how
often these antibodies occur in the general
population, and there are no data that
show these antibodies cause connective
tissue diseases such as SLE. There is
also a small but growing body of evidence
linking SLE to lipstick usage.[36]
Source: http://en.wikipedia.org/wiki/
Systemic_lupus_erythematosus
#Environmental_triggers
Medications Absent Drug-induced lupus erythematosus is a No documented
(generally) reversible condition that usually medications were
occurs in people considered as a factor
being treated for a long-term illness. Drug- for her underlying
induced lupus mimics SLE. However, condition.
symptoms of drug-induced lupus generally
disappear once the medication that
triggered the episode is stopped. More
than 38 medications can cause this
condition, the most common of which are
procainamide, hydralazine, quinidine, and
phenytoin. The strongest noninfectious

55
 causative agents are drugs. [14] The first
reported association was with
procainamide, [15] but other commonly
implicated drugs include minocycline, [16]
[17] terbinafine, [18] sulfasalazine, [19]
isoniazid, [20] phenytoin, [21] and
carbamazepine.

Source: https://online.epocrates.com/
diseases/10324/Systemic-lupus-
erythematosus/Etiology
Infection Present Numerous studies have investigated the Patient J.P. had an
role of infectious etiologies that may also incidental finding of
perpetuate autoimmunity. Patients with UTI upon her urinalysis
SLE have higher titers of antibodies to last July 12, 2017
Epstein-Barr virus (EBV), have increased
circulating EBV viral loads, and make
antibodies to retroviruses, including
antibodies to protein regions homologous
to nuclear antigens. In patients with SLE
and EBV infection, the B cells are not
primarily defective; rather, the SLE/EBV
phenomenon is due to a T-cell
abnormality, which causes failure in
normal immunoregulation of the B-cell
response. Viruses may stimulate specific
cells in the immune network. Chronic
infections may induce anti-DNA antibodies
or even lupuslike symptoms, and acute
lupus flares often follow bacterial
infections.

56
Source: http://emedicine.medscape.
com/article/332244-overview#a4

57
 CHAPTER 9
SYMPTOMATOLOGY
SYMPTOMS PRESENT RATIONALE JUSTIFICATION
The release of the chromatin nonhistone DNA binding protein high mobility group box Butterfly rashes
one (HMGB1) during cell activation and death, was demonstrated in skin lesions of were noted during
lupus patients. HMGB1 makes easier interaction and uptake (followed by the physical
/ inflammation) by macrophages and dendritic cells through receptor for advanced assessment and
Butterfly Rash
glycation end products and Toll-like receptors 2, 4, and 9 due the connection with was reflected in
nucleosomes and DNA released from apoptotic cells. patient’s chart

In addition, an antiapoptotic role for NO in keratinocytes, however, UV exposure

Oral and
X modulates local production of NO by the constitutively expressed nitric oxide
Nasopharyngeal Ulcers
synthase (iNOS). iNOS is expressed in human skin in the first 2 days after exposure
to UVA and UVB. An iNOS-specific signal appeared only 72 h after UV exposure and
persisted in the evolving skin lesions up to 1 month, evidencing a delayed and
prolonged expression of iNOS in the LE skin.
A potentially crucial role in the initiation of the autoimmune reaction cascade has Was not reflected
been attributed to UV-induced keratinocyte apoptosis. Ultraviolet irradiation leads to in patient’s chart
Photosensitivity X release of interleukin-10 (IL-10) by keratinocytes, which may be related with and not mentioned
increased autoantibody production and apoptotic damage in skin lesions of LE by the patient
patients.
Alopecia X Most frequently, the hair loss occurs at the onset of the illness and may be one of the No signs of hair

58
 first symptoms of the disease. The bulge area involvement of the follicles by the loss upon
inflammation that characterized chronic CLE supports the possibility that damage to assessment.
the stem cells, which reside on the bulge region, may be one triggering factor to No
permanent follicles loss. Therefore, the pathogenesis of scarring process in CLE may scales/dandruffs
be explained based on follicular stem cells. Cytokeratin 15 (CK15), a marker of stem noted upon
Dry Scalp X cells, has been used to show the bulge region involvement in the scarring process in assessment.
primary cicatricial alopecia and DLE [52]. Drugs used to treat lupus, such as
prednisone and immunosuppressive therapies, also may be responsible of reversible
hair loss.
The link between lupus and rheumatoid arthritis has to do with mutations of the gene Patient does not
STAT4. People who carry a mutated version of this gene have twice the risk of feel any joint pain.
developing lupus. They also have a 60 percent higher risk of developing rheumatoid
arthritis. Scientists know that when it happens, the risk of developing autoimmune
Arthritis X
disorders increases. The mutations of the STAT4 gene also increase the risk of
juvenile idiopathic arthritis and systemic scleroderma. The latter is a disease
characterized by tightening and hardening of the skin and the supporting connective
tissue.
Since SLE patients would develop arthritis, they will manifest a series of joint pains Patient does not
Polyarthralgia with since these are inflamed due to the attack of the immune system. Morning Stiffness feel any joint pain.
X
morning stiffness would occur as a compensatory mechanism to prevent movement that would
stimulate joint pain.
Hypertension / The pressure-natriuresis relationship is altered, so that a higher pressure is required It was written in the

59
 to excrete the same amount of sodium. Consistent with renal vasoconstriction and a patient’s chart of
rightward shift in the pressure-natriuresis relationship, glomerular filtration rate (GFR) positive in HPN
and renal plasma flow are reduced in patients with SLE. and a BP of
160/120 was
obtained during
physical
assessment
The central immunological disturbance in patients with SLE is autoantibody During her 1st
production. These antibodies are directed at several self-molecules found in the admission was she
nucleus, cytoplasm, and cell surface, in addition to soluble molecules such as IgG diagnosed of
and coagulation factors. Anti-double stranded DNA (ds-DNA) and anti-Sm antibodies nephritis as
are unique to patients with SLE. The Sm antigen is designated as a small nuclear reflected in
ribonucleoprotein (snRNP) and is composed of a unique set of uridine rich RNA patient’s chart. She
molecules bound to a common group of core proteins and other proteins associated was then
Nephritis / with the RNA molecules. Anti-Sm antibodies react with snRNP core proteins, diagnosed with
whereas anti-DNA antibodies bind to a conserved nucleic acid determinant widely nephritis together
present on DNA. Anti-DNA antibody titres frequently vary over time and disease with SLE in the 2nd
activity but anti-Sm antibody titres are usually constant. The most remarkable feature admission.
of anti-DNA antibodies is their association with glomerulonephritis. Anti-DNA
antibodies can be isolated in an enriched form from glomerular eluates of patients
with active lupus nephritis and anti-DNA antibodies can induce nephritis in normal
and severe combined immunodeficient subjects.

60
 (Mok, C. & Lau, C., 2003)
Since the kidney are affected by the attacks of the immune system, the nephrons are Presented in her
gradually loose its function in filtration. There will be an altered filtration process of Urinalysis having
Proteinuria /
the nephrons, which causes the proteins not to be removed from the urine and be 3.0 in Protein.
excreted.
Presented in her
CBC results having
Anemia / The immune system attacked the bone marrow, which affects the RBC production.
only 88.0g/L of
Hgb.
It was written in
her referral and
charts of having
Dysfunction of the innate and adaptive immune systems increases the risk of
incidental findings
Infections / infection in patients with SLE. Infectious agents have also been theorized to play a
of UTI. It was also
role in the pathogenesis of SLE.
presented by the
CBC results with
high WBC count
Since there is a problem with the filtration mechanism of the kidney due to SLE, Grade 3 Peripheral
certain substances are not well filtered and be excreted through the urine and one of Edema on the feet
Edema /
which is Sodium. If sodium retention occurs, it would be leaked to the extracellular of the patient were
spaces that causes edema. noted
Abdominal Pain and / The rheumatology and gastroenterology literature emphasizes etiologies of Patient’s abdomen

61
Distentions abdominal pain in patients with SLE such as peritonitis from polyserositis, dyspepsia was rigid and chief
from reflux, nausea and vomiting from bowel edema, ascites, mesenteric ischemia, complaint for
pancreatitis, pneumatosis intestinalis from necrotizing enterocolitis, and hepatobiliary admission was
abnormalities. But in clinical practice, caring for SLE patients in a community epigastric pain.
teaching hospital, these seem to be rare entities.

62
 CHAPTER 10
PATHOPHYSIOLOGY

PREDISPOSING PRECIPITATING
FACTORS: FACTORS:
-Genetics -Infections
-Gender
-Hormones

Apoptosis (programmed
cell death)

Exposed Nuclear
Antigens

Immune system
perceived NA as Less effective
foreign bodies clearance by the
immune system
resulting to more
Nuclear Antigens

Formation of
Nuclear
Antibodies

Nuclear Antibodies enters

the bloodstream with
complimentary system

Local Inflammation
Reaction

Skin Hemolytic Kidneys Serosa Heart Brain Joint

63
Butterfly Anemia Lupus Endocarditis Seizures Arthritis
Rash Leukopenia Nephritis Myocarditis Psychosi Myalgias
Alopenia Pericarditis s
(Hair Loss)
Mucosal Proteinuria
Ulcers Edema
Oliguria
HPN

Abdominal
Distention

64
 CHAPTER 11
DOCTOR’S ORDER
DATE DOCTORS ORDER RATIONALE REMARKS
ADMITTING ORDERS Patient is yet to be cleared for Infectious Disease Done
- Please admit to medical isolation room Level II under so she is sent to an Isolation Room to reduce
BLUE SERVICE chances for transmission and cross contamination.
- Secure consent to care Compliance of legal protocols of the institution Done
ensuring her safety under the treatment and
service of personnel.
- Start IVF PNSS 1L at 80cc/hour Retain/replenishes fluids and electrolytes loss DOne
since patient is having autoimmune condition and
suspected for infection (UTI)
07/12/17
DIAGNOSTICS
6:45PM
 CBC with PC - Provide screening as part of a complete blood Done
count (CBC) in a general physical examination,
especially upon admission to a health care
facility or before surgery
- Confirm an elevated platelet count caused by
SLE (Hypercoagulability)
- Confirm presence of infection since diagnosed
with UTI, reflected from WBC count.
 Urinalysis - Provide screening as part of a general physical Done

65
 examination, especially on admission to a
health care facility or before surgery.
- Determine the presence of a genitourinary
infection since patient was referred with UTI
- Monitor presence of bacteria and protein
caused by UTI and SLE (Proteinuria),
respectively.
 BUN, Creatinine - Evaluate renal function since patient was
diagnosed with Nephritis, complication caused
by SLE.
- Creatinine is assessed to verify the use of an
antibiotic.
 Chest X-ray – PAL Assess the underlying cause of respiratory
problems since dyspnea is present.
 Urine GS/CS - Provide rapid, presumptive information about
the type of potential pathogen present in the
specimen since patient has UTI.
- Assist in the diagnosis of suspected UTI.
- Determine the sensitivity of significant
organisms to antibiotics.
 Blood CS x 2 sites Evaluate patients with urinary tract infections and
rapidly progressing tissue infections/lesions

66
  Sodium, Calcium, Magnesium
THERAPEUTICS
 If ok with Infectious Disease, plan to start
Meropenem 1gm IVTT q8
 Continue Prednisone as follows:
o 10mg/tab 11/2 tab at 6AM
o 10mg/tab 1 tab at 1pm
*It should be 6am and 6pm since the order seemed to be
BID.
 Calvit tab 1 tab OD
 Hydroxychloroquine 200mg/tab 1 tab OD
- Assess renal functions.
- Level of sodium is assessed to confirm HPN
- SLE and Prednisone intake increases risk for
osteoporosis, assess levels of calcium to
indicate the use of supplements to help
maintain adequate bone density.
An antibiotic (bactericidal) that binds to penicillin-
binding proteins, which inhibits bacterial cell wall
synthesis. For UTI and Nephritis
- A glucocorticoid that inhibits inflammation
process caused by renal diseases (UTI and
Nephritis)
- Calcium supplements, possible for having low
calcium levels caused by SLE.
- An antimalarial/antirheumatic agent; treatment
for SLE
o Treat fatigue and moderate skin and
joint problems
o Prevent flares
67
  Losartan 100mg/tab 1 tab OD
 Amlodipine 10mg/tab 1 tab OD
 Carvedilol 25mg/tab 1 tab BID
- For pulse therapy if ok with IDS
- An antihypertensive agent that blocks
vasoconstrictor, aldosterone-secreting effects
of angiotensin II, inhibiting binding of
angiotensin II to AT1 receptors. For patient’s
HPN.
- Another antihypertensive agent that inhibits
calcium movement across cardiac and vascular
smooth muscle cell membranes, which dilates
peripheral arteries and decreases B/P by
vasodilation.
- Another antihypertensive that possesses
nonselective beta-blocking and alpha-
adrenergic blocking activity that causes
vasodilation. Treatment for the patient’s HPN
- Pulse therapy is the administration of large
doses of drugs in an intermittent manner to
enhance therapeutic effects and reduce
adverse effects.
o Dexamethasone and cyclophosphamide
have been widely used to treat various
dermatological disorders.
o Pulse corticosteroids have also been
68

- Monitor VS q4, I/O q shift
- Watch out for any unusualities
- Refer Accordingly
Confirmed with Dr. Hable
8:14pm
- No antibiotics for now
- For blood and urine GS/CS
tried in lupus and nephritis
o Corticosteroids, immunosuppressive,
antifungals, antivirals are the commonly
used drugs administered in pulse
doses.
- It has to be Infectious Disease cleared first
since Corticosteroids diminishes the immune
system to reduce inflammation processes.
Standardized protocols in monitoring the conditions
of the patient, especially for drug responsiveness.
o VS to monitor baseline data and
responsiveness to antihypertensives
and antibiotics
o I/O to monitor responsiveness to
therapy for renal disorders.
Awareness of drug therapy reactions and adverse
effects so that immediate remedies will be given.
Re-assess or re-evaluate presence of bacteria or
pathogens with response to the antibiotics.
69
- If patient remains asymptomatic for 48 hours and culture
studies are negative, may clear patient IDS

70
 CHAPTER 12
DIAGNOSTIC AND LAB TESTS

COMPLETE BLOOD COUNT WITH PLATELET

EXAM RESULT REFERENCE RANGES INDICATION
HGB 88.0 115 – 155 g/L Low hemoglobin may indicate
anemia.
HCT 0.27 0.36 – 0.48 Low hematocrit indicates
deficiency in iron, folate, or
vitamin B12.
RBC Count 2.63 4.2 – 6.1 x10^9/L Low RBC count indicates
vitamin B6, B12 or folate
deficiency.
WBC Count 14.99 5 – 10 x10^9/L High WBC count indicates
infection or inflammation.
NEUTROPHILS 90 55 – 75 High neutrophils indicate
infection.
LYMPHOCYTES 7.0 20 – 35 Low lymphocytes indicate
autoimmune disorders.
MONOCYTES 3 2 – 10 NORMAL
EOSINOPHILS 0 1–8 Low eosinophils indicate
infection.
BASOPHILS 0 0–1 NORMAL
PLATELET Count 192 150 – 400 x10^3/uL NORMAL
MCV 103 79.4 – 94.8 fl High MCV indicates
microcytic and hypochromic
anemia.
MCH 33.50 25.6 – 32.2 pg High MCH indicates a sign of
macrocytic anemia.
MCHC 32.50 32.2 – 35.5 g/dL NORMAL

71
 URINE EXAMINATION
EXAM RESULT REFERENCE RANGES INDICATION
Appearance CLEAR NORMAL
Color LIGHT NORMAL
YELLOW
Protein 3.0 Diseases and conditions may
3+ cause elevated levels of
protein in urine.
pH 6.0 NORMAL
Specific Gravity 1.015 NORMAL
Glucose NEGATIVE NORMAL
Micro-Albumin 3+ 10 – 19 High micro-albumin indicates
urinary tract infection.
Urine Bilirubin NEGATIVE 0 – 16 NORMAL
Urine Urobilinogen 3.4 3.4 – 17 NORMAL
Nitrite NEGATIVE NEGATIVE NORMAL
Leukocyte Esterase 2+ ca.125 0 – ca.14 NORMAL
Urine Ketone NEGATIVE 0 – 0.4 NORMAL
RBC 196 0 – 28 /uL High RBC indicates kidney
and urinary tract problems
such as infection, tumor, or
stones.
WBC 2729 0 – 27 /uL High WBC indicates
inflammation in the urinary
tract or kidneys.
Epithelial Cells 48 0 – 7 /uL High epithelial cells indicate
urinary tract infection or other
cause of inflammation.
Cast 0 0 – 2 /uL NORMAL

72
 Bacteria 4283 0 – 111 /uL High bacteria indicates
urinary tract infection.
Amorphous Crystals 0 NORMAL
Calcium Oxalates 0 NORMAL
Uric Acid 0 NORMAL
Mucus Threads 5.0 NORMAL

73
 CHAPTER 13
DRUG STUDY
Image

Generic Name Prednisone

Brand Name Prednisone Intensol, Rayos, Winpred

Classification PHARMACOTHERAPEUTIC: Adrenal corticosteroid.

CLINICAL: Glucocorticoid

Route, Dosage & Oral, 10mg ½ tab @ 6am and 1 tab @1pm, BID
Frequency
Mechanism of Action Inhibits accumulation of inflammatory cells at inflammation sites,
phagocytosis, lysosomal enzyme release/synthesis, release of
mediators of inflammation. Therapeutic Effect:
Prevents/suppresses cell-mediated immune reactions.
Decreases/prevents tis- sue response to inflammatory process.

Indication Arthritis; rheumatic carditis; allergic, collagen, intestinal tract,

multiple sclerosis exacerbations; liver, ocular, renal, skin
diseases; bronchial asthma; cerebral edema; malignancies.

Contraindication Acute superficial her- pes simplex keratitis, systemic fungal

infections, varicella, administration of live or attenuated virus
vaccines.

Side Effects Insomnia, heartburn, nervous- ness, abdominal distention,

diaphoresis, acne, mood swings, increased appetite, facial
flushing, delayed wound healing, increased susceptibility to

74
 infection, diarrhea, constipation.

Adverse Effects LONG-TERM THERAPY: Muscle wasting (esp. in arms, legs),

osteoporosis, spontaneous fractures, amenorrhea, cataracts,
glaucoma, peptic ulcer, CHF.

ABRUPT WITHDRAWAL FOLLOWING LONG-TERM THERAPY:

Anorexia, nausea, fever, headache, rebound inflammation,
fatigue, weakness, lethargy, dizziness, orthostatic hypotension.
Sudden discontinuance may be fatal.

Nursing Responsibilities
1. Indicated for many conditions. Assess involved systems before
and periodically during therapy.
2. Assess patient for signs of adrenal insufficiency (hypotension,
weight loss, weakness, nausea, vomiting, anorexia, lethargy,
confusion, restlessness) before and periodically during therapy.
3. Monitor intake and output ratios and daily weights. Observe
patient for peripheral edema, steady weight gain, rales/crackles,
or dyspnea. Notify health care professional if these occur.
4. Pedi: Children should have periodic evaluations of growth.
5. Lab Test Considerations: Monitor serum electrolytes and
glucose. May cause hyperglycemia, especially in persons with
diabetes. May cause hypokalemia. Patients on prolonged
courses of therapy should routinely have hematologic values,
serum electrolytes, and serum and urine glucose evaluated.
May decrease WBC counts.
6. Guaiac-tests tools. Promptly report presence of guaiac-positive
stools.
7. Suppress reactions to allergy skin tests.
8. Periodic adrenal function tests may be ordered to assess degree
of hypothalamic-pituitary-adrenal axis suppression in systemic
and chronic topical therapy.

Image

Generic Name Hydroxychloroquine

Brand Name Plaquenil

75
Classification PHARMACOTHERAPEUTIC: Amino-quinoline antimalarial.

CLINICAL: Antimalarial, antirheumatic.

Route, Dosage Oral, 200 mg tab, O.D.

& Frequency
Mechanism of Concentrates in parasite acid vesicles, interfering with parasite protein
Action (DNA/ RNA) synthesis. Antirheumatic action may involve suppressing
formation of antigens responsible for hypersensitivity reactions.

Therapeutic Effect: Inhibits parasite growth.

Indication Treatment of falciparum malaria (terminates acute attacks, cures

nonresistant strains); suppression of acute attacks, prolongation of interval
between treatment/relapse in vivax, ovale, malariae malaria. Treatment of
discoid or systematic lupus erythematosus, acute and chronic rheumatoid
arthritis

Contraindicatio Long-term therapy for children, psoriasis, retinal or visual field changes.
n

Side Effects Frequent: Transient headache, anorexia, nausea, vomiting.

Occasional: Visual disturbances, anxiety, fatigue, pruritus (esp. palms,

soles, scalp), irritability, personality changes, diarrhea, photosensitivity.

Adverse Ocular toxicity (esp. retinopathy) may progress even after drug is
Effects discontinued. Prolonged therapy: Peripheral neuritis, neuromyopathy,
hypotension, EKG changes, agranulocytosis, aplastic anemia,
thrombocytopenia, seizures, psychosis.

Over dosage: Headache, vomiting, visual disturbances, drowsiness,

seizures, hypokalemia followed by cardiovascular collapse, death.

Nursing 1. Assess deep tendon reflexes periodically to determine muscle weakness.

Responsibilitie Therapy may be discontinued should this occur.
s 2. Patients on prolonged high dose therapy should have eye exams prior to
and every 3 – 6 months during therapy to detect retinal damage.
3. Malaria or Lupus Erythematosus: Assess patient for improvement in signs
and symptoms of condition daily throughout course of therapy.
4. Rheumatoid Arthritis: Assess patient monthly for pain, swelling, and range
of motion.
5. Lab Test Considerations: Monitor CBC and platelet count periodically
throughout therapy. May cause decreased RBC, WBC, and platelet counts.
If severe decreases occur that are not related to the disease process,

76
 hydroxychloroquine should be discontinued.

Image

Generic Name Losartan

Brand Name Cozaar
Classification PHARMACOTHERAPEUTIC: Angioten- sin II receptor antagonist.

CLINICAL: Antihypertensive

Route, Dosage Oral, 100 mg tab, O.D.

& Frequency
Mechanism of Potent vasodilator. Blocks vasoconstrictor, aldosterone-secreting
Action effects of angiotensin II, inhibiting binding of angiotensin II to AT 1
receptors. Therapeutic Effect: Causes vasodilation, decreases
peripheral resistance, decreases B/P.

Indication Treatment of hypertension. Used alone or in combination with other

antihypertensives. Treatment of diabetic nephropathy, prevention of
stroke in pts with hypertension and left ventricular hypertrophy.

Contraindication Contraindications: None known.

Cautions: Renal/hepatic impairment, unstented renal arterial stenosis,

significant aortic/ mitral stenosis.

77
 Side Effects Frequent (8%): Upper respiratory tract infection.

Occasional (4%–2%): Dizziness, diarrhea, cough. Rare (1% or less):

Insomnia, dyspepsia, heartburn, back/leg pain, muscle cramps,
myalgia, nasal congestion, sinusitis, depression.

Adverse Effects Over dosage may manifest as hypotension and tachycardia.

Bradycardia occurs less often. Institute supportive measures.

Nursing 1. Assess BP (lying, sitting, standing) and pulse frequently during initial
Responsibilities dose adjustment and periodically during therapy. Notify health care
professional of significant changes.
2. Monitor frequency of prescription refills to determine compliance.
3. Assess patient for signs of angioedema (dyspnea, facial swelling).
May rarely cause angioedema.
4. Lab Test Considerations: Monitor renal function. May cause increase
BUN and serum creatinine.
5. May cause decrease AST, ALT, and serum bilirubin.
6. May cause hyperkalemia.
7. May causes light decrease hemoglobin and hematocrit.
8. Caution patient to avoid salt substitutes containing potassium or
foods containing high levels of potassium or sodium unless directed
by health care professional.
9. Caution patient to avoid sudden changes in position to decrease
orthostatic hypotension. Use of alcohol, standing for long periods,
exercising, and hot weather may increase orthostatic hypotension.
10. May cause dizziness. Caution patient to avoid driving or other
activities requiring alertness until response to medication is known.

Image

Generic Name Amlodipine

Brand Name Norvasc

78
Classification PHARMACOTHERAPEUTIC: Calcium channel blocker. CLINICAL:
Antihypertensive, antianginal

Route, Oral, 10 mg tab, OD

Dosage &
Frequency
Mechanism of Inhibits calcium movement across cardiac and vascular smooth muscle
Action cell membranes.

Therapeutic Effect: Dilates coronary arteries, peripheral arteries/

arterioles. Decreases total peripheral vascular resistance and B/P by
vasodilation.

Indication Management of hypertension, chronic stable angina, vasospastic

(Prinzmetal’s or variant) angina. May be used alone or with other
antihypertensives or antianginals.

Contraindicati Contraindications: None known.

on
Cautions: Hepatic impairment, aortic stenosis, hypertophic
cardiomyopathy.

Side Effects Frequent (greater than 5%): Peripheral edema, headache, flushing.
Occasional (5%–1%): Dizziness, palpitations, nausea, unusual fatigue
or weakness (asthenia). Rare (less than 1%): Chest pain, bradycardia,
orthostatic hypotension.

Adverse Overdose may produce excessive peripheral vasodilation, marked

Effects hypotension with re ex tachycardia.

Nursing 1. Monitor BP and pulse before therapy, during dose titration, and
Responsibilitie periodically during therapy. Monitor ECG periodically during prolonged
s therapy.
2. Monitor intake and output ratios and daily weight. Assess for signs of
HF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular
venous distention).
3. Angina: Assess location, duration, intensity, and precipitating factors of
patient’s anginal pain.
4. Lab Test Considerations: Total serum calcium concentrations are not
affected by calcium channel blockers.
5. Advise patient to take medication as directed, even if feeling well. Take
missed doses as soon as possible unless almost time for next dose;
do not double doses. May need to be discontinued gradually.
6. Instructpatientoncorrecttechniqueformonitoringpulse.Instructpatienttoc
ontact health care professional if heart rate is 50 bpm.
7. Caution patient to change positions slowly to minimize orthostatic
hypotension.

79
 8. May cause drowsiness or dizziness. Advise patient to avoid driving or
other activities requiring alertness until response to the medication is
known.

Image

Generic Name Carvedilol

Brand Name Coreg
Classification PHARMACOTHERAPEUTIC: Beta-adrenergic blocker.

CLINICAL: Anti-hypertensive

Route, Dosage & Oral, 25 mg tab, BID

Frequency
Mechanism of Action Possesses nonselective beta-blocking and alpha-adrenergic
blocking activity. Causes vasodilation. Therapeutic Effect:
Reduces cardiac output, exercise-induced tachycardia, re ex
orthostatic tachycardia; reduces peripheral vascular resistance.

Indication Treatment of mild to severe heart failure, left ventricular

dysfunction following MI, hypertension. Reduces risk of recurrent
MI in pts with heart failure or ischemic injury.

Contraindication Contraindications: Bronchial asthma or related bronchospastic

conditions, cardiogenic shock, decompensated heart failure,
severe hepatic impairment, second- or third-degree AV block,
severe bradycardia, or sick sinus syndrome (except in pts with
pacemaker).

Side Effects Carvedilol is generally well tolerated, with mild transient side
effects. Frequent (6%– 4%): Fatigue, dizziness.

Adverse Effects Overdose may produce profound bradycardia, hypotension,

bronchospasm, cardiac insufficiency, cardiogenic shock, cardiac
arrest. Abrupt withdrawal may result in diaphoresis, palpitations,

80
 head- ache, tremors. May precipitate CHF, MI in pts with cardiac
disease; thyroid storm in those with thyrotoxicosis; peripheral
ischemia in those with existing peripheral vascular disease.
Hypoglycemia may occur in pts with previously controlled
diabetes.

Nursing 1. Monitor BP and pulse frequently during dose adjustment period

Responsibilities and periodically during therapy. Assess for orthostatic
hypotension when assisting patient up from supine position.
2. Monitor intake and output ratios and daily weight. Assess
patient routinely for evidence of fluid overload (peripheral
edema, dyspnea, rales/ crackles, fatigue, weight gain, jugular
venous distention). Patients may experience worsening of
symptoms during initiation of therapy for HF.
3. Hypertension: Check frequency of refills to determine
adherence.
4. Lab Test Considerations: May cause increase BUN, serum
lipoprotein, potassium, triglyceride, and uric acid levels.
5. May cause increase ANA titers.
6. May cause q increase in blood glucose levels.
7. Toxicity and Overdose: Monitor patients receiving beta blockers
for signs of overdose (bradycardia, severe dizziness or fainting,
severe drowsiness, dyspnea, bluish fingernails or palms,
seizures). Notify health care professional immediately if these
signs occur.

Image

Generic Name Calcium Carbonate, vit D

Brand Name Calvit
Classification Calcium with vitamins
Route, Dosage & Oral, 1 tab, O.D
Frequency
Mechanism of Action Calcium and Phosphorous are the two major components of bone.

81
 They are important in the metabolism of cells in the body and bone,
therefore functions as a storage reservoir. Vitamin D is essential for
promoting absorption & utilization of Calcium & Phosphate and for
normal calcification of bone. It regulates serum Calcium
concentration – a homeostatic mechanism. It stimulates Calcium &
Phosphate absorption from small intestine and mobilize calcium
from bone. Cholecalciferol is transferred to the liver & converted
into Calcifediol (25 Hydroxycholecalciferol) which then is
transferred to kidneys & converted to Calcitriol (1,
25Dihydroxycholecalciferol). Calcitriol appears to act by: Increasing
absorption of Calcium from the intestine; Regulates the transfer of
Calcium ion from bone & re-absorption from distal renal tubule,
Ionized Plasma Calcium level regulates the secretion of PTH.
Therefore, Vit. D is included to increase Calcium absorption in
Calcium Supplement for hypoparathyroidism.

Indication Dietary supplement for adolescents & young adults during

periods of rapid growth & development. Prevention of
osteoporosis @ Calcium insufficiency & as dietary
supplement during pregnancy & lactation, pre- &
postmenopause.

Calvit Tablet is used for Low blood calcium level, Vitamin d

deficiency, Increase the force of contraction of the heart,
Bone formation, Blood coagulation and other conditions.
Calvit Tablet may also be used for purposes not listed in this
medication guide.

Contraindication • Allergies
• Difficulty absorbing nutrition from food
• Disease of the pancreas
• Heart disease
• High calcium levels
• Kidney disease

Side Effects • Constipation

• Stomach ache
• Loss of appetite
• Feeling of sickness
• Excessive thirst
Muscle weakness
Adverse Effects  Constipation in Children & Adolescence
  Loss of appetite
  Metallic taste

82
   Frequent urination
  Muscle Pain
  Bone Pain

Nursing Responsibilities 1. Movitor VS

2. Monitor Calcium level and phosphorus level
3. Check for any unusualities
4. Check if patient is allergic to this supplement
5. Encourage patient to IOF
6. Monitor ECG

Image

Generic Name Furosemide

Brand Name Lasix

Classification Loop Diuretics

Route, Dosage & Available forms :Tablets—20, 40, 80 mg; oral solution—10
Frequency mg/mL, 40 mg/5 mL; injection—10 mg/mL

Mechanism of Action inhibits reabsorption of Na and chloride mainly in the medullary

portion of the ascending Loop of Henle. Excretion
of potassium and ammonia is also increased while uric acid
excretion is reduced. It increases plasma-renin levels and
secondary hyperaldosteronism may result. Furosemide reduces
BP in hypertensives as well as in normotensives. It also reduces
pulmonary oedema before diuresis has set in.

Indication  Oral, IV: Edema associated with CHF, cirrhosis, renal

83
 disease
 IV: Acute pulmonary edema
 Oral: Hypertension

Contraindication  Severe sodium and water depletion, hypersensitivity to

sulphonamides and furosemide, hypokalaemia,
hyponatraemia, precomatose states associated
with liver cirrhosis, anuria or renal failure.
 Addison’s disease.

Side Effects

Adverse Effects  Fluid and electrolyte imbalance.

 Rashes, photosensitivity, nausea, diarrhoea, blurred
vision, dizziness, headache, hypotension. Bone
marrow depression (rare), hepatic dysfunction.
 Hyperglycaemia, glycosuria, ototoxicity.
 Potentially Fatal: Rarely, sudden death and cardiac
arrest. Hypokalaemia and magnesium depletion can
cause cardiac arrhythmias.

Nursing Responsibilities  Reduce dosage if given with other antihypertensives;

readjust dosage gradually as BP responds.
 Administer with food or milk to prevent GI upset.
 Give early in the day so that increased urination will not
disturb sleep.
 Avoid IV use if oral use is at all possible.
 WARNING: Do not mix parenteral solution with highly
acidic solutions with pH below 3.5.
 Do not expose to light, may discolor tablets or solution; do
not use discolored drug or solutions.
 Discard diluted solution after 24 hr.
 Refrigerate oral solution.
 Measure and record weight to monitor fluid changes.
 Arrange to monitor serum electrolytes, hydration, liver and
renal function.
 Record intermittent therapy on a calendar or dated
envelopes. When possible, take the drug early so
increased urination will not disturb sleep. Take with food or

84
 meals to prevent GI upset.
 Weigh yourself on a regular basis, at the same time and in
the same clothing, and record the weight on your calendar.
 Blood glucose levels may become temporarily elevated in
patients with diabetes after starting this drug

85
 CHAPTER 14
NURSING THEORIES

Jean Watson’s Theory of Human Caring

Jean Watson refers to the human being as "a valued person in and of him
or herself to be cared for, respected, nurtured, understood and assisted; in
general a philosophical view of a person as a fully functional integrated self.
Human is viewed as greater than and different from the sum of his or her parts."

Health is defined as a high level of overall physical, mental, and social

functioning; a general adaptive-maintenance level of daily functioning; and the
absence of illness, or the presence of efforts leading to the absence of illness.

Watson's definition of environment/society addresses the idea that nurses

have existed in every society, and that a caring attitude is transmitted from
generation to generation by the culture of the nursing profession as a unique way
of coping with its environment.

The nursing model states that nursing is concerned with promoting health,
preventing illness, caring for the sick, and restoring health. It focuses on health
promotion, as well as the treatment of diseases. Watson believed that holistic
health care is central to the practice of caring in nursing. She defines nursing as
"a human science of persons and human health-illness experiences that are
mediated by professional, personal, scientific, esthetic and ethical human
transactions."

Watson's model makes seven assumptions:

1. Caring can be effectively demonstrated and practiced only interpersonally.

86
2. Caring consists of carative factors that result in the satisfaction of certain
human needs.

3. Effective caring promotes health and individual or family growth.

4. Caring responses accept the patient as he or she is now, as well as what he or

she may become.

5. A caring environment is one that offers the development of potential while

allowing the patient to choose the best action for him or herself at a given point in
time.

6. A science of caring is complementary to the science of curing.

7. The practice of caring is central to nursing.

APPLICATION:

Using Watson’s theory of transpersonal caring will enable the nurses to

effectively provide holistic care to the patients. By focusing on the patient’s
wishes the nurses can achieve higher levels of cooperation with the patients and
family and in the process achieve greater efficiency, profitability and patient
satisfaction scores. Effective communication with the patient at all levels focusing
on the progress of treatment, timelines and the possible nature of upcoming
procedures; addressing the patients fear and anxiety; understanding the patient’s
needs and undertaking to provide for them such as spiritual and emotional
support.

Patricia Benner’s Novice to Expert Theory

This nursing theory proposes that expert nurses develop skills and
understanding of patient care over time through a proper educational background

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as well as a multitude of experiences. Dr. Benner's theory is not focused on how
to be a nurse, rather on how nurses acquire nursing knowledge - one could gain
knowledge and skills ("knowing how"), without ever learning the theory ("knowing
that").

Dr. Benner's Stages of Clinical Competence

Stage 1 Novice: This would be a nursing student in his or her first year of
clinical education; behavior in the clinical setting is very limited and inflexible.
Novices have a very limited ability to predict what might happen in a particular
patient situation. Signs and symptoms, such as change in mental status, can only
be recognized after a novice nurse has had experience with patients with similar
symptoms.
Stage 2 Advanced Beginner: Those are the new grads in their first jobs;
nurses have had more experiences that enable them to recognize recurrent,
meaningful components of a situation. They have the knowledge and the know-
how but not enough in-depth experience.
Stage 3 Competent: These nurses lack the speed and flexibility of
proficient nurses, but they have some mastery and can rely on advance planning
and organizational skills. Competent nurses recognize patterns and nature of
clinical situations more quickly and accurately than advanced beginners.
Stage 4 Proficient: At this level, nurses are capable to see situations as
"wholes" rather than parts. Proficient nurses learn from experience what events
typically occur and are able to modify plans in response to different events.
Stage 5 Expert: Nurses who are able to recognize demands and
resources in situations and attain their goals. These nurses know what needs to
be done. They no longer rely solely on rules to guide their actions under certain
situations. They have an intuitive grasp of the situation based on their deep
knowledge and experience. Focus is on the most relevant problems and not
irrelevant ones. Analytical tools are used only when they have no experience with
an event, or when events don't occur as expected.

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APPLICATION:
As future registered nurses, we are going to experience the 5 stages of
clinical competence. As a novice nurse in the emergency department, we are
presented with unfamiliar situations daily. Over time and experience, we begin to
anticipate the orders to be received before the physician has even assessed the
patient. Also in the instance of evidence based protocols, over time the expert
nurse no longer needs to refer to charts or protocols. Life saving measures are
implemented quickly with confidence and precision. With physician’s guidance,
experienced nurses help to save lives everyday.

Hildegard Peplau’s Interpersonal Relations Theory

The nursing model identifies four sequential phases in the interpersonal
relationship: orientation, identification, exploitation, and resolution.

The orientation phase defines the problem. It starts when the nurse meets the
patient, and the two are strangers. After defining the problem, the orientation
phase identifies the type of service needed by the patient. The patient seeks
assistance, tells the nurse what he or she needs, asks questions, and shares
preconceptions and expectations based on past experiences. Essentially, the
orientation phase is the nurse's assessment of the patient's health and situation.

The identification phase includes the selection of the appropriate assistance by a

professional. In this phase, the patient begins to feel as if he or she belongs, and
feels capable of dealing with the problem which decreases the feeling of
helplessness and hopelessness. The identification phase is the development of a
nursing care plan based on the patient's situation and goals.

The exploitation phase uses professional assistance for problem-solving

alternatives. The advantages of the professional services used are based on the

89
needs and interests of the patients. In the exploitation phase, the patient feels
like an integral part of the helping environment, and may make minor requests or
use attention-getting techniques. When communicating with the patient, the
nurse should use interview techniques to explore, understand, and adequately
deal with the underlying problem. The nurse must also be aware of the various
phases of communication since the patient's independence is likely to fluctuate.
The nurse should help the patient exploit all avenues of help as progress is made
toward the final phase. This phase is the implementation of the nursing plan,
taking actions toward meeting the goals set in the identification phase.

The final phase is the resolution phase. It is the termination of the professional
relationship since the patient's needs have been met through the collaboration of
patient and nurse. They must sever their relationship and dissolve any ties
between them. This can be difficult for both if psychological dependence still
exists. The patient drifts away from the nurse and breaks the bond between
them. A healthier emotional balance is achieved and both become mature
individuals. This is the evaluation of the nursing process. The nurse and patient
evaluate the situation based on the goals set and whether or not they were met.

The goal of psychodynamic nursing is to help understand one's own behavior,

help others identify felt difficulties, and apply principles of human relations to the
problems that come up at all experience levels. Peplau explains that nursing is
therapeutic because it is a healing art, assisting a patient who is sick or in need
of health care. It is also an interpersonal process because of the interaction
between two or more individuals who have a common goal. The nurse and
patient work together so both become mature and knowledgeable in the care
process.

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APPLICATION:
There are many different ways a nurse can approach each patient and
situation. Patients utilize the emergency room not only for critical care but also for
minor ailments due to inability to get in with primary care practitioners. It is vital
that in order to deliver high quality care to these patients, we must evaluate all
aspects of patient’s lifestyle. The first step, the orientation phase, is identifying
problems that can affect their care or outcome. Not only will their living
arrangements play a role in the time needed to recover, but ability to afford
prescriptions recommended. During the identifying stage, the nurse and patient
can work together to determine a feasible goal. As part of the exploitation stage,
patients and families are reaching out, seeking care that we as nurses can assist
them to find what works best for them. We are able to provide patients and
families with resources available for long-term care if needed. These are
examples of problem solving techniques finalizing the resolution phase.

91
 CHAPTER 15
NURSING CARE PLANS
Date/Time Assessment Need Diagnosis Objectives Intervention Evaluation
Subjective: Independent:
July 12, “Dako akong S Disturbed body After 1-3 hours of 1.) Monitor and record vital signs Goal Met
2017 @ tiyan ma’am, E image related to nursing R: This is to establish baseline
7:00PM karon ra man ni L presence of interventions, the data and reference After 2 hours of
unya tig.a pa F changes caused patient will be nursing
gyud kaayo. - by disease able to: 2.) Maintain a calm attitude in interventions, the
Naa pud koy P dealing with the patient patient was able to
edema duha sa E R: Systemic  Achieve R: To decrease the level of have improved
akong tiil.” R lupus reconciliation anxiety of the patient reconciliation
Objective: C erythematosus between self- between self-concept
E (SLE) is a concept and 3.) Encourage verbalization of and physical
 Butterfly
P chronic, the physical feelings, perceptions, and fear. changes, verbalize
rash on face
T multisystem changes R: Expression of feelings can feelings, perceptions,
noted
I disease caused by enhance the patent’s coping and fears, and also
 Bipedal
O involving disease strategies. identify certain
pitting
N connective  Verbalize coping mechanisms.
edema
/ tissue that feelings, 4.) Encourage good nutrition,
grade 3
S appears to perceptions, sleep habits, exercise, rest and
noted
E result from and fear relaxation techniques.
 Rigid and
distended
L production of  Identify R: To improve general health and
F autoantibodies. effective help prevent infection.
abdomen - Immune coping
noted C complexes and 5.) Teach patient relaxation
mechanisms
 Rashes on O other immune techniques such as deep
lower and N system breathing, progressive muscle
upper C constituents relaxation, and imagery.
extremities E combine to form R; To reduce emotional stress
noted P complement that may cause fatigue.
T that is deposited
in organs, 6.) Avoid direct sunlight and
P causing encourage use of sunscreen and
A inflammmation, wear protective clothing.
T and tissue R: To reduce the chance of
T necrosis. The exacerbations.
92
E disease may be Collaborative:
R mistaken for 7.) Administer analgesics as
N rheumatoid prescribed.
arthrtis, R: To enhance pain relief.
especially in
early course of
the disease.
Course of the
disease is highly
variable, but
complications of
SLE include
infection, renal
failure,
permanent
neurologic
impairmanet,
and death. The
disease is more
common on
women than
men, usually
women at
childbearing
age.

93
Date/Time Assessment Need Diagnosis Objectives Intervention Evaluation
July 12, Objectives: N Impaired tissue integrity After 8 hours of 1. Assess the patient’s 1. May interfere
2017 U related to inflammation level of distress. with the ability to
nursing
 Rash on T cope effectively
3-11 upper R Rational: interventions, 2. Note presence and with the disease,
and lower I In systemic lupus, the body's degree of edema. its physical
the patient will
extremitie T overactive immune system symptoms and its
s I forms antibodies that attack be able to 3. Assess skin for color, treatment.
 Pitting O and damage not just the skin
verbalize
texture, and turgor.
edema of N but other crucial tissues and 2. Determines
+3 A organs such as the kidneys, understanding of 4. Determine presence of fluid
L heart, lungs, blood and psychological effects of deficit or overload
condition and
- joints. This disease causes condition on client. that can
M inflammation in various causative adversely affect
E organs of our body. 5. Encourage adequate cell or tissue
factors.
T periods of rest and sleep. strength.
A
B Source: 6. Monitor laboratory 3. For
O http://www.lupusny.org/about- studies. comparative
L lupus/fight-lupus-body-and- baseline.
I mind/lupus-and-your-skin 7. Provide health
C teachings about the 4. Can be
- disease. devastating for
P client’s body or
A 8. Emphasize importance self-image.
T
of adequate nutritional
T 5. To limit
E and adequare fluid intake. metabolic
R demands.
N
6. For changes
indicative of
healing or
presence of
infection.

94
7. For the patient
to be aware of his
condition.

8. To maintain
general good
health and skin
turgor.

95
Date/Time Assessment Need Diagnosis Objectives Intervention Evaluation
July 12, S: “Dili nako ka- E Impaired Urinary After 2 hours of 1. Note age and gender of the Goal Partially Met
2017 ihi ug tarong kay L Elimination d/t nursing patient.

7:00pm sakit man gud. I dysfunction of interventions, the R: Incontinence and UTI are more After 2 hours of
prevalent in women and older
Usahay kay di M nephrons and patient will be nursing
adults
gyud ko kaihi.” I urinary tract able to: interventions, the
N infection - Verbalize patient was able to
2. Determine fluid intake and note
O: A understanding express her feelings
conditions of the skin and mucous
- Dysuria T R: Inflammation of of condition membranes.
regarding her
- WBC: 14.99; I the nephrons, the - Achieve R: Determine the hydration of the condition and
Urinalysis O structures within normal patient understood the
WBC: 2729 N the kidneys that elimination importance of
- Protein: 3+ filter the blood, is pattern 3. Monitor IVF Therapy of PNSS. following prescribed
P called Ensure that it is infusing well and no instructions of her

A glomerulonephritis, kinks. Refer if unusualities occur. physician. She was

T or nephritis. Lupus not able to achieve
4. Assist with developing toileting
T nephritis is the normal elimination
routines.
E term used when pattern.
R lupus causes
5. Encourage patient to verbalize
N inflammation in fears and concerns.
your kidneys, R: Open expression allows patient
making them to deal with feelings and begin
unable to properly problem solving
remove waste

96
from your blood or 6. Administer prescribed
control the amount medications.

of fluids in your R: Compliance of medication

regimen would improve patient
body.
condition.

Abnormal levels of
waste can build up
in the blood, and
edema (swelling)
can develop. Left
untreated,
nephritis can lead
to scarring and
permanent
damage to the
kidneys and
possibly end-stage
renal disease
(ESRD). People
with ESRD need
regular filtering of
their body’s waste
done by a
machine (dialysis)
or a kidney

97
transplant so that
at least one kidney
is working
properly.
(Anonymous,
2013)

98
 CHAPTER 16

RECOMMENDATIONS

As future nurses, we must emphasize the importance in continuity of care and

prevention of further complications in order to ensure holistic care as one of our

goals. For this to be possible, we would like to share what we had learned and

what we recommend to those who can be involved in health care.

To the Patient

We recommend the patient to be very compliant to what his doctor

instructed. She should be knowledgeable about her condition since she is able to

understand and is also coherent. With this, she should be active in participating

towards achieving wellness.

To the Family

We recommend that the family should help comply with the doctors’

prescribed medications, and follow doctor’s instructions. The family must ensure

the patient’s safety needs, and they should assist her nutritional needs. The

family should take immediate treatment for the patient’s condition. Lastly, it is

important for them to consider follow-up check ups to be needed and essential.

To the student nurse

We recommend the nursing students to properly monitor the condition of

their patients. Student nurses should also check the background of the

99
medications to be administered to their patients as to prevent complications.

Student nurses should always incorporate health teachings in every time they

can as to educate the family and the patient as well. Student nurses should not

only provide concrete interventions but emotional support is also equally

important to the family. Lastly, student nurses should provide supportive nursing

care according to the patient’s condition and should always have a goal of

promoting health of patients in every way possible.

To the Southern Philippines Medical Center

We would also like to pay tribute the Southern Philippines Medical Center

for serving as the main training ground for us student nurses in enhancing our

expertise and honing vital knowledge through performing patient-oriented

interventions with the supervision of our clinical instructors.

To the College of Nursing of the Ateneo de Davao University

We would like to recommend the School of Nursing to maintain its high

quality of education. May the high spirits of the clinical instructors be a beacon of

morale to the student nurses, and continue to help, guide, and teach us of the

do’s and don’ts of the clinical area. The School of Nursing should continue to

mold the students to be effective in their skills as well as their knowledge and

attitude towards the clients.

100
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