Systemic Lupus Erythematosus Ihuman Diagnosis

Systemic Lupus Erythematosus is a condition that affects the immune system of the body. It may affect any organ however the cause is not yet known. Below is an Ihuman case study that reviews a patient that has been diagnosed with this condition.

Primary Diagnosis: Systemic Lupus Erythematosus Status/Condition: (Critical, Guarded, Stable, etc.) Guarded Code Status: Full code

Allergies: No known allergies

Admit to Unit: Yes

Activity Level: Activities as tolerated

Diet: Regular

IVF (if ordered, include type and rate): N/A

Critical Drips (If ordered, include type and rate. Do not defer to ICU Protocol): None

Respiratory: 02 2liters PRN as needed

Medications: (include ALL, tx of primary condition, underlying conditions, pain, comfort needs etc. dose and route)

1. Planiquel 200 to 400 mg (155 to 310 mg base) daily, administered as a single daily dose or in two divided doses. Doses above 400 mg a day are not recommended
2. Omega-3 fatty acids 1 capsule by mouth
3. Prednisone 15mg po daily
4. Lasix 40mg IV twice daily 5Tylenol650mg po Q6hrs PRN fever
5. Morphine 2mg iv q4hrs PRN pain

Nursing Orders: Insert peripheral IV, Vital signs per unit protocol; report any abnormal values

Follow up Lab tests: CBC, CMP, UA, Erythrocyte sedimentation rate, Kidney and liver assessment, Urinalysis Antinuclear antibody (ANA) test

Diagnostic testing: Chest X-ray. Echocardiogram

Consults: Rheumatologist Dermatologist and Cardiologist consult

Patient Education and Health Promotion(address age appropriate patient education if applicable): Diagnosis Teaching:

• Lupus is a systemic autoimmune disease that occurs when your body's immune system attacks your own tissues and organs. Inflammation caused by lupus can affect many different body systems — including your joints, skin, kidneys, blood cells, brain, heart and lungs.
• Lupus can be difficult to diagnose because its signs and symptoms often mimic those of other ailments. Tedeschi et al (n.d) said the most distinctive sign of lupus a facial rash that resembles the wings of a butterfly unfolding across both cheeks occurs in many but not all cases of lupus. Some people are born with a tendency toward developing lupus, which may be triggered by infections, certain drugs or even sunlight. While there's no cure for lupus, treatments can help control symptoms.
• Teachings about the signs and symptoms of lupus that you experience will depend on which body systems are affected by the disease.de Jong,van Staa,& Cohen Tervaert(2017) states the most common signs  and symptoms include: Fatigue Fever Joint pain, stiffness and swelling Butterfly-shaped rash on the face that covers the cheeks and bridge of the nose or rashes elsewhere on the body. Skin lesions that appear or worsen with sun exposure (photosensitivity) Fingers and toes that turn white or blue when exposed to cold or during stressful periods (Raynaud's phenomenon) Shortness of breath Chest pain Dry eyes Headaches, confusion and memory loss.
• To accurately diagnose, Systemic lupus is difficult because signs and symptoms vary considerably from person to person. Signs and symptoms of lupus may vary over time and overlap with those of many other disorders. No one test can diagnose lupus. Akalanka Wijetunga, et al (2017)states the combination of blood and urine tests, signs and symptoms, and physical examination findings leads to the diagnosis,. This may include Complete blood count, Erythrocyte sedimentation rate, Kidney and liver assessment, Urinalysis Antinuclear antibody(ANA) test. Chest X-ray. Echocardiogram and biopsy
• Treatment for lupus depends on your signs and symptoms. Pascoe et al (2017) emphasize determining whether your signs and symptoms should be treated and what medications to use requires a careful discussion of the benefits and risks and as your signs and symptoms flare and subside, there may be need to change medications or dosages such as non-steroidal anti-inflammatory drugs (NSAIDs). Hydroxychloroquine (Plaquenil) methylprednisolone, Imuran and Rituximab but medication compliance is the key to resolution of flare ups
• Treatment facts include. keep your physician doctor appointment regularly .Be sun smart avoiding body exposure to sun Use protection cream during exposure ,Get regular exercise, avoid smoking .Eat a healthy diet. Immunizations should be up to date And take your medications as prescribed

Discharge planningand required follow-up care: Discharge home. Follow-up in 2 weeks,for blood work and CT scan or MRIrepeat in 6 weeks after surgery

References (minimum of 3, timely, that prove this plan follows current standard of care).

Akalanka Wijetunga, W. M. U., Satarasinghe, R. L., Dayananda, B. M., Darshani, G. K., &Wijetunga, W. M. U.

A. (2017). Unusual acute lupus hemophagocytic syndrome - a test of diagnostic criteria: a case report. Journalof Medical Case Reports, 11, 1–7. https://doi.org/10.1186/s13256-017-1339-7

de Jong, H. J. I., van Staa, T. P., &Cohen Tervaert, J. W. (2019).Statins in systemiclupus erythematosus. Annals of the Rheumatic Diseases, 78(5), 1–2. Retrieved from http://search.ebscohost.com/login.aspx? direct=true&db=ccm&AN=135888539&site=ehost-live

Pascoe, K., Lobosco, S., Bell, D., Hoskin, B., Chang, D. J., Pobiner,B., & Ramachandran, S. (2017). Patient-and Physician-reported Satisfaction with Systemic Lupus Erythematosus Treatment in US Clinical Practice. Clinical Therapeutics, 39(9), 1811–1826. https://doi.org/10.1016/j.clinthera.2017.07.039

Tedeschi SK, Johnson SR, Boumpas DT, et al. Multicriteria decision analysis process to develop new classification criteria for systemic lupus erythematosus. Annals of the Rheumatic Diseases. 2019; 78(5):634- 640. doi: 10.1136/annrheumdis-2018-214685

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