Second Careplan (not actual pt) Advice, tips, and guidance.

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I need some guidance on this.

Her primary diagnosis is SLE.

For the pathology of SLE I said: The etiology of SLE is associated with theproduction of autoantibodies; these antibodies rather than target pathogens,target the body's own tissues. This results in the formation of immunecomplexes which are the underlying cause of inflammation. The inflammation maylead to the dysfunction of organs.

My database asks for secondary diagnoses and the professor said sometimes we have to dig and figure out the 2nd diagnoses based on the pt info, our assessment, doctor orders, and lab values. Well as you can tell the paper says ...No secondary diagnosis available at this time.

When for example we know that we do not have the info ... like say we were given no Social History... we would put N/A ... so idk if I should put N/A even though the paper says no secondary diagnosis ... or go ahead and put something... argh ...

and if anything.... I would have to put depression? I'm not quite sure there is anything else physiologically wrong with her... the alopecia is a symptom of the 1st Dx and symptoms can't be 2nd/3rd/4th Dx.

As far as the problem list... I think she has the following (very general... not specific) problems:

emotional problems (due to the rashes and hair loss)

Skin problems (rashes)

Knowledge deficit (she's in the sun)

any opinions ... ? I just need some guidance.. a hot or cold.. a youre on the the right track or not. I liek figuring these things out... but I wanna make sure I ain't headin' for the end of a cliff.

Thanks...(=

Individual Care Plan #2(1).pdf

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Feeling of being over whelmed is common with auto-immune disorders. The med regimes are over whelming. Your life changes overnight. I am sure she is depressed.

They lose their identity their self esteem takes a hit. The meds cause side effects (prednisone). What pretty active woman wants to have a purple face and no hair. Of course she has a knowledge deficit or she is in denial she in newly diagnosed. She thinks her life is over....and essentially the life as she was living it will change. Is she coping well? Is she grieving for her old self? THey have chronic pain and paralyzing fatigue.....does she have family to help? Does she have a support system?

I have to run but I''ll be back! What do you think?

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Hi Esme12,

I think I posted to another careplan post you made as well. If you are making a nursing careplan for a patient with SLE, her primary dx would not be SLE. SLE is her medical dx. What are her symptoms? The 1st one would be the priority, so if it has anything to do with respiratory, or cardiac, that would be first. Disturbed Body image is also a dx and an important one if it is really bothering her. Do not assume and make up problems that are not really there. Many times, you will make a careplan and need to revise it after day 1 after seeing your patient and seeing what is really the issue. It is hard to really know what is going on when you havent even taken care of them yet. The 2nd day it will be crystal clear what the big priority problems are. Mobility, safety, many times are priority in general, risk for infection (prednisone), deficient knowledge could apply if she really needs a lot of teaching about it. Rashes could be impaired skin integrity or risk for impaired skin integrity if they are not open lesions. Rashes could also be contributing more to a disturbed body image though and less to skin integrity. If shes young and mobile I would say that body image is a bigger problem than skin integrity. Especially if she makes comments about it, which could be used in your aeb.

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Thank You Guys.

Well at my school the primary diagnosis, is the Dx the physician makes. The medical diagnosis. The 2nd diagnoses are not always bluntly stated and are left for us to solve... because my Prof says physicians don't always write out any secondary diagnoses? So we should be able to decipher based on orders, drugs, notes, labs... ect. We need to the 2nd Dx to better our patients treatment. no? =)

Sounds like the real issue here is her emotional state. The reading gives no insight about the rashes being open ... I imagine open areas are a big issue due to infection? I mean the rashes I'm sure could be resolved with ointments/medications and in turn we would believe that would solve the body image issue but... I guess fixing the issue at the root is better. and like Esme said, the meds have side effects.

Well, thanks again. (=

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Looking at the scenario provided I would say depression is a big Secondary diagnosis and the one that has caused her admission. The rashes with SLE sometimes never go away and are a hallmark of the disorder. The patients that have severe skin involvement have a ton of body image issues as they can't be covered with make-up and they just don't go away with a few creams/ointments/medications they are a part of the process itself.

The rashes are usually not open with SLE. There are some areas that are open like on the hands and at times and can be very puritic in nature. The avoidance of the sun is key and the meds taken for SLE accelerate the photosensitivity of the patients skin and patients must wear sunscreen indoors and avoid florescent light exposure.

The patient in the scenario life has changed and she isn't dealing well.

Tomorrow your life is forever changed. You can no longer go to school. You canot be a nurse. You are unemployed and canot ocupy yourself with yoru usual behaviors for maintaing a healthy lifestyle. You hae to take meds that make you gain weight, develop amoon face, supress your immune system Think about how you would feel. The sadness dispondency, the denial the anger, the grief. Are the coping mechanisms ineffective? Is she suffering from an interrupted family process? Is the patient grieving? Is her grieving complicated? Is the chick is just plain depressed. Does she feel a sense of hopelessness? Is low self esteem situational? All of this in response to the loss of her "beauty and health?

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