Proceso de atención de enfermería en paciente adulto con lupus eritematoso sistemico

Abstract

Systemic lupus erythematosus (SLE), is a chronic inflammatory rheumatological disease, characterized by the existence of multiple autoantibodies, some of them related to the typical characteristics of the disease; with the presence of lesions such as an erythema that is frequently located on the cheeks and nose with the shape of butterfly and systemic wings and that there are several bodies in the body that can be found to a greater degree in the skin, joints, mucous membranes, kidney, brain , heart, lung and infrequently the gastrointestinal tract. It affects more frequently women of childbearing age; its prevalence varies between 40 to 200 cases per 100,000 inhabitants. Its etiology is unknown, but if the existence of a multifactorial interaction is considered, where environmental, genetic and hormonal factors are involved. Within the clinical manifestations, the general symptoms such as fatigue, asthenia, anorexia, fever, and weight loss occur more frequently in patients with SLE, considered as initial symptoms of the disease or in other cases, as complications of the same, being fatigue the one that predominates in these cases, because it is a disabling symptom associated in turn with depressive episodes. The diagnosis will depend on the physical examination, autoimmunity studies, histopathological analysis and complementary examinations, in addition it must present at least four of the eleven classification criteria according to the American College of Rheumatology; the prognosis will depend on the clinical course of the disease. The aim of this study is to analyze Systemic Erythematosus Lupus to identify complications in the patient through the application of the Nursing Care Process, improving their quality of life. The clinical case is that of a 43-year-old female patient, who attended the Huaquillas Basic Hospital on 09/11/2017 due to generalized joint pain, more pain in the moderate-intensity urethral epigastrium, and more nausea associated with vomiting; the patient reports that she went to this health house approximately two weeks ago for presenting this clinical picture, discharging the same day, where the doctor prescribes medication that the patient does not remember; After 7 days, the picture reappears with dysuria accompanied by pain in the left lumbar region, edema in the face and lower extremities, asthenia, fatigue, reason for which the admission is decided, to the assessment; vital signs: TA: 97/63 mmHg; T °: 38.2°C; FR: 20X '; FC: 96 X '; SpO2: 100%; Physical examination: pale facies with presence of erythema, semi-hydrated oral mucous membranes, spontaneous rhythmic respirations tolerating room oxygen, with soft abdomen depressible with pain of moderate intensity on deep palpation, lower extremities with presence of edema +++ / +++ , decreased muscle tone and strength, blood count and upper and lower abdominal ultrasound with imaging results: Liver increased in echogenicity, Abundant gas in the abdomen. The next day, after assessment by a treating doctor, she is transferred to the Internal Medicine ward with a diagnosis of Systemic Lupus Erythematosus plus pyelonephritis, Electrocardiogram is performed, which is not evaluated by a specialist. The method that is applied is the analysis of the clinical history and scientific articles of relevant information. With the Comprehensive Analysis we identified the complications that can occur in the patient with Lupus; in the case of the patient, the Kidney was compromised due to atrophy; the Liver, which through ultrasound was identified increased echogenicity, and Skin by deterioration of the cutaneous integrity evidenced with the erythema. The risk factors related to the patient were gender, which in this case occurred in females, environmental factors due to being exposed to stress situations, previous infections, Exposure to ultraviolet rays, and a personal history of left atrophic kidney 9 years ago. In the case analyzed, the patient presented signs and symptoms characteristic of Systemic Lupus Erythematosus such as fatigue, erythema, joint pain, fever, and edema in the lower limbs. The nursing care plans were designed based on the clinic of the patient, applying the theory of Virginia Henderson, helping to improve the quality of life.