Powerpoint of Henoch Schonlein Purpura

PATIENT’S PROFILE

PATIENT ASSESSMENT

I. Patient profileName: “FIONA”Age: 17 years oldAddress: Lubi - lubi East Guinarona Dagami, LeyteOccupation: StudentDate and time admitted: March 04, 2010 @ 3:10 pmAttending Physician: Dr. Mary Antonette PicorroChief Complaint: Purpuric rash and feverDiagnosis: Henoch – Schonlein PurpuraDate of interview: March 07, 2010 @ 3:15 pmSource of Information: patientReliability: 90 – 95 %

II. Health HistoryPRESENT ILLNESS

2 weeks PTA, patient experienced unproductive cough with whitish mucous secretion accompanied with itching sensation of the throat due to changes in weather, relieved by herbal plant such as lagundi and home remedies such as increase fluid intake and lemonade.

1 week PTA, patient noted a palpable rash at lower extremities (both legs) assumed to have appeared after a mosquito bite. Thereafter, she noted the rashes to be increasing in number and now reaching the buttocks and back of trunk. No other associated signs and symptoms noted. She decided to go to a quack doctor in their barangay and was given an ointment (name unable to recall) for the rashes.

2 days PTA, after consulting with the quack doctor her condition showed no signs of progress. Still with rashes developed fever relieved by self medications of paracetamol 500mf tablet but still did not consult a physician

1 day PTA, fever persisted accompanied with body malaise which prompted her to consult at EVRMC and was advised to be admitted for further examination.

PAST ILLNESS

Received complete immunization. Has not yet experienced childhood illnesses such as measles, mumps, and chicken pox. Has already experienced common illnesses such as cough and colds, and fever. Paracetamol 500mg given for fever, herbal (lagundi), increase fluid intake, and lemonade as home remedies for cough and colds.Revealed no history of previous hospitalization nor injury experienced.No allergies to foods and drugs noted.

FAMILY HISTORY

Revealed history of DM on paternal side but denied heredo familial disease on maternal side.

GYNECOLOGIC HISTORY

She had her menarche when she was in her second year high school but cannot recall the exact date. Usually lasts for one week with heavy menstrual flow of dark red blood with clots consuming 2 to 3 sanitary pads a day fully soaked especially on first and second day. Occasionally experience dysmenorrhea and headache with no relief measures taken at home. 

PSYCHOSOCIAL HISTORY

A non smoker occasionally drinks for at least 2 – 3 glasses of alcoholic beverages (tuba and beer) per session with friends and classmate. When facing stressful situation she usually share it with her grandmother and follows her advise.Spend her leisure time at videoke at their neighbor and watching TV at her favourite shows (wowowee and primetime drama). 

III. Reaction and Expectations

She was a little uncomfortable and could not sleep well because of her condition. She expect to receive quality care in order for her to be well and recover soon.

PATTERNS OF FUNCTIONING

PRE – CLINICAL INSPECTION

CLINICAL INSPECTION OTHER SOURCES

1.Respiratory -has history of unproductive cough herbal meds. (lagundi)

increased fluid intake and lemonade serves as remedy

- no history of PTB and difficulty in breathing- no history of asthma

- a non smoker

- RR: 24 cpm- no cough and colds

- with normal breath sounds

X-ray:Impression:

Normal radiographic breath sounds

2.Circulatory -no history of hypertension- no history of dizziness, palpitation and chest pain

- BP: 100/70 mmHg- PR: 82 bpm

- presence of edema (non-pitting) and discolored part

( on both legs)- good capillary refill (less

than 2 seconds)- no cyanosis

- no pallor

-X-ray:Impression:Heart is not enlarge-with an IVF OF D5LR regulated @ 30 gtts/minute-on I & O monitoring

Patterns of functioning

result Normal values significanceHgb 127.0 g/l 120 - 160 NormalHct 0.41 % 0.36 – 0.47 Normal

erythrocytes 4.89mil/ul 4.2 – 5.4 mil/ul Normal

leukocytes 9.30mil/ul 4.5 – 10.0 mil/ul Normal

granulocytes 0.81 % 0.500 – 0.750 IncreaseInfection

lymphocytes 0.16 % 0.200 – 0.350 DecreaseImmune problem

monocytes 0.03 % 0.020 – 0.060 Normal

Platelet count: 651 mil/ul 150 - 450 Increase:May indicate

polycythemia or malignancy

MCH 26.00 pg 27 – 31 Decrease may indicatemicrocytic cells,possible for IDA

MCHC 311 g/l 320 - 360 Derease may indicate IDA or hemoglobinopathy

Hematology

Creatinine 49.0 umol/L 53-97 Low (possible renal

diseases )TP (total CHON) 72.0 g/L 66-87 Normal

Albumin 44.1 g/L 40-55 Normal

Globulin 27.9 g/L 17-33 Normal

Na 132.4 mmol/L 135-148 Low (myxedema)

K 3.8 mmol/L Normal

Cl 102.2 mmol/L Normal

3.Food and fluid intake -usual food taken are rice, fish, and

vegetables-eat 3x a day

-no food allergies-No food preferences

-consumed 8 – 9 glasses of water per

day-occasionally drinks

alcoholic beverages for at least 2 – 3 glasses

-skin is deep brown with palpable Purpuric rashes,

warm to touch, moist, good skin turgor

-nails convex in shape-pinkish conjunctiva, moist

-no dentures-good appetite (eat 3x a

day)-food taken are rice, fish,

vegetables, fruits, and bread

-consumed 5 – 6 glasses of water a day

-no NGT-presence of abdominal

pain with PS: 7

-with IVF of D5LR regulated at 30 gtts per

minute-patient is on I & O

-on DAT

4.Elimination -voids 3 – 4x a day with yellowish to pale urine approximately 1 ½ - 2

glasses (as estimated by patient)

-defecates every other day with yellow to brown stool

-seldomly experienced diarrhea, take diatabs as a

relief measure-seldomly experienced

constipation, relieved by increase fluid intake

-Voids 2 – 3x a day with yellow urine

approximately 1-1/2 glass (as estimated by

the patient)-defecates every other

day with yellow to green stool-no diarrhea

-no constipation

URINALYSIS:Macroscopic:Color: yellow

Transparency: turbidSpecific gravity: 0.36

pH: 5.0glucose: (-)

albumin: (+)Microscopic:

Pus cells: 10 – 20RBC: many

Bacteria: manyCreatinine: 49.0

5.Regulatory mechanism -experienced fever associated with chills takes paracetamol 500mg serves

as relief measure

-Temp: 38.4®C-febrile

-skin is deep brown, moist and warm to touch

-has palpable Purpuric rashes (reddish to brown) @ left extremities, back of trunk and buttocks area

6.Hygiene -takes a bath once a day-uses shampoo everyday-brushes teeth 3x a day

-changes clothes once a day-no allergies to soap and

shampoo

-general appearance is unkept-presence of palpable rashes

At the lower extremities, back of trunks, and buttocks

-head is normocephalic, no lesions, no palpable masses

-hair is black, equally distributed, presence of dandruff, no pediculosis-nails are long and dirty

-with halitosis-Did not take a bath since

admission- change clothes ones a day- brushes teeth ones a day

7.Exercise and locomotion -she consider walking household chores as

her exercise

-stays lying on bed-limited movements

from due to joint pain (such as walking)-decreased muscle

strength-neck:

No swelling, no enlargement of thyroid

glands, no palpable masses

8.Rest and sleep -usually sleeps 8 – 9 hours

-sleeping time is 9pm or 10pm and awakens

6am or 7am-does not take daytime

naps-favorite sleeping

position is side lying-uses 8 pillows

-no bedtime rituals

-yawning-presence of eye bags in

both eyes-number of hours sleep

is 4 – 5 hours-take daytime naps for

30 minutes-has difficulty of sleeping due to

pruritus- Uses one pillow

9.Communication and special senses

-right handed-no eyeglasses

-no hearing aid use-no history of visual and auditory disturbances

- no speech disturbances

-speaks in waray - waray

EYE:Eyelashes equally

distributed, whitish sclera, moist lacrimation,

pinkish and moist conjunctiva, presence of

eye bagsEARS:

Pinna is in line with outer cantus of the eye, no

lesions, no external canal discharges, no ear ache

NOSE:-no discharges - no epistaxis

10.Sensory -no history of convulsion

-no history of loss of consciousness

-no history of epilepsy

-conscious and oriented to time place, and

person

11.Pain and discomfort -does not take any medicine for pain if not

severe (such as mild headache) only applies VAPORAB or ointment

-has abdominal cramping pain (PS: 6)

-has joint pain at shoulder, knees, and ankle (PS: 7) usually

relieved by rest-skin: pruritus

-has facial grimace upon movement

12.Reaction or diversion -fond of singing videoke and watching TV

-resting and sleeping

-talking with her mother and father

13.Religious life -goes to church occasionally-prays rosary sometimes

-no religious medal worn

14.Coping mechanism -usually shares her problems to her

grandmother-whenever she is

frightened she just sleep

-feeling of discomfort and slightly irritable

(due to joint pains and pruritus)

15.Social occupations -do the household chores most of the

time-she wants to see

her father

-Stays in her bed-seldomly talks to her room mates

DRUG GENERAL ACTION

SPECEFIC ACTION

INDICATION CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILITI

ES

sulbactam + ampicillin

750 mg IVTT q8h

antibiotic Bactericidal action against

sensitive organisms;

inhibits synthesis of bacterial cell wall causing

cell death

-treatment of infections cause by

susceptible starins of shigella,

salmonella, S. Typhosa,

E.coli-skin and skin

structure infections

-with allergies to penicillins

And cephalospori

ns-use

cautiously with renal disorders

CNS: seizures

CV: heart failure

GI: sore mouth,

abdominal pain, nausea and vomiting,

diarrheaGU:

NEPHRITISHematology:

anemiaHypersensitivity: rash and

feverLocal: pain,

phlebitis

Observe 10 Rs

-assess history of

hypersensitivity and renal

disorder-assess

culture of infected area,

skin color, lesion, CBC, Hematocrit, urinalysis

DRUG GENERAL ACTION

SPECIFIC ACTION

INDICATIONS CONTRAINDICATIONS

ADVERSE REACTION

NURSING RESPONSIBILITI

ES

Paracetamol 300g IVTT

q4h

antipyretics Inhibits the synthesis of

prostaglandins that may serve as

mediators of pain and

fever

Mild painFever

Hypersensitivity- use cautiously in patient with hepatic disease

GI: hepatic failure,

hepatoxicityGV: renal

failureDerm: rash,

urticaria

- assess overall health

status- assess type, location and intensity of

pain- assess fever,

note presence of associated

signs (diaphoresis,tachycardia,m

alaise)

DRUG GENERAL ACTION

SPECIFIC ACTION

INDICATIONS CONTRAINDICATIONS

ADVERSE REACTION

NURSING RESPONSIBIL

ITIES

D5LR @ 30 gtts/min

Solution for intravenous

infusion and for replacement

and maintenance of

fluid therapy

- provides calories and

maintenance of fluid

- Fluid replacement and caloric

supplementation in patient who can’t maintain

adequate balance intake and who are

restricted from doing so.

- contraindicated

with patient with delirium

tremens use of solutions

contraindicated in patient with intracranial, intraspinal

hemorrhage

Endo: inappropriate

insulin secretion (long-term

F & E: hypokalemia, hyphostamia,

hyposmagnesia, fluid overload,Local: pain and irritation at IV

siteCNS: confusionCV: heart failure

with fluid overload

insusceptible patient

GU: glycosuria, osmoticdiuresis

Respi: pulmonary edema

Skin: sloughing and tissue necrosis

- assess hydration status

of the patient receiving IV

dextrose- Monitor I & O

-assess nutritional

status- Monitor IV site

frequently for phlebitis and

infection- Check vital

signs frequently report adverse

reaction promptly

- watch closely for signs and symptoms of fluid overload

HEMATOLOGYTEST RESULT NORMAL VALUES SIGNIFICANCE

Hgb 127.0 g/l 120 - 160 Normal

Hct 0.41 % 0.36 – 0.47 Normal

erythrocytes 4.89mil/ul 4.2 – 5.4 mil/ul Normal

leukocytes 9.30mil/ul 4.5 – 10.0 mil/ul Normal

granulocytes 0.81 % 0.500 – 0.750 IncreaseInfection

lymphocytes 0.16 % 0.200 – 0.350 DecreaseImmune problem

monocytes 0.03 % 0.020 – 0.060 Normal

Platelet count: 651 mil/ul 150 - 450 Increase:May indicate

polycythemia or malignancy

MCH 26.00 pg 27 – 31 Decrease may indicatemicrocytic

cells,possible for IDA

MCHC 311 g/l 320 - 360 Derease may indicate IDA or

hemoglobinopathy

URINALYSIS

Color Yellow normal

Transparency Turbid

Specific gravity 0.036 (1.005 – 1.030) decrease in chronic renal insufficiency

diabetes insipidus

PH 5.0 Decrease (acidic)

Glucose (-)

Albumin (+) Indicate microalbuminuria

Pus cells 10 – 20 May indicate UTI

RBC Many Increased may reflect tumor stones, trauma glomerular disorders,

cystitis

Epithelial cells Few

Bacteria Many Determine presence of UTI

Creatinine 49.0 umol/L 53-97 Low (possible renal diseases )

TP (total CHON) 72.0 g/L 66-87 Normal

Albumin 44.1 g/L 40-55 Normal

Globulin 27.9 g/L 17-33 Normal

Na 132.4 mmol/L 135-148 Low (myxedema)

K 3.8 mmol/L Normal

Cl 102.2 mmol/L Normal

NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

Impaired tissue integrity related to increase vascular permeability secondary to bacterial infection

SUBJECTIVE:“may mga makatol ngan nanbubutol ngadi hit akun mga paa ngan pablikbalik an akun hiranat” as verbalized by the patientOBJECTIVE:-palpable Purpuric rashes- lower extremities edematous (especially feet) -febrile-warm to touch and moist skin

Vital signsBP: 100/70 mmHgPR: 82 bpmRR: 24 cpmTemp: 38.4 ®CPS: 7

There is tissue deposition of IgA containing immune complexes especially within the small vessels. The abnormal response of the immune system is unclear why it occurs, but it seems to represents an unusual reaction of the body’s immune system that is response to infection (either bacterial or virus). Small vessels called capillaries in the skin are affected due to increase vascular permeability resulting to skin rash which is most prominent over the buttocks and behind the lower extremities.

After 8 hours of nurse patient intervention the patient will be able to:-Prevent/ minimize occurrence of complications- maintain normal range of temperature - demonstrate tissue regeneration

NURSING INTERVENTIONS RATIONALE EVALUATIONIndependent - Monitor vital signs note for elevated temperature and increase RR- Assist patient for TSB- Encourage increase intake of fluids- Emphasize good hand washing technique for all individual coming in contact with client- instruct SO to prevent skin to skin surface contact - instruct SO to provide freshly laundered bed linens.- keep skin free from pressure- elevate lower extremities if possible/appropriate -avoidance of lotions or soap that may irritable the skin

Dependent - sulbactam + ampicillin 750 mg IVTT q8h-paracetamol 300 mg IVTT q4h PRNCollaborative-Refer to nutritional support team

- provide baseline data changes usually precedes fever and alteration of Lab studies -helps lower elevated temp.-water therapy helps fight infection-reduces occurrence of complications (such as dermatitis)-prevent adherence to surface and encourages proper healing-promotes circulation and tissue regeneration -reduces swelling and promotes circulation-irritation may affect the underlying tissue which can alter in tissue regeneration.

- treatment for skin and skin structure infectious- for elevated temperature-Useful in establishing individualized nutritional needs & identifying appropriate routes

After 8 hours of nurse patient intervention the patient was able to:- maintain normal range of temperature with the help of TSB and paracetamol PRN as evidenced by body temp. of 37®C Goal met - prevent occurrence of complications as evidenced by absence of signs and manifestations of any complication such as (dermatitis) therefore goal met- partially demonstrate tissue regeneration due to lack of medicineTherefore goal partially met

NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

Impaired physical mobility related to joint paintsSubjective: “diri gud aku nakakakiwa ngan nakakalakat hin maupay kay masakit iton akun tiil pati iton akun kamot” As verbalized by the patientObjective: -limited ROM -decreased muscle strength -intolerance to activity and exercise -facial grimace -fatigue -with the following vital signs: BP:100/70 mmHg PR:82 bpm RR:24 CPM Temp:38.4®C NPS:7

In response to triggering event, the antigen stimulus activates monocytes and the lymphocytes. IgA form immune complexes with antigens. The immune complexes build up and are redeposited in synovial tissue triggering the inflammatory reactions (joint effusion, pain, and edema) that can ultimately damage the involved tissue. When damage occurs injured cells release chemical mediators such as bradykinin, serotonin, and prostaglandin that affect the exposed nerve endings of nociceptors (pain receptors) SOURCE: Medical surgical nursing by brunner and suddarts Volume 2 Page: 1887-1888

After 8 hrs of nurse – patient interaction and series of nsg. interventions patient will be able to:Verbalized reduce number of pain scale from 7 to 4

Maintain or increase strength and function of affected or compensatory body part through active or passive ROM exercises

Maintain bodily function (particularly extremities) with absence or limitation of contractures

Prevent occurrence of prolonged bed rest complications such as bed sores and pneumonia

Perform ADL’s within level of own ability with safety

NURSING INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT:1.Monitor vital signs2.Monitor degree of joint pain (using pain scale) 3.Assist with passive and active ROM and resistive exercises4.Encourage self care activities (eg. Changing clothes)5.Encourage deep breathing exercises6.Encourage client to maintain upright and erect posture when sitting, standing, and walking7.Maintain bed rest or chair rest when indicated8.Instruct SO to reposition patient frequently9.Instruct SO to position client with pillowsCOLLABORATIVE:1.Consult the physician or the occupational therapist and vocational specialist

-provide baseline data, changes on V/S (esp. Temp and RR) occur if there is pain-provides baseline data on the level of activity can patient tolerate-maintains and improve joint function, muscle strength and general stamina-strengthen shoulders and arms muscle needed for walking-promotes blood circulation especially to affected part-maximize joint function and maintain mobility-reduces fatigue and improves strength-relieves pressure on tissues and promotes circulation. And also prevents shearing abrasions of skin-promotes joint stability and maintain proper joint position and body alignment, minimizing contractures-useful in creating apprehensive individualized activity or exercise program

After 8 hrs of nurse – patient interaction and series of nsg. interventions patient was able to:Verbalized reduce of pain scale from 7 to 6 as evidenced by absence of facial grimace therefore goal partially metIncrease strength and function of affected area as evidenced by participating and increase tolerance in exercises such as walking, therefore goals metMaintain bodily function as evidenced by absence of contractures during performance of ADL’s (e.g toileting) therefore goal metPrevent occurrence of complications (bed sores and pneumonia) . As evidenced by absence of bed sore and pneumonia. Therefore goal met.Perform ADL’s within level of own ability as evidenced by tooth brushing and changing clothes without any assistance therefore goal met

NURSING DIAGNOSIS SCIENTIFIC ANALYSIS OBJECTIVES

Sleep pattern disturbances related to pruritus and discomfort secondary to disease processSUBJECTIVE: “danay dira aku nahingangaturog dara hit kakatol” As verbalized by the patientOBJECTIVES:-presence of eye bags-irritability-yawning-weakness-fatigue-with the following vital signs: BP:100/70 mmHg PR:82 bpm RR:24 cpm Temp:38.4 ®C

Pruritus and hyper irritability are related to

large amounts of histamine in the skin. This occurs in

response to immediate immunologic response

between specific antigen and antibody. The

interaction of foreign antigen which specific

antibodies causes subsequent release of histamine and other

mediators.

Med0-surg. Smeltzer et. AlVol.2 pp 1970-1865

After 8hrs of nurse patient interaction the patient will be able

to:-minimize pruritus and discomfort-Obtain adequate sleep as evidence

by :-No eye bags

-Minimize fatigue

NURSING INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT:

1. monitor vital signs

(Note for any changes beyond normal range)

2. promote quiet and peaceful environment by limiting visitor (especially during resting time)3.promote diversional activities

4. assist patient to assume comfortable position for rest or sleep

5.instruct patient to drink milk as indicated

6. advised wearing cotton next to the skin rather than synthetic materials

-provide baseline data(inadequate sleep may

affect vital signs)-reduces discomfort and irritation and promotes

adequate rest-distract client attention instead

of focusing to itching-helps hastens the feeling of

being sleepy

-helps acquire good sleep

-synthetic materials can trigger itching

After 8 hours of nurse patient interaction the patient was able to:Minimize discomfort and pruritus as evidenced by absence of scratching therefore goal metObtain adequate sleep as evidenced by 7 – 8 hours of sleep and absence

of eye bags therefore goal met

PATHOPHYSIOLOGY

Etiology: UNKNOWNBut may be due to unusual reaction of the body’s immune system in

response to this infection(Due to previous infection of the throat or breathing passages)

Immune response  

Antigen – antibody binding

 Formation of immune complexes

IMMUNE COMPLEX 

In small vessels(particularly in

capillaries )

In glomerulus

In intestinal epithelial

cells

Redeposited in synovial tissue

Increased vascular

permeability

Ultimately damage the

involved tissue

Irritation

Increased production of epithelial cells lining of the glomerulus

• Urticaria• Flushing•Pruritus

Results to skin rashes (palpable Purpuric rashes)

Results in• joint effusions•Joint pain and

edema

Thickening of glomerular filtration

membrane

Tissue damage and inflammation of stomach and

small intestines

Increased peristalsis

Scarring and loss of glomerular filtration

membranes

Bleeding and ulceration

Increased hyperactive bowel

sounds

Decreased GFR

Diarrhea

Decreased absorption

• Nausea and vomiting•fever•abdominal pain

GLOMERULAR NEPHRITIS