Question

Mrs. O. just returned from the hospital after being diagnosed with Systemic Lupus. In the hospital, she was on IV steroids. She is now on a lower dose of oral prednisone. She was in the hospital for one week as she is also a Type 1 Diabetic (since age 12). The autoimmune disorder caused her blood glucose levels to become erratic requiring stabilization of her usually controllable insulin dosage. While she had not been feeling well her doctor was not quite sure what was wrong. Her symptoms were fatigue, aching joints, and GI upsets. It was not until the de-stabilization of her diabetes and face rash that the doctor decided to have her admitted. At the same time, Mrs. O. informed the doctor that she thought she might be pregnant as she and her husband were wanting to have their first baby. They had married two years ago and have been trying for the past year. Mrs. O. is a manager for a large manufacturing firm and works 60-70 hours a week usually coming home tired from the stress of her job. Her husband is in sales and travels. Mrs. O. has a large extended family and is very close with her mother and five sisters and two brothers. She is the youngest and has always been "taken care of" by her family. You meet Mrs. O. on your first home visit and the first thing she wants to talk with you about is her new baby. She is pregnant and her family and husband are delighted. She is happy but very worried about the pregnancy and is trying not to think about this new disease.

In this Laboratory assignment you will be focusing on the following: Case management - Develop an initial assessment as the first step to a case management plan. What issues will need to be considered to manage this case? What resources might she need for her complex medical issues? Consider what other health care personnel will be important resources. How will her medical expenses be paid?

Communication - Focus on engagement. Identify the dynamics of her family support system. How will they help/challenge her care? Also in what ways will you assist her with her concerns and worries?

Teaching Needs - Focus on medications, medication interaction, the new diagnosis and what she needs to know, the impact of the Systemic Lupus on Diabetes, and a potentially high-risk pregnancy. Also, how will her job and stress impact her conditions and pregnancy? How will you assist in helping her achieve her "level" of wellness?

Answer 1

1.Initial assessment - Anxious about fetus condition due to presence of diseases -systemic lupus erythematous and diabetes as evidenced by her expression and speech.

# The issues to be managed and considered are :-

- systemic lupus erythematous sign and symptoms and their complications.

- diabetes sign and symptoms and it's complications.

- anxiety related to her baby's condition.

- No one is there at home other than her working husband to take care of her. Need for assistance.

- Financial support and emotional support .

# The resources she might be needed for her complex medical issues and the health care personals are:-

- a physician home visit for assessment of diseases condition and baby's status.

-a home nurse to provide basic care and management of disease condition and for prenatan care.

- a dietician visit to help her to have a proper nutritious and balanced diet that should be taken in view of her pregnancy and disease condition.

- support groups

- home laboratory facilities so that she does not have to go out to do laboratory investigation.

- Emergency care consultant and their number so that in case of emergency she can be contacted and actions can be taken at time.

- medical insurance plan for the effective use of resources without any delay due financial problems.

# Her medical expenses will be paid by the health insurance company . The disease come under Health insurance policy and also pregnancy advantages will be provided to the patient.

2. The patient's family is worried about their daughter and baby's condition due to presence of other diseases. As the patient is alone in the home they must be encouraged to live with their daughter to ensure proper care Both the family and patient must be provided emotional support. Encourage them to express their feelings and queries regarding the disease condition .Teach them the utilisation of defence mechanism or coping mechanisms to deal with the anxiety , providing essential information about how to take care of the patient and making her self sufficient and independent.

3. Teaching needs are :-

> teaching about diabetes ,how to check blood glucose ,how to administer insulin ( rotation of inject sites to prevent lipid dystrophy) what are the complications like hyperglycemia ,oral hypoglycemic agents should not be given in pregnancy because they're are teratogenic. About the healthy diet and lifestyle modification to be made like exercise,cessation of alcohol and smoking and over the counter medicines.

> teaching about systemic lupus erythematous -how to take care of arthritis pain ,what analgesic to be used in pregnancy ,how to take the corticosteroid therapy , teaching about the interaction like corticosteroid cause rise in blood sugar,edema etc. How to prevent infections because SLE is a auto immune disease it makes the individual immunocompromised .

> about pregnancy -she must be taught about the increased calorie requirements,the complications related to SLE and diabetes , about the health care check ups and investigation , the signs of labour induction and danger signs so that she can reach the hospital at time , teaching her how to prepare the kit of equipments which will be needed during pregnancy and after delivery, teaching her to maintain compliance to medications like folic acid and iron tablets to avoid neural tube defects and to take medication of diabetes and SLE to avoid complications.

# Providing education about stress and job ,that these factors cause build up of internal conflicts and cause increased stress which is bad and have a negative effect on the pregnant patient Undue stress causes the SLE to become adverse and shoot up of the blood sugar levels which are harmful for the fetus. Advise patient and family to have a break from job and avoid stressful situations for the proper care and development of the newborn and mother.

# To achieve her level of wellness ,the nurse must assistance in :-

- providing basic care

- educating about the disease condition and medications to be taken , their reactions and how to maintain complaince and how to manage complications.

- health education regarding lifestyle modification ,drug use and diet.

- providing emotional support and educating about the usage of coping mechanisms and teaching about relaxation methods to relieve stress.

- providing her and her baby comfort

- early identification of complications and it's management

- assisting her on delivery

- educating her about breastfeeding techniques and newborn care.