0CUES

DIAGNOSIS

Subjective:
“namumula
ang mukha
ko” as
verbalized by
the patient.

Disturbed
body image
related to
presence of
rash,
lesions,
alopecia
and loss of
strength

Objective:
Butterfly
rash on face
Loss of hair
(alopecia)
Vital signs
BP: 110/80
PR: 87
RR: 18
Temp: 36.8

BACKGROUN
D
KNOWLEDGE
SLE is a
chronic multisystem
disease
involving
connective
tissue that
appears to
result from
production of
autoantibodie
s. Immune
complexes
and other
immune
system
constituents
combine to
form
complement
that is
deposited in
organs,
causing
inflammation
and tissue
necrosis. The
disease may

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

After giving
nursing
interventions,
the patient’s
rash will be
minimized and
prevented.

To improve
general health
and help
prevent
infection

To cover
significant
areas of
alopecia

After giving
nursing
interventions,
the patient’s
rash was
minimized and
prevented.

To prevent oral
ulcer

To reduce
emotional
stress that may
cause fatigue

To reduce the
chance of
exacerbation

Use of some
drugs for Tx of
SLE can cause
sterility


Encourage good
nutrition, sleep
habits, exercise,
rest and
relaxation
technique.
Suggest
alternative
hairstyles or
wearing of
scarves or wigs.
Encourage good
oral hygiene
Teach the pt.
relaxation
techniques such
as deep
breathing,
progressive
muscle
relaxation and
imagery.
Avoid direct
exposure to
sunlight and
courage use of
sunscreen and
wear protective

renal failure. The disease is more common on women than men. clothing  Advice to avoid pregnancy during the time of the disease Collaborative:  Administer analgesics as prescribed  Enhance pain relief . Course of the disease is highly variable but complications of SLE include infection. but can affect children age 5-15. and death. usually women at childbearing age. especially in early course of the disease.be mistaken for rheumatoid arthritis. permanent neurologic impairment.

Determines the extent or involvement of .  Note poor hygiene and health practices. discharges. Note skin colour. To evaluate actual or potential impairment in circulation. as well as pt’s desire and ability to protect self and potential recurrence of tissue damage. texture and turgor and     Serves as baseline and will suggest treatment options. red scaly patches on the skin(referred to as discoid lupus). mouth. Early detection for early prevention. Some may exhibit thick. nasal. This could have an impact to tissue help.8 BACKGROUN D KNOWLEDGE Sufferers of SLE experience dermatologic al symptoms. Alopecia (hair loss). Then encourage to improve them.  Assess blood supply and sensation on affected area by checking the site for redness. temp and doing sensory tests. skin rash and or alopecia Objective: Butterfly rash on face Loss of hair (alopecia) Vital signs BP: 110/80 PR: 87 RR: 18 Temp: 36. Impaired skin integrity related to photosensit ivity.  Identify underlying pathology of tissue injury  After giving the nursing interventions the patient’s skin rash and lesions is minimized. from classic malar rash (butterfly rash) associated with the disease. urinary tract and vaginal ulcers and lesions on the skin are other OBJECTIVES INTERVENTIONS RATIONALE EVALUATION After giving the nursing interventions the patients’ skin rash and lesions will lessen or minimize.CUES DIAGNOSIS Subjective: “namumula ang mukha ko” as verbalized by the patient.

Reposition client Involving client in reasons for and decisions about times and positions.     Better circulation Enhance understanding and cooperation To provide a positive nitrogen . maximize energy availability for healing and meet comfort needs Minimize condition and promote healing.       assess areas of pigmentation of colour changes Inspect skin on daily basis.possible manifestation s. Maintain appropriate moisture environment for particular wound. describing wound lesions and rashes characteristics observed Encourage adequate periods of rest and sleep. Provide optimum nutrition and increased protein intake injury  Promotes timely intervention and revision of plan of care  To limit metabolic demands. Tiny tears in the delicate tissue around the eyes can occur after even minimal rubbing.

complications This can affect the skin damage and may affect its healing process. Emphasize importance of adequate nutritional and adequate fluid intake  Assist client in understanding and following medical regimen and developing program of preventive care  Discuss importance of health as well as measures in maintaining proper skin functioning  Instruct client on need to limit exposure to direct sunlight and use of sunscreen and skin products Collaborative:  Administer medications as prescribed by the balance to aid in skin and tissue healing and to maintain a general good health  To maintain general good health and skin turgor  For changes indicative of healing or presence of infection.   Enhance comfort and healing  To be aware of .

  Check for functional level of mobility.8 BACKGROUN D KNOWLEDGE SLE is a chronic multisystem disease involving connective tissue that appears to result from production of autoantibodie s. Assess for occupational or physical therapy consultations: a. ROM of . Vital signs BP: 110/80 PR: 87 RR: 18 Temp: 36. Impaired Physical Mobility related to decreased range of motion. Monitor all medications given. Immune complexes and other immune system constituents combine to form complement that is deposited in physician. Objective:. guides the design of best possible management plan. muscle weakness. CUES DIAGNOSIS Subjective:. minsan naninigas din to” as verbalized by the pt.  Restricted movement influences the capacity to perform most activities of daily living  Therapeutic exercises and assistive equipment may improve mobility. pain when moving. Encourage verbalization regarding limitation in mobility Evaluate patient’s ability to perform Activities of Daily Living efficiently and safely on a daily basis. After nursing interventions the patient maintained optimal functional mobility. medication the client is taking for possible interactions . OBJECTIVES INTERVENTIONS RATIONALE EVALUATION After nursing interventions the patient would be able to maintain optimal functional mobility   Understanding the particular level. limited physical endurance “dahil sa sakit ng kasukasuan ko hinsi ako makagalaw.

 Monitor nutritional needs as they relate to     Identifying barriers to mobility (e. Testing by a physical therapist may be needed.  Assess input and output record and nutritional pattern. Use of assistive ambulatory devices Assess for impediments to mobility  Assess the strength to perform ROM to all joints. Good nutrition . renal failure. Pressure ulcers build up more rapidly in patients with a nutritional insufficiency. usually  affected joints b. Course of the disease is highly variable but complications of SLE include infection. The disease may be mistaken for rheumatoid arthritis.. especially in early course of the disease. chronic arthritis versus stroke versus pain) guides design of an optimal treatment plan. The disease is more common on women than men. and death. permanent neurologic impairment. This assessment provides data on extent of any physical problems and guides therapy.organs .g. causing inflammation and tissue necrosis.

immobility.  also gives required energy for participating in an exercise or rehabilitative activities. Examines development or recession of complications.women at childbearing age. transfer bars. . and other assistance can enhance activity and lessen the danger of falls. but can affect children age 5-15. Assess presence or degree of exercise-related pain and changes in joint mobility. canes. Blockages such as throw rugs. children’s toys.    Evaluate the need for assistive devices.   Assess the safety of the environment. May require delaying augmenting exercises and holding until further healing occurs. Correct utilization of wheelchairs.

.   and pets can further control and limit one’s ability to ambulate harmlessly.  Assess the emotional response to the disability or limitation. physical therapy.  Consider the need for home assistance (e. Assess the patient’s or caregiver understands of immobility and its implications. Acceptance of temporary or more permanent limitations can vary broadly between individuals. visiting nurse). Obtaining suitable support or help for the patient can ensure a safe and proper progression of activity The risk for effects of immobility such . Each person has his or her personal interpretation of acceptable quality of life.  .g.

thrombophlebit is. redness. signs of constipation).   as muscle weakness. Homan’s sign. and depression are also to be considered in patients with temporary immobility. Note elimination status (e. Routine inspection of the skin (especially over bony prominences) will allow for prevention or early recognition and . shoulders. calf pain.g. skin breakdown.g. present patterns. sacrum. hips. usual pattern. pneumonia. a rise in temperature). ankles. and toes). Check for skin integrity for signs of redness and tissue ischemia (especially over ears.   Note for progressing thrombophlebitis (e. localized swelling. elbows. heels... Prolonged bed rest or immobility allows clot formation. constipation.

Immune complexes and other immune system treatment of pressure ulcers. CUES DIAGNOSIS Subjective: Acute and chronic pain related to inflammati on and increase disease activity. Massage. relaxation and thermal modalities After nursing interventions the patient showed improvement in comfort level and will incorporated pain mgt. position changes. exercise. Relaxation techniques. OBJECTIVES INTERVENTIONS RATIONALE EVALUATION After nursing interventions the patient will show improvement in comfort level and will incorporate pain mgt. Immobility promotes constipation. fatigue and lowered tolerance level “ang sakit ng kasukasuan ko. diversional activities. techniques in daily life 1. Objective: Vital signs BP: 110/80 PR: 87 BACKGROUN D KNOWLEDGE SLE is a chronic multisystem disease involving connective tissue that appears to result from production of autoantibodie s. Foam mattress. minsan masakit din ang ibang parte ng katawan ko” as verbelized by the pt. 1. decreasing the motility of the gastrointestinal tract. Pain may respond to nonpharmacologic interventions such as joint protection. techniques in daily life . rest c. Application of hot or cold b. tissue damage. supportive pillow. Provide variety of comfort measure a. splints d.

The individual’s description of pain is more reliable indicator that objective measurements . permanent neurologic impairment. 3.8 constituents combine to form complement that is deposited in organs . especially in early course of the disease. Encourage verbalization of feelings about pain and chronicity of disease. Knowledge of the disease and appropriate treatment may help patient avoid unsafe. causing inflammation and tissue necrosis. The disease may be mistaken for rheumatoid arthritis. The impact of pain on an individual’s life often leads to misconceptions about pin and pain management techniques 5. ineffective therapies 4. Course of the disease is highly variable but complications of SLE include infection. Assess for subjective changes in pain 2. Teach pathophysiology of pain and the disease itself and assist patient to recognize that pain often leads to unproven treatment methods.RR: 18 Temp: 36. 2. Assist in identification of pain that leads to use of unproven methods of treatment 5. Verbalization promotes coping 3. 4. renal failure.

usually women at childbearing age. body movement and facial expressions. Pain responds to individual or combination medication regimens 7. Administer antiinflammatory. Previous pain experiences and mgt. but can affect children age 5-15. 6. analgesic as prescribed. 7.and death. strategies may be different from those needed for persistent pain. Individualize medication schedule to meet patient’s need for pain management. The disease is more common on women than men. such as change in vital signs. 6. .