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Assessment

Subjective: “Dili nako malihok akong mga paa kay nanghupong” as verbalized by the patient.

Objective:

Edema on Feet noted Weakness on the affected area

Nursing Diagnosis • Impaired Physical Mobility related to edematous symptoms secondary to Lupus disease process

Planning • After 6 hours of nursing interventions, patient will be able to: maintain/increase strength and function of affected body parts, demonstrate prevention of further development of edema.

Nursing Interventions and Rationale
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Determine functional ability and reasons for impairment. Identifies need for/degree of intervention required. Noted emotional/behavioral responses to altered ability. Physical changes and loss of independence often create feeling of anger. Planned activities/visits with adequate rest periods as necessary. Prevents fatigue; conserves energy for continued participation. Encourage participation in self-care/recreational activities. Promotes independence and self-esteem; may enhance willingness to participate. Encouraged use of hand rails in hallway, stairwells, and bathroom. Promotes independence in mobility; reduces risk of falls. Elevate legs during rest period. Promotes relaxation and proper circulation Provide warm compress. Minimized edema on feet.

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patient will be able to establish/maintain normal patterns of bowel functioning. BP: 130/100 mmHg. o o o o .Evaluation • Goal Met as evidenced by patient able to maintain/increase strength and function of affected body parts. To obtain baseline data Monitored Vital Signs and InO. May contribute to diarrhea Assessed for consistency. Objective: At least 8 loose liquid stools Hyperactive bowel sounds noted Watery stools noted Poor skin turgor noted VS: T: 36. Nursing Diagnosis • Diarrhea related to adverse reaction of medications Planning • After a day of nursing interventions. Assessed reasons for problems. amount. demonstrates prevention of further development of edema. Identification/treatment of underlying medical condition is necessary to achieve optimal bowel function Determine presence of food/drug sensitivities. color and odor of stool. To know if the patient is at risk for Dehydration. ruled out medical causes. Identifies need/for degree of intervention required. Assessment • • Subjective: “Gikalibanga ko sukod ganihang buntag”. Nursing Interventions with Rationale o Monitored for signs and symptoms of Fluid and electrolyte imbalance. as verbalized by the patient. PR: 72. RR: 22.

and along with outher pain relief measures. o • Evaluation Goal Met as evidenced by patient able to establish maintain normal patterns of bowel functioning and shows no signs of electrolyte imbalance. Avoid stimulation of watery stools. before pain occurs or increases. The use of non-invasive pain measure can increase the o o o . after and if possible. To replace the Fluid and electrolyte lost. Objective: Restlessness noted (+) Grimace face noted Irritability noted. Nursing Interventions with Rationale o Determine/document presence of possible pathophysiological causes of pain. Encouraged to eat Low fiber diet. Pain is a subjective experience and must be described in order to plan effective treatment Encourage adequate rest periods.o Encouraged to Increase Oral Fluid Intake with Gatorade for fluid and electrolyte replacements. Pain scale of 6 out of 10 • Nursing Diagnosis • Alteration of Comfort related to joint pain secondary to disease process. during painful activities. To maximize level of functioning. Planning • At the end of 8hour span of care patient will be able to: demonstrate to relaxation of skills and diversional activities for individual situation. Teach the use of non-pharmacologic techniques before. Assessment • Subjective: “Dili ko koportable kay wala ko kasabot sa sakit sa akong joints” as verbalized by the patient. To prevent fatigue Discuss impact of pain on lifestyle/independence and ways.

patient will verbalize/identify the preventive measures for infection. Provide optimal pain relief with prescribed analgesics as ordered. Encouraged to use good hand washing and personal Hygiene techniques. To help preserve immune system. Nursing Interventions • • Assessed current medications particularly those that promote susceptibility to infection such as corticosteroids and immunosuppressive. Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction. Encouraged to eat a Balanced diet with adequate calories. demonstrate use of relaxation of skills and diversional activities for individual situation. o Create a quiet. Assessment • • Subjective: “Nagabalik-balik akong sip-on” Objective: Immunosuppressive therapy Nursing Diagnosis • Risk For Infection related to disease process Planning • After 8 hours span of nursing care. Instructed to report signs and symptoms of infection and reinforce the importance of reporting them to the physician. Analgesics help in pain relief. o Evaluation • Goal Met as evidenced by patient will be able to: report decrease inpain from 6 to 3. Early detection provides early treatment and prevents further complication. • • . non disruptive environment with dim lights and comfortable temperature when possible.release of endorphins and enhance the therapeutic effects of pain relief medications. Promote infection control.

Checked patient’s current immunization status. Immunization can minimize the possibility of having infection.• Instructed to minimize exposure to crowds and people with infections/contagious illness. • Evaluation • Goal Met as evidenced by patient able to verbalize and identify preventive measures fir infections. Avoid being infected with people having contagious disease. Patients with SLE are immunosupressed. .