Ruby Mae L.

Aguaviva N32

1. Acute Pain

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain Short term: 1. Assess the patient’s 1. To know the severe of Short term:
“started feeling related to joint Within 8 hours of pain description. the pain. Joint After 8 hours of
stiffness and or peripheral nursing intervention stiffness related to nursing intervention
pain in her nerve the patient will able (SLE) may not be the patient was able
joints” inflammation as to report pain and related to activity or to report pain and
evidences by stiffness at level overuse, it is instead a stiffness at level less
Objective: patient report less than 3 to 4 on a response to immune than 3 to 4 on a grade
 Grimace face of pain. grade of 0 to 1O. complexes of 0 to 1O.
 Guarding the proliferating and
hand Long term: setting up an Long term:
 Pain- Within 5 days of inflammatory response After 5 days of
associated nursing Intervention in that particular body nursing Intervention
sounds. the patient will able part. the patient was able
 Warmth to implement a pain 2. Usual signs of to implement a pain
 Swell management plan 2. Assess for the signs of inflammation may not management plan that
that includes joint inflammation be present with this includes
pharmacological and (warmth, redness, and disease. pharmacological and
nonpharmacological swelling) or decreased nonpharmacological
measures. motion. measures.
3. Pain management is
3. Assess previous directed at the
measures used to resolution of Goal met
alleviate pain. discomfort as it is
presenting at that
specific moment in
time, because relief
measures may change
with the affected
 joints.
4. Using some Crutches,
4. Encourage the patient walkers, and canes can
the use of ambulation be used to absorb some
aids when pain is of the weight from the
related to weight- inflamed extremity.
bearing. 5. These measures may
5. Encourage the use of augment other
nonpharmacological medications used to
measures such as diminish pain.
relaxation, distraction,
or guided imagery to
control pain. 6. Keep the pressure of
6. Instruct the patient to bed covers off the
apply a bed cradle. inflamed lower
extremities.
7. The sooner the
7. Administer Deltasone stiffness will abate.
(Prednisone), 20 mg Anti-inflammatory
per orem, once a day drugs should not be
and Plaguenil, 400 mg taken on an empty
once a day per orem as stomach.
prescribed by the
physician. Explain the
need for taking the
medication a day as
early in the morning as
possible with small
snack
8. Warmth reduces
8. Encourage the client to
stiffness and relieves
take a 15-minute warm
pain. Water should be
shower or bath on
warm. Excessive heat
arising.
 may promote skin
breakdown.
9. Collaboration with
9. Consult an occupational Specialty expertise
therapist for the may be recommended.
proper splinting of
affected joints
10. Encourage the client to 10. Splints provide rest to
wear splints as inflamed joints and
ordered. may
reduce muscle spasm.
2. Fatigue

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Fatigue related Short term: 1. Assess the client’s 1. This information may be Short term:
“Started feeling to disease Within 12 hours of description of helpful in developing After 12 hours of
usually tired and condition as nursing intervention fatigue: timing and organizing patterns nursing intervention
I take naps at evidence by the patient will able (Afternoon or all day), of activity that the patient was able
work but still weakness, lack to report reduction relationship to optimize the times to report reduction
wake up feeling of energy, and of fatigue as evidence activities, and when the client has the of fatigue as
fatigued” Inability to by able to perform aggravating and greatest energy evidence by able to
restore energy desired activities. alleviating factors. reserve perform desired
Objective: even after 2. Environmental stimuli activities.
 Weakness sleep Long term: 2. Instruct the client to can inhibit relaxation,
 Lack of Within 5 days of avoid stimulating interrupt sleep, and Long term:
energy nursing intervention foods (caffeine) or contribute to fatigue. After 5 days of
 Unable to the patient will able activities before 3. Warm water relaxes nursing intervention
maintain to demonstrate the bedtime. the muscle, facilitating the patient was able
usual level of use of energy- total body relaxation; to demonstrate the
physical conservation 3. Encourage a warm excessive heat may use of energy-
activity principles bath or washers promote skin conservation
immediately before breakdown. principles.
bedtime. 4. Good body alignment
will result in muscle
relaxation and comfort. Goal met

5. Maximize the muscle-

4. Encourage the client
relaxing benefits of the
to sleep in an
warm shower or bath.
anatomically correct
6. Repositioning promotes
position and not to
comfort.
prop up affected
joints
5. Encourage gentle
range-of-motion 7.  These devices can
 (ROM) exercises support movement and
(after a shower or activity, resulting in the
bath). conservation of energy.
6. Encourage the client 8. To help the client
to frequently change conserve energy and
position at night. reduce fatigue.
7. Teach the patient the 9. The client often needs
proper use of more energy than
assistive and adaptive others to complete the
devices same tasks. The client
often needs more
energy than others to
8. Organizing activities complete the same
for activities and tasks.
environment 10. Energy reserves may be
9. Encourage Pacing of depleted unless the
activities (an client respects the
alternating activity body’s need for
with rest) increased rest.

10. Encourage the patient

have Adequate rest
periods
3. Impaired skin integrity

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired skin Short term: 1. Assess the skin for 1. Small lesions may Short term:
“my rashes were integrity related to Within 6 hours integrity. develop on the oral After 6 hours
showing into my skin exacerbation of nursing intervention and nasal mucous nursing intervention
after the weekend disease. the patient will able membranes. Dislike the patient was
vacation at the to verbalize ability lesions that appear able to verbalize
beach” to cope with hair as a ability to cope with
loss dense maculopapular hair loss
Objective: rash may occur on
 Butterfly shape Long term: the client’s face or Long term:
rash on face Within 25 days of chest. After 25 days of
 Redness nursing intervention 2. Clients may respond nursing intervention
 Alopecia the patient will able 2. Assess for violently to the patient was
to maintain optimal photosensitivity. ultraviolet light or to able to maintain
skin integrity, as sunlight. Disease optimal skin
evidences by an flares or outbreaks integrity, as
absence of rashes of severe rash may evidences by an
and skin lesions occur in response to absence of rashes
exposure. and skin lesions.
3. These measures
promote healthy skin Goal met
3. Instruct the client
and healing in the
to clean, dry, and
presence of wounds.
moisturize intact
skin; use warm (not
hot) water,
especially over bony
prominences; use
unscented lotion.
Use a mild shampoo.
4. Encourage adequate 4. Scented lotions may
nutrition and contain alcohol, which
hydration. dries the skin.
Prescribed solutions
reduce dryness of
the scalp and
maintain skin
integrity.
5. Scalp hair loss may
5. Instruct the client
be the first sign of
that scalp hair loss
impending disease
occurs during
exacerbation. Scalp
exacerbation of
hair loss may not be
disease activity.
permanent. As
disease activity
subsides, scalp hair
begins to regrow.
6. Hair will regrow as
6. Instruct the client the dose decreases.
that scalp hair loss
may be caused by
high-dose
corticosteroids
(prednisone) and
immunosuppressant
drugs.
7. Encourage the 7. Hair loss may
patient to interfere with
investigate ways lifestyle and self-
(e.g., scarves, hats, image.
wigs) to conceal hair
loss.
8. Wear protective 8. The sun can
eyewear. Wear a
wide-brimmed hat
and carry an
umbrella. Wear
maximum protection
sunscreen (SPF 15
or above) in the sun.
9. Administer the 9. This antimalarial
hydroxychloroquine
(Plaguenil) 400 mg,
once a day per orem
as prescribed by the
physician.
10. Such devices aid in
10. Recommended
prophylactic
pressure-relieving
devices (e.g., special
mattress, elbow
pads).
exacerbate a skin
rash or precipitate a
disease flare. Special
lotions, glasses, and
other items may be
required to protect
the skin from
sunlight exposure
drug is a slow-acting
medicine used to
relieve or reduce
inflammation and
rash. It may take 8
to 12 weeks for
effect. The client
must follow up with
an ophthalmologist
every 6 months.
Topical cortisone
medication may
likewise be used.
the prevention of
skin breakdown.