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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 patients
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 patients
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

be mistaken
for
rheumatoid
arthritis,
especially in
early course
of the
disease.
Course of the
disease is
highly
variable but
complications
of SLE include
infection,
renal failure,
permanent
neurologic
impairment,
and death.
The disease is
more
common on
women than
men, usually
women at
childbearing
age, but can
affect
children age
5-15.

clothing
Advice to avoid
pregnancy
during the time
of the disease
Collaborative:
Administer
analgesics as
prescribed

Enhance pain
relief

CUES

DIAGNOSIS

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

Impaired
skin
integrity
related to
photosensit
ivity, skin
rash and or
alopecia

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

BACKGROUN
D
KNOWLEDGE
Sufferers of
SLE
experience
dermatologic
al symptoms;
from classic
malar rash
(butterfly
rash)
associated
with the
disease.
Some may
exhibit thick,
red scaly
patches on
the
skin(referred
to as discoid
lupus).
Alopecia (hair
loss), mouth,
nasal, 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.

Identify
underlying
pathology of
tissue injury

After giving the


nursing
interventions the
patients skin
rash and lesions
is minimized.

Note poor
hygiene and
health practices.
Then encourage
to improve them.

Assess blood
supply and
sensation on
affected area by
checking the site
for redness,
discharges, temp
and doing
sensory tests.
Note skin colour,
texture and
turgor and

Serves as
baseline and
will suggest
treatment
options, as well
as pts desire
and ability to
protect self and
potential
recurrence of
tissue damage.
This could have
an impact to
tissue help.
Early detection
for early
prevention.
To evaluate
actual or
potential
impairment in
circulation.

Determines the
extent or
involvement of

possible
manifestation
s. Tiny tears
in the delicate
tissue around
the eyes can
occur after
even minimal
rubbing.

assess areas of
pigmentation of
colour changes
Inspect skin on
daily basis,
describing
wound lesions
and rashes
characteristics
observed
Encourage
adequate periods
of rest and sleep.

Maintain
appropriate
moisture
environment for
particular wound.
Reposition client
Involving client
in reasons for
and decisions
about times and
positions.
Provide optimum
nutrition and
increased protein
intake

injury

Promotes
timely
intervention
and revision of
plan of care

To limit
metabolic
demands,
maximize
energy
availability for
healing and
meet comfort
needs
Minimize
condition and
promote
healing.

Better
circulation
Enhance
understanding
and
cooperation
To provide a
positive
nitrogen

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,
complications
This can affect
the skin
damage and
may affect its
healing
process.

Enhance
comfort and
healing

To be aware of

CUES

DIAGNOSIS

Subjective:;

Impaired
Physical
Mobility
related to
decreased
range of
motion,
muscle
weakness,
pain when
moving,
limited
physical
endurance

dahil sa
sakit ng
kasukasuan
ko hinsi ako
makagalaw,
minsan
naninigas din
to as
verbalized by
the pt.

Objective:;
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

physician.
Monitor all
medications
given.

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, guides
the design of
best possible
management
plan.

After nursing
interventions the
patient
maintained
optimal
functional
mobility.

Restricted
movement
influences the
capacity to
perform most
activities of
daily living

Therapeutic
exercises and
assistive
equipment may
improve
mobility.

Check for
functional level
of mobility.
Encourage
verbalization
regarding
limitation in
mobility
Evaluate
patients ability
to perform
Activities of Daily
Living efficiently
and safely on a
daily basis.
Assess for
occupational or
physical therapy
consultations:
a. ROM of

organs ,
causing
inflammation
and tissue
necrosis. The
disease may
be mistaken
for
rheumatoid
arthritis,
especially in
early course
of the
disease.
Course of the
disease is
highly
variable but
complications
of SLE include
infection,
renal failure,
permanent
neurologic
impairment,
and death.
The disease is
more
common on
women than
men, usually

affected joints
b. Use of
assistive
ambulatory
devices
Assess for
impediments to
mobility

Assess the
strength to
perform ROM to
all joints.

Assess input and


output record
and nutritional
pattern.

Monitor
nutritional needs
as they relate to

Identifying
barriers to
mobility (e.g.,
chronic arthritis
versus stroke
versus pain)
guides design
of an optimal
treatment plan.
This
assessment
provides data
on extent of
any physical
problems and
guides therapy.
Testing by a
physical
therapist may
be needed.
Pressure ulcers
build up more
rapidly in
patients with a
nutritional
insufficiency.
Good nutrition

women at
childbearing
age, but can
affect
children age
5-15.

immobility.

Evaluate the
need for
assistive devices.

Assess presence
or degree of
exercise-related
pain and
changes in joint
mobility.

Assess the safety


of the
environment.

also gives
required
energy for
participating in
an exercise or
rehabilitative
activities.
Correct
utilization of
wheelchairs,
canes, transfer
bars, and other
assistance can
enhance
activity and
lessen the
danger of falls.
Examines
development or
recession of
complications.
May require
delaying
augmenting
exercises and
holding until
further healing
occurs.
Blockages such
as throw rugs,
childrens toys,

Assess the
emotional
response to the
disability or
limitation.

Consider the
need for home
assistance (e.g.,
physical therapy,
visiting nurse).
Assess the
patients or
caregiver
understands of
immobility and
its implications.

and pets can


further control
and limit ones
ability to
ambulate
harmlessly.
Acceptance of
temporary or
more
permanent
limitations can
vary broadly
between
individuals.
Each person
has his or her
personal
interpretation
of acceptable
quality of life.
Obtaining
suitable
support or help
for the patient
can ensure a
safe and proper
progression of
activity
The risk for
effects of
immobility such

Note for
progressing
thrombophlebitis
(e.g., calf pain,
Homans sign,
redness,
localized
swelling, a rise in
temperature).
Check for skin
integrity for
signs of redness
and tissue
ischemia
(especially over
ears, shoulders,
elbows, sacrum,
hips, heels,
ankles, and
toes).
Note elimination
status (e.g.,
usual pattern,
present patterns,
signs of
constipation).

as muscle
weakness, skin
breakdown,
pneumonia,
constipation,
thrombophlebit
is, and
depression are
also to be
considered in
patients with
temporary
immobility.
Prolonged bed
rest or
immobility
allows clot
formation.

Routine
inspection of
the skin
(especially over
bony
prominences)
will allow for
prevention or
early
recognition and

CUES

DIAGNOSIS

Subjective:

Acute and
chronic
pain
related to
inflammati
on and
increase
disease
activity,
tissue
damage,
fatigue and
lowered
tolerance
level

ang sakit ng
kasukasuan
ko, minsan
masakit din
ang ibang
parte ng
katawan ko
as verbelized
by the pt.
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. Immune
complexes
and other
immune
system

treatment of
pressure ulcers.
Immobility
promotes
constipation,
decreasing the
motility of the
gastrointestinal
tract.

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

After nursing
interventions
the patient will
show
improvement in
comfort level
and will
incorporate pain
mgt. techniques
in daily life

1. Provide variety
of comfort
measure
a. Application
of hot or cold
b. Massage,
position
changes, rest
c. Foam
mattress,
supportive
pillow,
splints
d. Relaxation
techniques,
diversional
activities.

1. Pain may
respond to nonpharmacologic
interventions
such as joint
protection,
exercise,
relaxation and
thermal
modalities

After nursing
interventions the
patient showed
improvement in
comfort level and
will incorporated
pain mgt.
techniques in
daily life

RR: 18
Temp: 36.8

constituents
combine to
form
complement
that is
deposited in
organs ,
causing
inflammation
and tissue
necrosis. The
disease may
be mistaken
for
rheumatoid
arthritis,
especially in
early course
of the
disease.
Course of the
disease is
highly
variable but
complications
of SLE include
infection,
renal failure,
permanent
neurologic
impairment,

2. Encourage
verbalization of
feelings about
pain and
chronicity of
disease.
3. Teach
pathophysiology
of pain and the
disease itself
and assist
patient to
recognize that
pain often leads
to unproven
treatment
methods.
4. Assist in
identification of
pain that leads
to use of
unproven
methods of
treatment
5. Assess for
subjective
changes in pain

2. Verbalization
promotes
coping

3. Knowledge of
the disease and
appropriate
treatment may
help patient
avoid unsafe,
ineffective
therapies
4. The impact of
pain on an
individuals life
often leads to
misconceptions
about pin and
pain
management
techniques
5. The individuals
description of
pain is more
reliable
indicator that
objective
measurements

and death.
The disease is
more
common on
women than
men, usually
women at
childbearing
age, but can
affect
children age
5-15.

6. Administer antiinflammatory,
analgesic as
prescribed.

7. Individualize
medication
schedule to
meet patients
need for pain
management.

such as change
in vital signs,
body
movement and
facial
expressions.
6. Pain responds
to individual or
combination
medication
regimens
7. Previous pain
experiences
and mgt.
strategies may
be different
from those
needed for
persistent pain.