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

o Determine functional ability and reasons for impairment. Identifies need

for/degree of intervention required.

o Noted emotional/behavioral responses to altered ability. Physical changes and

loss of independence often create feeling of anger.

o Planned activities/visits with adequate rest periods as necessary. Prevents

fatigue; conserves energy for continued participation.

o Encourage participation in self-care/recreational activities. Promotes

independence and self-esteem; may enhance willingness to participate.

o Encouraged use of hand rails in hallway, stairwells, and bathroom. Promotes

independence in mobility; reduces risk of falls.

o Elevate legs during rest period. Promotes relaxation and proper circulation

o Provide warm compress. Minimized edema on feet.

Evaluation

• Goal Met as evidenced by patient able to maintain/increase strength and function of

affected body parts, demonstrates prevention of further development of edema.

Assessment

• Subjective: “Gikalibanga ko sukod ganihang buntag”, as verbalized by the patient.

• Objective: At least 8 loose liquid stools

Hyperactive bowel sounds noted

Watery stools noted

Poor skin turgor noted

VS: T: 36, PR: 72, RR: 22, BP: 130/100 mmHg.

Nursing Diagnosis

• Diarrhea related to adverse reaction of medications

Planning

• After a day of nursing interventions, patient will be able to establish/maintain normal

patterns of bowel functioning.

Nursing Interventions with Rationale

o Monitored for signs and symptoms of Fluid and electrolyte imbalance. Identifies
need/for degree of intervention required.

o Assessed reasons for problems; ruled out medical causes.

Identification/treatment of underlying medical condition is necessary to achieve
optimal bowel function

o Determine presence of food/drug sensitivities. May contribute to diarrhea

o Assessed for consistency, amount, color and odor of stool. To obtain baseline
data

o Monitored Vital Signs and InO. To know if the patient is at risk for Dehydration.
 o Encouraged to Increase Oral Fluid Intake with Gatorade for fluid and electrolyte
replacements. To replace the Fluid and electrolyte lost.

o Encouraged to eat Low fiber diet. Avoid stimulation of watery stools.

• Evaluation

Goal Met as evidenced by patient able to establish maintain normal patterns of bowel
functioning and shows no signs of electrolyte imbalance.

Assessment

• Subjective: “Dili ko koportable kay wala ko kasabot sa sakit sa akong joints” as

verbalized by the patient.

• Objective: Restlessness noted

(+) Grimace face noted

Irritability noted.

Pain scale of 6 out of 10

Nursing Diagnosis

• Alteration of Comfort related to joint pain secondary to disease process.

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.

Nursing Interventions with Rationale

o Determine/document presence of possible pathophysiological causes of pain.

Pain is a subjective experience and must be described in order to plan effective
treatment

o Encourage adequate rest periods. To prevent fatigue

o Discuss impact of pain on lifestyle/independence and ways. To maximize level of

functioning.

o Teach the use of non-pharmacologic techniques before, after and if possible,

during painful activities; before pain occurs or increases; and along with outher
pain relief measures. The use of non-invasive pain measure can increase the
 release of endorphins and enhance the therapeutic effects of pain relief
medications.

o Create a quiet, non disruptive environment with dim lights and comfortable
temperature when possible. Comfort and a quiet atmosphere promote a relaxed
feeling and permit the client to focus on the relaxation technique rather than
external distraction.

o Provide optimal pain relief with prescribed analgesics as ordered. Analgesics

help in pain relief.

Evaluation

• Goal Met as evidenced by patient will be able to: report decrease inpain from 6 to 3,
demonstrate use of relaxation of skills and diversional activities for individual situation.

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, patient will verbalize/identify the preventive measures
for infection.

Nursing Interventions

• Assessed current medications particularly those that promote susceptibility to infection

such as corticosteroids and immunosuppressive.

• Encouraged to use good hand washing and personal Hygiene techniques. Promote
infection control.

• Instructed to report signs and symptoms of infection and reinforce the importance of
reporting them to the physician. Early detection provides early treatment and prevents
further complication.

• Encouraged to eat a Balanced diet with adequate calories. To help preserve immune
system.
 • Instructed to minimize exposure to crowds and people with infections/contagious illness.
Avoid being infected with people having contagious disease. Patients with SLE are
immunosupressed.

• Checked patient’s current immunization status. Immunization can minimize the

possibility of having infection.

Evaluation

• Goal Met as evidenced by patient able to verbalize and identify preventive measures fir
infections.