Lague, Inah Krizia O.
BSN 3D
Systemic lupus erythematosus (SLE)
Nursing Diagnosis Desired Outcome Interventions
Impaired tissue integrity After 48 hours of nurse-client Assessed blood
related to altered interaction the client will be supply and
circulation as evidence by able to: sensation on
oral mucous membrane Verbalize affected area by
ulcers, presence of understanding of checking the site
alopecia and malar rash on condition and for redness,
the face causative factors. discharges,
Demonstrate temperature and
progressive doing sensory
improvement in wound tests.
or lesion healing Rationale: to
through behavior and evaluate actual/or
lifestyle changes and potential
prevent complications impairment in
or recurrence circulation
Maintain optimal Identifed
nutrition and physical underlying
well-being condition or
Identify measure in pathology
preventing and involved in tissue
treatment regimens to injury
enhance healing Rationale: serves
as baseline data
and will suggests
treatment
options, as well
as client’s desire
and ability to
protect self, and
potential for
recurrence of
tissue damage
Noted skin color,
texture, and
turgor and
assess areas of
pigmentation of
color changes.
Rationale:
determines the
extent or
involvement of
injury
Inspected skin
on daily basis,
describing
wound lesions
and rashes
characteristics
observed
Rationale:
promotes timely
intervention and
revision of plan of
care
Maintained
appropriate
moisture
environment for
particular wound
Rationale: to
minimize
condition and
promote healing
Repositioned
client, involving
client in reasons
for and decisions
about times and
positions
Rationale: to
enhance
understanding
and cooperation
Encouraged
early ambulation
or mobilization
Rationale:
promotes
circulation and
reduces risk
associated with
immobility and
prevent
excessive tissue
pressure
Provided
optimum nutrition
and increased
protein intake
Rationale: to
provide a positive
nitrogen balance
to aid in skin and
tissue healing
and to maintain a
general good
health.
Assisted client in
understanding
and following
medical regimen
and developing
program of
preventive care
Rationale:
enhances
cooperation and
optimizing
outcomes
Discussed the
importance of
health as well as
measures to
maintain proper
skin functioning
Rationale: for
changes
indicative of
healing or
presence of
infection,
complications
Acute Glomerulonephritis
Nursing Diagnosis Desired Outcome Interventions
Acute pain related to After 1 hour of nursing Monitored vital signs
inflammation of the interventions, the patient Observed nonverbal
renal cortex as will be able to: pain behaviour
evidenced by Demonstrate Provided comfort
restlessness ,muscle nonpharmalogical measures, quiet
guarding and facial methods that environment and calm
grimace whenever the provide relief activities
location of pain is Improve Encouraged use of
touched secondary to restlessness relaxation techniques
acute Verbalize the such as focus ed
glomerulonephrtis. decrease of pain breathing and imaging
from 6 to 3 scale Reviewed procedures
and tell patent when
treatment may cause
pain.
Monitored urine
characteristics
Monitored intake and
output
Performed a
comprehensive
assessment of pain
such as location ,
onset,characteristics
and frequency
Reviewed patient’s
Previous experiences
with pain and methods
found either helpful or
unhelpful for pain
control in the past.
Administed analgesics
as ordered
