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CUES

+ fever + muscle atrophy + alopecia


+ fatigue; tiredness + arthritis; joint pains + rash; butterfly rash
F.M.T., 21 years old, + anorexia + muscle weakness + light/photosensitivity
T
female, systemic + weight loss + avascular necrosis + depression
+ pleuritis + pericarditis + painless mouth sores
lupus erythematosus
+ nephritis + leucopenia + mottled erythema
+ pulmonary hypertension + thrombocytopenia in the hands
+ restlessness + dyspnea, shallow breathing

NURSING DIAGNOSES
Impaired gas exchange related to increased pulmonary vascular resistance
Decreased cardiac output related to increased pulmonary vascular resistance
Activity intolerance related to imbalance oxygen supply and demand
Imbalanced nutrition: less than body requirements related to loss of appetite
Fatigue related to inadequate energy production
Acute pain related to joint/systemic inflammation
Impaired physical mobility related to joint pain
Impaired skin integrity related to chronic inflammation
Mild to Moderate anxiety related to change in health status
Disturbed body image related to altered body function
Powerlessness related to low self-efficacy

OUTCOME CRITERIA
Gas exchange:
Correct breathing exercises
Well-rested
Cardiac output:
Demonstrate an increase in activity tolerance
Relax and participate in activities that reduce workload of the heart
Nutrition:
Demonstrate progressive weight gain
Plan and implement a healthy balanced diet for age and energy and calorie needs
Fatigue:
Report improved sense of energy
Plan and perform ADLs at level of ability
Well-rested and adequate sleep
Pain and discomfort:
Report that pain is relieved/controlled
Follow prescribed pharmacologic regimen
Identify and demonstrate non-pharmacologic methods that provide relief such as distraction
through reading, watching television, listening to guided imagery audios, etc.
Mobility:
Plan and participateINTERVENTIONS
in ADLs and desired activities
Plan and participate in non-strenuous exercises (e.g. brisk walking)
Anxiety:
Verbalize awareness of feelings of anxiety
Report anxiety is reduced to a manageable level
Appear relaxed
Monitoring Teaching
Self-esteem and self-efficacy
Verbalize acceptance of disease condition and symptoms, and relief of anxiety
Ma. Elaine Carla A. Tating
BSN III – D
Vital Pain Daily Periods Readine Correct Distraction SLE facts, its Precaution The average The importance of
signs: TPR level in weight; of rest ss to pursed-lip through prevalence, to avoid daily intake exercise and how it
BP q1-2 a scale daily and open up breathing reading causes, risk staying based on helps with the
hours: of 0-10 food sleep: or exercises books or factors and out in the BMI; average normal functioning
note with 0 intake amount verbaliz and its magazines, management sun to caloric of the body through
depth, as no and of e purpose watching The disease avoid or intake; improving blood
rate, and pain and amount exercise feelings television, process and prevent nutrition circulation; the
rhythm of 10 as of s in of and guided the normal exacerbati deficiencies effects of strenuous
RR; note severe calories hours anxiety imagery as function of on of skin and food activities; the
rate, hourly; taken; q8h and low- non- the body that rashes preferences importance of sleep
rhythm and IO q4h self- pharmacol responds in and rest
and every 15 esteem ogic the form of
sounds of minutes daily; techniques inflammation
heart; for 1-2 in coping
note hours with pain
change in after
Improvement
sudden administ
of coping
increase ration of
with anxiety;
or anti-
decrease inflamm
in systole; atory
T every 15 drug:
minutes PQRS of
for 1 hour Pain:
after location
administra of pain
tion of
antipyretic

Ma. Elaine Carla A. Tating


BSN III – D
INTERVENTIONS

Medication

Non-steroidal anti- Corticosteroi Immunosuppressiv Anti-malarial


inflammatory drugs ds e drugs drugs

Ma. Elaine Carla A. Tating


BSN III – D