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NCP: Patient with Systemic Lupus Erythematosus

Fatigue : related to chronic inflammation and altered immunity as evidenced by lack of energy, inability to
Nursing diagnosis maintain usual routine
1. Uses energy conservation techniques
Patient goals 2. Sets and completes priority activities
3. Adapts lifestyle to energy level
Intervention (NIC) Outcome (NOC)
Energy Management Energy conservation
 Assist patient in assigning priority to activities to  Uses energy conservation techniques ..........
accommodate energy levels.  Balances activity and rest .....
 Assist patient to schedule rest periods to  Organizes activities to conserve energy.......
temporarily reverse effect of fatigue.  Adapts lifestyle to energy level.......
 Teach activity organization and time-management
techniques to prevent fatigue. Measurement scale
 Encourage alternate rest and activity periods to 1= never demonstrated
promote recuperation and to foster maximum 2= rarely demonstrated
participation in activities. 3= sometimes demonstrated
 Instruct patient/significant other to recognize signs 4= often demonstrated
and symptoms of fatigue that require reduction in 5= consistently demonstrated
activity.
 Instruct patient/caregiver to notify health care
provider if signs and symptoms of fatigue persist
to increase patients support and familys
understanding of disease and related problems.

NCP: Systemic Lupus Erythematosus

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Acute pain : related to inflammatory process and inadequate comfort measures as evidenced by complaints of
Nursing diagnosis joint pain, ineffective pain management from current measures, reduction of activity to avoid exacerbating pain

Patient goal uses analgesics and nonpharmacologic measures appropriately to manage pain at an acceptable level.
Intervention (NIC) Outcome (NOC)
Pain Management Pain control
 Perform a comprehensive assessment of pain to include  Uses nonanalgesic relief measures ..........
location, characteristics, onset/duration, frequency,  Uses analgesics as recommended .....
quality, intensity or severity of pain, and precipitating  Reports uncontrolled symptoms to health care
factors to plan appropriate interventions. professional.......
 Ensure that patient receives attentive analgesic care to  Reports pain controlled.......
relieve pain.
 Teach use of nonpharmacologic techniques (e.g., Measurement scale
relaxation, guided imagery, distraction, and hot/cold 1= never demonstrated
application) before pain occurs or increases, and along 2= rarely demonstrated
with other pain relief measures, to replace or 3= sometimes demonstrated
supplement analgesics. 4= often demonstrated
5= consistently demonstrated

NCP: Systemic Lupus Erythematosus

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Impaired skin integrity related to photosensitivity, skin rash, and alopecia as evidenced by rash anywhere on
Nursing diagnosis body, butterfly rash on face, hair loss, areas of ulceration on fingertips, complaints of urticarial and
photosensitivity.
1. Maintain skin integrity with the use of topical treatment
Patient goals 2. Prevents exacerbations with the use of sunscreens and limited sun exposure
Intervention (NIC) Outcome (NOC)
Energy Management Tissue integrity: Skin and Mucous Membranes
 Inspect skin of patients at risk of breakdown daily.  Abnormal pigmentation ..........
 Document degree of skin breakdown to plan  Skill lesions .....
appropriate interventions.  Mucous membrane lesions.......
 Apply topical anti-inflammatory agent to affected area  Erythema .......
to control skin manifestations.
Measurement scale
Teaching: Disease Process 1= severe
 Discuss lifestyle changes that may be required to 2= substantial
prevent future complications and/or control disease 3= moderate
process (e.g., use of sunscreens and sun protective 4= mild
clothing when outdoors) as sun exacerbates 5= none
manifestations.
 Instruct the patient on measures to control/minimize
symptoms that are affecting the skin.

NCP: Systemic Lupus Erythematosus

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Deficient knowledge related to lack of exposure to and unfamiliarity with information resources as evidenced
Nursing diagnosis by questions about SLE, misinterpretation of information, and lack of adherence to treatment instructions
1. Describes the disease process and the rationale for prescribed treatment
Patient goals 2. Expresses confidence in ability to recognize complications and use precautions to prevent their occurrence
Intervention (NIC) Outcome (NOC)
Teaching: Disease Process Knowledge: Disease Process
 Describe disease process.  Specific disease process ..........
 Discuss therapy/treatment options to increase  Effects of disease .....
probability of successful long-term management.  Measures to minimize disease progression .......
 Provide family/caregiver with information about  Signs and symptoms of complications .......
patients progress to provide support during
exacerbation and increase their sense of involvement. Measurement scale
 Instruct patient on which signs and symptoms to report 1= no knowledge
to health care provider (e.g., fever, edema, decreased 2= limited knowledge
urine output, chest pain, and dyspnea) to ensure early 3= moderate knowledge
intervention. 4= substantial knowledge
 Refer patient to local community agencies/support 5= extensive knowledge
groups (e.g., Lupus Foundation, Arthritis Foundation)
to provide additional sources of information and
support.

NCP: Systemic Lupus Erythematosus