Vasculitis

Cues Nursing Diagnosis Background Desired Outcomes Nursing Intervention Rationale Evaluation
Knowledge
Subjective: -Chronic pain related Unpleasant sensory Patient will verbalize -Encourage -to evaluate coping -After 8 hours of
“Pirmi ako kikalintura. Pirmi to nerve infarction and emotional and demonstrate verbalization of abilities and to nursing intervention,
man nagakulog ang tabay ko“ characterized by experience arising relief and or control feelings about the identify areas of the patient was able
Pain scale: 7/10 shooting pains in the from actual or of pain or pain such as concern additional concern to verbalize
arms and legs and potential tissue discomfort. about tolerating acceptable level of
numbness. damage; sudden or pain, anxiety and pain as evidenced by
Objective: slow onset of any pessimistic thoughts pain scale: 3/10
-Difficulty to pinpoint pain intensity from mild
-Presence of purpura to severe constant
VS taken as follows: or recurring without
T: 39.1°c an anticipated or
P:110 bpm predictable end and
R:18 a duration of greater
BP: 120/80 mmHg than 6 months
Altered epidermis or
dermis

Hyperthermia Body temperature For the patient to Tepid Sponge Bath Nonpharmacologic At the end of the
related to elevated above demonstrate normal (TSB) performed. measures lower shift, after all the
medication as normal range body temperature body temperature nursing
Vital signs and promote interventions
evidenced by the and will not show
monitored every two rendered, the
increased body any associated comfort. Sponging
patient was able to
temperature of complications. hours reduces body
obtain a
39.1°c and the temperature by temperature of 38°c.
To maintain balance Encouraged patient
verbal complaint of increasing Patient experiences
of intake and output to drink plenty of
“Pirmi akong evaporation from normal fluid balance
within normal range water placed in a as evidenced by the
tigkakalintura” skin.
measured bottle. equal intake and
To obtain an output.
Administer
accurate core
Antipyretic drug as
temperature.
ordered
Vasculitis
Because insensible
fluid loss inceases by
10% for every
1°cincrease in
temperature, patient
must increase fluid
intake to prevent
dehydration.

Antipyretics act on
hypothalamus to
regulate
temperature.

Altered epidermis or Verbalize feelings of -To provide

Impaired skin -Assess blood supply Display timely
comparative
integrity related to dermis increased self- and sensation of skin healing of skin
baseline opportunity
leakage of blood into esteem and ability to surfaces and lesions without
for timely
the skin through manage situations affected areas on a complications.
intervention when
inflamed, damaged regular basis
problems are noted.
blood vessels as
-Promotes
evidenced by
circulation and
palpable purpura -Encourage early
reduces risks
ambulation or
associated with
mobilization
immobility.