Concept Mapping Sle

F.M.T., 21 years old, female, systemic T lupus erythematosus

+ + + + + + + +

fever fatigue; tiredness anorexia weight loss pleuritis nephritis pulmonary hypertension restlessness

CUES + muscle atrophy + arthritis; joint pains + muscle weakness + avascular necrosis + pericarditis + leucopenia + thrombocytopenia + dyspnea, shallow breathing

+ alopecia + rash; butterfly rash + light/photosensitivity + depression + painless mouth sores + mottled erythema in the hands

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

Monitoring

Ma. Elaine Carla A. Tating BSN III – D

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: INTERVENTIONS Plan and participate 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 Teaching Self-esteem and self-efficacy Verbalize acceptance of disease condition and symptoms, and relief of anxiety

Vital signs: TPR BP q1-2 hours: note depth, rate, and rhythm of RR; note rate, rhythm and sounds of heart; note change in sudden increase or decrease in systole; T every 15 minutes for 1 hour after administra tion of antipyretic

Pain level in a scale of 0-10 with 0 as no pain and 10 as severe hourly; and every 15 minutes for 1-2 hours after administ ration of antiinflamm atory drug: PQRS of Pain: location of pain

Daily weight; daily food intake and amount of calories taken; IO q4h

Periods of rest and sleep: amount of exercise s in hours q8h

Ma. Elaine Carla A. Tating BSN III – D

Readine ss to open up or verbaliz e feelings of anxiety and lowselfesteem daily;

Improvement of coping with anxiety;

Correct pursed-lip breathing exercises and its purpose

Distraction through reading books or magazines, watching television, and guided imagery as nonpharmacol ogic techniques in coping with pain

SLE facts, its prevalence, causes, risk factors and management The disease process and the normal function of the body that responds in the form of inflammation

Precaution to avoid staying out in the sun to avoid or prevent exacerbati on of skin rashes

The average daily intake based on BMI; average caloric intake; nutrition deficiencies and food preferences

The importance of exercise and how it helps with the normal functioning of the body through improving blood circulation; the effects of strenuous activities; the importance of sleep and rest

INTERVENTIONS

Medication

Non-steroidal antiinflammatory drugs

Ma. Elaine Carla A. Tating BSN III – D

Corticosteroi ds

Immunosuppressiv e drugs

Anti-malarial drugs