Vasculitis-1.docx

Vasculitis Cues Subjective: “Pirmi ako kikalintura. Pirmi man nagakulog ang tabay ko“ Pain scale: 7/10

Nursing Diagnosis -Chronic pain related to nerve infarction characterized by shooting pains in the arms and legs and numbness.

Objective: -Difficulty to pinpoint pain -Presence of purpura VS taken as follows: T: 39.1°c P:110 bpm R:18 BP: 120/80 mmHg

Hyperthermia related to medication as evidenced by the increased body temperature of 39.1°c and the verbal complaint of “Pirmi akong tigkakalintura”

Background Knowledge Unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe constant or recurring without an anticipated or predictable end and a duration of greater than 6 months Altered epidermis or dermis

Body temperature elevated above normal range

Desired Outcomes

Nursing Intervention

Rationale

Evaluation

Patient will verbalize and demonstrate relief and or control of pain or discomfort.

-Encourage verbalization of feelings about the pain such as concern about tolerating pain, anxiety and pessimistic thoughts

-to evaluate coping abilities and to identify areas of additional concern

-After 8 hours of nursing intervention, the patient was able to verbalize acceptable level of pain as evidenced by pain scale: 3/10

For the patient to demonstrate normal body temperature and will not show any associated complications.

Tepid Sponge Bath (TSB) performed.

Nonpharmacologic measures lower body temperature and promote comfort. Sponging reduces body temperature by increasing evaporation from skin.

At the end of the shift, after all the nursing interventions rendered, the patient was able to obtain a temperature of 38°c. Patient experiences normal fluid balance as evidenced by the equal intake and output.

To maintain balance of intake and output within normal range

Vital signs monitored every two hours Encouraged patient to drink plenty of water placed in a measured bottle. Administer Antipyretic drug as ordered

To obtain an accurate core temperature.

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.

Impaired skin integrity related to leakage of blood into the skin through inflamed, damaged blood vessels as evidenced by palpable purpura

Altered epidermis or dermis

Verbalize feelings of increased selfesteem and ability to manage situations

-Assess blood supply and sensation of skin surfaces and affected areas on a regular basis

-Encourage early ambulation or mobilization

-To provide comparative baseline opportunity for timely intervention when problems are noted. -Promotes circulation and reduces risks associated with immobility.

Display timely healing of skin lesions without complications.