Name: Andy Lim Age: 21 years old Sex: Female Ward: AH-1

Diagnosis: SLE, inflare (mucutaneous, nephritis, hematologic Chief Complaint: !ody "alaise and #allor
Name: Andy Lim Age: 21 years old Sex: Female Ward: AH-1
Diagnosis: SLE, inflare (mucutaneous, nephritis, hematologic Chief Complaint: !ody "alaise and #allor
Su$%ecti&e 'ue:
("asa)it ta) mga
tudlo ngan si)o*
As &er$ali+ed $y
the client
(#ag,gin)i)i-a )o
ta) )amot ngan
pag$u$uhat
masa)it amo
napa$ulig nala
a)o* as
&er$ali+ed $y the
client,
#ain at hips
el$o-s and
metacarpals -ith
a rating of ./10
1$%ecti&e 'ues:
Facial grimace
Limited 21"
As)ing
assistance
-hen standing
up
3ital Signs:
!#: 120/40
H2: 50
22: 26
7emp: 89,6
Acute pain
related to
inflammatory
process
secondary to
SLE as
evidenced by
joint pain

Acute attac)s of rheumatoid
arthritis occur as the 2F-:g;
comple<es precipitate in the
syno&ial fluid, 'omplement is
acti&ated that attracts
polymorphonuclear leu)ocytes,
-hose main function appears
to $e phagocytosis of
comple<es, 7he lysosomal
en+ymes released $y these
cells intensify the inflammatory
reaction and increase
destruction of the articular
cartilage, ;ranulation tissue
and inflammatory cells form a
mass of tissue called pannus
that erodes the articular
cartilage, 7he %oint space is
destroyed, and the resultant
scarring may completely
immo$ili+e the %oint or cause
$leeding and throm$osis in the
area,
Stiffness and pain in the
hands, feet or large %oints are
common complaints in clients
-ith systemic lupus, 7he %oint
appears red, -arm and tender
$ut do not e<hi$it the
deformities of rheumatoid
arthritis, 7his is due to early
onset of flare ups e<perienced
$y clients at adolescent or
early adult age -hich
contri$utes to increase in
antinuclear antigen -hich is
parallels to collagen diseases
such as rheumatoid arthritis
SH127 7E2":
After 80 minutes of nursing
inter&entions the client -ill:
a, :dentify causes of
%oint pain
$, 3er$ali+e of relief
and comfort
c, Ha&e rela<ed facial
e<pression and $ody
positioning
d, :dentify non-
pharmacological
inter&entions that
help alle&iate pain
L1=; 7E2":
After 2 days of nursing
inter&entions, the client -ill
$e a$le to:
a, "inimi+ed reports of
%oint pain
$, :mplement non-
pharmacologic
measures and other
pain management
techni>ues
appropriately
1, Assessed for signs and
symptoms of
pain/discomfort (e,g,,
&er$ali+ation of pain?
grimacing, reluctance to
mo&e, increased !/#?
tachycardia,
2, Assessed pain using pain
rating scale from 0-10
8, Assessed for referred pain
6, Assessed respiration,
$lood pressure and heart
rate -ith e&ery episode of
pain
., Assessed for aggra&ating
factors
9, :dentified precipitating
e&ent, if any? fre>uency,
duration intensity, and
location of pain
@, #laced patient at a
complete rest during pain
episodes? assume position of
comfort
4, #ro&ided comfort
measures such as pro&iding
pillo- on affected sides,
-:n order to pro&ide
appropriate inter&entions
once pain is felt $y client
7o differentiate pre-
e<isting and current pain
pattern
Help determine possi$ility
of underlying condition,
3ital signs are usually
altered in episodes of
acute pain
2educe or eliminate
factors causing pain
#ro&ides $aseline to
detect further
deterioration of status
and to e&aluate
inter&entions,
"o$ili+ation of affected
%oint increases pain
'old temperature
e<acer$ates %oint pains?
applying heat causes
Short term
goals met as
e&idenced $y:
A'lient
identified
causes of %oint
pain
A 3er$ali+ed
relief of
symptoms and
comfort
A2ela<ed
facial
e<pression
and $ody
positioning
Long term
goals -as not
met:
#ain scale
-as not
reduced to 8
Name: Andy Lim Age: 21 years old Sex: Female Ward: AH-1
Diagnosis: SLE, inflare (mucutaneous, nephritis, hematologic Chief Complaint: !ody "alaise and #allor
S1B2'E: F1'BS 1=
#A7H1#HCS:1L1;C $y
!ulloc) and Hen+e (p, 826
-arm compress etc,
5, Discussed non-
pharmacologic inter&entions
to alle&iate pain (positi&e
imagery, aromatic therapy,
di&ersional acti&ities
10, "aintained >uiet,
comforta$le en&ironment,
restrict &isitors as necessary
Dependent:
1, Administered
medications as
prescri$ed
a, #rednisone 20 mg/ta$
1D
$, Hydro<ychloro>uine
200mg 1 ta$ !:D
'olla$orati&e
1, 2efer to #7 for therapy
of %oints,
connecti&e tissues to $e
more fle<i$le, pro&iding
pillo- decreases mo$ility
of the affected %oint
Helps alle&iate pain or
channel pain,
#romotes rest and
comfort,
2elie&e pain and
facilitate ade>uate rest
and reco&ery,
Enters target cells and
$inds to intracellular
corticosteroid receptors,
there$y initiating many
comple< reactions that
are responsi$le for its
anti-inflammatory and
immunosuppressi&e
effects
Anti infecti&e for SLE
7o pre&ent muscle
shortening