V.

NURSING CARE PLAN

1ST PRIORITY
Nursing Diagnosis
Impaired skin
integrity related to
lesions at left and
right elbow

2ND PRIORITY

Related drug
therapeutics
Povidine Iodide
Nystatin
Levofloxacin

Related Lab
diagnostics

Short Term
Goal
After 8 hours of 1.
nursing
intervention:

Nursing
Interventions
Clean, dry and
1.
moisturize intact 2.
skin. Use warm
water.
3.
Patient will be 2. Encourage
able to
adequate nutrition
demonstrate
and hydration.
proper skin care
Serve foods rich in
and prevent
calories such as
further skin
beans.
integrity
3. Instruct to avoid
impairment.
harsh chemicals
e.g. detergents and
not to use soaps or
lotions with
alcohol.
4, Protect self form
exposure to
sunlight such as
using sun block
and long-sleeved
clothing.
5.Administer
medications as
ordered.
6. Assist in everyday
wound dressing.

Rationale
To keep skin intact.
To promote healing and
prevent infection.
To prevent skin irritation.
Alcohol dries the skin
which exacerbates the
condition.
4.

To prevent
exacerbations since
rashes are also
triggered by sunlight
exposure.

5.

To treat underlying
cause and prevent
infection thus
facilitating wound
healing.
To promote healing
and prevent
infection.

6.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
demonstrate
proper skin care
and prevent
further skin
impairment.

Nursing Diagnosis
Imbalanced
nutrition less than
body requirements
related to increased
glomerular
permeability
secondary to SLE.

Related drug
therapeutics
Ferrous Sulfate

Related Lab
diagnostics

Short Term
Goal
After 8 hours of
nursing
intervention:
Patient will be
able to consume
full share with
good appetite.

Nursing Interventions

Rationale

1. Encourage good oral 1. To enhance appetite

hygiene.
and oral intake.
2. Ensure a pleasant
2. To provide a
environment for
conducive
eating by covering
environment for
the wound with
eating.
dressing and closing
3. To provide
the door of the
information on
comfort room.
nutritious and
3. Suggest food sources
affordable food to
that are rich in
take.
protein, iron, and
4. To ensure intake of
potassium such as
needed nutrients and
fish, beans and
prevent
banana that are within
complications.
patients financial
5. To provide
capabilities.
knowledge on what
4. Instruct to adhere to
foods to take.
low-fat, high-protein
6. To provide for
and high-potassium
lacking nutrients and
diet as tolerated.
ensure adequate
5. Provide patient
intake of such.
teaching on
importance of well
balanced and
nutritious intake.
6. Prepare tolerable diet
specific to the needs
of the patient.
.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
consume full
share with good
appetite.

3rd PRIORITY

Nursing Diagnosis
Activity intolerance
related to local
inflammatory
process at lesions on
left right and left
arm and
surrounding areas as
manifested by
avoiding physical
activity, lying down
during the day and
reduced interaction
with people.

Related drug
therapeutics

Related Lab
diagnostics
Hemoglobin - 68

Short Term
Goal
After 8 hours
of nursing
intervention:
Patient will be
able to
perform
activities of
daily living
with minimal
limitations due
to pain.

Nursing
Interventions
1. Assist patient with
activities.
2. Promote comfort
measures such as deep
breathing and safe
environment.
3. Provide positive
atmosphere while
acknowledging
difficulty of the
situation for the
patient.
4. Increase
exercise/activity levels
gradually.
5. Involve significant
others in planning and
doing activities.

Rationale
1.
2.
3.
4.
5.

To protect the patient

from injury.
To enhance the patients
ability to participate in
activities.
Helps minimize
frustrations and
rechannels energy.
To assess level of
activity tolerance.
To encourage ongoing
support for the patient.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
perform activities
of daily living
with reports of
minimal
limitations
caused by pain.