Nursing care DISEASE IN SLE
A. Assessment
1. Anamnesis current medical history and physical examination focused on current symptoms and symptoms such as complaints have ever experienced tiredness, weakness, pain, stiffness, fever / hot, anorexia and the effects of these symptoms on lifestyle and self-image of the patient.
2. Skin
Rash eritematous, eritematous plaque on the scalp, face or neck.
3. Cardiovascular
Friction rub that accompanies myocarditis pericardium and pleural effusion.
Eritematous papuler and purpura lesions that become necrotic show vascular disorders occur at the tip of your fingers, elbows, toes and extensor surface of the forearm or the lateral side of the tanga.
4. Musculoskeletal System
Joint swelling, tenderness and pain when moving, feeling stiff in the morning.
5. Integumentary System
Acute lesions on the skin which consists of a butterfly-shaped rash across bridge of his nose and cheek.
Oral mucosal ulcers can be related to the cheek or palate durum.
6. Respiratory System
Pleuritis or pleural effusion.
7. Vascular system
Terminal arteriole inflammation that causes lesions papuler, eritematous and purpura at the end of the toe, hand, elbow and forearm extensor surface or lateral side of the hand and continues necrosis.
8. Renal System
Edema and hematuria.
9. Nervous System
Frequent depression and psychosis, as well as seizure attacks, Korean or other CNS manifestations.
B. Nursing problems that may arise
1. Painful
2. Fatigue
3. Impaired skin integrity
4. Damage to physical mobility
5. Body image disturbance
C. Intervention
1. Pain associated with inflammation and tissue damage.
Objective: The improvement in the level kennyamanan
Intervention:
a. Perform some action that gives comfort (heat / cold, massage, change of position, rest; foam mattress, pillow support, splint, relaxation techniques, activities that divert attention)
b. Give anti-inflammatory preparations, analgesics as recommended.
c. Adjust schedules to meet patient needs treatment for pain management.
d. Encourage the patient to express his feelings about the nature of chronic pain and illness.
e. Explain patofisiologik pain and help patients to realize that pain is often brought to the method of therapy has not proven beneficial.
f. Help in identifying a person’s life that brings pain to the patient using methods that have not been proven beneficial therapies.
g. Make a subjective assessment of changes in pain.
2. Exhaustion is associated with increased disease activity, pain, depression.
Objective: To involve the action as part of activities of daily living needed to change.
Intervention:
a. Give an explanation of fatigue:
• the relationship between disease activity and fatigue
• explain the actions to provide comfort while carry
• develop and maintain a sleep routine actions fatherly (warm water bath and relaxation techniques that makes it easy to sleep)
• explain the importance of a break to reduce systemic stress, and emotional artikuler
• explain how mengggunakan techniques to conserve energy
• identify the factors that cause physical and emotional fatigue.
b. Facilitate the development of scheduled events / proper rest.
c. Encourage the patient’s adherence to the therapy program.
d. Refer and push the conditioning program.
e. Encourage adequate nutrition, including sources of iron from food and supplements.
3. Damage to physical mobility related to a decrease range of motion, muscle weakness, pain when moving, limited physical endurance.
Objective: To obtain and maintain optimal functional mobility.
Intervention:
a. Encourage verbalization with regard to the limitations in mobility.
b. Assess the need for consultation occupational therapy / physiotherapy:
• Emphasizing the range of pain in the joints gherak
• Increase the use of hearing aids
• Describe the use of safe footwear.
• Use posture / body position correct settings.
c. Help the patient identify obstacles in its environment.
d. Encourage independence in mobility and assist if needed.
• Provide adequate time to perform activities
• Provide opportunities for a break after doing the activity.
• Strengthening the protection of the principle of joint return
4. Berhubungqan with body image disturbance and changes fisaik and psychological dependence resulting from chronic diseases.
Objective: To achieve reconciliation between the self concept and physical and psychological erubahan enyakit generated.
Intervention:
a. Help patients to identify the elements controlling disease symptoms and treatment.
b. Encourage verbalization of feelings, perceptions and fears
• To help assess the current situation and menganli masahnya.
• Assist menganli coping mechanism in the past.
• Helping to identify effective coping mechanisms.
5. Damage to the integrity of the skin associated with changes in skin barrier function, immune complex accumulation.
Goal: maintenance of skin integrity.
Intervention:
a. Protect the healthy skin of the possibility of maceration
b. Remove moisture from the skin
c. Keep it carefully against the risk of thermal sedera due to the use of warm compresses too hot.
d. Patient mentor to use cosmetics and sunscreen preparations.
e. Collaboration of NSAIDs and corticosteroids.
every patient is different sometimes, these are not necessarily always appear in patients with lupus erythematosus SLE Sistemisc
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