Jun 21st, 2015
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University of San Diego
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Goal met. The patient cooperates measures to improve nutrition and physical well-being. At the first day, patient was observe to have poor appetite but during the fourth day patient can be seen eating her meals gradually with the help of her folks.

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XIII. NURSING CARE PLANAssessmentNursing diagnosisRationaleDesire outcomeNursing interventionJustificationEvaluationAbnormal cues:>Malar or "butterfly" rash on the face>Discoid skin rash on hands, thighs and scalp>Photosensitivity>oral mucous membrane ulcers>joint pain>Patient is not oriented to time and place, forgetful-sunken eyes-Fatigue and weakness-poor appetite -dependent in her ADL-presence of alopeciaVital signs:RR=24 cpmTemp= 36.5C Laboratory results:-Antinuclear Anti Body result is 7.-HGB, HCT, RBC, platelet are decreased-WBC is increased-serum sodium slightly decreased>history of Rheumatoid Arthritis (2004)>history of UTI (March2011)Weakness:>Poor immune system>gender: female>poor hygiene>does not cooperate in treatment >does not exerciseStrengths/wellness:>strong support system>strong financial support Nursing diagnosis:Impaired tissue integrity related to inflammation, altered circulation as evidence by malar rash on the face, discoid skin rashes on hands, scalp and thighs, oral mucous membrane ulcers and presence of alopecia.Nanda definition: Damage to mucous membranes, corneal, integumentary or subcutaneous tissuesSource:Doenges, et al. Nurses Pocket Guide (12 Ed.). F.A. Davis company. 2010PredisposingGender: FemaleRace: AsianPrecipitatingInfection: UTI , PneumoniaUnknown etiologydefective immune regulatory mechanism Loss of immune toleranceincrease antigenic loadexcess

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