RLE 002

Cebu Normal University

College of Nursing
Cebu City
Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN
Assessment 3 points Goals 2 points Interventions 4 points Bibliography
Diagnosis 3 points Theoretical Basis 2 points Evaluation 1 point 15 points

Name of Student: Faye Andrea Go Francisco____________________________

Client’s Initials: S.____________________________________________________ Stressor Classification: (Please check)
Age: 41 y.o. Gender: Female Civil Status: Married Religion: Catholic______ ___/__ Physiological (body structure and functions)
Allergies: No known food and drug allergies____________________________ ______ Psychological (mental processes and emotion)
Diet: DAT____________________________________________________________ ______ Socio-cultural (relationships, social expectations)
Date of Admission: September 15, 2020 ________________________________ ______ Spiritual (influence of spiritual beliefs)
Diagnosis/Impression: Systemic Lupus Erythematosus (SLE)______________ ______ Developmental (developmental processes over the
lifespan)
NURSING DIAGNOSIS NURSING GOALS NURSING OUTCOME
Assessment Diagnosis Mutual Planning Interventions Actual Evaluation
(Goal attainable within the (with Rationale & Source)
shift)
Subjective: Short term goals: PRIMARY INTERVENTIONS Short term goals:
“I have experienced Chronic pain related to After 8 hours of nursing Promotive: After 8 hours of
tenderness in my joints for inflammation associated intervention, the patient I: Assess the impact of pain or stiffness nursing intervention,
10 years already. Recently, with increased disease will be able to: on the client’s ability to perform ADLs. the patient reported
I have also been activity as evidenced by a) Report immediate R: Physical activity may be severely relief of pain with a
experiencing stiffness upon verbalization of joint relief of pain and limited at times and strategies may have pain score of 3/10.
waking up”, as verbalized tenderness and general stiffness, and to be developed so that the client is able
by the patient. stiffness b) verbalize the to maintain a maximum level of function. Long term goals:
importance of S: (Martin & Martin, 2019) After 4 days of
Objective: pharmacological nursing intervention,
 Received patient and non- I: Accept client’s description of pain. the patient showed
awake and oriented pharmacological R: Pain is a subjective experience and improvement in her
to time, person, & methods that cannot be felt by others. overall well-being
place provide relief. S: (Doenges, Moorhouse, & Murr, 2019) (normal V/S, reduced
 Rash over the bridge Theoretical basis: joint inflammation,
noted As systemic lupus Long term goals: I: Assess for the signs of joint and pain).
 Facial grimacing at erythematosus (SLE) After 4 days of nursing inflammation (warmth, redness,
times progresses, a patient may intervention, the patient swelling) or decreased motion.
 Vitals signs are still develop lupus arthritis will be able to: R: Usual signs of inflammation may not
to be taken and which happens when the a) show improvement be present with this disease.
assessed joint linings or synovia are in overall well- S: (Martin & Martin, 2019)
inflamed, which happened being, and
to be the case experienced b) demonstrate/ initiate Preventive:
by the patient. This is behavioral I: Assess previous measures used to
characterized by joint pain, modifications of alleviate pain.
tenderness, and lifestyle and R: Clients may not know of or may not
generalized stiffness upon appropriate use of have tried all currently available
awakening. therapeutic treatments.
interventions. S: (Martin & Martin, 2019)
The priority nursing
diagnosis for this case is I: Encourage the client to assume an
chronic pain caused by anatomically correct position with all
inflamed joints. Chronic joints.
pain is an ongoing pain that R: Such measures assist in preventing
usually lasts longer than six the development of contractures.
(6) months. This type S: (Martin & Martin, 2019)
of pain can continue even
after the injury or illness I: Remind the client to avoid prolonged
that caused it has healed or periods of inactivity.
gone away. R: Activity is required to prevent further
stiffness and to prevent joints from
There are several non- freezing and muscles from becoming
pharmacological and atrophied.
pharmacological methods S: (Martin & Martin, 2019)
to help manage pain and
reduce joint inflammation
experienced by the client. SECONDARY INTERVENTIONS
Curative
Sources: I: Administer NSAIDs, as indicated, to
(Doenges, Moorhouse, & maximum dosage, as needed.
Murr, 2019) and (Martin & R: To reduce inflammation and relieve
Martin, 2019) pain.
S: (Doenges, Moorhouse, & Murr, 2019)
I: Establish collaborative approach for
pain management based on client’s
understanding about and acceptance of
available treatment options.
R: Pain medications may include pills or
patient-controlled analgesia (PCA)
based on client’s symptomatology and
mechanism of pain as well as tolerance
for pain and various analgesics.
S: (Doenges, Moorhouse, & Murr, 2019)

I: Evaluate and document client’s

response to analgesia and assist in
transitioning or altering drug regimen,
based on individual needs and
protocols.
R: Increasing or decreasing dosage, and
stepped program helps in self-
management of pain.
S: (Doenges, Moorhouse, & Murr, 2019)

I: Encourage the use of non-

pharmacological measures of pain
control such as relaxation, distraction,
or guided imagery.
R: These measures may augment other
medications used to diminish pain.
S: (Martin & Martin, 2019)

TERTIARY INTERVENTIONS
Rehabilitative
I: Provide for individualized physical
therapy or exercise program that can be
continued by the client after discharge.
R: Promotes active, rather than passive,
role and enhances sense of control.
S: (Doenges, Moorhouse, & Murr, 2019)
 I: Identify specific signs/symptoms and
changes in pain characteristics
requiring medical follow-up.
R: Provides opportunity to modify pain
management regimen and allows for
timely intervention for developing
complications.
S: (Doenges, Moorhouse, & Murr, 2019)

I: Discuss with SO(s) ways in which they

can assist client with pain management.
R: Family members/SOs may provide
assistance by supporting timely pain
control, and providing gentle massage
to reduce muscle tension.
S: (Doenges, Moorhouse, & Murr, 2019)

Bibliography:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis
Company.

Martin, P., & Martin, P. (2019, April 09). 4 Systemic Lupus Erythematosus Nursing Care Plans. Retrieved September 15, 2020, from
https://nurseslabs.com/systemic-lupus-erythematosus-nursing-care-plans/
 Nursing Care Plan Product Assessment Rubric
Score
Criteria 4 3 2 1 0
Assessment Cues are comprehensive and Cues are comprehensive and Cues do not substantiate the nursing No cues presented.
adequately substantiate the inadequately substantiate the nursing diagnosis.
nursing diagnosis. diagnosis.
Diagnosis It reflects the accurate The diagnosis selected reflects the The diagnosis selected reflects that no No diagnosis identified.
interpretation of the adequate interpretation of the effort to interpret information was
subjective and objective data subjective and objective data applied resulting in a flawed plan of
analyzed. Problem-Etiology analyzed but are not always the best care. PES format is usually not complete
(PE) format is observed. choice from the possible diagnoses or used correctly.
that could be interpreted from the
data. PE format is used correctly.
Theoretical It sufficiently explained the nursing It insufficiently explained the nursing No theoretical basis provided.
Basis diagnosis. diagnosis
Goals The identified goal reflects the time- The identified goal barely reflects the No goal formulated.
bounded measurable behavioral time-bounded measurable behavioral
elements. The criteria identified elements. The criteria identified
generally are individualized and will generally are individualized and will
lead to the control of the related lead to the control of the related factors
factors that contribute to the nursing that contribute to the nursing diagnosis.
diagnosis.
Interventions Specific Specific interventions can be Interventions developed can be linked Interventions developed are incomplete. No interventions to be
interventions can linked to specific outcomes. to specific outcomes but may be Inappropriate interventions may be implemented.
easily be linked to The interventions are realistic independent. The interventions may included in the plan of care.
specific outcomes. and usually appropriate to not be realistic and appropriate to the
The interventions the patient's current status. patient's current status.
are realistic and
appropriate to the
patient's current
status.

Evaluation The subjective and objective data that Subjective and objective data is
measures the outcome is collected and selected to reflect evaluation
analyzed correctly. without consideration of the
outcome criteria. Data
collection is not subjected to
analysis.

Bibliography Updated (within 5-10 years) and accurate References provided are not
references are provided. updated and inaccurate.