Dermatomyositis NCP

Nursing Care Plans
Cues and Clues / Data Nursing Diagnosis Scientific Rationale Objective/s Intervention/s Rationale Evaluation
Subjective Data:
Inadvice akong
gumamit daw ng mask
pero hindi masyadong
sinabi kung bakit, said
by the patient

Objective Data:
Patient uses mask and is
placed in the room
where there are more
space, less patients and
less bystanders. The
relatives on bedside
Risk for infection related
to medically induced
immunosuppression
Medications like
Methotrexate that the
patient takes has an
immunosuppressive
effects for which it
inhibits the DNA
synthesis and cell
reproduction

Short term:
After 2 hours of nursing
interventions, the
patient will be able to:
Verbalize
understanding of
being
immunosuppressed
and understanding
on infection
precautions
Participate and
comply with the
health teaching on
neutropenic diet

Long term:
After 2 shifts of nursing
interventions, the
patient will not manifest
signs and symptoms of
infection such as fever
and changes in WBC
Independent:
Teach about
infection precaution
and the need for
reverse isolation
(why she uses a
mask, placed in that
room, etc.) primarily
the relatives near
the bedside
Encourage to
increase fluid intake
and educate about
neutropenic diet
primarily what
should not be eaten
Note for any
increase and
decrease in the
temperature

Collaborative:
Monitor for the
recent results of CBC
especially the WBC
Administer
antibiotics , as
needed

For the patient to
have understanding
about
immunosuppression
and know the reason
and importance for
doing this

Preventing urine
stasis and reduce
risk for UTI. Have the
patient know what
not should be eaten

Immediate identify
manifestation of
infection

Inc. in WBC may
signal infection while
reduced WBC may
signal severe
immunodepression
Antibiotics used to
treat infection
After nursing
interventions, the
patient maintains beng
free from infection by
having no signs and
symptoms of it.
In cases of infection,
early recognition for the
relatives and patients
will aid in the early
necessary intervention.
The patient verbalize the
purpose and
understanding of the
infection precautions
and neutropenic diet

Nursing Care Plans
Subjective Data:
Hindi ko pa rin
nagagalaw mga paa ko.
Natutulog na lang ako at
gigising kung kailangan.
Paminsan sumasakit din
said by the patient.

Objective Data:
The client is bedridden
and on supine position.
There is manifestation of
muscle weakness
secondary to the disease
diagnosed to her. No
ambulation is being
done for 4 or more
hours although the
patient can stand by her
two feet.
Impaired physical
mobility related to
muscle weakness
Muscle weakness can
cause the patient
immobility and anxiety
to move and ambulate.
It encourages the
patient to just stay in
bed without any
ambulation. The patient
also said that she cant
move her legs but can
stand on her two feet
with the assistance of
the relatives.
Short term:
After 2 hours of nursing
interventions, the
patient will be able to:
Verbalize
understanding and
compliance about
preventing physical
immobility
Do the necessary
ambulation
Comply with the
ROM exercises

Long term:
After 2 shifts, the patient
will be able to verbalize
improvement with
muscle strength and
patient has maintained
adequate motor
function
Independent:
Assess motor skills,
ease and capability
of movement
Health teaching on
the importance of
physical mobilization
and maintaining
motor function
Encourage the client
to participate in the
activities and ROM
exercises.
Also encourage the
relatives to support
and assist with the
exercise

Collaborative:
Give medication for
pain, as ordered

To determine the
extent of capability
in doing ROM
exercises
For the patient to
understand the
purpose and have
the will and
motivation to
participate in the
activities or exercises
Enables the relatives
to participate in the
client care and
provide the
continuity of the
therapy

To reduce any
muscle pain,
enabling the patient
fully participate in
doing the exercises
At the end of nursing
interventions, the
patient continues
verbalized willingness to
participate in activities.
Given the limitations in
capability, the patient
was able to demonstrate
or perform ROM
exercises as tolerated.
The support system
provides continuity of
care and continues to be
active in the therapy. In
the long term, the
patient was able to
maintain strength and
motor function.

Nursing Care Plans
Subjective Data:
Paminsan nakakadumi
paminsan naman wala.
Tuwing umaga at mga 2
araw pang lumilipas,
said by the patient.

Objective Data:
Low frequency of bowel
movement. 2 days
without bowel
movement. Most of the
time she does not do
any ambulation. The
patient is also not in
intravenous therapy.
Risk for constipation
related to inadequate
fluid intake and fiber
The level of activity
affects bowel movement
as ambulation stimulates
bowel movement.
Decrease in the amount
of fluid intake also
affects the passage of
stool. Decrease in these
two can result to
constipation

Short term:
At the end of 2 hours of
nursing interventions
will be able to:
Verbalized
understanding and
willingness to
participate in the
bowel program
Show signs of fluid
volume
improvement
Establish
consistency of
peristaltic
movement and
normal bowel
pattern and
function

Long term:
At the end of 2 shifts,
the patient will not be
constipated
Independent:
Teach the patients
and her relatives
importance of
adequate fluid,
electrolytes and
fiber
Increase oral fluid
intake
Encourage fiber rich
foods
Encourage activity
and exercise within
clients limitation of
activity, as tolerated
Continuous
monitoring of intake
and output and
weight

Collaborative:
Administer oral
rehydration
solutions (ORS), as
ordered

For the patient to
understand the
purpose of the
therapy also
increasing the
compliance as the
relatives can also
participate
For replacement of
essential fluids
Provides bulks and
facilitates passage
of stool through the
colon
For stimulation of
GI motility and
maintaining
optimum GI
function
Dehydration, weight
loss may signal
complication

For rehydration in
cases of immediate
need and attention
At the end of the nursing
interventions, there
were no manifestations
of constipation.

Dermatomyositis NCP

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Nursing Care Plans

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