summary of hx and assessment, 3 nursing diagnosis, 5 nursing interventions to address the nursing diagnosis (non-pharmacological and pharmacological).

Summary of the History and Assessment. Patient, a female 40 years old has been diagnosed as having an autoimmune disease. The patient is frequently in pain and tired due to the inflammation. This limits her ability to do daily tasks. She has difficulty sleeping at night, as well as muscle weakness & joint stiffness throughout the day .

Nursing Diagnosis #1: Activity Intolerance related to chronic pain & fatigue secondary to the autoimmune disorder.
Nursing Interventions: 1) Encourage light exercise such as stretching or walking 2) Provide education on proper diet & nutrition 3) Provide emotional support 4) Refer to physical therapist 5) Administer anti-inflammatory medication as prescribed by physician.

Nursing Diagnosis #2: Impaired Sleep Pattern related to chronic pain & fatigue secondary to the autoimmune disorder.
Nursing Interventions: 1) Recommend use of relaxation techniques such as deep breathing or yoga 2) Limit caffeine intake throughout the day 3) Investigate potential underlying causes of insomnia 4 ) Administer sleep aid medications (non-benzodiazepines based on patient’s history ) 5 ) Refer for cognitive behavioral therapy.

Nursing Diagnosis #3 : Risk for Injury related to decreased muscle strength & joint stiffness secondary to the autoimmune disorder .
Nursing Interventions: 1 ) Encourage regular physical activity in order increase muscle strength 2 ) Use assistive devices such rollators when walking 3 ) Offer assistance with daily activities that require bending 4 ) Administer analgesics or steroids per doctor’s orders 5 ) Educate patient on proper body positioning while using available resources like pillows/cushions