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

Abstract of Historical past and Evaluation: Affected person is a 40-year-old feminine who has been recognized with an autoimmune dysfunction. She suffers from frequent ache as a result of irritation and fatigue, which limits her day by day actions. She has issue sleeping at evening, in addition to muscle weak point & joint stiffness all through the day .

Nursing Analysis #1: Exercise Intolerance associated to persistent ache & fatigue secondary to the autoimmune dysfunction.
Nursing Interventions: 1) Encourage mild train resembling stretching or strolling 2) Present training on correct weight loss program & diet 3) Present emotional assist 4) Discuss with bodily therapist 5) Administer anti-inflammatory treatment as prescribed by doctor.

Nursing Analysis #2: Impaired Sleep Sample associated to persistent ache & fatigue secondary to the autoimmune dysfunction.
Nursing Interventions: 1) Suggest use of rest strategies resembling deep respiration or yoga 2) Restrict caffeine consumption all through the day 3) Examine potential underlying causes of insomnia 4 ) Administer sleep support drugs (non-benzodiazepines primarily based on affected person’s historical past ) 5 ) Refer for cognitive behavioral remedy.

Nursing Analysis #3 : Threat for Damage associated to decreased muscle power & joint stiffness secondary to the autoimmune dysfunction .
Nursing Interventions: 1 ) Encourage common bodily exercise so as improve muscle power 2 ) Use assistive gadgets such rollators when strolling 3 ) Provide help with day by day actions that require bending 4 ) Administer analgesics or steroids per physician’s orders 5 ) Educate affected person on correct physique positioning whereas utilizing obtainable sources like pillows/cushions