Assessment Diagnosis Analysis Goals and Objective
Interventions Rationale Evaluation
Subjective: Patient complains of nearly constant swelling,
stiffness, and pain, with occasional numbness and tingling in her
hands, wrists, and elbows Patient reported her pain using a visual
analog scale (VAS) as 8/10 and stated that the morning pain was
frequently unbearable, rating it as 9/10-10/10 Objective: Swelling
on metacarpal phalangeal joints and her proximal interphalangeal
joints bilaterally Wrists and elbows were warm, with mild edema and
tenderness to palpation
Self-care deficits related to loss of motion
Rheumatoid arthritis is a chronic progressive disease causing
inflammation in the joints and distention of tissues resulting in
painful deformity and immobility, especially in the fingers,
wrists, feet, and ankles
Short-term After6 hours of nursing interventions, the patient
will: -identify individual areas of weakness or needs -demonstrate
techniques and lifestyles changes to meet self-care needs Long-Term
After1weekof nursing interventions, the patient will be able to:
-Perform self-care activities within level of own ability -
Independent 1.Assist patient to identify self-care activities
2.Develop a plan based on the patients perceptions and priorities
on how to establish and achieve goals to meet self-care needs a.
Provide appropriate assistive devices. b.Reinforce correct and safe
use of assistive devices 3.Allow patient sufficient time to
complete tasks to fullest extent of ability Collaborative 1.Consult
with rehabilitation specialists like OT
1.The ability to perform self-care activities is influenced by
disease activity 2.Assistive device may enhance self-care
abilities. 3.Gives opportunity for greater senseof self-confidence
. 1.Helpful in determining assistive devices.
Short-term After6 hours of nursing interventions, the patient
was able to: -identify individual areas of weakness or needs
-demonstrate techniques and lifestyles changes to
meetself-careneeds Long-Term After1weekof nursing interventions,
the patient was be able to: -Perform self-care activities within
level of own ability
