Nanda, Nursing Care Plan, Nursing Assessment, Nursing Diagnosis, Nursing Interventions

Disturbed Body Image and Impaired Skin Integrity r/t Systemic Lupus Erythematosus (SLE)


Systemic Lupus Erythematosus (SLE) is a multisystem inflammatory disease or inflammation that causes presumably due to changes in the immune system. (Albar, 2003).
The etiology of some collagen-vascular disease is often unknown, but the immune system is involved as a mediator of the disease. (Delafuente, 2002).

The immune system normally protects us from disease caused by bacteria, viruses, and others from outside the body. But in patients with lupus, the immune system becomes redundant, so that it attacks the body itself, therefore it is called an autoimmune disease. This disease causes inflammation in various organs of our body, for example: skin will be reddish or erythema, and also the joints, lungs, kidneys, brain, blood, and others. Therefore, the disease is systemic because of the almost all parts of our body. If Lupus only on the skin only, whereas other organs are not affected, it is called cutaneous lupus that are less harmful than the Systemic Lupus (Systemic Lupus / SLE).

Patients with SLE require treatment and proper care and correct. Treatment in patients with SLE is intended to address the symptoms and induction of remission and maintain remission as long as possible in the development of the disease. Because the clinical manifestations are highly variable, the treatment is based on the manifestations that appear in each individual.


Disturbed Body Image related to changes and physical dependence, and psychological, caused by chronic disease.

Purpose: achieving reconciliation between self-concept, and the physical and psychological changes caused by disease.

Action Plans:

1. Help the patient to recognize the elements of control and treatment of disease symptoms.

2. Encourage verbalization of feelings, perceptions and fear.
  • Help assess the current situation and identify the problem.
  • Help identify coping mechanisms in the past.
  • Help identify effective coping mechanisms.

Impaired Skin Integrity related to changes in skin barrier function, accumulation of immune complexes.

Purpose: maintenance of skin integrity.

Action Plans:
  1. Protect client's skin healthy, against the possibility of maceration.
  2. Remove moisture from the skin.
  3. Supervise carefully against the risk of thermal injury due to the use of warm compresses too hot.
  4. Advise patients to use cosmetics and sunscreen preparations.
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