System Care Map-Impaired Immune System

Assessment

and

Data Collection
Three NANDA-I Approved Nursing Diagnosis
One Smart Goal for EACH Nursing Diagnosis
Two Nursing Interventions with Rationale for EACH Nursing Diagnosis

Disease Process:

HIV-positive patients have a damaged immune system, increasing their risk of opportunistic infection. The risk of opportunistic infection is decreased by compliance with antiretroviral therapy and preventive medications such as co-trimoxazole. A patient’s lifestyle and nutrition also dictate the occurrence of opportunistic infections such as cough (Justiz & Naik, 2022).

Common Labwork/Diagnostics:

ELISA test

CD4+ T-cell count

Viral load

Liver function test

Thyroid function test

Assessment Data (consider subjective, objective, and health history):

Subjective data: Current medications, social history, general and respiratory system review.

Objective data: Physical examination, vital signs, and respiratory assessment.

Nursing Diagnosis:

Infection-related to HIV, as evidenced by the patient complaining they have not been feeling well lately and have a dry cough.

Nursing Diagnosis:

Hyperthermia related to HIV infection, as evidenced by the patient’s temperature of 102 degrees Fahrenheit, pulse rate of 102 beats per minute, and respiratory rate of 28 breaths per minute.

Nursing Diagnosis

Anxiety related to a new situation, as evidenced by the patient’s complaints of dry cough, chilling, and feeling unwell.
SMART Goal:

To prevent progression and treat existing infections (Justiz & Naik, 2022).

SMART Goal:

To stabilize the patient’s temperature back to the normal range within at least four hours of admission (Justiz & Naik, 2022).

SMART Goal:

To reduce the patient’s anxiety level.
1. Ensure the patient is compliant with their antiretroviral therapy. Test the patient’s CD4 T-cell count to monitor response to antiretroviral therapy in cases where the patient is compliant. Antiretroviral therapy prevents HIV complications such as infections (Kemnic & Gulick, 2022).

2. Ensure symptomatic relief by treating the patient’s symptoms, such as dry cough.

1. Adjust the room temperature and advise the patient to remove excess clothing to improve the patient’s comfort and regulate temperature (Nguyen et al., 2022).

2. Use antipyretics and a tepid sponge bath to decrease fever and cool down the body.

1. Assess the patient’s anxiety level to determine the appropriate way to approach them.

2. Educate the patient on HIV and opportunistic infections. Patients who understand their situation are calmer and experience less anxiety (Ong et al., 2022).

References
Justiz Vaillant, A.A., & Naik, R. (2022). HIV-1 Associated Opportunistic Infections. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539787/

Kemnic, T.R., & Gulick, P.G. (2022). HIV Antiretroviral Therapy. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513308/

Nguyen, T. K., Nguyen, Y. H., Nguyen, H. T., Khong, Q. M., & Tran, N. K. (2022). Etiologies of fever of unknown origin in HIV/AIDS patients, Hanoi, Vietnam. BMC infectious diseases, 22(1), 61. https://doi.org/10.1186/s12879-022-07049-3

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Assessment and Data Collection	Three NANDA-I Approved Nursing Diagnosis	One Smart Goal for EACH Nursing Diagnosis	Two Nursing Interventions with Rationale for EACH Nursing Diagnosis
Disease Process: HIV-positive patients have a damaged immune system, increasing their risk of opportunistic infection. The risk of opportunistic infection is decreased by compliance with antiretroviral therapy and preventive medications such as co-trimoxazole. A patient’s lifestyle and nutrition also dictate the occurrence of opportunistic infections such as cough (Justiz & Naik, 2022). Common Labwork/Diagnostics: ELISA test CD4+ T-cell count Viral load Liver function test Thyroid function test Assessment Data (consider subjective, objective, and health history): Subjective data: Current medications, social history, general and respiratory system review. Objective data: Physical examination, vital signs, and respiratory assessment.	Nursing Diagnosis: Infection-related to HIV, as evidenced by the patient complaining they have not been feeling well lately and have a dry cough. Nursing Diagnosis: Hyperthermia related to HIV infection, as evidenced by the patient’s temperature of 102 degrees Fahrenheit, pulse rate of 102 beats per minute, and respiratory rate of 28 breaths per minute. Nursing Diagnosis Anxiety related to a new situation, as evidenced by the patient’s complaints of dry cough, chilling, and feeling unwell.	SMART Goal: To prevent progression and treat existing infections (Justiz & Naik, 2022). SMART Goal: To stabilize the patient’s temperature back to the normal range within at least four hours of admission (Justiz & Naik, 2022). SMART Goal: To reduce the patient’s anxiety level.	1. Ensure the patient is compliant with their antiretroviral therapy. Test the patient’s CD4 T-cell count to monitor response to antiretroviral therapy in cases where the patient is compliant. Antiretroviral therapy prevents HIV complications such as infections (Kemnic & Gulick, 2022). 2. Ensure symptomatic relief by treating the patient’s symptoms, such as dry cough. 1. Adjust the room temperature and advise the patient to remove excess clothing to improve the patient’s comfort and regulate temperature (Nguyen et al., 2022). 2. Use antipyretics and a tepid sponge bath to decrease fever and cool down the body. 1. Assess the patient’s anxiety level to determine the appropriate way to approach them. 2. Educate the patient on HIV and opportunistic infections. Patients who understand their situation are calmer and experience less anxiety (Ong et al., 2022).