We’ll write everything from scratch Question For this assignment, you will demonstrate knowledge of the diagnostic process using the template below. You will identify common assessment data, three priority nursing diagnoses, client-centred outcomes, and nursing interventions with rationale for a client with impaired immunity. Impaired Immune System Care Map Course Competency Describe strategies for safe effective, multidimensional nursing practice when providing care for clients experiencing immunologic, infectious and inflammatory disorders. Instructions Tom Howard, a 45-year-old man with HIV from the community, has come to the clinic because he reports he has not been feeling well recently. During the intake process, Tom complains of a dry cough and chills. The intake nurse takes his vital signs, and they are Temp 102 degrees Fahrenheit, Pulse 102, Respiration 28 breaths per minute, and Blood pressure 135/86. The clinic physician refers Tom to the local hospital for a s
Impaired Immune System Care Map
Impaired Immune System Care Map
| 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 weakens the client’s immune system, allowing various pathogens, including bacteria and viruses, to cause opportunistic infections. Common Labwork/Diagnostics: Common labwork/diagnostics for major opportunistic infections include · Complete Blood Count (CBC) · Viral Load test · Sputum cultures · Chest X-rays Assessment Data (consider subjective, objective, and health history): Subjective · The client complains of feeling well recently · The client complains of a dry cough
Objective · T: 102 degrees Fahrenheit · HR: 102 beats/minute · RR: 28/minute · BP: 135/86 mmHg
Health History · HIV+ client · Tom is 45-years-old |
Nursing Diagnosis 1:
The patient is at increased risk of bacterial, viral, and fungal infections as related to the poor primary immune system due to HIV-positive status. Nursing Diagnosis 2: Impaired airway clearance related to pulmonary tuberculosis infection as evidenced by the dry cough. Nursing Diagnosis Hyperthermia related to opportunistic infection related to opportunistic infections as evidenced by the elevated core temperature. |
SMART Goal 1:
Improve patient’s knowledge of HIV management and opportunistic infection risk reduction in the next 6 hours
SMART Goal 2: Improve the patient’s airway clearance and pulmonary tuberculosis infection symptoms in 24 hours. SMART Goal3: Help the patient to maintain a body temperature below 98.6° F within 6 hours. |
Goal 1 interventions
1. Patient education on HIV self-management Rationale: Interventions such as patient education improve self-management in patients with HIV patients (Areri et al., 2020). 2. Introduce the patient to antiretrovirals therapy. Rationale: Antiretroviral therapy can strengthen his immunity’s ability to fight off infections. Goal 2 Interventions 1. Educate the patient on the need to adhere to medication for the next six months. Rationale: Improved adherence to the TB care regimen can improve outcomes. 2. Patient counselling Rationale: Patient counselling and education improve patient adherence to medication and treatment outcomes (Pradipta et al., 2020). Goal 3 interventions 1. Focus on treating the underlying causes. Rationale: Elevated body temperature indicates an issue with the body’s thermoregulation. Managing the factor of deregulation can help manage the patient’s temperature. 2. Improve the patient’s intake of cool fluids. Rationale: Cool fluids can reduce high temperatures and help with dehydration. |
References
Areri, H. A., Marshall, A., & Harvey, G. (2020). Interventions to improve self-management of adults living with HIV on Antiretroviral Therapy: A systematic review. PLOS ONE