Module 09 Assignment: Impaired Immune System Care Map
Module 09 Assignment Impaired Immune System Care Mappurpose of Assig
Module 09 Assignment – Impaired Immune System Care Map Purpose of Assignment 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-centered outcomes, and nursing interventions with rationale for a client with impaired immunity. Course Competency · Describe strategies for safe effective multidimensional nursing practice when providing care for clients experiencing immunologic, infectious and inflammatory disorders. Instructions Use the template directly below these instructions to complete a care map to design care for a client with impaired immunity. Tom Howard, a 45-year old man with HIV from the community, has come to the clinic because he reports he had not been feeling well recently. During the intake process, Tom complains of a dry cough and chilling. The intake nurse takes his vital signs, and they are: Temp 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure 135/86. The clinic physician refers Tom to the local hospital for a suspected opportunistic infection. Use at least two scholarly sources to support your care map. Be sure to cite your sources in-text and on a reference page using APA format. Check out the following link for information about writing SMART goals and to see examples: You can find useful reference materials for this assignment in the School of Nursing guide: Have questions about APA? Visit the online APA guide: Subjective Subjective Subjective Objective Objective Objective Diagnostic Diagnostic Diagnostic Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis SMART Goal SMART Goal SMART Goal Nursing Interventions Nursing Interventions Nursing Interventions
Paper For Above instruction
Introduction
The immune system plays a vital role in safeguarding the body against infectious agents, as well as monitoring and eliminating abnormal cells. When immunity is impaired, individuals become vulnerable to infections and opportunistic diseases that can significantly impact their health and quality of life. This paper presents a comprehensive nursing care plan for Tom Howard, a 45-year-old man with HIV, illustrating the process from assessment to intervention. The plan emphasizes evidence-based strategies to improve patient outcomes, grounded in current scholarly literature.
Assessment Data
Assessment of a patient with suspected immunodeficiency involves gathering comprehensive subjective and objective data. Tom Howard reports feeling unwell, with symptoms including a dry cough and chills, which are indicative of possible respiratory infection. Vital signs reveal a fever of 102°F, tachycardia with a pulse of 102 beats per minute, tachypnea with 28 breaths per minute, and blood pressure of 135/86 mmHg. The febrile state suggests ongoing infection, which is common in immunocompromised patients such as those with HIV. Additional assessment should include checking for other signs of infection, such as fatigue, weight loss, lymphadenopathy, and skin changes, as well as reviewing medical history for prior opportunistic infections and medication adherence (Loomba et al., 2019). Laboratory tests, including CD4 count, viral load, complete blood count (CBC), blood cultures, and chest imaging, are essential for confirming diagnoses and guiding care.
Diagnostic Tests and Health History
Diagnostic evaluations focus on identifying opportunistic infections common in HIV-positive patients. Chest X-ray can reveal pneumonias such as Pneumocystis jirovecii. CD4 counts less than 200 cells/mm³ significantly increase risk for opportunistic infections. History of prior infections, ART adherence, nutritional status, and social determinants of health influence management plans (Deeks et al., 2021). These assessments provide a holistic understanding of the patient's immunologic status and help tailor interventions.
Nursing Hypotheses / Diagnoses
Based on assessment data, the primary nursing diagnosis is Risk for Infection related to immunosuppression secondary to HIV, evidenced by fever, chills, and cough. Additional diagnoses include Ineffective Airway Clearance related to respiratory infection, and Imbalanced Nutrition: Less than Body Requirements related to systemic illness and increased metabolic demands. These diagnoses guide targeted interventions to prevent complications and promote recovery (NANDA-I, 2018).
SMART Goals
An example of a SMART goal related to the primary diagnosis is: "The patient will demonstrate improved airway clearance, evidenced by normal breath sounds and eased breathing, within 48 hours, as demonstrated by nurse assessment and patient report." This goal is Specific, Measurable, Achievable, Relevant, and Time-bound, aligning with best practice standards to maximize patient outcomes (Huang & Lin, 2019).
Nursing Interventions and Rationales
1. Administer prescribed oxygen therapy and medications such as antibiotics or antivirals as indicated, to control infection and improve oxygenation. Evidence supports that early pharmacological intervention reduces morbidity in immunocompromised patients (Bhaskaran et al., 2020).
2. Encourage fluid intake to prevent dehydration, facilitate mucociliary clearance, and assist in the reduction of fever. Adequate hydration aids in mobilizing secretions and supports immune function (Leibovitz et al., 2018).
3. Implement respiratory treatments such as chest physiotherapy or incentive spirometry, to enhance airway clearance. Respiratory interventions reduce the risk of atelectasis and pneumonia in immunocompromised clients (McCarthy & Brightwell, 2020).
4. Monitor vital signs and oxygen saturation regularly to assess response to treatment and detect early signs of deterioration. Continuous assessment allows timely intervention and reduces respiratory complications.
5. Provide patient education regarding medication adherence, infection prevention practices, and nutrition to empower the patient in managing their condition. Education increases compliance and fosters self-care, which are critical for immunocompromised individuals (Carlson et al., 2020).
6. Assist with nutritional support, including high-protein, high-calorie diets, to promote healing and maintain strength. Nutritional status directly influences the immune response (Foster et al., 2019).
7. Coordinate with interdisciplinary team members, including infectious disease specialists and nutritionists, to develop a comprehensive care plan that addresses all aspects of the patient’s health status.
8. Encourage hand hygiene and infection control measures to reduce the risk of additional infections. Proper infection control is essential in immunocompromised patients to prevent secondary infections (World Health Organization, 2022).
9. Assess and manage psychosocial factors, providing emotional support and counseling as needed, recognizing the psychological burden associated with chronic illnesses like HIV.
10. Plan for follow-up care and laboratory monitoring, including CD4 counts and viral loads, to evaluate the effectiveness of treatment and adjust interventions accordingly.
Conclusion
Effective nursing care for immunocompromised patients such as those with HIV requires a comprehensive, evidence-based approach centered around careful assessment, targeted diagnoses, and strategic interventions. By employing current scholarly resources, nurses can optimize outcomes, prevent complications, and support patients’ overall health and well-being. Continuous evaluation and interdisciplinary collaboration are vital components of managing complex immunologic disorders.
References
- Bhaskaran, K., van Benthem, B. H. B., & Mora, C. (2020). Early antivirals and antibiotics in the management of immunocompromised patients: A review. Journal of Infectious Diseases, 222(7), 1093-1102.
- Carlson, R., Becker, B., & Williams, M. (2020). Patient education strategies in managing immunosuppressed populations. Nursing Clinics of North America, 55(2), 175-186.
- Deeks, S. G., Overbaugh, J., & Phillips, A. (2021). HIV infection. Nature Reviews Disease Primers, 7, 13.
- Foster, C., Thomas, S. T., & Taylor, K. (2019). Role of nutrition in immune system function. Nutrition Reviews, 77(4), 231-241.
- Huang, K., & Lin, T. (2019). Developing SMART goals for nursing: A practical guide. Journal of Nursing Education, 58(3), 159-163.
- Loomba, S., Goyal, A., & Kumar, A. (2019). Assessment strategies for immunocompromised patients. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, 13, 117954841987079.
- Leibovitz, E., Golan-Del-Cor, S., & Ben-David, A. (2018). Hydration therapy in infectious diseases: A review. Journal of Clinical Medicine, 7(11), 350.
- McCarthy, C., & Brightwell, R. (2020). Respiratory management in immunocompromised adult patients. Critical Care Nursing Quarterly, 43(2), 148-158.
- NANDA International. (2018). Nursing Diagnoses: Definitions and Classification. 2018-2020. John Wiley & Sons.
- World Health Organization. (2022). Infection prevention and control strategies in healthcare settings. WHO Publications.