Module 09 Assignment: Impaired Immune System Care Map 226219

Module 09 Assignment Impaired Immune Systemcare Mapsystem Care Mappu

Develop a care map for a client with an impaired immune system, specifically focusing on one suspected opportunistic infection. Include assessment and data collection, three NANDA-I approved nursing diagnoses, one SMART goal for each diagnosis, and two nursing interventions with rationale for each goal. Use at least two scholarly sources supporting your care plan, citing in APA format.

Paper For Above instruction

Introduction

The immune system plays a crucial role in protecting the body against infectious agents. When compromised, individuals are susceptible to opportunistic infections, which can significantly deteriorate health and require comprehensive nursing care. This paper presents a detailed care map for a 45-year-old man, Tom Howard, diagnosed with an impaired immune system likely due to HIV/AIDS, focusing specifically on the opportunistic infection of Toxoplasmosis. The care plan encompasses assessment and data collection, nursing diagnoses, SMART goals, and nursing interventions supported by scholarly evidence.

Assessment and Data Collection

Disease Process:

Toxoplasmosis is caused by the protozoan parasite Toxoplasma gondii. In immunocompromised individuals, such as those with HIV/AIDS, the parasite can cause severe neurological and systemic manifestations. The infection occurs through ingestion of contaminated food or water, contact with cat feces, or congenital transmission. In immunosuppressed clients, Toxoplasma can reactivate, leading to encephalitis, which can be life-threatening (Luft & Remington, 1992).

Common Lab Work/Diagnostics:

- Toxoplasma gondii IgG and IgM antibodies (serology)

- Brain MRI or CT to identify encephalitic lesions

- CD4 count (to assess immune function)

- Lumbar puncture for cerebrospinal fluid analysis

Assessment Data:

Subjective: Reports of headache, confusion, fever, and vision changes.

Objective: Elevated temperature (102°F), altered mental status, neurological deficits, and general malaise.

Health History: HIV positive for 5 years, inconsistent ART adherence, previous opportunistic infections, weight loss, and fatigue.

Nursing Diagnosis 1

Risk Nursing Diagnosis: Risk for infection related to immunosuppression secondary to HIV/AIDS.

Related to: Decreased CD4 count, impaired immune response.

As evidenced by: Laboratory data indicating low CD4 counts (

SMART Goal 1

The client will remain free from new infections during hospitalization and within the next month, as evidenced by absence of new infection signs and normal vital signs within 48 hours.

Interventions and Rationale 1

1. Implement strict infection control precautions. Rationale: To prevent exposure to new pathogens in immunocompromised clients (Gunn et al., 2019).
2. Monitor temperature, wound status, and signs of infection regularly. Rationale: Early detection of infections facilitates prompt intervention and reduces morbidity (Bartolomé et al., 2018).

Nursing Diagnosis 2

Actual Nursing Diagnosis: Impaired cerebral tissue perfusion related to Toxoplasma encephalitis as evidenced by neurological deficits, altered mental status, and MRI findings.

SMART Goal 2

The client’s neurological status will improve, with orientation restored and reduced headache within 72 hours of initiation of therapy, as evidenced by neurological assessment.

Interventions and Rationale 2

1. Administer prescribed anti-Toxoplasma medications (e.g., pyrimethamine, sulfadiazine). Rationale: To eradicate the parasite and reduce neurological damage (Luft & Remington, 1992).
2. Perform neurological assessments every 4 hours, including Glasgow Coma Scale scoring. Rationale: To monitor neurological status and detect deterioration early (Schmidt et al., 2018).

Nursing Diagnosis 3

Risk Nursing Diagnosis: Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure secondary to cerebral edema.

Related to: Inflammatory response from infection and cerebral inflammation.

As evidenced by: Altered consciousness and increased intracranial pressure signs.

SMART Goal 3

The client will exhibit decreased intracranial pressure symptoms, maintaining stable neurological status within 96 hours, evidenced by absence of worsening headache and stable Glasgow Coma Scale score.

Interventions and Rationale 3

1. Elevate head of bed to 30 degrees. Rationale: Facilitates venous drainage from the brain, reducing intracranial pressure (Gunn et al., 2019).
2. Administer corticosteroids as prescribed. Rationale: To decrease cerebral edema and reduce intracranial pressure (Schmidt et al., 2018).

Conclusion

Implementing a comprehensive care plan for patients with immunosuppression and opportunistic infections like Toxoplasmosis is essential to prevent complications, promote recovery, and enhance quality of life. Proper assessment, targeted nursing diagnoses, measurable SMART goals, and evidence-based interventions enable nurses to deliver safe, effective, and client-centered care. Ensuring rigorous infection control, vigilant monitoring, and timely treatment are cornerstones in managing such complex cases.

References

• Bartolomé, L., Picón, M. J., & Gámez, M. (2018). Infection control in immunocompromised patients: A literature review. Journal of Clinical Nursing, 27(23-24), 4730–4738.
• Gunn, J., He, Z., & Bhatia, K. (2019). Nursing management of patients with intracranial pressure: Evidence-based guidance. Critical Care Nursing Clinics of North America, 31(4), 421–437.
• Luft, B. J., & Remington, J. S. (1992). Toxoplasmic encephalitis in AIDS patients. The New England Journal of Medicine, 327(23), 1643–1648.
• Schmidt, D. J., McCrory, M. A., & Bickford, C. (2018). Neurological assessment in critically ill patients. Critical Care Nurse, 38(2), 38–44.
• Smith, R., & Jones, P. (2020). HIV/AIDS-related opportunistic infections: Pathophysiology and management. Journal of Infectious Diseases, 222(3), 385–397.
• World Health Organization. (2021). Guidelines on the management of HIV/AIDS. Geneva: WHO Publications.
• Jones, C., & Standish, T. (2019). Nursing care for immunocompromised patients. Nursing Clinics of North America, 54(3), 347–360.
• Centers for Disease Control and Prevention (CDC). (2022). HIV infection diagnosis and management. CDC.gov.
• Remington, J. S., & Klein, J. O. (2014). Infectious diseases of the fetus and newborn infant. Elsevier.
• Gaber, J., & Moss, N. (2021). Evidence-based practices in managing opportunistic infections in HIV. Infection Control & Hospital Epidemiology, 42(1), 11–19.