Impaired Immune System Care Plan
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 attacks and kills CD4 cells, leading to low immunity in an individual and making them susceptible to opportunistic infections caused by viruses, bacteria, and fungi (Waymack, 2023).
Common Labwork/Diagnostics: Major opportunistic infections are usually tested with the following common diagnostics/lab work: · Viral load test · Complete blood count · Chest X-ray · Sputum text (Vaillant, 2023)
Assessment Data (consider subjective, objective, and health history): Subjective · The patient reports that he has not been feeling well of late · The patient complains of a dry cough and chills Objective T: 102 degrees Fahrenheit HR: 102 b/min RR: 28 b/min BP: 135/86 mm Hg Health History · Tom is a 45-year-old male · Known HIV client
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1. Nursing Diagnosis:
Risk of bacterial, fungal, and viral infection as related to impaired immune system due to positive HIV status.
2. Nursing Diagnosis: Ineffective airway clearance related to pulmonary bacterial infection, as evidenced by the chills and dry cough.
3. Nursing Diagnosis Hyperthermia related to infection, as evidenced by the elevated body temperature of 102 degrees. |
1. SMART Goal:
Enhance patient education on the management of HIV and reduce the risk of opportunity infection in the next one hour.
2. SMART Goal: Enhance the patient’s airway clearance and suppress pulmonary tuberculosis infection symptoms in 24 hours.
3. SMART Goal: Reduce the body temperature and maintain it below 98.6oF within three hours. |
Nursing Intervention I
1. Patient Education on Nutrition and Antiretrovirals Rationale: Eating a balanced diet helps in boosting the immune function of the patient. Antiretroviral therapy helps in the suppression of viral load (Waymack, 2023). 2. Patient Education on Opportunistic Infections Rationale: Patient education will be used to empower the patient to understand their condition. Understanding opportunistic infections, their signs and symptoms, the causes, and prevention will enable a patient to be in charge of managing their health as they will be more informed (Waymack, 2023).
Nursing intervention II 1. Administer Antibiotic Medications Rationale: Antibiotics target bacterial infections and kill bacteria, which leads to symptoms subsiding (Patel, 2023). 2. Patient Education Rationale: Patient education will improve medication adherence to avoid opportunistic infections such as cough (Patel, 2023).
Nursing Intervention III 1. Treating the Underlying Cause of Disease Rationale: Fever is illness-related, and treating the illness helps in bringing the temperature down (Balli, 2022). 2. Encourage Intake of Cool Fluids and Reduce Clothing. Rationale: Taking cool fluids and reducing clothing will help with heat loss and reduce body temperature (Balli, 2022). |
References
Balli, S. (2022, September 11). Physiology, fever. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK562334/#:~:text=In%20hyperthermia%2C%20the%20set%2Dpoint,in%20patients%20with%20severe%20infections.
Patel, P. (2023, May 26). Antibiotics. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK535443/#:~:text=Various%20microorganisms%20have%20medical%20significance,treat%20and%20prevent%20bacterial%20infections.
Vaillant, A. A. J. (2023, January 27). HIV-1–Associated opportunistic infections. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK539787/
Waymack, J. R. (2023, May 3). Acquired immune deficiency syndrome. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK537293/#:~:text=HIV%20is%20a%20retrovirus%20that,off%20opportunistic%20infections%20and%20malignancies.
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Question
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-centred outcomes, and nursing interventions with rationale for a client with impaired immunity.
Impaired Immune System Care Plan
Course Competency
Describe strategies for safe, effective, multidimensional nursing practice when providing care for clients experiencing immunologic, infectious and inflammatory disorders.