Impaired Immune System Care Plan

and

Data Collection

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

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.

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 98.6^oF within three hours.

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).