NUR 2356 Module 09 Assignment Impaired Immune System Care Map

NUR 2356 Module 09 Assignment Impaired Immune System Care Map 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: IMPAIRED IMMUNE SYSTEM CARE MAP 2 Subjective Subjective Subjective Objective Objective Objective Diagnostic Diagnostic Diagnostic Subjective: * Unwillingness to eat; patient states, “I have a loss of appetite.” * Patient states, “It hurts to chew my food. My mouth is sore.” Objective: * Underweight (10% to 20% below ideal body weight for normal age, height, & build), * Canker sores in mouth (red & swollen oral mucous membranes), * Patient refuses to eat, chew, & swallow food, * Excessive loss of hair, * Decreased urinary output, * Poor skin turgor Diagnostic: Laboratory values * RBC count < 4.5 million/mL; WBC count < 4,500 µL (daily lab draws in hospital; every 3-6 months outside of hospital) * Fasting glucose (blood sugar) test (outside of 75-125 mg/dL range) completed every 6-8 hours * ALT, AST, albumin (< 3.8 g/dL), & bilirubin tests (completed every 6 months outside of hospital; daily while in hospital) Increased albumin Subjective: * Patient states, “I am having difficulty breathing.” Objective: * Elevated BP & HR (135/86 & 102 BPM), *Abnormal levels of ABGs & SPO2 levels (SPO2 88%) *Abnormal breathing pattern (labored, deep breathing; 28 BPM) * Orthopneic positioning Diagnostic: * Arterial Blood Gas (ABG), PaCO2, PaO2, & pH levels to measure pH, O2 & CO2 levels in the blood * Chest x-ray to reveal the etiology factors of the impaired gas exchange * Low Hgb count (< 13.5 g/dL or 135 g/L for men) confirming reduction of oxygen delivery to the tissues * TB screening test to determine infection of the lungs * Biopsy of lung tissue to test for pneumonia (Project Inform, 2011) Subjective: * Patient states that he has chills * Patient states that he has not been feeling well lately * Patient states that he has a cough Objective: * Fever (temp 102 F) * Productive dry cough * Diaphoresis Diagnostic: Laboratory values * Blood tests: CBC to determine infection, anemia, etc. (daily lab draws in hospital; every 3-6 month outside of hospital); WBC count > 10,000/mm3; CD4+ count (the higher the better, but usually very low); platelet count < 150,000 µL; RBC count < 4.5 million/mL; Hematocrit < 40% * Urine tests- test to check for bacteria & viruses * Throat swabs- test to check for bacteria & viruses * Stool sample- test to check for bacteria & viruses * CT scan & MRI- imaging tests to look for sources of infection IMPAIRED IMMUNE SYSTEM CARE MAP 3 levels signify dehydration & decreased levels signify malnutrition, liver failure, & kidney disease. * Serum electrolyte values (potassium increased & sodium decreased in malnutrition) * Transferrin to test for iron (lowers when serum protein lowers) (Project Inform, 2011) * Biopsy of lung tissue to test for pneumonia * Abnormal liver function tests * Creatinine & BUN tests to asses kidney function (Project Inform, 2011) Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis Imbalanced nutrition: less than body requirements related to increased metabolic rate/nutritional needs as evidenced by fever & abnormal laboratory results (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) Impaired gas exchange related to altered oxygen supply as evidenced by abnormal breathing rate (tachypnea), (respiratory rate of 28 BPM) (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) Risk for infection related to inadequate immune system as evidenced by dry cough & abnormal vital signs (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) SMART Goal SMART Goal SMART Goal Specific: The desired outcome is to maintain adequate nutrition for optimal body & cellular function. Adequate nutrition is necessary to meet the body’s demands. This goal is important to help maintain a healthy weight, strengthen the immune system, & absorb HIV medications. Healthcare professionals involved with this plan of care are nurses, nutritionists, dietitians, & HIV PCP. It is important that the patient is compliant during treatment to ensure adequate nutrition requirements are being met in order to maintain a healthy body weight & strengthen the immune system. Specific: The desired outcomes are to maintain optimal gas exchange as evidenced by usual mental status, unlabored respirations at 12-20 per minute, oximetry results within normal range (95%-100%), blood gases within normal range, & baseline heartrate for patient. Patient will also maintain clear lung fields & remain free of signs of respiratory infections. This goal is important because gas exchange is the delivery of oxygen from the lungs into the bloodstream, and the elimination of carbon dioxide from the bloodstream to the lungs, (Martin, 2018). This Specific: The desired outcomes are for the patient to remain free of infections & their complications during their entire stay in the hospital & achieve timely healing of wounds/lesions. This patient is at risk for infection because his natural defense mechanisms are inadequate to protect them from the inevitable injuries & exposures that occur throughout the course of living. Infections occur when an organism invades a susceptible host & the patient’s immune system cannot combat the invading organism adequately, (Gulanick & Myers, 2014).