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 ...

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: http://rasmussen.libanswers.com/faq/212524 You can find useful reference materials for this assignment in the School of Nursing guide: https://guides.rasmussen.edu/nursing/referenceebooks Have questions about APA? Visit the online APA guide: https://guides.rasmussen.edu/apa Subjective Subjective Subjective Objective Objective Objective Diagnostic Diagnostic Diagnostic Subjective: Unwillingness to eat. Patient states, “I have a loss of appetite.” Objective: Patient refuses to eat, chew, and swallow food. Diagnostic: Obtain Laboratory values Subjective: Patient says, “I am having difficulty breathing.” Objective: Elevated BP & HR (135/86 & 102 BPM) Diagnostic: Chest x-ray to reveal the etiology factors of the impaired gas exchange 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: Obtain Laboratory values Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis Fatigue related to decreased metabolic energy production as evidenced by decreased performance, lethargy, and lack of energy (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) Anxiety/fear related to separation from support system as evidenced by difficulty breathing 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 Patient will report improved sense of energy by the end of the week. Goal partially met. Patient will perform ADLs, with assistance as necessary each day. Goal met. Patient will verbalize awareness of feelings and healthy ways to deal with them by end of the week Patient will display appropriate range of feelings and lessened fear/anxiety by end of month Patient will achieve timely healing of wounds/lesions by end of the month. Goal in progress Patient will be afebrile and free of purulent drainage/secretions and other signs of infectious conditions by end of the week. Nursing Interventions 1. Assess sleep patterns and note changes in thought processes and behavior. Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of drugs and chemotherapies, and developing CNS disease 2. Recommend scheduling activities for periods when patient has most energy. Planning allows patient to be active during times when energy level is higher, which may restore a feeling of well- being and a sense of control. 3. Establish realistic activity goals with patient. Provides for a sense of control and 1. Assure patient of confidentiality within limits of situation. Provides reassurance and opportunity for patient to problem-solve solutions to anticipated situations 2. Maintain frequent contact with patient. Talk with and touch patient. Limit use of isolation clothing and masks. Provides assurance that patient is not alone or rejected; conveys respect for and acceptance of the person, fostering trust 3. Provide accurate, consistent information regarding prognosis. Avoid arguing about patient’s 1. Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen. Multiple medication regimen is difficult to maintain over a long period of time 2. Wash hands before and after all care contacts. Instruct patient and SO to wash hands as indicated. Reduces risk of cross- contamination. 3. Discuss extent and rationale for isolation precautions and maintenance of personal hygiene. Promotes cooperation with regimen and may lessen feelings of isolation. feelings of accomplishment. Prevents discouragement from fatigue of overactivity 4. Encourage patient to do whatever possible: self-care, sit in chair, short walks. Increase activity level as indicated. May conserve strength, increase stamina, and enable patient to become more active without undue fatigue and discouragement 5. Identify energy conservation techniques: sitting, breaking ADLs into manageable segments. Weakness may make ADLs almost impossible for patient to complete 6. Monitor physiological response to activity: changes in BP, respiratory rate, or heart rate. Tolerance varies greatly, depending on the stage of the disease process, nutrition state, fluid balance, and number or type of opportunistic diseases that patient has been subject to 7. Encourage nutritional intake. Adequate intake or utilization of nutrients is necessary to meet increased energy needs for activity 8. Refer to physical and/or occupational therapy. Programmed daily exercises and activities help patient maintain and increase strength and muscle tone, enhance sense of well-being (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) perceptions of the situation. Can reduce anxiety and enable patient to make decisions and choices based on realities 4. Be alert to signs of withdrawal, anger, or inappropriate remarks as these can be signs of in denial or depression. Patient may use defense mechanism of denial and continue to hope that diagnosis is inaccurate 5. Provide open environment in which patient feels safe to discuss feelings or to refrain from talking. Helps patient feel accepted in present condition without feeling judged, and promotes sense of dignity and control. 6. Permit expressions of anger, fear, despair without confrontation. Acceptance of feelings allows patient to begin to deal with situation. 7. Recognize and support the stage patient and/or family is at in the grieving process. Choice of interventions as dictated by stage of grief, coping behaviors 8. Explain procedures, providing opportunity for questions and honest answers. Accurate information allows patient to deal more effectively with the reality of the situation, thereby reducing anxiety and fear of the known. (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) 4. Monitor vital signs,