Care Map for a Client with Impaired Immunity: Addressing Nursing Diagnoses and Interventions for a Patient with HIV

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 the template directly below these instructions to complete a care map to design care for a client with impaired immunity. For this assignment, include the following: assessment and data collection (including disease process, common labwork/diagnostics, subjective, objective, and health history data), three NANDA-I approved nursing diagnosis, one SMART goal for each nursing diagnosis, and two nursing interventions with rationale for each SMART goal for a client with a immune system disorder.

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

ANSWER

Care Map for a Client with Impaired Immunity: Addressing Nursing Diagnoses and Interventions for a Patient with HIV

Assessment data

Tom Howard, a 45-year-old man with HIV
Complaints of dry cough and chilling
Vital signs: Temperature 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure 135/86

Disease process

Tom, being HIV-positive, is at risk for opportunistic infections due to impaired immunity. His symptoms of dry cough, chilling, and elevated temperature may indicate the presence of an opportunistic infection.

Common labwork/diagnostics

To further evaluate Tom’s condition, the following labwork/diagnostics may be performed:
1. Complete blood count (CBC) to assess for any abnormalities in white blood cell count, specifically CD4+ T-cell count, which indicates immune function.
2. Sputum culture to identify any pathogens causing the respiratory symptoms.
3. Chest X-ray to evaluate the presence of any pulmonary complications.

Subjective and objective data
Subjective data
Complaints of dry cough and chilling.

Objective data
Vital signs: Temperature 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure 135/86.

Health history data

Tom has a history of HIV, indicating impaired immunity.
It is essential to assess Tom’s HIV viral load and his current antiretroviral therapy regimen to evaluate the effectiveness of his treatment.

Three NANDA-I Approved Nursing Diagnoses

Impaired Gas Exchange related to respiratory infection secondary to impaired immunity as evidenced by a dry cough, elevated temperature, and increased respiratory rate.
Risk for Infection related to impaired immune function secondary to HIV infection.
Deficient Knowledge regarding management of opportunistic infections related to limited understanding and lack of exposure to education on HIV and its associated complications.

One SMART Goal for EACH Nursing Diagnosis

SMART Goal for Impaired Gas Exchange

By the end of the shift, the patient’s respiratory rate will decrease to within the normal range (12-20 breaths per minute), and oxygen saturation will be maintained above 95% on room air.

SMART Goal for Risk for Infection

Within 24 hours, the patient will demonstrate improved understanding of infection prevention measures and will verbalize at least three strategies to minimize the risk of infection.

SMART Goal for Deficient Knowledge

Within two days, the patient will be able to explain the importance of adherence to antiretroviral therapy and identify three signs and symptoms of opportunistic infections that require immediate medical attention.

Two Nursing Interventions with Rationale for EACH Nursing Diagnosis

Nursing Interventions for Impaired Gas Exchange

Intervention: Administer prescribed antipyretics and encourage increased fluid intake.
Rationale: Antipyretics help reduce fever, which can alleviate the patient’s discomfort and improve gas exchange. Increased fluid intake helps thin respiratory secretions, making them easier to expectorate.

Intervention: Position the patient in an upright or semi-Fowler’s position.
Rationale: The upright or semi-Fowler’s position promotes optimal lung expansion, enhances oxygenation, and facilitates effective coughing and expectoration.

Nursing Interventions for Risk for Infection

Intervention: Educate the patient about proper hand hygiene and demonstrate the correct technique.
Rationale: Proper hand hygiene is a fundamental infection prevention measure. Educating the patient about hand hygiene empowers them to reduce the risk of infection transmission.

Intervention: Emphasize the importance of adherence to antiretroviral therapy and regular follow-up appointments.
Rationale: Consistent adherence to antiretroviral therapy helps maintain optimal immune function and reduces the risk of opportunistic infections. Regular follow-up appointments allow for monitoring of the patient’s HIV status and adjustment of treatment, if necessary.

Nursing Interventions for Deficient Knowledge

Intervention: Provide education materials and resources on HIV, opportunistic infections, and self-care practices.
Rationale: Providing educational materials and resources allows the patient to access reliable information, deepen their understanding of the disease process, and learn about self-care practices that can minimize the risk of opportunistic infections.

Intervention: Encourage the patient to ask questions and clarify any misconceptions.
Rationale: Encouraging active participation and clarifying misconceptions promote a better understanding of the disease process, treatment, and self-care practices. This empowers the patient to make informed decisions and actively manage their health.

In conclusion, the care map for a client with impaired immunity includes an assessment of relevant data, three NANDA-I approved nursing diagnoses, SMART goals for each diagnosis, and two nursing interventions with rationales for each SMART goal. By addressing these aspects, healthcare professionals can provide comprehensive care and support to individuals with immune system disorders, such as HIV.

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