Care Map for Tom Howard: Client with Impaired Immunity

QUESTION

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.

Please include sources

ANSWER

Care Map for Tom Howard: Client with Impaired Immunity

Assessment and Data Collection

Disease Process:
Tom Howard, a 45-year-old man, has a history of HIV, indicating impaired immunity.
Presenting symptoms include a dry cough, chills, fever (102°F), and elevated vital signs (pulse 102, respiration 28, blood pressure 135/86).

Common Labwork/Diagnostics:
CD4+ T-cell count: To assess the severity of immunosuppression.
HIV viral load: To monitor the level of HIV in the bloodstream.
Chest X-ray: To evaluate lung involvement and potential opportunistic infections.
Sputum culture and sensitivity: To identify the specific pathogen causing the cough.
Complete blood count (CBC): To assess white blood cell count and overall health status.

Subjective Data:
Complaints of a dry cough and chills.
No appetite, weight loss, and generalized weakness.
Fatigue, night sweats, and history of recurrent infections.

Objective Data:
Elevated temperature (102°F).
Increased pulse rate (102).
Elevated respiratory rate (28).
Slightly elevated blood pressure (135/86).

Health History Data:
Known HIV-positive status.
Previous opportunistic infections or complications.
Medication history, including antiretroviral therapy (ART) adherence.
Immunization history and current status.

Nursing Diagnosis

1. Ineffective Airway Clearance related to lung infection secondary to impaired immunity (NANDA-I)

SMART Goal: Within 48 hours, the client will demonstrate improved airway clearance as evidenced by the absence of productive cough and improved breath sounds on auscultation.

Nursing Interventions
a. Administer prescribed antiretroviral therapy (ART) as ordered to reduce HIV viral load and enhance immune function, thereby reducing the risk of opportunistic infections.
b. Encourage and assist the client in performing deep breathing exercises and incentive spirometry to promote lung expansion and effective coughing.

Rationale: ART reduces viral replication, allowing the immune system to strengthen. Deep breathing exercises and incentive spirometry help clear mucus and improve lung function, promoting airway clearance.

2. Imbalanced Nutrition: Less than Body Requirements related to anorexia secondary to illness and impaired immunity (NANDA-I)

SMART Goal: By the end of the week, the client will demonstrate an improved nutritional status, as evidenced by weight stabilization or gain and the ability to consume at least 75% of prescribed meals.

Nursing Interventions:
a. Collaborate with a registered dietitian to develop a personalized nutrition plan that addresses the client’s dietary preferences, restrictions, and nutritional needs.
b. Monitor the client’s intake and provide nutritional counseling and education to promote dietary compliance.

Rationale: Collaborative nutritional planning ensures tailored care, while monitoring and education encourage the client to meet nutritional goals, strengthening immunity.

3. Risk for Infection related to immunosuppression and exposure to healthcare environment (NANDA-I)

SMART Goal: Over the next month, the client will remain free from new opportunistic infections, as evidenced by the absence of new infection-related symptoms and stable vital signs.

Nursing Interventions
a. Implement strict infection control measures, including hand hygiene, use of personal protective equipment, and isolation precautions, as necessary.
b. Monitor vital signs, especially temperature, and promptly report any signs of fever or infection to the healthcare team for timely intervention.

Rationale: Rigorous infection control practices minimize the risk of healthcare-associated infections, while vigilant monitoring allows for early detection and treatment of infections, preserving the client’s immune system.

In conclusion, Tom Howard, a client with impaired immunity due to HIV, presents with symptoms of an opportunistic infection. A comprehensive care map incorporates assessment data, nursing diagnoses, SMART goals, and nursing interventions to address his specific needs effectively. These interventions aim to enhance airway clearance, improve nutritional status, and reduce the risk of infection, ultimately promoting Tom’s overall health and well-being.