RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
1.
Behavioral Objectives
Apply the terms listed in the content
column appropriate to the client’s
situations.
Content Outline
I. Application of terms
A. Antigen-antibody reaction
B. Autoanitbodies
C. Autoimmune
D. Azotemia
E. Biliary artresia
F. Donor
G. Exacerbation (flares)
H. Gout
I. Histamine
J. Hypersensitivity
K. Immunoglobulins
L. Immunity
M. Phagocytosis
N. Raynaud’s phenomenon
O. Sjogren’s syndrome
P. Tophi
Q. T cells
R. Uremia
Clinical Objectives
Facilitate the development of
client coping mechanisms during
alterations in health status.
Lehne (2010)
Perform therapeutic and
preventive nursing measures and
administer treatments and
medications as authorized by
law and determined by the BNE.
Evaluate, document, and report
responses to medications,
treatments, and procedures and
communicate the same to other
health care professionals clearly
and accurately.
Collaborate with other health
care providers with treatments
and procedures.
Inform and support health care
rights of clients.
2.
Compare and contrast the normal
anatomy and physiology to the
pathophysiology of the selected
disease processes in the immune
system across the life span.
II. Anatomy and physiology of the immune system
A. Developmental considerations
1. Infant
2. Child
3. Adolescent
4. Adult
5. Older adult
B. Pathophysiology of the immune system.
3.
Analyze factors included in the
assessment of the client experiencing
selected complex problems of the
immune system, including the
developmental and cultural
considerations.
III. Immune system assessment
A. Interview
1. Chief complaint
2. History of present illness
3. Prior medical history
4. Medication history (prescription/non-
Learning Opportunities
Readings:
Lewis (2007)
McKinney (2009)
CD-ROM:
#4006 HIV & AIDS
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
Behavioral Objectives
Content Outline
prescription)
5. Family/social/occupational history
6. Knowledge of health maintenance
7. Identify risk factors for immune disorders
8. Allergy history
B. Physical exam
1. Breathing pattern/airway
2. Bones/joints
3. Level of consciousness
4. Vital signs
5. Skin
6. Mucus membranes
7. Graft
8. I&O
9. Lymph nodes
C. Diagnostic tests
1. Radiology
a. Chest xray
b. Flat plate/joint
c. Computerized axial tomography (CT)
d. Magnetic resonance imaging (MRI)
e. Sonogram
f. Liver scan
g. Renal arteriogram
2. Endoscopic
a. Arthroscopy
3. Laboratory studies
a. Rheumatoid factor
b. Erythrocyte sedimentation rate (ESR)
c. CBC
d. C4 complement
e. C-reactive protein (CRP)
f. Antinuclear antibody (ANA)
g. Liver enzymes
h. Blood urea nitrogen (BUN)
i. Creatnine
j. ABO antigen
k. HLA antigen
l. Radioallergosorbent test (RAST)
Clinical Objectives
Learning Opportunities
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
Behavioral Objectives
4.
Differentiate between the etiology,
pathophysiology, and clinical
manifestations of selected immune
problems.
Content Outline
m. IgE
n. Paper radioimmunosorbent test
(PRIST)
o. Enzyme linked immunosorbent assay
(ELISA)
p. Chem 20
q. PT/PTT
4. Other
a. Arthrocentesis
b. Biopsy
c. Skin tests
D. Cultural influences
1. Hereditary
2. Environmental
3. Health beliefs/practices
E. Developmental
1. Age specific assessment data
a. Muscle tone
b. Vital signs
c. Fluid/electrolytes
d. Nutritional
2. Behavioral/emotional response to health
care providers
Clinical Objectives
IV. Selected complex immune problems
A. Rheumatoid arthritis
B. Systemic lupus erythematous
C. Acquired immunodeficiency syndrome
(AIDS)
1. Pneumocystis carnii pneumonia
2. Protein calorie malnutrition
3. AIDS Dementia
D. Complimentary Alternative Medicine (CAM)
1.
Learning Opportunities
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
5.
Behavioral Objectives
Discuss analysis, planning
implementation and evaluation for
the nursing management of clients
with selected complex immune
problems.
Content Outline
V. Selected nursing diagnoses/implementation/
evaluation
A. High risk for infections
1. Independent interventions
2. Assessment for rejection and infection
3. Age related hydration status
4. Intake & output
5. Monitor pertinent diagnostic tests
6. Maintain skin integrity
7. Vital signs
8. I&O
a. Daily weight
b. Monitor surgical sites, wound
drainage
c. Ambulate
d. Turn, cough and deep breathing
9. Collaborative interventions
a. Administer replacement fluids
(1) Oral
(2) IV
(3) Blood products
b. Administer medications and monitor
for desired effects/adverse/side
effects/drug interactions
(1) Antibiotics
(2) Immunosuppressive agents
(3) Antipyretics
(4) Steroids
(5) Anti-fungals
(6) Analgesics
(7) Non-steroidal anti-inflammatory
(NSAID)
(8) Protease-inhibitors
(9) Non-nucleoside reverse
transcriptase inhibitors
(10) Anti-retrovirals
Clinical Objectives
Learning Opportunities
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
Behavioral Objectives
Content Outline
c. ABG’S
d. Collection of specimens for culture
e. Pulse oximetry
f. Activity/positioning
10. Recognition of complications
a. Rejection of organ
b. Septic shock
c. Graft rejection
d. Death
e. Impaired wound healing
f. Depression
11. The client will have no sign/symptom of
infection as evidenced by:
a. Normal temperature
b. Pulse and BP WNL
c. Lab values WNL
d. Urine output at least 30 cc per hour
e. No redness, swelling or
inflammation at surgical site
B. Ineffective breathing pattern:
1. Independent interventions
a. Assessment of airway/breathing
patterns
b. Precipitating factors
c. I&O
d. Vital signs
e. Elevate HOB
f. Monitor IV/site care
g. Monitor O2 levels
h. Teach life style modifications
i. Remove allergens from environment
j. Report unexpected observations
k. Limit exposure to persons with URI’s
l. Avoid tufted bedspreads, stuffed
toys, feather pillows
m. Avoid fabrics that cause itching
n. Use air filters or air conditioning
Clinical Objectives
Learning Opportunities
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
Behavioral Objectives
Content Outline
Wear a mask during times of increase
exposure
p. Avoid sprays and perfumes
q. Avoid foods that cause reactions
r. Teach to wear medic alert bracelet
2. Collaborative interventions
a. Administer medications and monitor
for desired/effects/adverse
effects/side effects
(1) Steroids
(2) Bronchodialators
(3) Antibiotics
b. Oxygen
c. IV fluids
3. Recognition’s of complications
a. Anaphylactic shock
b. Pulmonary infection
c. Death
d. Cardiac arrest
4. Community resources
a. Home Health
b. Asthma Foundation
5. The client will have an adequate breathing
pattern as evidenced by:
a. No strider
b. Lungs clear to auscultation
c. Reports no respiratory discomfort
d. Identifies pertinent allergens to avoid
e. Identifies 3 methods of reducing risk
of allergic reaction.
C. Ineffective coping
1. Independent interventions
a. Encourage verbalization of feelings
b. Refer to chaplain/social
worker/counselor
c. Involve family in care
d. Foster independence
e. Assess for coping strategies
f. Activity as tolerated
o.
Clinical Objectives
Learning Opportunities
RNSG 2414 – Integrated Care of the Client with Complex Health Care Needs
Unit V – Care of the Client Experiencing Problems with the Immune System
Behavioral Objectives
Content Outline
Patient education
Develop plan for managing
symptoms
i. Range of motion
Collaborative interventions
a. Administer medications and observe
for desired effects/adverse
effects/side effects
(1) Antidepressants
b. Physical therapy
c. Rehabilitation program
Recognition of complications
a. Depression
b. Psychosis
c. Kidney damage
d. Seizures
e. Sleep pattern disturbance
f. Progressive debilitation
g. Pain
h. Anorexia
i. Weight loss
j. Deformity
k. Pericarditis
l. Pleural effusion
m. Necrosis
The client will demonstrate effective
coping as exhibited by:
a. Stating ways to manage disease
process
b. Verbalizes concerns about impact of
disease on appearance and function
c. Sets and achieves meaningful goals
participates in activities that maintain
functioning
Clinical Objectives
Learning Opportunities
g.
h.
2.
3.
4.
N/ADN Spring/RNSG 2414 Unit V Immune
Reviewed 06/11