lecture on immune system298
TRANSCRIPT
8/4/2019 Lecture on Immune System298
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Nursing Practice 2
NFP 524
Nursing Management of theImmune, Endocrine andLymphatic Disorders.
Lecturer: Sr M. TuikubulauDate:29 /08 / 2011
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OBJECTIVES
At the end of this lecture, you should beable to :
Identify the allergic reactions with asystematic response.
Describe symptoms of anaphylaxis and
appropriate first aid management.
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Cont.
Discuss medical & surgical
management
of patients with immunologicaldisorders
Use the nursing process to plan thecare for patient with immune system
disorders.
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HIV Infection
ASSESSMENT
Subjective Data- social behavior that putsthe patient’s life at risk of HIV:
Have you ever had blood transfusions ?
Have you ever shared needles ?
Have you ever had STI ?
Have you ever had any sexual experiencewith an infected person.
How is pt coping. Any family support?
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Objective data
vital signs
bloods/ laboratory/ radiography
tests body weight
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NURSING DIAGNOSIS
Anxiety/ fear related to family
rejection.
Social isolation/ self care deficitrelated to low self esteem.
Diarrhea / impaired oral mucousmembrane related to weakened
immune system. Acute pain related HIV infection.
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PLANNING
Keep viral load as low as possible. Prevent the spread of HIV infection.
Promote healthier lifestyle.
Knowledgeable about the disease.
Maintain or develop healthy,
supportive relationship.
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IMPLEMENTATION
1) Health Promotion
Detect HIV infection early. Prevent HIV infection.
Education, including knowledge, attitude
and behaviors. Emphasis to;o general population
o pregnant women
o individual patient. Empowerpatient to take control of
preventative measures.
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2) Acute Intervention
• Establish long term, trustingrelationship, life support,intervention with treatment and
drugs, family support and hygieneneeds.
• Provide emotional and spiritual
support.
Develop resources for legal needs,
wills and power of attorney
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3) Prevent Infection
Visitors/ relatives may be need to wear
mask/ gloves.Monitor lab results for signs ofinfection.
Reinforce hand washing, thoroughhygiene, dietary precaution.
Avoid unprotected sex.Advice against sharing of needles.
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Care
Maximize quality of life.
Resolve life and death issues
Educate about treatment options.
Continue physical care; treatments,drugs, comfort and hygiene needs.
Support patient and family in a
trusting relationship. Empower patient to identify needs,direct care, seek services.
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EVALUATION
Free of secondary infections.
Maintains self care in feeding,bathing, hygiene, dressing andtoileting.
Regains body weight.
Has self confidence: freely
discusses fears and concerns. Maintains social interaction andfamily support.
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Systemic Lupus Erythematosus
(SLE)
ASSESSMENTSubjective data- history of exposureto ultraviolet radiation, drugs,
chemicals, viral infection, familyhistory of autoimmune disorders
Objective data- fever, periorbital
edema, alopecia, pleural friction rub,murmurs, oral and pharyngeal ulcers,facial weakness, seizures, arthritis,
proteinuria.
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NURSING DIAGNOSIS
Fatigue related to disease process.
Acute pain related disease process.
Impaired skin integrity related tophotosensitivity
Activity intolerance related toweakness and fatigue.
Ineffective therapeutic regime relatedto lack of knowledge of long term
management.
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PLANNING
Minimize pain and fatigue. Maintain skin integrity.
Patient is more knowledgeable
about long term management. Increase tolerance for activity.
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NURSING INTERVENTION
Analyze energy level patterns.
Assist patient to prioritize activities. Assess for pain and administeranalgesics as required.
Keep skin clean and dry. Apply skinointment.
Discuss the need to limit sun exposure.
Allow rest periods in betweenactivities.
Teach and relatives about disease
processes.
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Teach patient to report signs and
symptoms of complications of the disease.
Wear bracelets. Inform patient about the availability of
support services.
Discuss the use of non-pharmacologicalpain intervention eg. relaxation, music,occupational therapy.
Common medications: NSAIDS,corticosteroids, cytotoxic agents, skin
ointments.
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EVALUATION
Skin integrity intact.
Patient appears more relaxed.
Patient is more informed about theavailability of support services.
Patient verbalizes improved generalwell being.
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Allergic Disorders.
ASSESSMENT
subjective data: family history, past
and present allergies; insect, stings,
presence of pests at home/ work,review pt’s life style and stress levels.
objective data: rashes, dryness,
scaliness, scratches, irritation,wheezing, stridor, thick sputum.Abnormal chest and blood results.
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NURSING DIAGNOSIS
Knowledge deficit related to life style
modifications to control allergies.
Altered health maintenance relatedto effects of allergy.
Recurring allergy related to lack ofexposure to treatment.
Ineffective airway clearance relatedto bronchoconstriction.
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PLANNING
To maintain patent airway. To prevent shock.
Able to demonstrate knowledge of
treatment.
Able to better understand thedisease processes and its treatment.
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NURSING INTERVENTION
Ensure a patent airway (by suction /
inserting airway.) Remove allergen if present.
Administer adrenaline as per Dr’s
orders. Give high flow oxygen.
Keep warm.
Administer histamine.
Maintain blood pressure with fluids,
volume expanders.
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Keep close watch on respiratoryeffort and cardiac rhythm.
Anticipate intubations with severe
respiratory effort.
Anticipate tracheotomy with severelaryngeal oedema.
Monitor vital signs/ LOC/ O2 sat.
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EVALUATION
Understands allergens to which she is
sensitive.
Modifies lifestyle to reduce exposure
to allergens. Better knowledge of medications, side
effects and demonstrates correct use
of anaphylaxis drugs.
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TUTORIAL ACTIVITY
GROUP ACTIVITIES.
Describe the nursing management
using the nursing process for the patientwith :
Multiple Myeloma.
Diabetic Mellitus (Type 1 & Type 2)
Hodgkin’s Disease.
Diabetic Ketoacidosis(DKA)
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NURSING
MANAGEMENTLeptospirosis
Goiter
Graves Disease
Diabetic Hypoglycemia
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Reference
Brown, D., Edwards, H. (2005).Lewi’s medical - surgical nursing:
assessment and management of clinical problems . Australia. Elsevier.Pp 276- 280.
Phipps, W., Sands, J., Marek, J.
(1995). Medical- Surgical Nursing: concepts & clinical practice. St.Louis. Mosby.