wk 4 nfp 202
TRANSCRIPT
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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 InfectionASSESSMENT
Subjective Data- social behavior that putsthe patients 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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IMPLEMENTATION1) 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 pts 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 DIAGNOSISKnowledge 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 Drs
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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EVALUATIONUnderstands 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.
TERMINOLOGY
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TERMINOLOGYUrticaria, angioedema, lysis, suddenonset,chills,ischemia,necrosis, life
threatening, edematous,
Anaphylactic, laryngeal stridor, convulsion,
pruritic, tetany, paresthesia.
Erythematoes wheals, hypersensitivity,hyperglycemia, glycosuria, polyuria,polydipsia, polyphgia,
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ENDOCRINE SYSTEMIntroduction
Endocrine dysfunction in most instances canbe classified as resulting fromHypersecretion or Hyposecretion. The
excess or deficient secretion can resultfrom:
1.primary dysfunction of any of the
endocrine glands.2. abnormal function of the pituitary glands .
THYROIDECTOMY POST OP
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THYROIDECTOMY-POST OPCARE
Assessment
Monitor vital signs q2-4hrMonitor quality of voice ,presence /absence ofstridor, c/o of dyspnea &choking sensation q1hrfor 8 hours, then q2hr for4-8 hrs and then q4hr.
Monitor for signs of tetanyand paresthesia.
N/Diagnosis
Ineffective breathingpattern r/t trachealobstruction.
Risk for injury (trauma) r/tincreased neuromuscularexcitability and lowcalcium.
Knowledge deficit r/t noprevious exposed to
information.
td
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contdPlanning
Maintain adequate air
exchange ( SpO2 >95%),ABG=
No injuries occur: showno changes in vital signs
neuromuscularexcitability.
Patient to understandfrequent vital signs and
neurological assessment.Describe plan for followup care.
Implementations
Keep head of bed elevated30. Encourage deep breathing, coughing and turning q2-4hr.
Report any signs ofhemorrhage, air -wayobstruction.
Assess mental status and
motor strength. Ambulate pt as own tolerance.
Maintain fluid intake as perfluid balance chart.
Teach pt and relatives about
wound care, prescribed drugs,diet, and symptoms to report ifdischarged.
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DIABETES MELLITUSIntroduction: Diabetes mellitus (DM) is a
group of metabolic diseases characterized byhyperglycemia resulting from defects ininsulin secretion, insulin action or both.Uncontrolled DM may result in long term
damage, dysfunction and failure of variousorgans.
Diabetes cannot be cured, but it can becontrolled. Thus the professional nurse has
the challenge and responsibility to help ptsgain the knowledge, skills and attitudenecessary for self-care (Ulchaker 2001).
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Nursing managementNursing Diagnosis
Fluid volume deficit
Risk for fatigue
Risk for infection
Altered in nutrition
Knowledge deficit indisease, drugs, self careskills.
Planning
Exhibit physical signs offluid balance(wt,skinturgor normal)
B/P & Pulse are within
normal rangeDecrease in risk forinfection
Exhibit signs of nutritional
adequacyVerbalizes knowledge onDM
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contdImplementation
Infuse fluid as per fluidbalance chart
Encourage oral fluidintake
Encourage meal intakeas prepared & refer todietician
Administer prescribedmedication
(insulin/antibiotics).Educate pt on causesand prevention of DM andcomplication.
Evaluation
Fluid balance is improvede.g. increase wt.
Fatigue has improved.
Risk for infection has
decreased.An adequate level ofknowledge is evidenced
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Nursing management
DIABETIC MANAGEMENT
Monitoring
Medication
Exercise
Education
Meal plan: Nutrition management is thecornerstone of all therapy in all types ofDM.
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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)
Hodgkins Disease.
Diabetic Ketoacidosis(DKA)
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NURSING
MANAGEMENTLeptospirosis
Goiter
Graves Disease
Diabetic Hypoglycemia
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ReferenceBrown, D., Edwards, H. (2005).Lewis medical- surgical nursing:
assessment and management ofclinical problems. Australia. Elsevier.Pp 276- 280.
Phipps, W., Sands, J., Marek, J.
(2001).Medical- Surgical Nursing:concepts & clinical practice.(6thed).
St.Louis. Mosby.