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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.