Nursing Practice 2 NFP 524

Nursing Management of the Immune, Endocrine and Lymphatic Disorders. Lecturer: Sr M. Tuikubulau Date:29 /08 / 2011

OBJECTIVES
At the end of this lecture, you should be able to : Identify the allergic reactions with a systematic response. Describe symptoms of anaphylaxis and appropriate first aid management.

Cont.
Discuss medical & surgical

management of patients with immunological disorders

Use the nursing process to plan the

care for patient with immune system disorders.

HIV Infection
ASSESSMENT
Subjective Data- social behavior that puts the 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 experience with an infected person. How is pt coping. Any family support?

Objective data vital signs bloods/ laboratory/ radiography tests body weight

NURSING DIAGNOSIS
Anxiety/ fear related to family rejection. Social isolation/ self care deficit related to low self esteem. Diarrhea / impaired oral mucous membrane related to weakened immune system. Acute pain related HIV infection.

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.

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. Empower patient to take control of preventative measures.

2) Acute Intervention
Establish long term, trusting relationship, life support, intervention with treatment and drugs, family support and hygiene needs. Provide emotional and spiritual support. Develop resources for legal needs, wills and power of attorney

3)

Prevent Infection

Visitors/ relatives may be need to wear mask/ gloves. Monitor lab results for signs of infection. Reinforce hand washing, thorough hygiene, dietary precaution. Avoid unprotected sex. Advice against sharing of needles.

4)Ambulatory and Home 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.

EVALUATION
Free of secondary infections. Maintains self care in feeding, bathing, hygiene, dressing and toileting. Regains body weight. Has self confidence: freely discusses fears and concerns. Maintains social interaction and family support.

Systemic Lupus Erythematosus (SLE)

ASSESSMENT
Subjective data- history of exposure to ultraviolet radiation, drugs, chemicals, viral infection, family history of autoimmune disorders Objective data- fever, periorbital edema, alopecia, pleural friction rub, murmurs, oral and pharyngeal ulcers, facial weakness, seizures, arthritis, proteinuria.

NURSING DIAGNOSIS
Fatigue related to disease process. Acute pain related disease process. Impaired skin integrity related to photosensitivity Activity intolerance related to weakness and fatigue. Ineffective therapeutic regime related to lack of knowledge of long term management.

PLANNING
Minimize

pain and fatigue. Maintain skin integrity. Patient is more knowledgeable about long term management. Increase tolerance for activity.

NURSING INTERVENTION
Analyze energy level patterns. Assist patient to prioritize activities. Assess for pain and administer analgesics as required. Keep skin clean and dry. Apply skin ointment. Discuss the need to limit sun exposure. Allow rest periods in between activities. Teach and relatives about disease processes.

contd
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-pharmacological pain intervention eg. relaxation, music, occupational therapy.

Common medications: NSAIDS, corticosteroids, cytotoxic agents, skin ointments.

EVALUATION
Skin integrity intact. Patient appears more relaxed. Patient is more informed about the availability of support services. Patient verbalizes improved general well being.

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.

NURSING DIAGNOSIS
Knowledge

deficit related to life style modifications to control allergies. Altered health maintenance related to effects of allergy. Recurring allergy related to lack of exposure to treatment. Ineffective airway clearance related to bronchoconstriction.

PLANNING
To maintain patent airway. To prevent shock. Able to demonstrate knowledge of treatment. Able to better understand the disease processes and its treatment.

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.

Contd
Keep close watch on respiratory effort and cardiac rhythm. Anticipate intubations with severe respiratory effort. Anticipate tracheotomy with severe laryngeal oedema. Monitor vital signs/ LOC/ O2 sat.

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.

TERMINOLOGY
Urticaria, angioedema, lysis, sudden onset,chills,ischemia,necrosis, life threatening, edematous, Anaphylactic, laryngeal stridor, convulsion, pruritic, tetany, paresthesia. Erythematoes wheals, hypersensitivity, hyperglycemia, glycosuria, polyuria, polydipsia, polyphgia,

ENDOCRINE SYSTEM
Introduction Endocrine dysfunction in most instances can be classified as resulting from Hypersecretion or Hyposecretion. The excess or deficient secretion can result from: 1.primary dysfunction of any of the endocrine glands. 2. abnormal function of the pituitary glands .

THYROIDECTOMY-POST OP CARE Assessment N/Diagnosis

Monitor vital signs q2-4hr Monitor quality of voice , presence /absence of stridor, c/o of dyspnea & choking sensation q1hr for 8 hours, then q2hr for 4-8 hrs and then q4hr. Monitor for signs of tetany and paresthesia.
Ineffective breathing

pattern r/t tracheal obstruction. Risk for injury (trauma) r/t increased neuromuscular excitability and low calcium. Knowledge deficit r/t no previous exposed to information.

contd
Planning Maintain adequate air exchange ( SpO2 > 95%),ABG= No injuries occur: show no changes in vital signs neuromuscular excitability. Patient to understand frequent vital signs and neurological assessment. Describe plan for follow up care. Implementations
Keep head of bed elevated

30. Encourage deep breathing , coughing and turning q2-4hr. Report any signs of hemorrhage, air -way obstruction. Assess mental status and motor strength. Ambulate pt as own tolerance. Maintain fluid intake as per fluid balance chart. Teach pt and relatives about wound care, prescribed drugs, diet, and symptoms to report if discharged.

DIABETES MELLITUS
Introduction: Diabetes mellitus (DM) is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action or both. Uncontrolled DM may result in long term damage, dysfunction and failure of various organs. Diabetes cannot be cured, but it can be controlled. Thus the professional nurse has the challenge and responsibility to help pts gain the knowledge, skills and attitude necessary for self-care (Ulchaker 2001).

Nursing management
Nursing Diagnosis

Fluid volume deficit Risk for fatigue Risk for infection Altered in nutrition Knowledge deficit in disease, drugs, self care skills.

Planning Exhibit physical signs of fluid balance(wt,skin turgor normal) B/P & Pulse are within normal range Decrease in risk for infection Exhibit signs of nutritional adequacy Verbalizes knowledge on DM

contd
Implementation Infuse fluid as per fluid balance chart Encourage oral fluid intake Encourage meal intake as prepared & refer to dietician Administer prescribed medication (insulin/antibiotics). Educate pt on causes and prevention of DM and complication. Evaluation Fluid balance is improved e.g. increase wt. Fatigue has improved. Risk for infection has decreased. An adequate level of knowledge is evidenced

Nursing management
DIABETIC MANAGEMENT Monitoring Medication Exercise Education Meal plan: Nutrition management is the cornerstone of all therapy in all types of DM.

TUTORIAL ACTIVITY
GROUP ACTIVITIES. Describe the nursing management using the nursing process for the patient with : Multiple Myeloma. Diabetic Mellitus (Type 1 & Type 2) Hodgkins Disease. Diabetic Ketoacidosis(DKA)

NURSING MANAGEMENT
Leptospirosis
Goiter Graves Disease Diabetic Hypoglycemia

Reference
Brown, D., Edwards, H. (2005). Lewis medical- surgical nursing: assessment and management of clinical problems. Australia. Elsevier. Pp 276- 280. Phipps, W., Sands, J., Marek, J. (2001). Medical- Surgical Nursing: concepts & clinical practice.(6th ed). St.Louis. Mosby.