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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.