Nursing Care Plan Mr. MJ, 62, male was admitted due to sustained injuries from a fall. His records show that he was previously diagnosed with HIV infection and epilepsy as a secondary coexisting condition. Currently, he has been suffering from seizures and gait dysfunction…
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This has been attributed to the added effects of aging and medications. The client’s nutrition status is below the normal level, compared with his healthy physique when the signs and symptoms of HIV infection and epileptic occurrences had not manifested yet. His serum cholesterol is higher than the normal boundary. No respiratory conditions can be traced from his recent medical check- up. Risk for secondary infection Assessment The patient was lying on his bed, conscious and coherent. However, he was not oriented to time, place, and person. Wounds and excoriations were noted on his lower extremities. No breathing difficulties noted upon examination. Nutrition status was noted below the normal level. Increased cholesterol level was appreciated on laboratory results. His vital signs were recorded as: Temperature: 37.4 ?C, Respiratory rate: 24 cpm, Pulse rate: 92 bpm, Blood Pressure: 130/ 110 mmHg. Nursing Diagnosis Risk for secondary infection related to compromised immune system secondary to HIV infection Planning Within this shift, the patient will not be able to develop infection, and would learn ways to prevent it. Intervention and rationale Assess the patient for signs of infection including fever, chills, and diaphoresis; cough; shortness of breath; oral pain or painful swallowing; creamy-white patches in oral cavity; urinary frequency, urgency, or dysuria; redness, swelling, or drainage from wounds; vesicular lesions on face, lips, or perianal area. Any sign of delayed wound healing may give clues that the patient is currently having an infectious process (Black & Hawks, 2005). Assess the patient’s cognition and mental status. In the elderly population, the signs of infection may appear initially as changes in the mental status and consciousness (Burke & Laramie, 2004). Teach patient or caregiver about need to report possible infection. Prompt reporting of infection increases the chances of faster recovery (Smeltzer & Bare, 2006). Do not allow any fresh flowers in the patient’s room. Fresh flowers carry microorganisms that could cause harm to the immune- compromised people (Burke & Laramie, 2004). Do not allow the patient to eat raw foods, including fruits and vegetables. Raw foods contain considerably increased number of microorganisms that could potentially cause another infection (Smeltzer & Bare, 2006). Monitor for medication interactions, infections, electrolyte imbalance, and depression. Elderly patients may have other pathological conditions that could necessarily affect hydration status and predispose other medication side- effects (Black & Hawks, 2005). Encourage independence but assist if the patient cannot perform an activity. While it can be necessary to assist the patient in completing activities most of the time, providing opportunities of independence could increase his sense of well- being (Smeltzer & Bare, 2006). Monitor food and fluid intake. Nutrition status generally affects the rate of wound healing and recovery from infection (Black & Hawks, 2005). Teach the patient about the importance of hand-washing and appropriate hygienic practices. These activities prevent the incidence of infection (Smeltzer & Bare, 2006). Evaluation At the end of the shift, the client did not develop any signs of secondary infection. In addition, the patient learned of the importance of hand- washing, hygienic practices, eating the right kinds of food, and maintaining a healthy lifestyle.
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