II.Nursing Diagnosis
• Ineffective airway clearance
• Risk for infection
• Acute or chronic pain
• Impaired skin integrity
• Deficient fluid volume
• Deficient knowledge
• Bathing or hygiene self-care deficit
• Risk for injury
• Ineffective coping
III.Planning and Outcome Identification
• The goals for a client diagnosed with an immunologic disorder include improved airway clearance, prevention of infection, increased comfort, improvement and maintenance of skin integrity, increased knowledge regarding disease, prevention and self-care, absence of complications and injury, and improved coping.
IV.Implementation
• Assess respiratory status, including assessment of lungs, rate and depth of respirations, effort of breathing, use of accessory muscles, cyanosis, restlessness and anxiety or any change in level of consciousness.
• Minimize the risk of infection.
• Instruct the client on ways to avoid infection, including the importance of personal hygiene and avoidance of people with infections and large crowds.
• Instruct the client to wash the affected area with warm water before applying topical creams. Instruct him to wash his hands before and after administering topical creams.
• Provide pain relief. Assess the client’s pain, rule out any complications, implement any nonpharmmacologic intervention (e.g. ice, cold, massage) to relieve pan, administer pain medication, and evaluate the effectiveness of interventions.
• Promote skin integrity
• Assess the skin and mucous membranes for any rashes, color changes, lesions, pallor, purpura, hydration and inflammation.
• Keep skin clean and dry. do not use harsh soaps.
• Maintain fluid balance. Monitor client’s intake and output, and maintain 30 ml/hour urinary output, use a urometer to ensure accurate output. Assess for hydration.
• Provide client and family teaching.
• Teach the client about the disease process and possible triggers.
• Teach the client measures to minimize or prevent exposure to the allergens.
• Discuss emergency measures (e.g. use of epinephrine) and medication therapy, including the use of corticosteroids to reduce inflammation.
• Teach the client danger signs and symptoms to report including respiratory distress and infection.
• Promote self-care. Assist the client with ADLs as needed, but promote independence. Use any energy-saving techniques available.
• Prevent injury. Instruct the client to wear identification tags or bracelets concerning allergies or disease.
• Promote client and family coping.
• Teach the client and his family ways to cope with chronic illness, including verbalization of feelings and ways to prevent exacerbations.
• Provide referrals to counselors and support groups.
V.Outcome Evaluation
• The client displays no respiratory distress, as evidenced by an absence of chest tightness, wheezing, cyanosis, cough, and exaggerated expiratory effort.
• The client shows no symptoms of opportunistic infection, such as fatigue, fever, night swats, weight loss, and diarrhea.
• The client verbalizes relief of joint pain and discomfort
• The client exhibits clean, dry skin that is free from rash, itching, burning, scaling ulcerations and infection.
• The client has intact skin and oral mucosa.
• The client maintains adequate fluid and electrolyte balance and nutritional status.
• The client can verbalize an understanding, preventive measures, and treatment of the disease process and the signs and symptoms that should be reported to that health care provider.
• The client is able to care for himself and perform independent ADLs.
• The client remains free from injury.
• The client is able to verbalize appropriate coping mechanisms to control anxiety.