NUR2180: Physical Assessment Module 09 Assignment –
Impaired Immune System Care Map
Instructions
Use the template directly below these instructions to complete a care map to design care for
a client with impaired immunity.
Tom Howard, a 45-year old man with HIV from the community, has come to the clinic
because he reports he had not been feeling well recently. During the intake process, Tom
complains of a dry cough and chilling. The intake nurse takes his vital signs, and they are:
Temp 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure
135/86. The clinic physician refers Tom to the local hospital for a suspected opportunistic
infection.
Subjective Subjective Subjective
Patient complains of dry Patient verbalizes that he is, Unwilling to eat. Patient states, “I
cough, experiencing chills “having difficulty breathing”. have a loss of appetite”.
and just not ‘feeling well’.
Objective Objective Objective
Patient has a fever (102℉), Elevated respirations-28/min Patient refuses to eat, chew, and
noted a dry productive cough, Elevated BP- 135/86 swallow food.
and diaphoresis. Tachycardia- 102/bpm
Diagnostic Diagnostic Diagnostic
Obtain Laboratory values -Chest x-ray to reveal the Obtain Laboratory values
CBC, BUN, CMP. etiology factors of the CBC, BUN, CMP.
-influenza/covid-19 test impaired gas exchange.
-Chest X-ray -Oxygen saturation.
-EKG
Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Risk for infection related to Anxiety/fear related to Fatigue related to decreased
inadequate immune system as separation from support metabolic energy production as
evidenced by dry cough & system as evidenced by evidenced by decreased
abnormal vital signs. difficulty breathing. performance, lethargy, and lack of
(Ackley & Ladwig, 2008), energy
(Myers, Gulanick, 2014) (Ackley & Ladwig, 2008), (Ackley & Ladwig, 2008),
(Gulanick & Myers, 2014) (Gulanick & Myers, 2014)
SMART Goal SMART Goal SMART Goal
Impaired Immune System Care Map
Instructions
Use the template directly below these instructions to complete a care map to design care for
a client with impaired immunity.
Tom Howard, a 45-year old man with HIV from the community, has come to the clinic
because he reports he had not been feeling well recently. During the intake process, Tom
complains of a dry cough and chilling. The intake nurse takes his vital signs, and they are:
Temp 102 degrees Fahrenheit, Pulse 102, Respirations 28 breaths per minute, Blood pressure
135/86. The clinic physician refers Tom to the local hospital for a suspected opportunistic
infection.
Subjective Subjective Subjective
Patient complains of dry Patient verbalizes that he is, Unwilling to eat. Patient states, “I
cough, experiencing chills “having difficulty breathing”. have a loss of appetite”.
and just not ‘feeling well’.
Objective Objective Objective
Patient has a fever (102℉), Elevated respirations-28/min Patient refuses to eat, chew, and
noted a dry productive cough, Elevated BP- 135/86 swallow food.
and diaphoresis. Tachycardia- 102/bpm
Diagnostic Diagnostic Diagnostic
Obtain Laboratory values -Chest x-ray to reveal the Obtain Laboratory values
CBC, BUN, CMP. etiology factors of the CBC, BUN, CMP.
-influenza/covid-19 test impaired gas exchange.
-Chest X-ray -Oxygen saturation.
-EKG
Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Risk for infection related to Anxiety/fear related to Fatigue related to decreased
inadequate immune system as separation from support metabolic energy production as
evidenced by dry cough & system as evidenced by evidenced by decreased
abnormal vital signs. difficulty breathing. performance, lethargy, and lack of
(Ackley & Ladwig, 2008), energy
(Myers, Gulanick, 2014) (Ackley & Ladwig, 2008), (Ackley & Ladwig, 2008),
(Gulanick & Myers, 2014) (Gulanick & Myers, 2014)
SMART Goal SMART Goal SMART Goal
