Impaired Immune System Care Map
Purpose of Assignment
For this assignment, you will demonstrate knowledge of the diagnostic process using the template below. You will identify common assessment data, three priority nursing diagnoses, client-centered outcomes, and nursing interventions with rationale for a client with impaired immunity.
Course Competency
- Describe strategies for safe effective multidimensional nursing practice when providing care for clients experiencing immunologic, infectious and inflammatory disorders.
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 |
| Objective | Objective | Objective |
| Diagnostic | Diagnostic | Diagnostic |
| Nursing Diagnosis | Nursing Diagnosis | Nursing Diagnosis |
| SMART Goal | SMART Goal | SMART Goal |
| Nursing Interventions | Nursing Interventions | Nursing Interventions |
Module 09 Assignment – Impaired Immune System Care Map Rubric
Total Assessment Points – 65
| Levels of Achievement | ||||
| Criteria | Emerging | Competence | Proficiency | Mastery |
| Data Collection
(10 Pts) |
Lacks several basic factors of the disease process and common lab work. | Identifies all basic factors of the disease process and common lab work. | Identifies all basic factors of the disease process, common lab work, and other diagnostic tests. | Identifies all basic factors of the disease process, common lab work, other diagnostic tests and health history. |
| Points – 0-7 | Points – 8 | Points – 9 | Points – 10 | |
| Nursing Hypothesis/Diagnosis (should fit the data)
(10 Pts) |
Nursing hypothesis/diagnosis is insufficient and/or does not fit the data. | Writes nursing hypothesis/diagnosis in the correct format with little connection to identified data. | Writes nursing hypothesis/diagnosis in the correct format with an adequate connection to identified data. | Writes nursing hypothesis/diagnosis in the correct format with a strong connection to identified data. |
| Points – 0-7 | Points – 8 | Points – 9 | Points – 10 | |
| SMART Goal (should reflect the diagnosis and follow guidelines)
(15 Pts) |
The goal meets few SMART goal guidelines and/or is not related to the nursing diagnosis. | The goal meets some of the SMART goal guidelines and is related to the nursing diagnosis. | The goal meets most of the SMART goal guidelines and is related to the nursing diagnosis. | The goal meets all of the SMART goal guidelines and is related to the nursing diagnosis. |
| Points – 0-11 | Points – 12 | Points – 13 | Points – 14-15 | |
| Interventions and Rationale
(20 Pts) |
Lacks appropriate interventions to assist the client in resolving the factors leading to the problem. | Write 3 interventions to assist the client in resolving the factors leading to the problem with appropriate references. | Write 5 interventions to assist the client in resolving the factors leading to the problem with appropriate references. | Writes more than 5 interventions to assist the client in resolving the factors leading to the problem with appropriate references. |
| Points – 0-15 | Points – 16 | Points – 17-18 | Points –19- 20 | |
| APA Citation
(5 Pts) |
APA in-text citations and references are missing. | Attempted to use APA in-text citations and references. | APA in-text citations and references are used with few errors. | APA in-text citations and references are used correctly. |
| Points- 0-2 | Points- 3 | Points- 4 | Points- 5 | |
| Spelling and Grammar
(5 Pts) |
Numerous spelling and grammar errors, which detract from the audience’s ability to comprehend material. |
Some spelling and grammar errors, which detract from the audience’s ability to comprehend material. |
Few spelling and grammar errors. | Minimal to no spelling and grammar errors. |
| Points- 0-2 | Points- 3 | Points- 4 | Points- 5 | |
