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CAGAYAN STATE UNIVERSITY 18
NCM 112
2. Physical Assessment immunity and medical-
Findings inflammation, as Background Information: TM is surgical
3. Laboratory and basis of nursing a 28-year-old female who arrives nursing (15th
Diagnostic Tests care in the emergency department ed.). Wolters
a. Blood Chemistry and Complete a experiencing severe difficulty Kluwer.
Other Blood Tests thorough and breathing, widespread hives, and
b. Cross Matching accurate swelling around her eyes and
c. Allergy Testing assessment of lips. She reports that she was at
C. Nursing Diagnoses the immunologic a friend’s birthday party where
1. Risk for Infection function of the she unknowingly consumed a
2. Ineffective Protection given patient dessert containing peanuts, to
3. Latex Allergy Identify and which she has a known severe
Response prioritize allergy. Within minutes of eating,
4. Social Isolation nursing she began to feel her throat
5. Impaired Skin problems of tightening and a tingling
Integrity patients with sensation on her lips.
D. Planning of Nursing Care for Clients altered immune
with Problems with the Immune response Case Details: Upon arrival, TM
System Collaborate with is visibly distressed, with audible
1. Other Connective the patient with wheezing and use of accessory
Tissue Disorders altered immune muscles to breathe. Her vital
a. Lupus Erythematosus function in the signs are as follows: heart rate
b. Marfan Syndrome planning and 120 bpm, blood pressure 90/50
2. Immunodeficiencies implementation mmHg, respiratory rate 28
a. Primary (Congenital) of nursing care breaths/min, and oxygen
Immunodeficiencies Evaluate saturation 88% on room air. The
b. Secondary (Acquired) rendered medical team quickly administers
Immunodeficiencies nursing care high-flow oxygen, and TM is
3. Hypersensitivity and and modify care noted to have an epinephrine
Allergies plan auto-injector in her purse, which
a. Type I: Rapid accordingly, she has not used.
Hypersensitivity specific for the
b. Type II: Cytotoxic needs of the Questions for Discussion:
Reaction patients with
problems with
F-ODI-2056
Revision No. 07 January 31, 2024
