Student Nurses Community

NURSING CARE PLAN AIDS/HIV

ASSESSMENT

SUBJECTIVE:
I always feel
tired and
lately Im
prone to
infections as
verbalized by
the patient.
OBJECTIVE:
Overwhelmin
g lack of
energy
Inability to
maintain
usual
routines
Decreased
performance
V/S taken as
follows:
T: 36.5 C
P: 65
R: 16
BP: 100/80

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

Fatigue may
be related to
decrease in
metabolic
energy
production,
increased
energy
requirements
,
overwhelmin
g
psychological
and
emotional
demands,
and altered
body
chemistry
such as side
effects of
medication or
insulin
resistance.

Human
immunodeficie
ncy virus is a
particle that
has an outer
envelope with
special
docking
proteins
known as gp41
and gp120
that assist in
finding a host.
Inside the
virus has two
protein
coatings and
the generic
material with
reverse
transcriptase
(RT) attached.
The first
challenge is
for the HIV
particle to get
inside a host
cell. HIV
accomplishes
this task by

After 8
hours or
nursing
intervention
s, the
patient will:

Independent:

Report
improved
sense of
energy
Participate
in desired
activities
at level of
ability; and
Identify
individual
areas of
control;
and
Engage in
energy
conservati
on
techniques
.

RATIONALE

Multiple factors
can cause and
Assess sleep
aggravate
patterns and
fatigue,
other factors
including sleep
that may be
deprivation,
aggravating
emotional
fatigue
distress, side
effects of
Encourage
drugs, and
timely
developing
evaluation of
central nervous
fatigue if new
system disease.
medications
Fatigue is
have been
added to the
present in
regimen.
variable
degrees as part
Discuss reality
of HIV infection
of patients
process but is
feelings of
often
exhaustion
aggravated by
and identify
nutritional
limitations
deficiencies
imposed by
and side effects
fatigue state.
of certain
Assist patient
medications.
to set realistic

Helpful in
activity goals,
planning
determining
activities within
individual
tolerance
priorities and

EVALUATIO
N
After 8 hours
of nursing
intervention
s, the
patient was
able to:
Report
improved
sense of
energy
Participate
in desired
activities
at level of
ability; and
Identify
individual
areas of
control;
and
Engage in
energy
conservati
on
techniques
.

Student Nurses Community

finding a way
into the hosts
bloodstream.
One of the cell
that it
hijacks is the
CD4+
lymphocytes,
also known as
the CD4+ cell,
helper/inducer
T-call, or T4
cell. This cell
directs
immune
system
defenses and
regulates the
activity of all
immune
system cells. If
the HIV
successfully
enters the
CD4+ cell, it
can then
create more
virus particles.

responsibilitie
s.
Discuss
energy
conservation
techniques
such as sitting
instead of
standing for
activities, as
appropriate.
Encourage
adequate rest
periods during
the day.
Instruct in
stress
management
techniques,
such as
breathing
exercises,
visualization,
and music
and light
therapy.
Collaborative:
Administer
intravenous
fluid as
prescribed
Identify

levels.
Patient may
need to alter
priorities and
delegate some
responsibilities
to manage
fatigue and
optimize
performance.
Enables patient
to become
aware in which
energy
expenditures
can be
maximized to
complete
necessary
tasks.
Helps patient
recoup energy
to manage
desired
activities.
Reduction of
stress factors in
patients life
can minimize
energy output.

Student Nurses Community

available
resource and
support
systems.