CHAPTER I OBJECTIVES AND INTRODUCTION

A. OBJECTIVES I did this case study for us to enchance my knowledge and to understand more information about HIV/AIDS, this to give us an idea of how I could give proper nursing care plan of my clients with the condition, and so that I could apply them on my future exposures as students and eventually as nurses. I also did this case study as a part of our requirement in our clinical exposure.

B. INTRODUCTION Human immunodeficiency virus infection / acquired immunodeficiency syndrome (HIV/AIDS) is a disease of the human immune system caused by infection with human immunodeficiency virus (HIV). During the initial infection, a person may experience a brief period of influenza-like illness. This is typically followed by a prolonged period without symptoms. As the illness progresses, it interferes more and more with the immune system, making the person much more likely to get infections, including opportunistic infections and tumors that do not usually affect people who have working immune systems.

HIV is transmitted primarily via unprotected sexual intercourse (including anal and even oral sex), contaminated blood transfusions, hypodermic needles, and from mother to child during pregnancy, delivery, or breastfeeding. Some bodily fluids, such as saliva and tears, do not transmit HIV. Prevention of HIV infection, primarily through safe sex and needle-exchange programs, is a key strategy to control the spread of the disease. There is no cure or vaccine;

however, antiretroviral treatment can slow the course of the disease and may lead to a near-normal life expectancy. While antiretroviral treatment reduces the risk of death and complications from the disease, these medications are expensive and may be associated with side effects.

Genetic research indicates that HIV originated in west-central Africa during the early twentieth century. AIDS was first recognized by the Centers for Disease Control and Prevention (CDC) in 1981 and its causeHIV infectionwas identified in the early part of the decade. Since its discovery, AIDS has caused nearly 30 million deaths (as of 2009). As of 2010, approximately 34 million people have contracted HIV globally. AIDS is considered a pandemica disease outbreak which is present over a large area and is actively spreading.

HIV/AIDS has had a great impact on society, both as an illness and as a source of discrimination. The disease also has significant economic impacts. There are many misconceptions about HIV/AIDS such as the belief that it can be transmitted by casual non-sexual contact. The disease has also become subject to many controversies involving religion

CHAPTER II ASSESSMENT

A. Nursing Health History 1. Personal Data Name Age Sex Address Civil Status Nationality Religion Birth Place Admission Date Time Diagnosis : Mr. W : 35 years old : Male : Boulevard street number 5 : Married : Indonesian : Islamic : Makassar : : February 18, 2013 : 12.30 pm : HIV/AIDS

2. Past Medical History The client is never been admitted in a hospital before. The client stated that she was confined at X hospital because of her

diarrhea for 2 weeks, also he experienced the developed fever. He have been admitted in a clinic because of diarrhea but didnt get better.

3. Present Medical History The client was admitted February 18, 2013 at 12.30 pm with a chief complaint of diarrhea for 2 weeks.

client consulted at the emergency room, client was managed at Emergency Room and subsequently admitted

4. Family Health History He also stated that they dont have a history of other hereditary disease. B. Physical Assessment 1. Vital Sign Blood Pressure 120/80 mmHg, Pulse 120x/mnt, Respiration rate 28x/menit, Temperature 39C 2. Head to Toe Assessment He has tattoos anywhere. Deficit self care. He was defecate 15 times a day, level of consciousness compos mentis, Dry turgor, weight 53 kg

C. Laboratory Exams Hb 11 g / dL, 20.000/Ul leukocytes, thrombocyte 160.000/UL, Na 8 mmol / L, K 2.8 mmol / L, Cl 11 mmol / L, Examination of blood (DPL)

D. Treatment
1. Antipyretic medicines like paracetamol and etc. 2. Infection Control Opurtunistik

The purpose to eliminate, control, and recovery opurtunistik infection, nasokomial, or sepsis.
3. AZT therapy (Azidotimidin)

This therapy use to inhibited replication of the HIV by inhibiting the enzyme inverting traskriptase. AZT available to AIDS clients of its T4 cell count <> 3. Now, AZT available to clients with HIV positive asymptomatic and T4 cells> 500 mm3.

4. New Antiviral Therapy

Several new antiviral activity that increasing the immune system by inhibiting viral replication or break the chains of viral reproduction process. These medications are: a. Didanosine b. Ribavirin c. Diedoxycytidine d. Recombinant soluble CD 4
5. Virus Vaccines and Reconstruction 6. Education to avoid alcohol and drugs, health meal, avoid stress,

lack of nutrition that annoying with immune function.

E. Resume of Client Tn. W, 35 years old, came to the Emergency (ER) X Hospital on 18 February 2013 at 12:30 pm, with complaints of diarrhea for 2 weeks and did not get better after seeing a doctor. Mr. W said that he has fever and diarrhea 15 times a day and loss weight 7 kg in one month and no appetite. He said not understand about the disease and did not get better. The results of laboratory are: Hb 11 g/dL, leukocytes 20.000/Ul, thrombocyte 160.000/UL, Na 8 mmol/L, K 2.8 mmol/L, Cl 11 mmol/L and medical diagnosis is AIDS. Client attached IVFD RL 8 hours/kolf on right hand. Then he was admitted in Melati room on the 18th of February 2013 at 15:00 pm. At the time of the assessment, date 19 February 2013 data obtained, client said that his fever, no appetite. Clients say anxious, confused and do not understand about the disease that didnt get better. Clients seem weak, BB 53 kg, dry turgor. The results of a physical examination vital signs : BP: 120/80 mmHg, HR: 18x/min, RR: 24x/min, P: 90x/min, T: 39C. The results of laboratory are Hb
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11 g/dL, leukocytes 20.000/Ul, thrombocyte 160.000/UL, Na 8 mmol/L, K 2.8 mmol/L, Cl 11 mmol/L.

F. Anatomy and Physiology

Immune System is a human defence system as protection against infection from foreign macromolecules, including viruses, bacteria, protozoa and parasites. The immune system also plays a role in resistance to body proteins and other molecules like occurs in autoimmunity. (Wikipedia.com) Function of the Immune System are: 1. Marrow All immune system cells to come from mother cells in the bone marrow. The bone marrow is where the red blood cells, white blood cells (including lymphocytes and macrophages). 2. Thymus In the thymus gland lymphoid cells undergo a process of maturation 3. Lymph

4. Mucosa associated lymphoid tissue (MALT)

System immune also as: 1. Defense Mechanisms Non Specific Nonspecific defense mechanism called the natural immune response. Which is the body's non-specific defense mechanisms a skin with its gland, mucosa of the enzyme, and other glands such as the tear glands. 2. Specific Defense Mechanisms Specific defense mechanism called the immune response obtained are Humoral and Cellular Immunity. Humoral immunity is immunity, played by B lymphocyte cells. The task will be carried by B cells immunoglobulin secreted by plasma cells. There are five classes of immunoglobulins are known to us, namely IgM, IgG, IgA, IgD, and IgE. Cellular immunity is defined as an immune response to antigens played by T lymphocytes. 3. Antibody (immunoglobulin) kind of antibody are A, D, E, G, M

G. Pathophysiology
Attacking T lymphocytes, nerve cells, macrophages, monocytes, lymphocytes B

HIV Vruses

Damage a cell

Immunocompromise

HIV- positive

Infectious germs of a pathogen Target organs

Flora normal pathogens

Psychological reaction

Oral Manifestation

Neurologic Manifestation

Gastrointestinal
Biliari Disfunction

Respiratory

Dermatology

Sensory

Oral Lesion

Dementia Complex

Encephalopat hy Acute

Diarrhea

Hepatitis

Anorectal Disease

Infec tion

Itch, Sepsis, Pain

Impaired vision and hearing

Fluid Volume Deficit

activity intolerans

Impaired sense of comfort: pain

Ineffective airway clearance

Impaired mobilization

Impaired Body Image

Impaired sense of comfort: pain

Hipertermi

Ineffective Breath System

Impaired of Defecate

Nutrition inadequate

Nutrition inadequat e

Fluid Volume Deficit

Impaired Sensory

CHAPTER III IMPLEMENTATION

A. List Of Prioritized Nursing Diagnosis 1. High body temperature associated with the disease process. 2. Fluid volume deficit related to excessive output. 3. Less of knowledge related to the lack of information

B. Nursing Care Plan

Nursing Care Plan Assesment Nursing Diagnosis Planning After nursing action 3x24 hours, the body temperature down until normal. Criteria results: - Body temperature within normal range 3637C - Clients free of fever Nursing Intervention 1. Consider the causes of fever 2. Give warm compresses Rationale 1. Client looks a cooperative 2. Giving a warm compress to stimulate a decrease in body temperature. 3. Water is the body's temperature control. Every rise in temperatures in excess of normal, increased metabolic needs water 4. Thin clothes will be easy to Evaluation S: The client said it was no longer a fever O: Clients seem fresh again. Vital signs: BP: 120/80 mmHg HR: 18x/min T: 37,5C RR: 24x/min P: 90x/min A: Problem

Data Subjective: High body temperature - He said fever associated Data Objective: with the disease - He looks weak process. - The results of laboratory are: Hb: 11 g/dL Leukocytes: 20.000/Ul, Thrombocyte: 160.000/UL Na: 8 mmol/L K: 2.8 mmol/L Cl: 11 mmol/L. - Vital signs are: BP: 120/80 mmHg HR: 18x/min T: 39C RR: 28x/min

3. Levels of calories and give plenty of drinks (liquid)

4. Advise wearing thin

P: 90x/min

Data Subjective: - He said has diarrhea for 2 weeks and did not get better after seeing a doctor. He was diarrhea 15 times a day. Data Objective: - Weight: 53 kg - He looks weak - Intravenous normal saline

Fluid volume deficit related to excessive output.

clothes that absorb sweat. solved absorb sweat. 5. Observation 5. Observation of P: Intervention is stopped of vital signs, vital signs is especially early detection temperature to determine and pulse the complications that happen so quickly take action 6. Give a 6. The provision medicines, of medicines, especially especially anti-pyretic. antibiotics will kill the bacteria that accelerate the healing process while antipyretics to lower body temperature. After nursing 1. Skin turgor, 1. Indirect S: Client said action 3x24 mucous indicators of he was hours, the membranes, fluid status. diarrhea fluid volume and thirst 2. Maintaining O: Client looks will be 2. Monitor fluid fluid balance, still weak, adequate for intake and reduce the Feces is body output at thirst, moisten mushy requirements least 2500 ml the mucosa. consistency, / day Fluid intake of 3. Remove yellow color, 3. Can reduce at least 2500 skin turgor diarrhea. potential food ml/day medium. that causes diarrhea Vital Sign: Collaborated 1. Give 1. Reduced BP: 120/80 mmHg

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infusion 20 drops/min - Dry turgor - Vital Signs: BP: 120/80 mmHg HR: 18x/min T: 39C RR: 28x/min

medications as indicated: antiemetikum , antidiarrhea or antispasmodi c.

1. Monitor the results of laboratory tests

sense of HR: 18x/min wanting to T: 37,5C vomit, stool consistency RR: 24x/min decreases the P: 90x/min amount of reducing A : Partially intestinal solved the spasm and problem peristalsis. 2. aware of the P :Intervention existence of is continued electrolyte disturbances and to determine the need electrolytes 3. Required to support the volume of circulation, especially if the income is inadequate 1. Provide basic S: Client said knowledge in have which clients understood can make the disease informed and its choices treatment. 2. Correcting O: Clients can myths and answer all misconception questions s, improve properly safety for clients / others A: Problem 3. Giving clients solved control

2. Give fluid or electrolyte through a feeding tube

Data Subjective: - He said not understand about the disease and did not get better Data Objective: -

Less of knowledge related to the lack of information

After done 1. Review the 1x30 minute disease nursing process and actions, what is the Expressing hope of the understanding future of the 2. Review the condition of way of the client / transmission process and of disease treatment of certain diseases 3. Provide information

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on the reduces the management risk of of symptoms embarrassme that nt and complement increase medical rules, comfort such as: intermittent diarrhea 4. Emphasize 4. Provide an the need for opportunity to continuing change the medical care rules to meet and the changing evaluation needs / individual 5. Identify 5. Facilitate the community transfer of resources, acute care such as: environment, hospital / supporting the residential recovery with treatment independence center (if any) C. Discharge Planning MEDICINE Advice client to continue taking his prescribe medicines

P: Intervention is stopped

ENVIRONMENT AND EXERCISE Maintain a quite, pleasant, environment to promote comfortable Support and eliminate stigma and insults to people who are already infected with HIV, because not all people with HIV due to immoral behavior TREATMENT Continue home medications Encourage client to take multivitamins for immunity

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HEALTH TEACHING Intruct client to drink much a water. Instruct client to wearing a thin clothes. Instruct client to dont share needles or syringe Instruct client to dont have unprotected sex Instruct client to dont share razors or tootbrushes Avoid contact with other peoples blood

OUT CLIENT FOLLOW-UP Client will be advised to go back in the hospital in aspecific data to have a follow-up check up after Consult doctor for are any problems or complications encountered DIET Encourage client to increase intake TKTP for weight come back normally Foods that contain iron (egg, fish, potato, spinach, corn), magnesium (green vegetables), folat acid (broccoli, beans) vit B12 (tomato), vit A (apple, carrot) Advice client to eat smaller-than-normal amounts of food of mealtime SPIRITUALITY Encourage client to communicate with God Encourage client to communicate with family and other people Advise client to clear the tattoes because in islamic, it is prohibited.

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CHAPTER IV DISCUSSION

The cause HIV/AIDS is the retro virus, called human immunodeficiency virus (HIV). HIV is a retrovirus that infects the vital organs of the human immune system. You get AIDS after becoming infected with the HIV virus by unsafe sex, contact with blood of an infected person for example by using a contaminated injection needle, for mother to child during pregnancy, childbirth or breastfeeding because the virus is transmitted through blood, sperm, vaginal fluids, pre-seminal fluids, breastmilk. The transmission of HIV infection and AIDS consists of five phases are the window period, acute phase of primary HIV infection, The infection is asymptomatic, immune suppression is symptomatic and last AIDS. Based on the above case, Mr. W infected with the HIV virus by contact with blood of an infected person for example by using a contaminated injection needle. Hes belong Immune Suppression is symptomatic with symptoms of fever, diarrhea and weakness. Diagnosis priority is high body temperature associated with the disease process which aims to show the temperature within normal limits because the temperature is 39C. So we must do implementation is check his temperature. After that, we can compress on his forehead and armpit with warm water according nail us. If the temperature not decrease, we can give his a paracetamol 1x500 mg. Dont forget to advise wearing thin clothes that absorb sweat and drink much water. We always too to observation of vital signs, especially temperature and pulse by 1 hours. After the intervention client was found look better condition, the problem is resolved and the intervention is stopped.

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CHAPTER V CONCLUSION
HIV is a virus that enters the human body through body fluids (blood, semen, vaginal fluid and breast milk) and damage to the immune system or the durability of the body so that the man lost his durability and easily affected by the disease. AIDS Acquired, it means to come by because of the spread and be transmitted from one person to another. Immunno-Deficiency, it means a decrease in or loss of immunity/durability of the body to fight the disease. AIDS are symptoms of the disease because of the decline in the body's durability. The durability of the body that are reduced or lost due to already undermined by the HIV virus. The cause is the retro virus, called human immunodeficiency virus (HIV). HIV can be transmitted through: sexual transmission, perinatal transmission, blood transmission. You dont have a risk of becoming infected with the virus by saliva or shaking hands. The transmission of HIV infection and AIDS consists of five phases, namely: the window Period (no symptoms), acute phase of primary HIV infection, the infection is asymptomatic, immune Suppression is symptomatic (fever, night sweats, the diarrhea, the neuropathy, weakness, rash) and last is AIDS (it brings the infection and tumor weight opportunist on the various system of the body, and the manifestation of the neurologist). The complication of HIV/AIDS are pneumonia, some cancers, such as kaposi's sarcoma, invasive cervical cancer, lung cancer, rectal carcinomas and etc. Tests for the diagnosis of HIV infection are ELISA, western blot, P24 antigen test and additional tests, these additional tests include complete urinalysis, tests of feces, liver function (sgot/sgpt), alkaline phosphatase, kidney function (ureum/creatinin) etc. HIV/AIDS is a world epidemic. Although we are making new advances in combating this virus, there are many new infections every year. The best way to keep yourself safe is to stay
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informed. You should know what how it spreads and how to prevent it. You should take a HIV/AIDS test if you are involved in any risky behaviors. You should tell others the importance of getting tested and prevention. There is no cure for this virus, so there is no room for ignorance on this matter.

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