13 AIDS (HIV Positive) Nursing Care Plans

Acquired immunodeficiency syndrome (AIDS) is a serious secondary

immunodeficiency disorder caused by the retrovirus, human immunodeficiency virus
(HIV). Both diseases are characterized by the progressive destruction of cell-mediated
(T-cell) immunity with subsequent effects on humoral (B-cell) immunity because of the
pivotal role of the CD4+helper T cells in immune reactions. Immunodeficiency makes
the patient susceptible to opportunistic infections, unusual cancers, and other
abnormalities.
AIDS results from the infection of HIV which has two forms: HIV-1 and HIV-2. Both
forms have the same model of transmission and similar opportunistic infections
associated with AIDS, but studies indicate that HIV-2 develops more slowly and
presents with milder symptoms than HIV-1. Transmission occurs through contact with
infected blood or body fluids and is associated with identifiable high-risk behaviors.
Persons with HIV/AIDS have been found to fall into five general categories: (1)
homosexual or bisexual men, (2) injection drug users, (3) recipients of infected blood
or blood products, (4) heterosexual partners of a person with HIV infection, and (5)
children born to an infected mother. The rate of infection is most rapidly increasing
among minority women and is increasingly a disease of persons of color.

Nursing Care Plans

There is no cure yet for either HIV or AIDS. However, significant advances have been
made to help patients control signs and symptoms and impair disease progression. In
this post, are 13 AIDS/HIV Positive Nursing Care Plans (NCP).
Diagnostic Studies

Confirming Diagnosis: Signs and symptoms may occur at any time after
infection, but AIDS isnt officially diagnosed until the patients CD4+ T-cell
count falls below 200 cells/mcl or associated clinical conditions or disease.

CBC: Anemia and idiopathic thrombocytopenia (anemia occurs in up to 85%

of patients with AIDS and may be profound). Leukopenia may be present;
differential shift to the left suggests infectious process (PCP), although shift to
the right may be noted.

PPD: Determines exposure and/or active TB disease. Of AIDS patients, 100%

of those exposed to active Mycobacterium tuberculosis will develop the
disease.

Serologic: Serum antibody test: HIV screen by ELISA. A positive test result
may be indicative of exposure to HIV but is not diagnostic because falsepositives may occur.

Western blot test: Confirms diagnosis of HIV in blood and urine.

Viral load test:

o

RI-PCR: The most widely used test currently can detect viral RNA
levels as low as 50 copies/mL of plasma with an upper limit of
75,000 copies/mL.

bDNA 3.0 assay: Has a wider range of 50500,000 copies/mL.

Therapy can be initiated, or changes made in treatment approaches,
based on rise of viral load or maintenance of a low viral load. This is
currently the leading indicator of effectiveness of therapy.

T-lymphocyte cells: Total count reduced.

CD4+ lymphocyte count (immune system indicator that mediates

several immune system processes and signals B cells to produce
antibodies to foreign germs): Numbers less than 200 indicate severe
immune deficiency response and diagnosis of AIDS.

T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or

higher) of suppressor cells to helper cells (T8+ to T4+) indicates
immune suppression.

Polymerase chain reaction (PCR) test: Detects HIV-DNA; most

helpful in testing newborns of HIV-infected mothers. Infants carry
maternal HIV antibodies and therefore test positive by ELISA and
Western blot, even though infant is not necessarily infected.

STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and
other common STDs may be positive.

Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid,

lesions, sputum, and secretions may be done to identify the opportunistic
infection. Some of the most commonly identified are the following:
o

Protozoal and helminthic infections: PCP, cryptosporidiosis,

toxoplasmosis.

Fungal infections: Candida albicans (candidiasis), Cryptococcus

neoformans (cryptococcus), Histoplasma
capsulatum (histoplasmosis).

Bacterial infections: Mycobacterium avium-intracellulare (occurs

with CD4 counts less than 50), miliary mycobacterial
TB, Shigella (shigellosis),Salmonella (salmonellosis).

Viral infections: CMV (occurs with CD4 counts less than 50), herpes
simplex, herpes zoster.

Neurological studies, e.g., electroencephalogram (EEG), magnetic

resonance imaging (MRI), computed tomography (CT) scans of the
brain; electromyography (EMG)/nerve conduction studies: Indicated
for changes in mentation, fever of undetermined origin, and/or changes in
sensory/motor function to determine effects of HIV infection/opportunistic
infections.

Chest x-ray: May initially be normal or may reveal progressive interstitial

infiltrates secondary to advancing PCP (most common opportunistic disease)
or other pulmonary complications/disease processes such as TB.

Pulmonary function tests: Useful in early detection of interstitial

pneumonias.

Gallium scan: Diffuse pulmonary uptake occurs in PCP and other forms of
pneumonia.

Biopsies: May be done for differential diagnosis of Kaposis sarcoma (KS) or

other neoplastic lesions.

Bronchoscopy/tracheobronchial washings: May be done with biopsy

when PCP or lung malignancies are suspected (diagnostic confirming test for
PCP).

Barium swallow, endoscopy, colonoscopy: May be done to identify

opportunistic infection (e.g., Candida, CMV) or to stage KS in the GI system.

Nursing Priorities
1. Prevent/minimize development of new infections.
2. Maintain homeostasis.
3. Promote comfort.
4. Support psychosocial adjustment.
5. Provide information about disease process/prognosis and treatment needs.
Discharge Goals

1. Infection prevented/resolved.
2. Complications prevented/minimized.
3. Pain/discomfort alleviated or controlled.
4. Patient dealing with current situation realistically.
5. Diagnosis, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.

1. Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

Imbalanced Nutrition: Less Than Body Requirements

May be related to

Inability or altered ability to ingest, digest and/or metabolize nutrients:

nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract
infections, fatigue

Increased metabolic rate/nutritional needs (fever/infection)

Possibly evidenced by

Weight loss, decreased subcutaneous fat/muscle mass (wasting)

Lack of interest in food, aversion to eating, altered taste sensation

Abdominal cramping, hyperactive bowel sounds, diarrhea

Sore, inflamed buccal cavity

Abnormal laboratory results: vitamin/mineral and protein deficiencies,

electrolyte imbalances

Desired Outcomes

Maintain weight or display weight gain toward desired goal.

Demonstrate positive nitrogen balance, be free of signs of malnutrition, and

display improved energy level.

Nursing Interventions

Rationale

Assess patients ability to chew, taste, and

Lesions of the mouth, throat, and

swallow.

esophagus (often caused by candidiasis,

herpes simplex, hairy leukoplakia, kaposis

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sarcoma other cancers) and metallic or
other taste changes caused by
medications may cause dysphagia, limiting
patients ability to ingest food and
reducing desire to eat.
Hypermotility of intestinal tract is common
and is associated with vomiting and
diarrhea, which may affect choice of

Auscultate bowel sounds.

diet/route. Lactose intolerance and

malabsorption (with CMV, MAC,
cryptosporidiosis) contribute to diarrhea
and may necessitate change in diet or
supplemental formula.

Weigh as indicated. Evaluate weight in

Indicator of nutritional adequacy of

terms of premorbid weight. Compare

intake. Because of depressed immunity,

serial weights and anthropometric

some blood tests normally used for testing

measurements.

nutritional status are not useful.

Medications used can have side effects
affecting nutrition. ZDV can cause altered
taste, nausea and vomiting; Bactrim can

Note drug side effects.

cause anorexia, glucose intolerance and

glossitis; Pentam can cause altered taste
and smell; Protease inhibitors can cause
elevated lipids, blood sugar increase due
to insulin resistance.

Plan diet with patient and include SO,

Including patient in planning gives sense

suggesting foods from home if

of control of environment and may

appropriate. Provide small, frequent meals

enhance intake. Fulfilling cravings for

and snacks of nutritionally dense foods

noninstitutional food may also improve

and non acidic foods and beverages, with

intake. In this population, foods with a

choice of foods palatable to patient.

higher fat content may be recommended

Encourage high-calorie and nutritious

as tolerated to enhance taste and oral

foods, some of which may be considered

intake.

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appetite stimulants. Note time of day

when appetite is best, and try to serve
larger meal at that time.
Limit food(s) that induce nausea and/or
vomiting or are poorly tolerated by patient

Pain in the mouth or fear of irritating oral

because of mouth sores or dysphagia.

lesions may cause patient to be reluctant

Avoid serving very hot liquids and foods.

to eat. These measures may be helpful in

Serve foods that are easy to swallow like

increasing food intake.

eggs, ice cream, cooked vegetables.

Schedule medications between meals (if
tolerated) and limit fluid intake with
meals, unless fluid has nutritional value.

Gastric fullness diminishes appetite and

food intake.

Encourage as much physical activity as

May improve appetite and general feelings

possible.

of well-being.
Reduces discomfort associated with

Provide frequent mouth care, observing

nausea and vomiting, oral lesions,

secretion precautions. Avoid alcohol-

mucosal dryness, and halitosis. Clean

containing mouthwashes.

mouth may enhance appetite and provide

comfort.

Provide rest period before meals. Avoid

stressful procedures close to mealtime.
Remove existing noxious environmental
stimuli or conditions that aggravate gag
reflex.
Encourage patient to sit up for meals

Record ongoing caloric intake.

Maintain NPO status when appropriate.

Insert or maintain nasogastric (NG) tube

Minimizes fatigue; increases energy

available for work of eating and reduces
chances of nausea or vomiting food.
Reduces stimulus of the vomiting center in
the medulla.
Facilitates swallowing and reduces risk of
aspiration.
Identifies need for supplements or
alternative feeding methods.
May be needed to reduce nausea and
vomiting.
May be needed to reduce vomiting or to

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administer tube feedings. Esophageal
irritation from existing infection (Candida,

as indicated.

herpes, or KS) may provide site for

secondary infections and trauma;
therefore, NG tube should be used with
caution.

Administer medications as indicated:

Antiemetics: prochlorperazine
(Compazine), promethazine (Phenergan),
trimethobenzamide (Tigan)

Reduces incidence of nausea and vomiting,

possibly enhancing oral intake.
Given with meals (swish and hold in

Sucralfate (Carafate) suspension; mixture

mouth) to relieve mouth pain, enhance

of Maalox, diphenhydramine (Benadryl),

intake. Mixture may be swallowed for

and lidocaine (Xylocaine);

presence of pharyngeal or esophageal

lesions.
Corrects vitamin deficiencies resulting
from decreased food intake and/or

Vitamin supplements

disorders of digestion and absorption in

the GI system. Avoid megadoses and
suggested supplemental level is two times
the recommended daily allowance (RDA).
Marinol (an antiemetic) and Megace (an

Appetite stimulants: dronabinol

(Marinol), megestrol (Megace),
oxandrolone (Oxandrin)

antineoplastic) act as appetite stimulants

in the presence of AIDS. Oxandrin is
currently being studied in clinical trials to
boost appetite and improve muscle mass
and strength.
Reduces elevated levels of tumor necrosis
factor (TNF) present in chronic illness

TNF-alpha inhibitors: thalidomide;

contributing to wasting or cachexia.

Studies reveal a mean weight gain of 10%
over 28 wk of therapy.

Antidiarrheals: diphenoxylate (Lomotil),

Inhibit GI motility subsequently decreasing

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diarrhea. Imodium or Sandostatin are

loperamide (Imodium), octreotide

effective treatments for secretory diarrhea

(Sandostatin);

(secretion of water and electrolytes by

intestinal epithelium).

Antibiotic therapy: ketoconazole

May be given to treat and prevent

(Nizoral), fluconazole (Diflucan).

infections involving the GI tract.

2. Fatigue
Nursing Diagnosis

Fatigue

May be related to

Decreased metabolic energy production, increased energy requirements

(hypermetabolic state)

Overwhelming psychological/emotional demands

Altered body chemistry: side effects of medication, chemotherapy

Possibly evidenced by

Unremitting/overwhelming lack of energy, inability to maintain usual routines,

decreased performance, impaired ability to concentrate, lethargy/listlessness

Disinterest in surroundings

Desired Outcomes

Report improved sense of energy.

Perform ADLs, with assistance as necessary.

Participate in desired activities at level of ability

Nursing Interventions

Rationale
Multiple factors can aggravate fatigue,

Assess sleep patterns and note changes in

thought processes and behavior.

including sleep deprivation, emotional

distress, side effects of drugs and
chemotherapies, and developing CNS
disease.

Nursing Interventions
Recommend scheduling activities for
periods when patient has most energy.
Plan care to allow for rest periods. Involve
patient and SO in schedule planning.

Rationale
Planning allows patient to be active during
times when energy level is higher, which
may restore a feeling of well-being and a
sense of control. Frequent rest periods are
needed to restore or conserve energy.
Provides for a sense of control and feelings

Establish realistic activity goals with

of accomplishment. Prevents

patient.

discouragement from fatigue of

overactivity.

Encourage patient to do whatever

possible: self-care, sit in chair, short
walks. Increase activity level as indicated.

May conserve strength, increase stamina,

and enable patient to become more active
without undue fatigue and
discouragement.

Identify energy conservation techniques:

sitting, breaking ADLs into manageable

Weakness may make ADLs almost

segments. Keep travelways clear of

impossible for patient to complete.

furniture. Provide or assist with

Protects patient from injury during

ambulation and self-care needs as

activities.

appropriate.
Tolerance varies greatly, depending on the
Monitor physiological response to

stage of the disease process, nutrition

activity: changes in BP, respiratory rate, or

state, fluid balance, and number or type of

heart rate.

opportunistic diseases that patient has

been subject to.
Adequate intake or utilization of nutrients
is necessary to meet increased energy

Encourage nutritional intake.

needs for activity. Continuous stimulation

of the immune system by HIV infection
contributes to a hypermetabolic state.
Programmed daily exercises and activities

Refer to physical and/or occupational

help patient maintain and increase

therapy.

strength and muscle tone, enhance sense

of well-being.

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Provides assistance in areas of individual

Refer to community resources

need as ability to care for self becomes

more difficult.
Presence of anemia or hypoxemia reduces

Provide supplemental O2 as indicated.

oxygen available for cellular uptake and

contributes to fatigue.

3. Acute/Chronic Pain
Nursing Diagnosis

Acute/Chronic Pain

May be related to

Tissue inflammation/destruction: infections, internal/external cutaneous

lesions, rectal excoriation, malignancies, necrosis

Peripheral neuropathies, myalgias, and arthralgias

Abdominal cramping

Possibly evidenced by

Reports of pain

Self-focusing; narrowed focus, guarding behaviors

Alteration in muscle tone; muscle cramping, ataxia, muscle weakness,

paresthesias, paralysis

Autonomic responses; restlessness

Desired Outcomes

Report pain relieved/controlled.

Demonstrate relaxed posture/facial expression.

Be able to sleep/rest appropriately.

Nursing Interventions

Rationale

Assess pain reports, noting location,

Indicates need for or effectiveness of

intensity (010 scale), frequency, and

interventions and may signal development

time of onset. Note nonverbal cues like

or resolution of complications. Chronic

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pain does not produce autonomic

restlessness, tachycardia, grimacing.

changes; however, acute and chronic pain

can coexist.

Instruct and encourage patient to report

Efficacy of comfort measures and

pain as it develops rather than waiting

medications is improved with timely

until level is severe.

intervention.

Encourage verbalization of feelings.

Provide diversional activities: provide
reading materials, light exercising,
visiting, etc.

Can reduce anxiety and fear and thereby

reduce perception of intensity of pain.
Refocuses attention; may enhance coping
abilities.

Perform palliative measures: repositioning,

Promotes relaxation and decreases muscle

massage, ROM of affected joints.

tension.
Promotes relaxation and feeling of wellbeing. May decrease the need for narcotic

Instruct and encourage use of

analgesics (CNS depressants) when a

visualization, guided imagery, progressive

neuro/motor degenerative process is

relaxation, deep-breathing techniques,

already involved. May not be successful in

meditation, and mindfulness.

presence of dementia, even when

dementia is minor. Mindfulness is the skill
of staying in the here and now.

Provide oral care.

Apply warm or moist packs to pentamidine
injection and IV sites for 20 min after
administration.

Oral ulcerations and lesions may cause

severe discomfort.
These injections are known to cause pain
and sterile abscesses

Administer analgesics and/or antipyretics,

Provides relief of pain and discomfort;

narcotic analgesics. Use patient-controlled

reduces fever. PCA or around-the-clock

analgesia (PCA) or provide around-the-

medication keeps the blood level of

clock analgesia with rescue doses prn.

analgesia stable, preventing cyclic

undermedication or overmedication. Drugs
such as Ativan may be used to potentiate

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effects of analgesics.

4. Impaired Skin Integrity

Nursing Diagnosis

Impaired Skin Integrity

Risk factors may include

Decreased level of activity/immobility, altered sensation, skeletal prominence,

changes in skin turgor

Malnutrition, altered metabolic state

May be related to (actual)

Immunologic deficit: AIDS-related dermatitis; viral, bacterial, and fungal

infections (e.g., herpes, Pseudomonas, Candida); opportunistic disease
processes (e.g., KS)

Excretions/secretions

Possibly evidenced by

Skin lesions; ulcerations; decubitus ulcer formation

Desired Outcomes

Be free of/display improvement in wound/lesion healing.

Demonstrate behaviors/techniques to prevent skin breakdown/promote

healing.

Nursing Interventions

Rationale

Assess skin daily. Note color, turgor,

circulation, and sensation. Describe and

Establishes comparative baseline providing

measure lesions and observe changes.

opportunity for timely intervention.

Take photographs if necessary.

Maintain and instruct in good skin

Maintaining clean, dry skin provides a

hygiene: wash thoroughly, pat dry

barrier to infection. Patting skin dry

carefully, and gently massage with lotion

instead of rubbing reduces risk of dermal

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trauma to dry and fragile skin. Massaging
increases circulation to the skin and

or appropriate cream.

promotes comfort. Isolation precautions

are required when extensive or open
cutaneous lesions are present.

Reposition frequently. Use turn sheet as

needed. Encourage periodic weight shifts.
Protect bony prominences with pillows,
heel and elbow pads, sheepskin.
Maintain clean, dry, wrinkle-free linen,
preferably soft cotton fabric.

Encourage ambulation as tolerated.

Reduces stress on pressure points,

improves blood flow to tissues, and
promotes healing.
Skin friction caused by wet or wrinkled or
rough sheets leads to irritation of fragile
skin and increases risk for infection.
Decreases pressure on skin from
prolonged bedrest.

Cleanse perianal area by removing stool

with water and mineral oil or commercial

Prevents maceration caused by diarrhea

product. Avoid use of toilet paper if

and keeps perianal lesions dry. Use of

vesicles are present. Apply protective

toilet paper may abrade lesions.

creams: zinc oxide, A & D ointment.

File nails regularly.
Cover open pressure ulcers with sterile
dressings or protective barrier: Tegaderm,
DuoDerm, as indicated.

Long and rough nails increase risk of

dermal damage.
May reduce bacterial contamination,
promote healing.

Provide foam, flotation, alternate pressure

Reduces pressure on skin, tissue, and

mattress or bed.

lesions, decreasing tissue ischemia.

Obtain cultures of open skin lesions.

Identifies pathogens and appropriate

treatment choices.

Apply and administer medications as

Used in treatment of skin lesions. Use of

indicated.

agents such as Prederm spray can

stimulate circulation, enhancing healing
process. When multidose ointments are

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used, care must be taken to avoid crosscontamination.

Cover ulcerated KS lesions with wet-towet dressings or antibiotic ointment and

nonstick dressing, as indicated.

Protects ulcerated areas from

contamination and promotes healing

Refer to physical therapy for regular

Promotes improved muscle tone and skin

exercise and activity program.

health.

5. Impaired Oral Mucous Membrane

Nursing Diagnosis

Impaired Oral Mucous Membrane

May be related to

Immunologic deficit and presence of lesion-causing pathogens, e.g., Candida,

herpes, KS

Dehydration, malnutrition

Ineffective oral hygiene

Side effects of drugs, chemotherapy

Possibly evidenced by

Open ulcerated lesions, vesicles

Oral pain/discomfort

Stomatitis; leukoplakia, gingivitis, carious teeth

Desired Outcomes

Display intact mucous membranes, which are pink, moist, and free of
inflammation/ulcerations.

Demonstrate techniques to restore/maintain integrity of oral mucosa.

Nursing Interventions

Rationale

Assess mucous membranes and document

Edema, open lesions, and crusting on oral

all oral lesions. Note reports of pain,

mucous membranes and throat may cause

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swelling, difficulty with chewing and

pain and difficulty with chewing and

swallowing.

swallowing.

Provide oral care daily and after food

Alleviates discomfort, prevents acid

intake, using soft toothbrush, non abrasive

formation associated with retained food

toothpaste, non alcohol mouthwash, floss,

particles, and promotes feeling of well-

and lip moisturizer.

being.

Rinse oral mucosal lesions with saline and

Reduces spread of lesions and

dilute hydrogen peroxide or baking soda

encrustations from candidiasis, and

solutions.

promotes comfort.

Suggest use of sugarless gum and candy.

Plan diet to avoid salty, spicy, abrasive,

and acidic foods or beverages. Check for
temperature tolerance of foods. Offer cool
or cold smooth foods.

Stimulates flow of saliva to neutralize

acids and protect mucous membranes.
Abrasive foods may open healing lesions.
Open lesions are painful and aggravated
by salt, spice, acidic foods or beverages.
Extreme cold or heat can cause pain to
sensitive mucous membranes.

Encourage oral intake of at least 2500

Maintains hydration and prevents drying of

mL/day.

oral cavity.

Encourage patient to refrain from

Smoke is drying and irritating to mucous

smoking.

membranes.

Obtain culture specimens of lesions.

Administer medications, as
indicated: nystatin (Mycostatin),
ketoconazole (Nizoral).
TNF-alpha inhibitor, e.g., thalidomide.

Reveals causative agents and identifies

appropriate therapies.
Specific drug choice depends on particular
infecting organism(s) like Candida.
Effective in treatment of oral lesions due
to recurrent stomatitis.

Refer for dental consultation, if

May require additional therapy to prevent

appropriate.

dental losses.

6. Disturbed Thought Process

Nursing Diagnosis

Disturbed Thought Process

May be related to

Hypoxemia, CNS infection by HIV, brain malignancies, and/or disseminated

systemic opportunistic infection, cerebrovascular accident (CVA)/hemorrhage;
vasculitis

Alteration of drug metabolism/excretion, accumulation of toxic elements;

renal failure, severe electrolyte imbalance, hepatic insufficiency

Possibly evidenced by

Altered attention span; distractibility

Memory deficit

Disorientation; cognitive dissonance; delusional thinking

Sleep disturbances

Impaired ability to make decisions/problem-solve; inability to follow complex

commands/mental tasks, loss of impulse control

Desired Outcomes

Maintain usual reality orientation and optimal cognitive functioning.

Nursing Interventions
Assess mental and neurological status
using appropriate tools.

Rationale
Establishes functional level at time of
admission and provides baseline for future
comparison.
May contribute to reduced alertness,

Consider effects of emotional distress.

confusion, withdrawal, and hypoactivity,

Assess for anxiety, grief, anger.

requiring further evaluation and

intervention.

Monitor medication regimen and usage.

Actions and interactions of various

medications, prolonged drug half-life
and/or altered excretion rates result in
cumulative effects, potentiating risk of
toxic reactions. Some drugs may have
adverse side effects: haloperidol (Haldol)

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can seriously impair motor function in
patients with AIDS dementia complex.

Investigate changes in personality,

response to stimuli, orientation and level
of consciousness; or development of
headache, nuchal rigidity, vomiting, fever,
seizure activity.

Changes may occur for numerous reasons,

including development or exacerbation of
opportunistic diseases or CNS infection.
Early detection and treatment of CNS
infection may limit permanent impairment
of cognitive ability.

Maintain a pleasant environment with

Providing normal environmental stimuli

appropriate auditory, visual, and cognitive

can help in maintaining some sense of

stimuli.

reality orientation.

Provide cues for reorientation. Put radio,

television, calendars, clocks, room with an

Frequent reorientation to place and time

outside view if necessary. Use patients

may be necessary, especially during fever

name. Identify yourself. Maintain

and/or acute CNS involvement. Sense of

consistent personnel and structured

continuity may reduce associated anxiety.

schedules as appropriate.
Discuss use of datebooks, lists, other

These techniques help patient manage

devices to keep track of activities.

problems of forgetfulness.

Encourage family and SO to socialize and

Familiar contacts are often helpful in

provide reorientation with current news,

maintaining reality orientation, especially

family events.

if patient is hallucinating.

Encourage patient to do as much as

possible: dress and groom daily, see
friends, and so forth.

Can help maintain mental abilities for

longer period.
Bizarre behavior and/or deterioration of
abilities may be very frightening for SO

Provide support for SO. Encourage

discussion of concerns and fears

and makes management of care or dealing

with situation difficult. SO may feel a loss
of control as stress, anxiety, burnout, and
anticipatory grieving impair coping
abilities.

Nursing Interventions

Rationale

Provide information about care on an

Can reduce anxiety and fear of unknown.

ongoing basis. Answer questions simply

Can enhance patients understanding and

and honestly. Repeat explanations as

involvement and cooperation in treatment

needed.

when possible.

Reduce provocative and noxious stimuli.

If patient is prone to agitation, violent

Maintain bed rest in quiet, darkened room

behavior, or seizures, reducing external

if indicated.

stimuli may be helpful.

Decrease noise, especially at night.

Promotes sleep, reducing cognitive

symptoms and effects of sleep deprivation.

Maintain safe environment: excess

furniture out of the way, call bell within
patients reach, bed in low position and

Provides sense of security and stability in

rails up; restriction of smoking (unless

an otherwise confusing situation.

monitored by caregiver/SO), seizure

precautions, soft restraints if indicated.
Discuss causes or future expectations and

Obtaining information that ZDV has been

treatment if dementia is diagnosed. Use

shown to improve cognition can provide

concrete terms.

hope and control for losses.

Administer medications as indicated:

Effective in treatment of oral lesions due

Antifungal useful in treatment of

to recurrent stomatitis.

cryptococcal meningitis.

ZDV (Retrovir) and other antiretrovirals

alone or in combination

Antipsychotics: haloperidol (Haldol),

and/or antianxiety
agents: lorazepam(Ativan).

Shown to improve neurological and mental

functioning for undetermined period of
time.
Cautious use may help with problems of
sleeplessness, emotional lability,
hallucinations, suspiciousness, and
agitation.
May help patient gain control in presence

Refer to counseling as indicated.

of thought disturbances or psychotic

symptomatology.

7. Anxiety/Fear
Nursing Diagnosis

Anxiety

Fear

May be related to

Threat to self-concept, threat of death, change in health/socioeconomic

status, role functioning

Interpersonal transmission and contagion

Separation from support system

Fear of transmission of the disease to family/loved ones

Possibly evidenced by

Increased tension, apprehension, feelings of helplessness/hopelessness

Expressed concern regarding changes in life

Fear of unspecific consequences

Somatic complaints, insomnia; sympathetic stimulation, restlessness

Desired Outcomes

Verbalize awareness of feelings and healthy ways to deal with them.

Display appropriate range of feelings and lessened fear/anxiety.

Demonstrate problem-solving skills.

Use resources effectively.

Nursing Interventions
Assure patient of confidentiality within
limits of situation.

Rationale
Provides reassurance and opportunity for
patient to problem-solve solutions to
anticipated situations.

Maintain frequent contact with patient.

Provides assurance that patient is not

Talk with and touch patient. Limit use of

alone or rejected; conveys respect for and

isolation clothing and masks.

acceptance of the person, fostering trust.

Provide accurate, consistent information

Can reduce anxiety and enable patient to

regarding prognosis. Avoid arguing about

make decisions and choices based on

patients perceptions of the situation.

realities.

Nursing Interventions

Rationale
Patient may use defense mechanism of
denial and continue to hope that diagnosis

Be alert to signs of withdrawal, anger, or

inappropriate remarks as these can be
signs of indenial or depression. Determine
presence of suicidal ideation and assess
potential on a scale of 110.

is inaccurate. Feelings of guilt and spiritual

distress may cause patient to become
withdrawn and believe that suicide is a
viable alternative. Although patient may
be too sick to have enough energy to
implement thoughts, ideation must be
taken seriously and appropriate
intervention initiated.

Provide open environment in which patient

Helps patient feel accepted in present

feels safe to discuss feelings or to refrain

condition without feeling judged, and

from talking.

promotes sense of dignity and control.

Permit expressions of anger, fear, despair

without confrontation. Give information

Acceptance of feelings allows patient to

that feelings are normal and are to be

begin to deal with situation.

appropriately expressed.
Recognize and support the stage patient

Choice of interventions as dictated by

and/or family is at in the grieving process.

stage of grief, coping behaviors

Explain procedures, providing opportunity

for questions and honest answers. Arrange
for someone to stay with patient during
anxiety-producing procedures and
consultations.
Identify and encourage patient interaction
with support systems. Encourage
verbalization and interaction with
family/SO.

Accurate information allows patient to deal

more effectively with the reality of the
situation, thereby reducing anxiety and
fear of the known.

Reduces feelings of isolation. If family

support systems are not available, outside
sources may be needed immediately

Provide reliable and consistent information

Allows for better interpersonal interaction

and support for SO.

and reduction of anxiety and fear.

Include SO as indicated when major

Ensures a support system for patient, and

decisions are to be made.

allows SO the chance to participate in

patients life. If patient, family, and SO are

Nursing Interventions

Rationale
in conflict, separate care consultations and
visiting times may be needed.

Discuss Advance Directives, end-oflifedesires or needs. Review specific

wishes and explain various options clearly.

May assist patient or SO to plan

realistically for terminal stages and death.
Many individuals do not understand
medical terminology or options,

Refer to psychiatric counseling (psychiatric

May require further assistance in dealing

clinical nurse specialist, psychiatrist, social

with diagnosis or prognosis, especially

worker).

when suicidal thoughts are present.

Provides opportunity for addressing

Provide contact with other resources as

spiritual concerns. May help relieve

indicated: Spiritual advisor or hospice staff

anxiety regarding end-of-life care and

support for patient/SO.

8. Social Isolation
Nursing Diagnosis

Social Isolation

May be related to

Altered state of wellness, changes in physical appearance, alterations in

mental status

Perceptions of unacceptable social or sexual behavior/values

Inadequate personal resources/support systems

Physical isolation

Possibly evidenced by

Expressed feeling of aloneness imposed by others, feelings of rejection

Absence of supportive SO: partners, family, acquaintances/friends

Desired Outcomes

Identify supportive individual(s).

Use resources for assistance.

Participate in activities/programs at level of ability/desire.

Nursing Interventions

Rationale
Isolation may be partly self-imposed

Ascertain patients perception of situation.

because patient fears rejection/reaction of

others.

Spend time talking with patient during and

Patient may experience physical isolation

between care activities. Be supportive,

as a result of current medical status and

allowing for verbalization. Treat with

some degree of social isolation secondary

dignity and regard for patients feelings.

to diagnosis of AIDS.

Limit or avoid use of mask, gown, and

gloves when possible and when talking to
patient.

Reduces patients sense of physical

isolation and provides positive social
contact, which may enhance self-esteem
and decrease negative behaviors.
When patient has assistance from SO,

Identify support systems available to

patient, including presence of and/or
relationship with immediate and extended
family.

feelings of loneliness and rejection are

diminished. Patient may not receive usual
or needed support for coping with lifethreatening illness and associated grief
because of fear and lack of understanding
(AIDS hysteria).
Gloves, gowns, mask are not routinely
required with a diagnosis of AIDS except
when contact with secretions or excretions
is expected. Misuse of these barriers

Explain isolation precautions and

enhances feelings of emotional and

procedures to patient and SO.

physical isolation. When precautions are

necessary, explanations help patient
understand reasons for procedures and
provide feeling of inclusion in what is
happening.

Encourage open visitation (as able),

telephone contacts, and social activities
within tolerated level.
Encourage active role of contact with SO.

Participation with others can foster a

feeling of belonging.
Helps reestablish a feeling of participation

Nursing Interventions

Rationale
in a social relationship. May lessen
likelihood of suicide attempts.

Develop a plan of action with patient: Look

at available resources; support healthy
behaviors. Help patient problem-solve
solution to short-term or imposed
isolation.

Having a plan promotes a sense of control

over own life and gives patient something
to look forward to and actions to
accomplish.
Indicators of despair and suicidal ideation

Be alert to verbal or nonverbal cues:

are often present; when these cues are

withdrawal, statements of despair, sense

acknowledged by the caregiver, patient is

of aloneness. Ask patient if thoughts of

usually willing to talk about thoughts of

suicide are being entertained.

suicide and sense of isolation and

hopelessness.

9. Powerlessness
Nursing Diagnosis

Powerlessness

May be related to

Confirmed diagnosis of a potentially terminal disease, incomplete grieving

process

Social ramifications of AIDS; alteration in body image/desired lifestyle;

advancing CNS involvement

Possibly evidenced by

Feelings of loss of control over own life

Depression over physical deterioration that occurs despite patient compliance

with regimen

Anger, apathy, withdrawal, passivity

Dependence on others for care/decision making, resulting in resentment,

anger, guilt

Desired Outcomes

Acknowledge feelings and healthy ways to deal with them.

Verbalize some sense of control over present situation.

Make choices related to care and be involved in self-care.

Nursing Interventions

Rationale
Patients with AIDS are usually aware of
the current literature and prognosis unless
newly diagnosed. Powerlessness is most
prevalent in a patient newly diagnosed

Identify factors that contribute to patients

with HIV and when dying with AIDS. Fear

feelings of powerlessness: diagnosis of a

of AIDS (by the general population and

terminal illness, lack of support systems,

the patients family/SO) is the most

lack of knowledge about present situation.

profound cause of patients isolation. For

some homosexual patients, this may be
the first time that the family has been
made aware that patient lives an
alternative lifestyle.

Assess degree of feelings of

Determines the status of the individual

helplessness: verbal or nonverbal

patient and allows for appropriate

expressions indicating lack of control, flat

intervention when patient is immobilized

affect, lack of communication.

by depressed feelings.

Encourage active role in planning

activities, establishing realistic and
attainable daily goals. Encourage patient

May enhance feelings of control and self-

control and responsibility as much as

worth and sense of personal responsibility.

possible. Identify things that patient can

and cannot control.
Many factors associated with the
Encourage Living Will and durable medical
power of attorney documents, with specific
and precise instructions regarding
acceptable and unacceptable procedures
to prolong life.

treatments used in this debilitating and

often fatal disease process place patient at
the mercy of medical personnel and other
unknown people who may be making
decisions for and about patient without
regard for patients wishes, increasing loss
of independence.

Nursing Interventions

Rationale
The individual can gain a sense of
completion and value to his or her life

Discuss desires and assist with planning

when he or she decides to be involved in

for funeral as appropriate.

planning this final ceremony. This provides

an opportunity to include things that are
of importance to the person.

10. Deficient Knowledge

Nursing Diagnosis

Deficient Knowledge

May be related to

Lack of exposure/recall; information misinterpretation

Cognitive limitation

Unfamiliarity with information resources

Possibly evidenced by

Questions/request for information; statement of misconception

Inaccurate follow-through of instructions, development of preventable

complications

Desired Outcomes

Verbalize understanding of condition/disease process and potential

complications.

Identify relationship of signs/symptoms to the disease process and correlate

symptoms with causative factors.

Verbalize understanding of therapeutic needs.

Correctly perform necessary procedures and explain reasons for actions.

Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing Interventions

Rationale

Review disease process and future

Provides knowledge base from which

expectations.

patient can make informed choices.

Nursing Interventions

Rationale

Determine level of independence or

dependence and physical condition. Note

Helps plan amount of care and symptom

extent of care and support available from

management required and need for

family and SO and need for other

additional resources.

caregivers.
Corrects myths and misconceptions;
Review modes of transmission of disease,
especially if newly diagnosed.

promotes safety for patient and others.

Accurate epidemiological data are
important in targeting prevention
interventions.

Instruct patient and caregivers concerning

infection control, using good handwashing
techniques for everyone (patient, family,
caregivers); using gloves when handling
bedpans, dressings or soiled linens;
wearing mask if patient has productive
cough; placing soiled or wet linens in

Reduces risk of transmission of diseases;

plastic bag and separating from family

promotes wellness in presence of reduced

laundry, washing with detergent and hot

ability of immune system to control level

water; cleaning surfaces with bleach and

of flora.

water solution of 1:10 ratio, disinfecting

toilet bowl and bedpan with full-strength
bleach; preparing patients food in clean
area; washing dishes and utensils in hot
soapy water (can be washed with the
family dishes).
Stress necessity of daily skin care,
including inspecting skin folds, pressure

Healthy skin provides barrier to infection.

points, and perineum, and of providing

Measures to prevent skin disruption and

adequate cleansing and protective

associated complications are critical.

measures: ointments, padding.

Ascertain that patient or SO can perform

The oral mucosa can quickly exhibit

necessary oral and dental care. Review

severe, progressive complications. Studies

Nursing Interventions

Rationale
indicate that 65% of AIDS patients have

procedures as indicated. Encourage

some oral symptoms. Therefore,

regular dental care.

prevention and early intervention are

critical.

Review dietary needs (high-protein and

high-calorie) and ways to improve intake
when anorexia, diarrhea, weakness,
depression interfere with intake.
Discuss medication regimen, interactions,
and side effects

Promotes adequate nutrition necessary for

healing and support of immune system;
enhances feeling of well-being.
Enhances cooperation with or increases
probability of success with therapeutic
regimen.

Provide information about symptom

management that complements medical

Provides patient with increased sense of

regimen; with intermittent diarrhea, take

control, reduces risk of embarrassment,

diphenoxylate (Lomotil) before going to

and promotes comfort.

social event.
Stress importance of adequate rest.

Helps manage fatigue; enhances coping

abilities and energy level.

Encourage activity and exercise at level

Stimulates release of endorphins in the

that patient can tolerate.

brain, enhancing sense of well-being.

Stress necessity of continued healthcare

Provides opportunity for altering regimen

and follow-up.

to meet individual and changing needs.

Smoking increases risk of respiratory

Recommend cessation of smoking.

infections and can further impair immune

system.

Identify signs and symptoms requiring

medical evaluation: persistent fever and

Early recognition of developing

night sweats, swollen glands, continued

complications and timely interventions

weight loss, diarrhea, skin blotches and

may prevent progression to life-

lesions, headache, chest pain and

threatening situation.

dyspnea.
Identify community resources: hospice

Facilitates transfer from acute care setting

Nursing Interventions
and residential care centers, visiting
nurse, home care services, Meals on
Wheels, peer group support.

Rationale
for recovery/independence or end-of-life
care.

11. Risk for Injury

Nursing Diagnosis

Risk for Injury

Risk factors may include

Abnormal blood profile: decreased vitamin K absorption, alteration in hepatic

function, presence of autoimmune antiplatelet antibodies, malignancies (KS),
and/or circulating endotoxins (sepsis)

Desired Outcomes

Display homeostasis as evidenced by absence of bleeding.

Nursing Interventions

Rationale
Protects patient from procedure-related

Avoid injections, rectal temperatures and

rectal tubes. Administer rectal
suppositories with caution.

causes of bleeding: insertion of

thermometers, rectal tubes can damage or
tear rectal mucosa. Some medications
need to be given via suppository, so
caution is advised.

Maintain a safe environment. Keep all

necessary objects and call bell within

Reduces accidental injury, which could

patients reach and place bed in low

result in bleeding.

position.
Maintain bed rest or chair rest when
platelets are below 10,000 or as
individually appropriate. Assess
medication regimen.

Reduces possibility of injury, although

activity needs to be maintained. May need
to discontinue or reduce dosage of a drug.
Patient can have a surprisingly low platelet
count without bleeding.

Nursing Interventions
Hematest body fluids: urine, stool,
vomitus, for occult blood.

Rationale
Prompt detection of bleeding or initiation
of therapy may prevent critical
hemorrhage.

Observe for or report epistaxis,

Spontaneous bleeding may indicate

hemoptysis, hematuria, non menstrual

development of DIC or immune

vaginal bleeding, or oozing from lesions or

thrombocytopenia, necessitating further

body orifices and/or IV insertion sites.

evaluation and prompt intervention.

Monitor for changes in vital signs and skin

color: BP, pulse, respirations, skin pallor
and discoloration.
Evaluate change in level of consciousness.

Presence of bleeding and hemorrhage may

lead to circulatory failure and shock.
May reflect cerebral bleeding.
Detects alterations in clotting capability;

Review laboratory studies: PT, aPTT,

clotting time, platelets, Hb/Hct.

identifies therapy needs. Many individuals

(up to 80%) display platelet count below
50,000 and may be asymptomatic,
necessitating regular monitoring.
Transfusions may be required in the event

Administer blood products as indicated.

of persistent or massive spontaneous

bleeding.
These medications reduce platelet

Avoid use of aspirin products and NSAIDs,

especially in presence of gastric lesions.

aggregation, impairing and prolonging the

coagulation process, and may cause
further gastric irritation, increasing risk of
bleeding.

12. Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk for Deficient Fluid Volume

Risk factors may include

Excessive losses: copious diarrhea, profuse sweating, vomiting

Hypermetabolic state, fever

Restricted intake: nausea, anorexia; lethargy

Desired outcomes

Maintain hydration as evidenced by moist mucous membranes, good skin

turgor, stable vital signs, individually adequate urinary output.

Nursing Interventions

Rationale

Monitor vital signs, including CVP if

available. Note hypotension, including

Indicators of circulating fluid volume.

postural changes.
Note temperature elevation and duration
of febrile episode. Administer tepid sponge
baths as indicated. Keep clothing and
linens dry. Maintain comfortable
environmental temperature.
Assess skin turgor, mucous membranes,
and thirst.

Around 97%, fever is one of the most

frequent symptoms experienced by
patients with HIV infections. Increased
metabolic demands and associated
excessive diaphoresis result in increased
insensible fluid losses and dehydration.
Indirect indicators of fluid status.
Increased specific gravity and decreasing

Measure urinary output and specific

gravity. Measure and estimate amount of
diarrheal loss. Note insensible losses.

urinary output reflects altered renal

perfusion and circulating volume.
Monitoring fluid balance is difficult in the
presence of excessive GI and insensible
losses.
Although weight loss may reflect muscle
wasting, sudden fluctuations reflect state

Weigh as indicated.

of hydration. Fluid losses associated with

diarrhea can quickly create a crisis and
become life-threatening.

Monitor oral intake and encourage fluids of

Maintains fluid balance, reduces thirst, and

at least 2500 mL/day.

keeps mucous membranes moist.

Make fluids easily accessible to patient;

Enhances intake. Certain fluids may be too

use fluids that are tolerable to patient and

painful to consume (acidic juices) because

that replace needed electrolytes

of mouth lesions.

Nursing Interventions

Rationale
May help reduce diarrhea. Use of lactose-

Eliminate foods potentiating diarrhea

free products helps control diarrhea in the

lactose-intolerant patient.
Antibiotic therapies disrupt normal bowel

Encourage use of live culture yogurt or

flora balance, leading to diarrhea. Must be

OTC Lactobacillus acidophilus (lactaid).

taken 2 hr before or after antibiotic to

prevent inactivation of live culture.
May be necessary to support or augment

Administer fluids and electrolytes via

circulating volume, especially if oral intake

feeding tube and IV, as appropriate.

is inadequate, nausea and vomiting

persists.
Alerts to possible electrolyte disturbances

Monitor laboratory studies as indicated:

and determines replacement

Serum or urine electrolytes; BUN/Cr; Stool

needs.Evaluates renal perfusion and

specimen collection.

function. Bowel flora changes can occur

with multiple or single antibiotic therapy.
May be necessary when other measures

Maintain hypothermia blanket if used.

fail to reduce excessive fever/insensible

fluid losses.

13. Risk for Infection

Nursing Diagnosis

Risk for Infection

Risk factors may include

Inadequate primary defenses: broken skin, traumatized tissue, stasis of body

fluids

Depression of the immune system, chronic disease, malnutrition; use of

antimicrobial agents

Environmental exposure, invasive techniques

Possibly evidenced by

Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

the problem has not occurred and nursing interventions are directed at
prevention.

Desired Outcomes:

Achieve timely healing of wounds/lesions.

Be afebrile and free of purulent drainage/secretions and other signs of

infectious conditions.

Identify/participate in behaviors to reduce risk of infection.

Nursing Interventions

Rationale
Multiple medication regimen is difficult to

Assess patient knowledge and ability to

maintain opportunistic infection
prophylactic regimen.

maintain over a long period of time.

Patients may adjust medication regimen
based on side effects experienced,
contributing to inadequate prophylaxis,
active disease, and resistance.

Wash hands before and after all care

contacts. Instruct patient and SO to wash

Reduces risk of cross-contamination.

hands as indicated.
Provide a clean, well-ventilated

Reduces number of pathogens presented

environment. Screen visitors and staff for

to the immune system and reduces

signs of infection and maintain isolation

possibility of patient contracting a

precautions as indicated.

nosocomial infection.

Discuss extent and rationale for isolation

precautions and maintenance of personal
hygiene.

Promotes cooperation with regimen and

may lessen feelings of isolation.
Provides information for baseline data;
frequent temperature elevations and onset

Monitor vital signs, including temperature.

of new fever indicates that the body is

responding to a new infectious process or
that medications are not effectively
controlling incurable infections.

Assess respiratory rate and depth; note

Respiratory congestion or distress may

dry spasmodic cough on deep inspiration,

indicate developing PCP; however, TB is on

Nursing Interventions

Rationale
the rise and other fungal, viral, and

changes in characteristics of sputum, and

presence of wheezes or rhonchi. Initiate
respiratory isolation when etiology of
productive cough is unknown.

bacterial infections may occur that

compromise the respiratory system. CMV
and PCP can reside together in the lungs
and, if treatment is not effective for PCP,
the addition of CMV therapy may be
effective.
Neurological abnormalities are common
and may be related to HIV or secondary
infections. Symptoms may vary from

Investigate reports of headache, stiff neck,

subtle changes in mood and sensorium

altered vision. Note changes in mentation

(personality changes or depression) to

and behavior. Monitor for nuchal rigidity

hallucinations, memory loss, severe

and seizure activity.

dementias, seizures, and loss of vision.

CNS infections (encephalitis is the most
common) may be caused by protozoal and
helminthic organisms or fungus.
Oral candidiasis, KS, herpes, CMV, and

Examine skin and oral mucous membranes

cryptococcosis are common opportunistic

for white patches or lesions.

diseases affecting the cutaneous

membranes.

Clean patients nails frequently. File, rather

than cut, and avoid trimming cuticles.

Reduces risk of transmission of pathogens

through breaks in skin. Fungal infections
along the nail plate are common.
Esophagitis may occur secondary to oral

Monitor reports of heartburn, dysphagia,

candidiasis, CMV, or herpes.

retrosternal pain on swallowing, increased

Cryptosporidiosis is a parasitic infection

abdominal cramping, profuse diarrhea.

responsible for watery diarrhea (often

more than 15L/day).

Inspect wounds and site of invasive

devices, noting signs of local inflammation
and infection.
Wear gloves and gowns during direct

Early identification and treatment of

secondary infection may prevent sepsis.
Use of masks, gowns, and gloves is

Nursing Interventions

Rationale

contact with secretions and excretions or

any time there is a break in skin of
caregivers hands. Wear mask and

required for direct contact with body

protective eyewear to protect nose,

fluids, e.g., sputum, blood/blood products,

mouth, and eyes from secretions during

semen, vaginal secretions.

procedures (suctioning) or when

splattering of blood may occur.
Prevents accidental inoculation of
caregivers. Use of needle cutters and
Dispose of needles and sharps in rigid,

recapping is not to be practiced.

puncture-resistant containers.

Accidental needlesticks should be reported

immediately, with follow-up evaluations
done per protocol.

Label blood bags, body fluid containers,

Prevents cross-contamination and alerts

soiled dressings and linens, and package

appropriate personnel and departments to

appropriately for disposal per isolation

exercise specific hazardous materials

protocol.

procedures.

Clean up spills of body fluids and/or blood

with bleach solution (1:10); add bleach to
laundry.

Kills HIV and controls other

microorganisms on surfaces.

Other Possible Nursing Care Plans

Hopelessnessrelated to nature of condition and poor prognosis.

Interrupted family processmay be related to the nature of AIDS condition,

role disturbance, and uncertain future.

Chronic Sorrowrelated to loss of body function and its effects on lifestyle.

Risk for Caregiver Role Strainmay be related to multiple needs of ill person
and chronicity of the disease.

The following are associated with AIDS dementia:

Impaired Environmental Interpretation Syndromemay be related to

dementia, depression, possible evidenced by consistent disorientation,

inability to follow simple directions or instructions, loss of social functioning

from memory decline.

Ineffective Protectionmay be related to chronic disease affecting immune

and neurological systems, inadequate nutrition, drug therapies, possibly
evidenced by deficient immunity, impaired healing, neurosensory alterations,
maladaptive stress response, fatigue, anorexia or disorientation.