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Nursing Diagnosis:
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
Desired Outcomes:
Wear gloves and gowns during direct contact Use of masks, gowns, and gloves is required by
with secretions/excretions or any time there is Occupational Safety and Health Administration
a break in skin of caregivers hands. Wear mask (OSHA, 1992) for direct contact with body fluids, e.g.,
and protective eyewear to protect nose, sputum, blood/blood products, semen, vaginal
mouth, and eyes from secretions during secretions.
procedures (e.g., suctioning) or when
splattering of blood may occur.
Label blood bags, body fluid containers, soiled Prevents cross-contamination and alerts appropriate
dressings/ linens, and package appropriately for personnel/departments to exercise specific hazardous
disposal per isolation protocol. materials procedures.
Clean up spills of body fluids/blood with bleach Kills HIV and controls other microorganisms on
solution (1:10); add bleach to laundry. surfaces.
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 false-positives 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.
o 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.
o T-lymphocyte cells: Total count reduced.
o 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.
o T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of suppressor cells to
helper cells (T8+ to T4+) indicates immune suppression.
o 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.
o Fungal infections: Candida albicans (candidiasis), Cryptococcus
neoformans (cryptococcus), Histoplasma capsulatum (histoplasmosis).
o Bacterial infections: Mycobacterium avium-intracellulare (occurs with CD4 counts less
than 50), miliary mycobacterial TB, Shigella (shigellosis),Salmonella (salmonellosis).
o 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
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.
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Remove existing noxious environmental stimuli or Reduces stimulus of the vomiting center in the
conditions that aggravate gag reflex. medulla.
Maintain NPO status when appropriate. May be needed to reduce nausea and vomiting.
Antibiotic therapy: ketoconazole (Nizoral), May be given to treat and prevent infections
fluconazole (Diflucan). involving the GI tract.
2. Fatigue
Nursing Diagnosis
Fatigue
May be related to
Possibly evidenced by
Desired Outcomes
Encourage patient to do whatever possible: self- May conserve strength, increase stamina, and
care, sit in chair, short walks. Increase activity level enable patient to become more active without
as indicated. undue fatigue and discouragement.
Nursing Interventions Rationale
Nursing Diagnosis
Acute/Chronic Pain
May be related to
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
Instruct and encourage patient to report pain as it Efficacy of comfort measures and medications is
develops rather than waiting until level is severe. improved with timely intervention.
Nursing Diagnosis
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
Desired Outcomes
Provide foam, flotation, alternate pressure Reduces pressure on skin, tissue, and lesions,
mattress or bed. decreasing tissue ischemia.
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Display intact mucous membranes, which are pink, moist, and free of inflammation/ulcerations.
Demonstrate techniques to restore/maintain integrity of oral mucosa.
Assess mucous membranes and document all oral Edema, open lesions, and crusting on oral mucous
lesions. Note reports of pain, swelling, difficulty membranes and throat may cause pain and
with chewing and swallowing. difficulty with chewing and swallowing.
Provide oral care daily and after food intake, using Alleviates discomfort, prevents acid formation
soft toothbrush, non abrasive toothpaste, non associated with retained food particles, and
alcohol mouthwash, floss, and lip moisturizer. promotes feeling of well-being.
Rinse oral mucosal lesions with saline and dilute Reduces spread of lesions and encrustations from
hydrogen peroxide or baking soda solutions. candidiasis, and promotes comfort.
Plan diet to avoid salty, spicy, abrasive, and acidic Abrasive foods may open healing lesions. Open
foods or beverages. Check for temperature lesions are painful and aggravated by salt, spice,
tolerance of foods. Offer cool or cold smooth acidic foods or beverages. Extreme cold or heat
foods. can cause pain to sensitive mucous membranes.
Nursing Interventions Rationale
Nursing Diagnosis
May be related to
Possibly evidenced by
Desired Outcomes
Assess mental and neurological status using Establishes functional level at time of admission
appropriate tools. and provides baseline for future comparison.
development of headache, nuchal rigidity, detection and treatment of CNS infection may limit
vomiting, fever, seizure activity. permanent impairment of cognitive ability.
Maintain a pleasant environment with appropriate Providing normal environmental stimuli can help in
auditory, visual, and cognitive stimuli. maintaining some sense of reality orientation.
Discuss use of datebooks, lists, other devices to These techniques help patient manage problems
keep track of activities. of forgetfulness.
Encourage patient to do as much as possible: dress Can help maintain mental abilities for longer
and groom daily, see friends, and so forth. period.
Provide information about care on an ongoing Can reduce anxiety and fear of unknown. Can
basis. Answer questions simply and honestly. enhance patients understanding and involvement
Repeat explanations as needed. and cooperation in treatment when possible.
Reduce provocative and noxious stimuli. Maintain If patient is prone to agitation, violent behavior, or
bed rest in quiet, darkened room if indicated. seizures, reducing external stimuli may be helpful.
Maintain safe environment: excess furniture out of Provides sense of security and stability in an
the way, call bell within patients reach, bed in low otherwise confusing situation.
position and rails up; restriction of smoking (unless
Nursing Interventions Rationale
Discuss causes or future expectations and Obtaining information that ZDV has been shown to
treatment if dementia is diagnosed. Use concrete improve cognition can provide hope and control
terms. for losses.
ZDV (Retrovir) and other antiretrovirals alone or in Shown to improve neurological and mental
combination functioning for undetermined period of time.
Nursing Diagnosis
Anxiety
Fear
May be related to
Possibly evidenced by
Desired Outcomes
Maintain frequent contact with patient. Talk with Provides assurance that patient is not alone or
and touch patient. Limit use of isolation clothing rejected; conveys respect for and acceptance of
and masks. the person, fostering trust.
suicidal ideation and assess potential on a scale of suicide is a viable alternative. Although patient
110. may be too sick to have enough energy to
implement thoughts, ideation must be taken
seriously and appropriate intervention initiated.
Recognize and support the stage patient and/or Choice of interventions as dictated by stage of
family is at in the grieving process. grief, coping behaviors
Identify and encourage patient interaction with Reduces feelings of isolation. If family support
support systems. Encourage verbalization and systems are not available, outside sources may be
interaction with family/SO. needed immediately
Provide reliable and consistent information and Allows for better interpersonal interaction and
support for SO. reduction of anxiety and fear.
Discuss Advance Directives, end-of-life desires or May assist patient or SO to plan realistically for
needs. Review specific wishes and explain various terminal stages and death. Many individuals do
options clearly. not understand medical terminology or options,
Nursing Diagnosis
Social Isolation
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Diagnosis
Powerlessness
May be related to
Possibly evidenced by
Desired Outcomes
Assess degree of feelings of helplessness: verbal or Determines the status of the individual patient and
nonverbal expressions indicating lack of control, allows for appropriate intervention when patient is
flat affect, lack of communication. immobilized by depressed feelings.
Encourage active role in planning activities, May enhance feelings of control and self-worth
establishing realistic and attainable daily goals. and sense of personal responsibility.
Encourage patient control and responsibility as
Nursing Interventions Rationale
Nursing Diagnosis
Deficient Knowledge
May be related to
Possibly evidenced by
Desired Outcomes
Discuss medication regimen, interactions, and side Enhances cooperation with or increases probability
effects of success with therapeutic regimen.
Encourage activity and exercise at level that Stimulates release of endorphins in the brain,
patient can tolerate. enhancing sense of well-being.
Stress necessity of continued healthcare and Provides opportunity for altering regimen to meet
follow-up. individual and changing needs.
Nursing Interventions Rationale
Nursing Diagnosis
Desired Outcomes
Hematest body fluids: urine, stool, vomitus, for Prompt detection of bleeding or initiation of
occult blood. therapy may prevent critical hemorrhage.
Nursing Diagnosis
Desired outcomes
Maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital
signs, individually adequate urinary output.
Assess skin turgor, mucous membranes, and thirst. Indirect indicators of fluid status.
Monitor oral intake and encourage fluids of at Maintains fluid balance, reduces thirst, and keeps
least 2500 mL/day. mucous membranes moist.
Nursing Interventions Rationale
Make fluids easily accessible to patient; use fluids Enhances intake. Certain fluids may be too painful
that are tolerable to patient and that replace to consume (acidic juices) because of mouth
needed electrolytes lesions.
Nursing Diagnosis
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:
Discuss extent and rationale for isolation Promotes cooperation with regimen and may
precautions and maintenance of personal hygiene. lessen feelings of isolation.
Inspect wounds and site of invasive devices, noting Early identification and treatment of secondary
signs of local inflammation and infection. infection may prevent sepsis.
Label blood bags, body fluid containers, soiled Prevents cross-contamination and alerts
dressings and linens, and package appropriately appropriate personnel and departments to
for disposal per isolation protocol. exercise specific hazardous materials procedures.
Clean up spills of body fluids and/or blood with Kills HIV and controls other microorganisms on
bleach solution (1:10); add bleach to laundry. surfaces.
http://nurseslabs.com/13-aids-hiv-positive-nursing-care-plan/