HIV/AIDS Nursing Care Plan & Management

 Description

  • HIV is the human immuno deficiency virus. It is the virus that can lead to acquired immune deficiency syndrome, or AIDS.
    • H – Human – This particular virus can only infect human beings.
    • I – Immunodeficiency – HIV weakens your immune system by destroying important cells that fight disease and infection. A “deficient” immune system can’t protect you.
    • V – Virus – A virus can only reproduce itself by taking over a cell in the body of its host.
  • Human Immunodeficiency Virus is a lot like other viruses, including those that cause the “flu” or the common cold. But there is an important difference – over time, your immune system can clear most viruses out of your body. That isn’t the case with HIV – the human immune system can’t seem to get rid of it. Scientists are still trying to figure out why.
  • We know that HIV can hide for long periods of time in the cells of your body and that it attacks a key part of your immune system – your T-cells or CD4 cells. Your body has to have these cells to fight infections and disease, but HIV invades them, uses them to make more copies of itself, and then destroys them.
  • Over time, HIV can destroy so many of your CD4 cells that your body can’t fight infections and diseases anymore. When that happens, HIV infection can lead to AIDS.
  • To understand what AIDS is, let’s break it down:
    • A – Acquired – AIDS is not something you inherit from your parents. You acquire AIDS after birth.
    • I – Immuno – Your body’s immune system includes all the organs and cells that work to fight off infection or disease.
    • D – Deficiency – You get AIDS when your immune system is “deficient,” or isn’t working the way it should.
    • S – Syndrome – A syndrome is a collection of symptoms and signs of disease. AIDS is a syndrome, rather than a single disease, because it is a complex illness with a wide range of complications and symptoms.
  • Acquired Immunodeficiency Syndrome is the final stage of HIV infection. People at this stage of HIV disease have badly damaged immune systems, which put them at risk for opportunistic infections (OIs).
  • You will be diagnosed with AIDS if you have one or more specific OIs, certain cancers, or a very low number of CD4 cells. If you have AIDS, you will need medical intervention and treatment to prevent death.
Causes
  • HIV causes AIDS. Two HIV strains have been identified: HIV-1 and HIV-2. HIV-1 is the prototype virus and is responsible for most cases of AIDS in the United States. HIV-2 is found chiefly in West Africa, appears to be less easily transmitted, and has a longer incubation period.
  • Susceptibility to infection is unclear. The presence of sexually transmitted infections (STIs) with open lesions, such as herpes and syphilis, may increase the patient’s susceptibility to viral entry.
  • People with cytomegalovirus and Epstein-Barr virus infections may also be more susceptible because of an increased number of target cells. Routes of transmission are through sexual contact (male to male, male to female, female to male, and female to female); by blood to blood or transfusion contact (generally blood products given between 1977 and 1985); through the use of needles contaminated by an HIV-infected person; by blood or other HIV-infected fluids coming in contact with open lesions or mucous membranes; and by mother to child during the in utero period, during delivery, or by breastfeeding.
  • The time from the onset of HIV transmission to the development of AIDS varies from a few months to years. The median incubation period is 10 years.
Pathophysiology
  1. Human beings produce antibodies against specific infections.
  2. When HIV infection takes place, anti-HIV antibodies are produced but they do not appear immediately. This is called the “window effect”.
  3. In some cases, antibodies to HIV become detectable 4 to 6 weeks after infection.
  4. When HIV is in circulation, it invades several types of cells – the lymphocytes, macrophages, the Langerhans cells, and neurons within the CNS.
  5. HIV attacks the body’s immune system.
  6. The organism attaches to a protein molecule called CD4 which is found in the surface of T4 cells.
  7. Once the virus enters the T4, it inserts its genetic materials into the T4 cell’s nucleus taking over the cell to replicate itself.
  8. Eventually the T4 cell dies after having been used to replicate HIV.
  9. The virus mutates rapidly making it more difficult for the body’s immune system to ‘recognize” the invaders.
  10. HIV infection progresses through several stages.
  11. The clinical course of HIV infection begins when a person becomes infected with HIV through:
    • sexual contact with infected person
    • injection of infected blood or blood products
    • Perinatal or vertical transmission.
Transmission

HIV is transmitted by three main routes: sexual contact, exposure to infected body fluids or tissues, and from mother to child during pregnancy, delivery, or breastfeeding (known as vertical transmission).There is no risk of acquiring HIV if exposed to feces, nasal secretions, saliva, sputum, sweat, tears, urine, or vomit unless these are contaminated with blood.It is possible to be co-infected by more than one strain of HIV—a condition known as HIV superinfection.

Sexual
  • The most frequent mode of transmission of HIV is through sexual contact with an infected person.Worldwide, the majority of cases of transmission occur through heterosexual contacts (i.e. sexual contacts between people of the opposite sex).However, the pattern of transmission varies significantly between countries. In the United States, as of 2009, most sexual transmission occurred in men who have sex with men,with this population accounting for 64% of all new cases.
Body fluids
  • The second most frequent mode of HIV transmission is via blood and blood products.Blood-borne transmission can be through needle-sharing during intravenous drug use, needle stick injury, transfusion of contaminated blood or blood product, or medical injections with unsterilized equipment
Mother-to-child
  • HIV can be transmitted from mother to child during pregnancy, during delivery, or through breast milk. This is the third most common way way in which HIV is transmitted globally.In the absence of treatment, the risk of transmission before or during birth is around 20% and in those who also breastfeed 35%. As of 2008, vertical transmission accounted for about 90% of cases of HIV in children.With appropriate treatment the risk of mother-to-child infection can be reduced to about 1%.Preventive treatment involves the mother taking antiretroviral during pregnancy and delivery, an elective caesarean section, avoiding breastfeeding, and administering antiretroviral drugs to the newborn.Many of these measures are however not available in the developing world.If blood contaminates food during pre-chewing it may pose a risk of transmission.
Signs and symptoms

There are three main stages of HIV infection: acute infection, clinical latency and AIDS.

Acute Infection

As early as 2-4 weeks after exposure to HIV (but up to 3 months later), people can experience an acute illness, often described as “the worst flu ever.” This is called acute retroviral syndrome (ARS), or primary HIV infection, and it’s the body’s natural response to HIV infection. During primary HIV infection, there are higher levels of virus circulating in the blood, which means that people can more easily transmit the virus to others.


Symptoms can include:

  • Fever
  • Chills
  • Rash
  • Night sweats
  • Muscle aches
  • Sore throat
  • Fatigue
  • Swollen lymph nodes
  • Ulcers in the mouth
Clinical Latency

After the initial infection and seroconversion, the virus becomes less active in the body, although it is still present.During this period, many people do not have any symptoms of HIV infection. This period is called the “chronic” or “latency” phase. This period can last up to 10 years—sometimes longer.

AIDS

When HIV infection progresses to AIDS, many people begin to suffer from fatigue, diarrhea, nausea, vomiting, fever, chills, night sweats, and even wasting syndrome at late stages. Many of the signs and symptoms of AIDS come from opportunistic infections which occur in patients with a damaged immune system.


HIV-Positive Without Symptoms
  • Many people who are HIV-positive do not have symptoms of HIV infection. Often people only begin to feel sick when they progress toward AIDS (Acquired Immunodeficiency Syndrome). Sometimes people living with HIV go through periods of being sick and then feel fine.
  • While the virus itself can sometimes cause people to feel sick, most of the severe symptoms and illnesses of HIV disease come from the opportunistic infections that attack a damaged immune system. It is important to remember that some symptoms of HIV infection are similar to symptoms of many other common illnesses, such as the flu, or respiratory or gastrointestinal infections.
Common Opportunistic Infections
  1. Pneumocystis carinii pneumonia
  2. Oral candidiasisopportunistic infection
  3. Toxoplasmosis of the CNS
  4. Chronic diarrhea/wasting syndrome
  5. Pulmonary/extra-pulmonary tuberculosis
  6. Cancers
    1. Kaposi’s sarcoma – affects small blood vessels and internal organs
    2. Cervical dysplasia and cancer. Researchers found out that women with HIV have higher rates of this type of cancer. Cervial carcinoma is associated with Human Papilloma Virus (HPV).
    3. Non-Hodgkin’s lymphoma – cancerous tumor of the lymph nodes. This is usually a late manifestation of HIV infection.


Diagnostic Examination:
 Test Normal Result Abnormality with Condition Explanation
 Enzyme-linked immunosorbent assay (ELISA) and Western blot Negative for HIV antibodies Positive for HIV antibodies Positive ELISA test is confirmed by a Western blot
 T lymphocyte and B lymphocyte subsets; CD4 counts, CD4 percentages B cells: 65–4785/mL; CD4 T cells: 450–1400/mL; CD4 to CD8 T cell ratio: 1:3.5 B and T cell values decreased. CD4 counts less than 500/mL are generally associated with symptoms; CD4 counts less than 200/mL are associated with severe immune suppression. Any HIVinfected person with a CD4 level less than 200/mL is considered to have AIDS HIV infects cells with the CD4 protein marker
 Viral load: polymerase chain reaction (PCR) Negative Detects number of copies/mL; test has a lower limit of 400 copies/mL but can reach levels at 30,000 copies/mL and higher; ultrasensitive assay has a lower limit of 40 copies/mL Quantitative assay that measures amount of HIV-1 RNA in plasma
  • Other Tests: Complete blood count; HIV p24 antigen, viral culture, indirect fluorescent antibody
PRIMARY NURSING DIAGNOSIS
Risk for infection related to immune deficiency
  • OUTCOMES. Immune status; Respiratory status: Gas exchange; Respiratory status: Ventilation; Thermoregulation
  • INTERVENTIONS. Infection control; Infection protection; Respiratory monitoring; Temperature regulation
Pharmacologic Treatment
  • “AIDS Drugs” are medicines used to treat but not to cure HIV infection.
  • These drugs are sometimes referred to as “anteroviral drugs.”
  • These work by inhibiting the reproduction of the virus. There are two groups of anteroviral drugs:

1. Reverse trancriptase inhibitors – they inhibit the enzyme called reverse transcriptase which is needed to “copy” information for the virus to replicate. These drugs are:

    1. Zedovudine (ZDV) – Retirvir
    2. Zalcitabine – Havid
    3. Stavudine – Zerit
    4. Lamivudine – Epivir
    5. Nevirapine – Viramune
    6. Didanosine – Videx
2. Protease inhibitors. They work by inhibiting the enzyme protease which are needed for the assembly of viral particles.
These drugs are:
    1. Saquinavir – Invarase
    2. Ritonavir – Norvir
    3. Indinavir – Crixivan
Nursing Management:
  1. Health education – The healthcare worker must:
    • Know the patient
    • Avoid fear tactics
    • Avoid judgmental and moralistic messages
    • Be consistent and concise
    • Use positive statement
    • Give practical advice
  2. Practice universal/standard precaution
    • There is a need for a thorough medical handwashing after every contact with patient and after removing the gown and gloves, and before leaving the room of an AIDS suspect or known AIDS patient.
    • Use of universal barrier or Personal Protective Equipment (PPE) e.g., cap, mask, gloves, CD gown, face shield/goggles are very necessary.
  3. Prevention
    • Care should be taken to avoid accidental pricks from sharp instruments contaminated with potentially infectious materials form AIDS patient.
    • Gloves should be worn when handling blood specimens and other body secretions as well as surfaces, materials and objects exposed to them.
    • Blood and other specimens should be labeled with special warning “AIDS Precaution”.
    • Blood spills should be cleaned immediately using common household disinfectants, like “chlorox”.
    • Needles should not be bent after use, but should be disposed into a puncture-resistant container.
    • Personal articles like razor or razor blades, toothbrush should not be shared with other members of the family. Razor blades may be disposed in the same manner as needles are disposed.
    • Patients with active AIDS should be isolated.
The Four Cs in the Management of HIV/AIDS
  1. Compliance – giving of information and counseling the client which results to the client’s successful treatment, prevention and recommendation.
  2. Counseling/education
    • Giving instruction about the treatment
    • Disseminating information about the disease
    • Providing guidance on how to avoid contracting STD again
    • Sharing facts about HIV and AIDS
  3. Contact tracing
    • Tracing out and providing treatment or partners
  4. Condoms
    • Promoting the use of condom, giving instructions about its use, and giving away available condoms
References:
  • http://www.cdc.gov/hiv/topics/basic/
  • http://www.aids.gov/hiv-aids-basics/hiv-aids-101/how-you-get-hiv-aids/index.html
  • http://en.wikipedia.org/wiki/HIV/AIDS#Sexual
  • http://nursingcrib.com/communicable-diseases/aids-hiv/
  • Handbook of Common Communicable and Infectious Diseases, 2006 Ed
  • Disease and Disorder A Nursing Therapeutic Manual, 2007
  • https://ufandshands.org/sites/default/files/graphics/images/en/17015.jpg
  • http://seapci.multiply.com/journal/item/3/Pathophysiology-of-AIDSHIV

Nursing Care Plan

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
  • Assess patient’s ability to chew, taste, and swallow.
    • Rationale: Lesions of the mouth, throat, and esophagus (often caused by candidiasis, herpes simplex, hairy leukoplakia, kaposi’s sarcoma other cancers) and metallic or other taste changes caused by medications may cause dysphagia, limiting patient’s ability to ingest food and reducing desire to eat.
  • Auscultate bowel sounds.
    • Rationale: Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea, which may affect choice of 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 terms of premorbid weight. Compare serial weights and anthropometric measurements.
    • Rationale: Indicator of nutritional adequacy of intake. Because of depressed immunity, some blood tests normally used for testing nutritional status are not useful.
  • Note drug side effects.
    • Rationale: Medications used can have side effects affecting nutrition. ZDV can cause altered taste, nausea and vomiting; Bactrim can 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, suggesting foods from home if appropriate. Provide small, frequent meals and snacks of nutritionally dense foods and non acidic foods and beverages, with choice of foods palatable to patient. Encourage high-calorie and nutritious foods, some of which may be considered appetite stimulants. Note time of day when appetite is best, and try to serve larger meal at that time.
    • Rationale: Including patient in planning gives sense of control of environment and may enhance intake. Fulfilling cravings for noninstitutional food may also improve intake. In this population, foods with a higher fat content may be recommended as tolerated to enhance taste and oral intake.
  • Limit food(s) that induce nausea and/or vomiting or are poorly tolerated by patient because of mouth sores or dysphagia. Avoid serving very hot liquids and foods. Serve foods that are easy to swallow like eggs, ice cream, cooked vegetables.
    • Rationale: Pain in the mouth or fear of irritating oral lesions may cause patient to be reluctant to eat. These measures may be helpful in increasing food intake.
  • Schedule medications between meals (if tolerated) and limit fluid intake with meals, unless fluid has nutritional value.
    • Rationale: Gastric fullness diminishes appetite and food intake.
  • Encourage as much physical activity as possible.
    • Rationale: May improve appetite and general feelings of well-being.
  • Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes.
    • Rationale: Reduces discomfort associated with nausea and vomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth may enhance appetite and provide comfort.
  • Provide rest period before meals. Avoid stressful procedures close to mealtime.
    • Rationale: Minimizes fatigue; increases energy available for work of eating and reduces chances of nausea or vomiting food.
  • Remove existing noxious environmental stimuli or conditions that aggravate gag reflex.
    • Rationale: Reduces stimulus of the vomiting center in the medulla.
  • Encourage patient to sit up for meals
    • Rationale: Facilitates swallowing and reduces risk of aspiration.
  • Record ongoing caloric intake.
    • Rationale: Identifies need for supplements or alternative feeding methods.
  • Maintain NPO status when appropriate.
    • Rationale: May be needed to reduce nausea and vomiting.
  • Insert or maintain nasogastric (NG) tube as indicated.
    • Rationale: May be needed to reduce vomiting or to administer tube feedings. Esophageal irritation from existing infection (Candida, 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)
    • Rationale: Reduces incidence of nausea and vomiting, possibly enhancing oral intake.
  • Sucralfate (Carafate) suspension; mixture of Maalox, diphenhydramine (Benadryl), and lidocaine (Xylocaine);
    • Rationale: Given with meals (swish and hold in mouth) to relieve mouth pain, enhance intake. Mixture may be swallowed for presence of pharyngeal or esophageal lesions.
  • Vitamin supplements
    • Rationale: Corrects vitamin deficiencies resulting from decreased food intake and/or disorders of digestion and absorption in the GI system. Avoid megadoses and suggested supplemental level is two times the recommended daily allowance (RDA).
  • Appetite stimulants: dronabinol (Marinol),  megestrol (Megace), oxandrolone (Oxandrin)
    • Rationale: Marinol (an antiemetic) and Megace (an 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.
  • TNF-alpha inhibitors: thalidomide;
    • Rationale: Reduces elevated levels of tumor necrosis factor (TNF) present in chronic illness contributing to wasting or cachexia. Studies reveal a mean weight gain of 10% over 28 wk of therapy.
  • Antidiarrheals:  diphenoxylate (Lomotil), loperamide (Imodium), octreotide (Sandostatin);
    • Rationale: Inhibit GI motility subsequently decreasing diarrhea. Imodium or Sandostatin are effective treatments for secretory diarrhea (secretion of water and electrolytes by intestinal epithelium).
  • Antibiotic therapy: ketoconazole (Nizoral), fluconazole (Diflucan).
    • Rationale: May be given to treat and prevent infections involving the GI tract.
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
  • Assess sleep patterns and note changes in thought processes and behavior.
    • Rationale: Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of drugs and chemotherapies, and developing CNS disease.
  • 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.
  • Establish realistic activity goals with patient.
    • Rationale: Provides for a sense of control and feelings of accomplishment. Prevents discouragement from fatigue of overactivity.
  • Encourage patient to do whatever possible: self-care, sit in chair, short walks. Increase activity level as indicated.
    • Rationale: 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 segments. Keep travelways clear of furniture. Provide or assist with ambulation and self-care needs as appropriate.
    • Rationale: Weakness may make ADLs almost impossible for patient to complete. Protects patient from injury during activities.
  • Monitor physiological response to activity: changes in BP, respiratory rate, or heart rate.
    • Rationale: Tolerance varies greatly, depending on the stage of the disease process, nutrition state, fluid balance, and number or type of opportunistic diseases that patient has been subject to.
  • Encourage nutritional intake.
    • Rationale: Adequate intake or utilization of nutrients is necessary to meet increased energy needs for activity. Continuous stimulation of the immune system by HIV infection contributes to a hypermetabolic state.
  • Refer to physical and/or occupational therapy.
    • Rationale: Programmed daily exercises and activities help patient maintain and increase strength and muscle tone, enhance sense of well-being.
  • Refer to community resources
    • Rationale: Provides assistance in areas of individual need as ability to care for self becomes more difficult.
  • Provide supplemental O2 as indicated.
    • Rationale: Presence of anemia or hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.
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
  • Assess pain reports, noting location, intensity (0–10 scale), frequency, and time of onset. Note nonverbal cues like restlessness, tachycardia, grimacing.
    • Rationale: Indicates need for or effectiveness of interventions and may signal development or resolution of complications. Chronic pain does not produce autonomic changes; however, acute and chronic pain can coexist.
  • Instruct and encourage patient to report pain as it develops rather than waiting until level is severe.
    • Rationale: Efficacy of comfort measures and medications is improved with timely intervention.
  • Encourage verbalization of feelings.
    • Rationale: Can reduce anxiety and fear and thereby reduce perception of intensity of pain.
  • Provide diversional activities: provide reading materials, light exercising, visiting, etc.
    • Rationale: Refocuses attention; may enhance coping abilities.
  • Perform palliative measures: repositioning, massage, ROM of affected joints.
    • Rationale: Promotes relaxation and decreases muscle tension.
  • Instruct and encourage use of visualization, guided imagery, progressive relaxation, deep-breathing techniques, meditation, and mindfulness.
    • Rationale: Promotes relaxation and feeling of well-being. May decrease the need for narcotic analgesics (CNS depressants) when a neuro/motor degenerative process is already involved. May not be successful in presence of dementia, even when dementia is minor. Mindfulness is the skill of staying in the here and now.
  • Provide oral care.
    • Rationale: Oral ulcerations and lesions may cause severe discomfort.
  • Apply warm or moist packs to pentamidine injection and IV sites for 20 min after administration.
    • Rationale: These injections are known to cause pain and sterile abscesses
  • Administer analgesics and/or antipyretics, narcotic analgesics. Use patient-controlled analgesia (PCA) or provide around-the-clock analgesia with rescue doses prn.
    • Rationale: Provides relief of pain and discomfort; reduces fever. PCA or around-the-clock medication keeps the blood level of analgesia stable, preventing cyclic undermedication or overmedication. Drugs such as Ativan may be used to potentiate effects of analgesics.
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
  • Assess skin daily. Note color, turgor, circulation, and sensation. Describe and measure lesions and observe changes. Take photographs if necessary.
    • Rationale: Establishes comparative baseline providing opportunity for timely intervention.
  • Maintain and instruct in good skin hygiene:  wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream.
    • Rationale: Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to dry and fragile skin. Massaging increases circulation to the skin and 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.
    • Rationale: Reduces stress on pressure points, improves blood flow to tissues, and promotes healing.
  • Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric.
    • Rationale: Skin friction caused by wet or wrinkled or rough sheets leads to irritation of fragile skin and increases risk for infection.
  • Encourage ambulation as tolerated.
    • Rationale: Decreases pressure on skin from prolonged bedrest.
  • Cleanse perianal area by removing stool with water and mineral oil or commercial product. Avoid use of toilet paper if vesicles are present. Apply protective creams: zinc oxide, A & D ointment.
    • Rationale: Prevents maceration caused by diarrhea and keeps perianal lesions dry. Use of toilet paper may abrade lesions.
  • File nails regularly.
    • Rationale: Long and rough nails increase risk of dermal damage.
  • Cover open pressure ulcers with sterile dressings or protective barrier: Tegaderm, DuoDerm, as indicated.
    • Rationale: May reduce bacterial contamination, promote healing.
  • Provide foam, flotation, alternate pressure mattress or bed.
    • Rationale: Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia.
  • Obtain cultures of open skin lesions.
    • Rationale: Identifies pathogens and appropriate treatment choices.
  • Apply and administer medications as indicated.
    • Rationale: Used in treatment of skin lesions. Use of agents such as Prederm spray can stimulate circulation, enhancing healing process. When multidose ointments are used, care must be taken to avoid cross-contamination.
  • Cover ulcerated KS lesions with wet-to-wet dressings or antibiotic ointment and nonstick dressing, as indicated.
    • Rationale: Protects ulcerated areas from contamination and promotes healing
  • Refer to physical therapy for regular exercise and activity program.
    • Rationale: Promotes improved muscle tone and skin health.
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
  • Assess mucous membranes and document all oral lesions. Note reports of pain, swelling, difficulty with chewing and swallowing.
    • Rationale: Edema, open lesions, and crusting on oral mucous membranes and throat may cause pain and difficulty with chewing and swallowing.
  • Provide oral care daily and after food intake, using soft toothbrush, non abrasive toothpaste, non alcohol mouthwash, floss, and lip moisturizer.
    • Rationale: Alleviates discomfort, prevents acid formation associated with retained food particles, and promotes feeling of well-being.
  • Rinse oral mucosal lesions with saline and dilute hydrogen peroxide or baking soda solutions.
    • Rationale: Reduces spread of lesions and encrustations from candidiasis, and promotes comfort.
  • Suggest use of sugarless gum and candy.
    • Rationale: Stimulates flow of saliva to neutralize acids and protect mucous membranes.
  • Plan diet to avoid salty, spicy, abrasive, and acidic foods or beverages. Check for temperature tolerance of foods. Offer cool or cold smooth foods.
    • Rationale: 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 mL/day.
    • Rationale: Maintains hydration and prevents drying of oral cavity.
  • Encourage patient to refrain from smoking.
    • Rationale: Smoke is drying and irritating to mucous membranes.
  • Obtain culture specimens of lesions.
    • Rationale: Reveals causative agents and identifies appropriate therapies.
  • Administer medications, as indicated: nystatin (Mycostatin), ketoconazole (Nizoral).
    • Rationale: Specific drug choice depends on particular infecting organism(s) like Candida.
  • TNF-alpha inhibitor, e.g., thalidomide.
    • Rationale: Effective in treatment of oral lesions due to recurrent stomatitis.
  • Refer for dental consultation, if appropriate.
    • Rationale: May require additional therapy to prevent dental losses.
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.
  • Consider effects of emotional distress. Assess for anxiety, grief, anger.
    • Rationale: May contribute to reduced alertness, confusion, withdrawal, and hypoactivity, requiring further evaluation and intervention.
  • Monitor medication regimen and usage.
    • Rationale: 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) 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.
    • Rationale: 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 appropriate auditory, visual, and cognitive stimuli.
    • Rationale: Providing normal environmental stimuli can help in maintaining some sense of reality orientation.
  • Provide cues for reorientation. Put radio, television, calendars, clocks, room with an outside view if necessary. Use patient’s name. Identify yourself. Maintain consistent personnel and structured schedules as appropriate.
    • Rationale: Frequent reorientation to place and time may be necessary, especially during fever and/or acute CNS involvement. Sense of continuity may reduce associated anxiety.
  • Discuss use of datebooks, lists, other devices to keep track of activities.
    • Rationale: These techniques help patient manage problems of forgetfulness.
  • Encourage family and SO to socialize and provide reorientation with current news, family events.
    • Rationale: Familiar contacts are often helpful in maintaining reality orientation, especially if patient is hallucinating.
  • Encourage patient to do as much as possible: dress and groom daily, see friends, and so forth.
    • Rationale: Can help maintain mental abilities for longer period.
  • Provide support for SO. Encourage discussion of concerns and fears
    • Rationale: Bizarre behavior and/or deterioration of abilities may be very frightening for SO 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.
  • Provide information about care on an ongoing basis. Answer questions simply and honestly. Repeat explanations as needed.
    • Rationale: Can reduce anxiety and fear of unknown. Can enhance patient’s understanding and involvement and cooperation in treatment when possible.
  • Reduce provocative and noxious stimuli. Maintain bed rest in quiet, darkened room if indicated.
    • Rationale: If patient is prone to agitation, violent behavior, or seizures, reducing external stimuli may be helpful.
  • Decrease noise, especially at night.
    • Rationale: Promotes sleep, reducing cognitive symptoms and effects of sleep deprivation.
  • Maintain safe environment: excess furniture out of the way, call bell within patient’s reach, bed in low position and rails up; restriction of smoking (unless monitored by caregiver/SO), seizure precautions, soft restraints if indicated.
    • Rationale: Provides sense of security and stability in an otherwise confusing situation.
  • Discuss causes or future expectations and treatment if dementia is diagnosed. Use concrete terms.
    • Rationale: Obtaining information that ZDV has been shown to improve cognition can provide hope and control for losses.

Administer medications as indicated:

  • Effective in treatment of oral lesions due to recurrent stomatitis.
    • Rationale: Antifungal useful in treatment of cryptococcal meningitis.
  • ZDV (Retrovir) and other antiretrovirals alone or in combination
    • Rationale: Shown to improve neurological and mental functioning for undetermined period of time.
  • Antipsychotics: haloperidol (Haldol), and/or antianxiety agents: lorazepam (Ativan).
    • Rationale: Cautious use may help with problems of sleeplessness, emotional lability, hallucinations, suspiciousness, and agitation.
  • Refer to counseling as indicated.
    • Rationale: May help patient gain control in presence of thought disturbances or psychotic symptomatology.
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. Talk with and touch patient. Limit use of isolation clothing and masks.
    • Rationale: Provides assurance that patient is not alone or rejected; conveys respect for and acceptance of the person, fostering trust.
  • Provide accurate, consistent information regarding prognosis. Avoid arguing about patient’s perceptions of the situation.
    • Rationale: Can reduce anxiety and enable patient to make decisions and choices based on realities.
  • 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 1–10.
    • Rationale: Patient may use defense mechanism of denial and continue to hope that diagnosis 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 feels safe to discuss feelings or to refrain from talking.
    • Rationale: Helps patient feel accepted in present condition without feeling judged, and promotes sense of dignity and control.
  • Permit expressions of anger, fear, despair without confrontation. Give information that feelings are normal and are to be appropriately expressed.
    • Rationale: Acceptance of feelings allows patient to begin to deal with situation.
  • Recognize and support the stage patient and/or family is at in the grieving process.
    • Rationale: Choice of interventions as dictated by 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.
    • Rationale: Accurate information allows patient to deal more effectively with the reality of the situation, thereby reducing anxiety and fear of the known.
  • Identify and encourage patient interaction with support systems. Encourage verbalization and interaction with family/SO.
    • Rationale: Reduces feelings of isolation. If family support systems are not available, outside sources may be needed immediately
  • Provide reliable and consistent information and support for SO.
    • Rationale: Allows for better interpersonal interaction and reduction of anxiety and fear.
  • Include SO as indicated when major decisions are to be made.
    • Rationale: Ensures a support system for patient, and allows SO the chance to participate in patient’s life. If patient, family, and SO are in conflict, separate care consultations and visiting times may be needed.
  • Discuss Advance Directives, end-of-life desires or needs. Review specific wishes and explain various options clearly.
    • Rationale: 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 clinical nurse specialist, psychiatrist, social worker).
    • Rationale: May require further assistance in dealing with diagnosis or prognosis, especially when suicidal thoughts are present.
  • Provide contact with other resources as indicated: Spiritual advisor or hospice staff
    • Rationale: Provides opportunity for addressing spiritual concerns. May help relieve anxiety regarding end-of-life care and support for patient/SO.
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
  • Ascertain patient’s perception of situation.
    • Rationale: Isolation may be partly self-imposed because patient fears rejection/reaction of others.
  • Spend time talking with patient during and between care activities. Be supportive, allowing for verbalization. Treat with dignity and regard for patient’s feelings.
    • Rationale: Patient may experience physical isolation as a result of current medical status and some degree of social isolation secondary to diagnosis of AIDS.
  • Limit or avoid use of mask, gown, and gloves when possible and when talking to patient.
    • Rationale: Reduces patient’s sense of physical isolation and provides positive social contact, which may enhance self-esteem and decrease negative behaviors.
  • Identify support systems available to patient, including presence of and/or relationship with immediate and extended family.
    • Rationale: When patient has assistance from SO, feelings of loneliness and rejection are diminished. Patient may not receive usual or needed support for coping with life-threatening illness and associated grief because of fear and lack of understanding (AIDS hysteria).
  • Explain isolation precautions and procedures to patient and SO.
    • Rationale: 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 enhances feelings of emotional and 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.
    • Rationale: Participation with others can foster a feeling of belonging.
  • Encourage active role of contact with SO.
    • Rationale: Helps reestablish a feeling of participation 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.
    • Rationale: Having a plan promotes a sense of control over own life and gives patient something to look forward to and actions to accomplish.
  • Be alert to verbal or nonverbal cues: withdrawal, statements of despair, sense of aloneness. Ask patient if thoughts of suicide are being entertained.
    • Rationale: Indicators of despair and suicidal ideation are often present; when these cues are acknowledged by the caregiver, patient is usually willing to talk about thoughts of suicide and sense of isolation and hopelessness.
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
  • Identify factors that contribute to patient’s feelings of powerlessness: diagnosis of a terminal illness, lack of support systems, lack of knowledge about present situation.
    • 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 with HIV and when dying with AIDS. Fear of AIDS (by the general population and the patient’s family/SO) is the most profound cause of patient’s 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 helplessness: verbal or nonverbal expressions indicating lack of control, flat affect, lack of communication.
    • Rationale: Determines the status of the individual patient and allows for appropriate intervention when patient is immobilized by depressed feelings.
  • Encourage active role in planning activities, establishing realistic and attainable daily goals. Encourage patient control and responsibility as much as possible. Identify things that patient can and cannot control.
    • Rationale: May enhance feelings of control and self-worth and sense of personal responsibility.
  • Encourage Living Will and durable medical power of attorney documents, with specific and precise instructions regarding acceptable and unacceptable procedures to prolong life.
    • Rationale: Many factors associated with the 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 patient’s wishes, increasing loss of independence.
  • Discuss desires and assist with planning for funeral as appropriate.
    • Rationale: The individual can gain a sense of completion and value to his or her life when he or she decides to be involved in planning this final ceremony. This provides an opportunity to include things that are of importance to the person.
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
  • Review disease process and future expectations.
    • Rationale: Provides knowledge base from which patient can make informed choices.
  • Determine level of independence or dependence and physical condition. Note extent of care and support available from family and SO and need for other caregivers.
    • Rationale: Helps plan amount of care and symptom management required and need for additional resources.
  • Review modes of transmission of disease, especially if newly diagnosed.
    • Rationale: Corrects myths and misconceptions; 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 plastic bag and separating from family laundry, washing with detergent and hot water; cleaning surfaces with bleach and water solution of 1:10 ratio, disinfecting toilet bowl and bedpan with full-strength bleach; preparing patient’s food in clean area; washing dishes and utensils in hot soapy water (can be washed with the family dishes).
    • Rationale: Reduces risk of transmission of diseases; promotes wellness in presence of reduced ability of immune system to control level of flora.
  • Stress necessity of daily skin care, including inspecting skin folds, pressure points, and perineum, and of providing adequate cleansing and protective measures: ointments, padding.
    • Rationale: Healthy skin provides barrier to infection. Measures to prevent skin disruption and associated complications are critical.
  • Ascertain that patient or SO can perform necessary oral and dental care. Review procedures as indicated. Encourage regular dental care.
    • Rationale: The oral mucosa can quickly exhibit severe, progressive complications. Studies indicate that 65% of AIDS patients have some oral symptoms. Therefore, 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.
    • Rationale: Promotes adequate nutrition necessary for healing and support of immune system; enhances feeling of well-being.
  • Discuss medication regimen, interactions, and side effects
    • Rationale: Enhances cooperation with or increases probability of success with therapeutic regimen.
  • Provide information about symptom management that complements medical regimen; with intermittent diarrhea, take diphenoxylate (Lomotil) before going to social event.
    • Rationale: Provides patient with increased sense of control, reduces risk of embarrassment, and promotes comfort.
  • Stress importance of adequate rest.
    • Rationale: Helps manage fatigue; enhances coping abilities and energy level.
  • Encourage activity and exercise at level that patient can tolerate.
    • Rationale: Stimulates release of endorphins in the brain, enhancing sense of well-being.
  • Stress necessity of continued healthcare and follow-up.
    • Rationale: Provides opportunity for altering regimen to meet individual and changing needs.
  • Recommend cessation of smoking.
    • Rationale: Smoking increases risk of respiratory infections and can further impair immune system.
  • Identify signs and symptoms requiring medical evaluation: persistent fever and night sweats, swollen glands, continued weight loss, diarrhea, skin blotches and lesions, headache, chest pain and dyspnea.
    • Rationale: Early recognition of developing complications and timely interventions may prevent progression to life-threatening situation.
  • Identify community resources: hospice and residential care centers, visiting nurse, home care services, Meals on Wheels, peer group support.
    • Rationale: Facilitates transfer from acute care setting for recovery/independence or end-of-life care.