Acquired immunodeficiency syndrome (AIDS) is the final result of infection with a retrovirus, the human

immunodeficiency virus (HIV).

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; presence of signs and symptoms establishes an actual diagnosis.]

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.

AIDS Nursing Care Plan: Risk for Infection

Nursing Interventions Rationale

Multiple medication regimen is difficult to maintain

Assess patient knowledge and ability to over a long period of time. Patients may adjust
maintain opportunistic infection prophylactic medication regimen based on side effects
regimen. experienced, contributing to inadequate prophylaxis,
active disease, and resistance.

Wash hands before and after all care contacts.

Reduces risk of cross-contamination.
Instruct patient/SO to wash hands as indicated.

Provide a clean, well-ventilated environment. Reduces number of pathogens presented to the

Screen visitors/staff for signs of infection and immune system and reduces possibility of patient
maintain isolation precautions as indicated. contracting a nosocomial infection.

Discuss extent and rationale for isolation

Promotes cooperation with regimen and may lessen
precautions and maintenance of personal
feelings of isolation.
hygiene.

Provides information for baseline data; frequent

Monitor vital signs, including temperature. temperature elevations/onset of new fever indicates
that the body is responding to a new infectious

Assess respiratory rate/depth; note dry
spasmodic cough on deep inspiration, changes
in characteristics of sputum, and presence of
wheezes/rhonchi. Initiate respiratory isolation
when etiology of productive cough is unknown.
Investigate reports of headache, stiff neck,
altered vision. Note changes in mentation and
behavior. Monitor for nuchal rigidity/seizure
activity.
Examine skin/oral mucous membranes for
white patches or lesions. (Refer to ND: Skin
Integrity, impaired, actual and/or risk for, and
ND: Oral Mucous Membrane, impaired.)
Clean patients nails frequently. File, rather
than cut, and avoid trimming cuticles.
Monitor reports of heartburn, dysphagia,
retrosternal pain on swallowing, increased
abdominal cramping, profuse diarrhea.
Inspect wounds/site of invasive devices, noting Early identification/treatment of secondary infection
signs of local inflammation/infection.
Wear gloves and gowns during direct contact
with secretions/excretions or any time there is
a break in skin of caregivers hands. Wear mask
and protective eyewear to protect nose,
mouth, and eyes from secretions during
process or that medications are not effectively
controlling noncurable infections.
Respiratory congestion/distress may indicate
developing PCP (the most common opportunistic
disease); however, TB is on the rise and other fungal,
viral, and bacterial infections may occur that
compromise the respiratory system. Note: 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 subtle changes in mood/sensorium
(personality changes or depression) to hallucinations,
memory loss, severe 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 cryptococcosis
are common opportunistic diseases affecting the
cutaneous membranes.
Reduces risk of transmission of pathogens through
breaks in skin. Note: Fungal infections along the nail
plate are common.
Esophagitis may occur secondary to oral candidiasis,
CMV, or herpes. Cryptosporidiosis is a parasitic
infection responsible for watery diarrhea (often more
than 15L/day).
may prevent sepsis.
Use of masks, gowns, and gloves is required by
Occupational Safety and Health Administration
(OSHA, 1992) for direct contact with body fluids, e.g.,
sputum, blood/blood products, semen, vaginal
secretions.
procedures (e.g., suctioning) or when
splattering of blood may occur.

Prevents accidental inoculation of caregivers. Use of

needle cutters and recapping is not to be practiced.
Dispose of needles/sharps in rigid, puncture-
Note: Accidental needlesticks should be reported
resistant containers.
immediately, with follow-up evaluations done per
protocol.

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.

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 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

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

Lesions of the mouth, throat, and esophagus

(often caused by candidiasis, herpes simplex, hairy
leukoplakia, kaposis sarcoma other cancers) and
Assess patients ability to chew, taste, and
metallic or other taste changes caused by
swallow.
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 diet/route. Lactose intolerance
Auscultate bowel sounds. and malabsorption (with CMV, MAC,
cryptosporidiosis) contribute to diarrhea and may
necessitate change in diet or supplemental
formula.

Indicator of nutritional adequacy of

Weigh as indicated. Evaluate weight in terms of
intake. Because of depressed immunity, some
premorbid weight. Compare serial weights and
blood tests normally used for testing nutritional
anthropometric measurements.
status are not useful.

Medications used can have side effects affecting

nutrition. ZDV can cause altered taste, nausea and
vomiting; Bactrim can cause anorexia, glucose
Note drug side effects. 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,
Including patient in planning gives sense of control
frequent meals and snacks of nutritionally dense
of environment and may enhance intake. Fulfilling
foods and non acidic foods and beverages, with
cravings for noninstitutional food may also
choice of foods palatable to patient. Encourage
improve intake. In this population, foods with a
high-calorie and nutritious foods, some of which
higher fat content may be recommended as
may be considered appetite stimulants. Note time
tolerated to enhance taste and oral intake.
of day when appetite is best, and try to serve
larger meal at that time.
 Nursing Interventions
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.
Schedule medications between meals (if tolerated)
and limit fluid intake with meals, unless fluid has
nutritional value.
Encourage as much physical activity as possible.
Provide frequent mouth care, observing secretion
precautions. Avoid alcohol-containing
mouthwashes.
Provide rest period before meals. Avoid stressful
procedures close to mealtime.
Remove existing noxious environmental stimuli or Reduces stimulus of the vomiting center in the
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 as
indicated.
Administer medications as indicated:
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.
Gastric fullness diminishes appetite and food
intake.
May improve appetite and general feelings of well-
being.
Reduces discomfort associated with nausea and
vomiting, oral lesions, mucosal dryness, and
halitosis. Clean mouth may enhance appetite and
provide comfort.
Minimizes fatigue; increases energy available for
work of eating and reduces chances of nausea or
vomiting food.
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
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.
 Nursing Interventions Rationale

Antiemetics: prochlorperazine (Compazine),

Reduces incidence of nausea and vomiting,
promethazine (Phenergan), trimethobenzamide
possibly enhancing oral intake.
(Tigan)

Given with meals (swish and hold in mouth) to

Sucralfate (Carafate) suspension; mixture of
relieve mouth pain, enhance intake. Mixture may
Maalox, diphenhydramine (Benadryl), and
be swallowed for presence of pharyngeal or
lidocaine (Xylocaine);
esophageal lesions.

Corrects vitamin deficiencies resulting from

decreased food intake and/or disorders of
digestion and absorption in the GI system. Avoid
Vitamin supplements
megadoses and suggested supplemental level is
two times the recommended daily allowance
(RDA).

Marinol (an antiemetic) and Megace (an

Appetite stimulants: dronabinol antineoplastic) act as appetite stimulants in the
(Marinol), megestrol (Megace), oxandrolone presence of AIDS. Oxandrin is currently being
(Oxandrin) 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 contributing to
TNF-alpha inhibitors: thalidomide;
wasting or cachexia. Studies reveal a mean weight
gain of 10% over 28 wk of therapy.

Inhibit GI motility subsequently decreasing

Antidiarrheals: diphenoxylate (Lomotil), diarrhea. Imodium or Sandostatin are effective
loperamide (Imodium), octreotide (Sandostatin); treatments for secretory diarrhea (secretion of
water and electrolytes by intestinal epithelium).

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

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, including

Assess sleep patterns and note changes in thought sleep deprivation, emotional distress, side effects
processes and behavior. of drugs and chemotherapies, and developing CNS
disease.

Planning allows patient to be active during times

Recommend scheduling activities for periods when
when energy level is higher, which may restore a
patient has most energy. Plan care to allow for rest
feeling of well-being and a sense of control.
periods. Involve patient and SO in schedule
Frequent rest periods are needed to restore or
planning.
conserve energy.

Provides for a sense of control and feelings of

Establish realistic activity goals with patient. accomplishment. Prevents discouragement from
fatigue of overactivity.

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

Identify energy conservation techniques: sitting,

Weakness may make ADLs almost impossible for
breaking ADLs into manageable segments. Keep
patient to complete. Protects patient from injury
travelways clear of furniture. Provide or assist with
during activities.
ambulation and self-care needs as appropriate.

Tolerance varies greatly, depending on the stage of

Monitor physiological response to activity: changes the disease process, nutrition state, fluid balance,
in BP, respiratory rate, or heart rate. and number or type of opportunistic diseases that
patient has been subject to.

Adequate intake or utilization of nutrients is

necessary to meet increased energy needs for
Encourage nutritional intake. activity. Continuous stimulation of the immune
system by HIV infection contributes to a
hypermetabolic state.

Programmed daily exercises and activities help

Refer to physical and/or occupational therapy. patient maintain and increase strength and muscle
tone, enhance sense of well-being.

Provides assistance in areas of individual need as

Refer to community resources
ability to care for self becomes more difficult.

Presence of anemia or hypoxemia reduces oxygen

Provide supplemental O2 as indicated. 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

Indicates need for or effectiveness of interventions

Assess pain reports, noting location, intensity (0
and may signal development or resolution of
10 scale), frequency, and time of onset. Note
complications. Chronic pain does not produce
nonverbal cues like restlessness, tachycardia,
autonomic changes; however, acute and chronic
grimacing.
pain can coexist.

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.

Can reduce anxiety and fear and thereby reduce

Encourage verbalization of feelings.
perception of intensity of pain.

Provide diversional activities: provide reading

Refocuses attention; may enhance coping abilities.
materials, light exercising, visiting, etc.

Perform palliative measures: repositioning, Promotes relaxation and decreases muscle

massage, ROM of affected joints. tension.
 Nursing Interventions Rationale

Promotes relaxation and feeling of well-being. May

decrease the need for narcotic analgesics (CNS
Instruct and encourage use of visualization, guided depressants) when a neuro/motor degenerative
imagery, progressive relaxation, deep-breathing process is already involved. May not be successful
techniques, meditation, and mindfulness. in presence of dementia, even when dementia is
minor. Mindfulness is the skill of staying in the
here and now.

Oral ulcerations and lesions may cause severe

Provide oral care.
discomfort.

Apply warm or moist packs to pentamidine

These injections are known to cause pain and
injection and IV sites for 20 min after
sterile abscesses
administration.

Provides relief of pain and discomfort; reduces

Administer analgesics and/or antipyretics, narcotic fever. PCA or around-the-clock medication keeps
analgesics. Use patient-controlled analgesia (PCA) the blood level of analgesia stable, preventing
or provide around-the-clock analgesia with rescue cyclic undermedication or overmedication. Drugs
doses prn. such as Ativan may be used to potentiate 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,

Establishes comparative baseline providing
and sensation. Describe and measure lesions and
opportunity for timely intervention.
observe changes. Take photographs if necessary.

Maintaining clean, dry skin provides a barrier to

Maintain and instruct in good skin hygiene: wash
thoroughly, pat dry carefully, and gently massage
with lotion or appropriate cream.
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 Reduces stress on pressure points, improves blood
prominences with pillows, heel and elbow pads, flow to tissues, and promotes healing.
sheepskin.
 Nursing Interventions Rationale

Skin friction caused by wet or wrinkled or rough

Maintain clean, dry, wrinkle-free linen, preferably
sheets leads to irritation of fragile skin and
soft cotton fabric.
increases risk for infection.

Decreases pressure on skin from prolonged

Encourage ambulation as tolerated.
bedrest.

Cleanse perianal area by removing stool with

water and mineral oil or commercial product. Prevents maceration caused by diarrhea and keeps
Avoid use of toilet paper if vesicles are present. perianal lesions dry. Use of toilet paper may
Apply protective creams: zinc oxide, A & D abrade lesions.
ointment.

Long and rough nails increase risk of dermal

File nails regularly.
damage.

Cover open pressure ulcers with sterile dressings

May reduce bacterial contamination, promote
or protective barrier: Tegaderm, DuoDerm, as
healing.
indicated.

Provide foam, flotation, alternate pressure Reduces pressure on skin, tissue, and lesions,
mattress or bed. decreasing tissue ischemia.

Identifies pathogens and appropriate treatment

Obtain cultures of open skin lesions.
choices.

Used in treatment of skin lesions. Use of agents

such as Prederm spray can stimulate circulation,
Apply and administer medications as indicated. enhancing healing process. When multidose
ointments are used, care must be taken to avoid
cross-contamination.

Cover ulcerated KS lesions with wet-to-wet

Protects ulcerated areas from contamination and
dressings or antibiotic ointment and nonstick
promotes healing
dressing, as indicated.

Refer to physical therapy for regular exercise and

Promotes improved muscle tone and skin health.
activity program.
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 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.

Stimulates flow of saliva to neutralize acids and

Suggest use of sugarless gum and candy.
protect mucous membranes.

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

Maintains hydration and prevents drying of oral

Encourage oral intake of at least 2500 mL/day.
cavity.

Smoke is drying and irritating to mucous

Encourage patient to refrain from smoking.
membranes.

Reveals causative agents and identifies

Obtain culture specimens of lesions.
appropriate therapies.

Administer medications, as indicated: nystatin Specific drug choice depends on particular

(Mycostatin), ketoconazole (Nizoral). infecting organism(s) like Candida.

Effective in treatment of oral lesions due to

TNF-alpha inhibitor, e.g., thalidomide.
recurrent stomatitis.

May require additional therapy to prevent dental

Refer for dental consultation, if appropriate.
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 Rationale

Assess mental and neurological status using Establishes functional level at time of admission
appropriate tools. and provides baseline for future comparison.

May contribute to reduced alertness, confusion,

Consider effects of emotional distress. Assess for
withdrawal, and hypoactivity, requiring further
anxiety, grief, anger.
evaluation and intervention.

Actions and interactions of various medications,

Monitor medication regimen and usage.
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.

Changes may occur for numerous reasons,

Investigate changes in personality, response to
including development or exacerbation of
stimuli, orientation and level of consciousness; or
opportunistic diseases or CNS infection. Early
 Nursing Interventions Rationale

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.

Provide cues for reorientation. Put radio,

Frequent reorientation to place and time may be
television, calendars, clocks, room with an outside
necessary, especially during fever and/or acute
view if necessary. Use patients name. Identify
CNS involvement. Sense of continuity may reduce
yourself. Maintain consistent personnel and
associated anxiety.
structured schedules as appropriate.

Discuss use of datebooks, lists, other devices to These techniques help patient manage problems
keep track of activities. of forgetfulness.

Familiar contacts are often helpful in maintaining

Encourage family and SO to socialize and provide
reality orientation, especially if patient is
reorientation with current news, family events.
hallucinating.

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.

Bizarre behavior and/or deterioration of abilities

Provide support for SO. Encourage discussion of
concerns and fears
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 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.

Promotes sleep, reducing cognitive symptoms and

Decrease noise, especially at night.
effects of sleep deprivation.

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

monitored by caregiver/SO), seizure precautions,

soft restraints if indicated.

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.

Administer medications as indicated:

Effective in treatment of oral lesions due to Antifungal useful in treatment of cryptococcal

recurrent stomatitis. meningitis.

ZDV (Retrovir) and other antiretrovirals alone or in Shown to improve neurological and mental
combination functioning for undetermined period of time.

Cautious use may help with problems of

Antipsychotics: haloperidol (Haldol), and/or
sleeplessness, emotional lability, hallucinations,
antianxiety agents: lorazepam (Ativan).
suspiciousness, and agitation.

May help patient gain control in presence of

Refer to counseling as indicated. 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 Rationale

Provides reassurance and opportunity for patient

Assure patient of confidentiality within limits of
to problem-solve solutions to anticipated
situation.
situations.

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.

Provide accurate, consistent information regarding

Can reduce anxiety and enable patient to make
prognosis. Avoid arguing about patients
decisions and choices based on realities.
perceptions of the situation.

Patient may use defense mechanism of denial and

Be alert to signs of withdrawal, anger, or
continue to hope that diagnosis is inaccurate.
inappropriate remarks as these can be signs of
Feelings of guilt and spiritual distress may cause
indenial or depression. Determine presence of
patient to become withdrawn and believe that
 Nursing Interventions Rationale

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.

Helps patient feel accepted in present condition

Provide open environment in which patient feels
without feeling judged, and promotes sense of
safe to discuss feelings or to refrain from talking.
dignity and control.

Permit expressions of anger, fear, despair without

Acceptance of feelings allows patient to begin to
confrontation. Give information that feelings are
deal with situation.
normal and are to be appropriately expressed.

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

Explain procedures, providing opportunity for

Accurate information allows patient to deal more
questions and honest answers. Arrange for
effectively with the reality of the situation, thereby
someone to stay with patient during anxiety-
reducing anxiety and fear of the known.
producing procedures and consultations.

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.

Ensures a support system for patient, and allows

SO the chance to participate in patients life. If
Include SO as indicated when major decisions are
patient, family, and SO are in conflict, separate
to be made.
care consultations and visiting times may be
needed.

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,

May require further assistance in dealing with

Refer to psychiatric counseling (psychiatric clinical
diagnosis or prognosis, especially when suicidal
nurse specialist, psychiatrist, social worker).
thoughts are present.
 Nursing Interventions Rationale

Provides opportunity for addressing spiritual

Provide contact with other resources as indicated:
concerns. May help relieve anxiety regarding end-
Spiritual advisor or hospice staff
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 because

Ascertain patients perception of situation.
patient fears rejection/reaction of others.

Spend time talking with patient during and

Patient may experience physical isolation as a
between care activities. Be supportive, allowing for
result of current medical status and some degree
verbalization. Treat with dignity and regard for
of social isolation secondary to diagnosis of AIDS.
patients feelings.

Reduces patients sense of physical isolation and

Limit or avoid use of mask, gown, and gloves when provides positive social contact, which may
possible and when talking to patient. enhance self-esteem and decrease negative
behaviors.

When patient has assistance from SO, feelings of

loneliness and rejection are diminished. Patient
Identify support systems available to patient,
may not receive usual or needed support for
including presence of and/or relationship with
coping with life-threatening illness and associated
immediate and extended family.
grief because of fear and lack of understanding
(AIDS hysteria).
 Nursing Interventions Rationale

Gloves, gowns, mask are not routinely required

Explain isolation precautions and procedures to
patient and SO.
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

Participation with others can foster a feeling of
contacts, and social activities within tolerated
belonging.
level.

Helps reestablish a feeling of participation in a

Encourage active role of contact with SO. social relationship. May lessen likelihood of suicide
attempts.

Develop a plan of action with patient: Look at

Having a plan promotes a sense of control over
available resources; support healthy behaviors.
own life and gives patient something to look
Help patient problem-solve solution to short-term
forward to and actions to accomplish.
or imposed isolation.

Indicators of despair and suicidal ideation are

Be alert to verbal or nonverbal cues: withdrawal,
often present; when these cues are acknowledged
statements of despair, sense of aloneness. Ask
by the caregiver, patient is usually willing to talk
patient if thoughts of suicide are being
about thoughts of suicide and sense of isolation
entertained.
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
Identify factors that contribute to patients feelings diagnosed with HIV and when dying with AIDS.
of powerlessness: diagnosis of a terminal illness, Fear of AIDS (by the general population and the
lack of support systems, lack of knowledge about patients family/SO) is the most profound cause of
present situation. 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 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
much as possible. Identify things that patient can
and cannot control.
Encourage Living Will and durable medical power
of attorney documents, with specific and precise
instructions regarding acceptable and
unacceptable procedures to prolong life.
Discuss desires and assist with planning for funeral
as appropriate.
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
patients wishes, increasing loss of independence.
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.
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

Provides knowledge base from which patient can

Review disease process and future expectations.
make informed choices.

Determine level of independence or dependence

Helps plan amount of care and symptom
and physical condition. Note extent of care and
management required and need for additional
support available from family and SO and need for
resources.
other caregivers.

Corrects myths and misconceptions; promotes

Review modes of transmission of disease, safety for patient and others. Accurate
especially if newly diagnosed. epidemiological data are important in targeting
prevention interventions.

Instruct patient and caregivers concerning

infection control, using good handwashing Reduces risk of transmission of diseases; promotes
techniques for everyone (patient, family, wellness in presence of reduced ability of immune
caregivers); using gloves when handling bedpans, system to control level of flora.
dressings or soiled linens; wearing mask if patient
 Nursing Interventions Rationale

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 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

Healthy skin provides barrier to infection.
inspecting skin folds, pressure points, and
Measures to prevent skin disruption and
perineum, and of providing adequate cleansing
associated complications are critical.
and protective measures: ointments, padding.

The oral mucosa can quickly exhibit severe,

Ascertain that patient or SO can perform necessary progressive complications. Studies indicate that
oral and dental care. Review procedures as 65% of AIDS patients have some oral symptoms.
indicated. Encourage regular dental care. Therefore, prevention and early intervention are
critical.

Review dietary needs (high-protein and high-

Promotes adequate nutrition necessary for healing
calorie) and ways to improve intake when
and support of immune system; enhances feeling
anorexia, diarrhea, weakness, depression interfere
of well-being.
with intake.

Discuss medication regimen, interactions, and side Enhances cooperation with or increases probability
effects of success with therapeutic regimen.

Provide information about symptom management

Provides patient with increased sense of control,
that complements medical regimen; with
reduces risk of embarrassment, and promotes
intermittent diarrhea, take diphenoxylate (Lomotil)
comfort.
before going to social event.

Helps manage fatigue; enhances coping abilities

Stress importance of adequate rest.
and energy level.

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

Smoking increases risk of respiratory infections

Recommend cessation of smoking.
and can further impair immune system.

Identify signs and symptoms requiring medical

evaluation: persistent fever and night sweats, Early recognition of developing complications and
swollen glands, continued weight loss, diarrhea, timely interventions may prevent progression to
skin blotches and lesions, headache, chest pain life-threatening situation.
and dyspnea.

Identify community resources: hospice and

Facilitates transfer from acute care setting for
residential care centers, visiting nurse, home care
recovery/independence or end-of-life care.
services, Meals on Wheels, peer group support.
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 causes of

Avoid injections, rectal temperatures and rectal bleeding: insertion of thermometers, rectal tubes
tubes. Administer rectal suppositories with can damage or tear rectal mucosa. Some
caution. medications need to be given via suppository, so
caution is advised.

Maintain a safe environment. Keep all necessary

Reduces accidental injury, which could result in
objects and call bell within patients reach and
bleeding.
place bed in low position.

Reduces possibility of injury, although activity

Maintain bed rest or chair rest when platelets are
needs to be maintained. May need to discontinue
below 10,000 or as individually appropriate. Assess
or reduce dosage of a drug. Patient can have a
medication regimen.
surprisingly low platelet count without bleeding.

Hematest body fluids: urine, stool, vomitus, for Prompt detection of bleeding or initiation of
occult blood. therapy may prevent critical hemorrhage.

Observe for or report epistaxis, hemoptysis,

Spontaneous bleeding may indicate development
hematuria, non menstrual vaginal bleeding, or
of DIC or immune thrombocytopenia, necessitating
oozing from lesions or body orifices and/or IV
further evaluation and prompt intervention.
insertion sites.

Monitor for changes in vital signs and skin color:

Presence of bleeding and hemorrhage may lead to
BP, pulse, respirations, skin pallor and
circulatory failure and shock.
discoloration.
 Nursing Interventions Rationale

Evaluate change in level of consciousness. May reflect cerebral bleeding.

Detects alterations in clotting capability; identifies

Review laboratory studies: PT, aPTT, clotting time, therapy needs. Many individuals (up to 80%)
platelets, Hb/Hct. display platelet count below 50,000 and may be
asymptomatic, necessitating regular monitoring.

Transfusions may be required in the event of

Administer blood products as indicated.
persistent or massive spontaneous bleeding.

These medications reduce platelet aggregation,

Avoid use of aspirin products and NSAIDs, impairing and prolonging the coagulation process,
especially in presence of gastric lesions. 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

Indicators of circulating fluid volume.
hypotension, including postural changes.

Around 97%, fever is one of the most frequent

Note temperature elevation and duration of febrile
symptoms experienced by patients with HIV
episode. Administer tepid sponge baths as
infections. Increased metabolic demands and
indicated. Keep clothing and linens dry. Maintain
associated excessive diaphoresis result in
comfortable environmental temperature.
increased insensible fluid losses and dehydration.

Assess skin turgor, mucous membranes, and thirst. Indirect indicators of fluid status.

Increased specific gravity and decreasing urinary

Measure urinary output and specific gravity. output reflects altered renal perfusion and
Measure and estimate amount of diarrheal loss. circulating volume. Monitoring fluid balance is
Note insensible losses. difficult in the presence of excessive GI and
insensible losses.

Although weight loss may reflect muscle wasting,

sudden fluctuations reflect state of hydration.
Weigh as indicated.
Fluid losses associated with diarrhea can quickly
create a crisis and become life-threatening.

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.

May help reduce diarrhea. Use of lactose-free

Eliminate foods potentiating diarrhea products helps control diarrhea in the lactose-
intolerant patient.

Antibiotic therapies disrupt normal bowel flora

Encourage use of live culture yogurt or balance, leading to diarrhea. Must be taken 2 hr
OTC Lactobacillus acidophilus (lactaid). before or after antibiotic to prevent inactivation of
live culture.

May be necessary to support or augment

Administer fluids and electrolytes via feeding tube
circulating volume, especially if oral intake is
and IV, as appropriate.
inadequate, nausea and vomiting persists.

Alerts to possible electrolyte disturbances and

Monitor laboratory studies as indicated: Serum or
determines replacement needs.Evaluates renal
urine electrolytes; BUN/Cr; Stool specimen
perfusion and function. Bowel flora changes can
collection.
occur with multiple or single antibiotic therapy.

May be necessary when other measures fail to

Maintain hypothermia blanket if used.
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

maintain over a long period of time. Patients may
Assess patient knowledge and ability to maintain
adjust medication regimen based on side effects
opportunistic infection prophylactic regimen.
experienced, contributing to inadequate
prophylaxis, active disease, and resistance.

Wash hands before and after all care contacts.

Instruct patient and SO to wash hands as Reduces risk of cross-contamination.
indicated.

Provide a clean, well-ventilated environment. Reduces number of pathogens presented to the

Screen visitors and staff for signs of infection and immune system and reduces possibility of patient
maintain isolation precautions as indicated. contracting a nosocomial infection.

Discuss extent and rationale for isolation Promotes cooperation with regimen and may
precautions and maintenance of personal hygiene. lessen feelings of isolation.

Provides information for baseline data; frequent

Monitor vital signs, including temperature. temperature elevations and onset of new fever
indicates that the body is responding to a new
 Nursing Interventions Rationale

infectious process or that medications are not

effectively controlling incurable infections.

Respiratory congestion or distress may indicate

Assess respiratory rate and depth; note dry
spasmodic cough on deep inspiration, changes in
characteristics of sputum, and presence of
wheezes or rhonchi. Initiate respiratory isolation
when etiology of productive cough is unknown.
developing PCP; however, TB is on the rise and
other fungal, viral, and 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 subtle changes in mood
Investigate reports of headache, stiff neck, altered
and sensorium (personality changes or depression)
vision. Note changes in mentation and behavior.
to hallucinations, memory loss, severe dementias,
Monitor for nuchal rigidity and seizure activity.
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 for
cryptococcosis are common opportunistic diseases
white patches or lesions.
affecting the cutaneous membranes.

Reduces risk of transmission of pathogens through

Clean patients nails frequently. File, rather than
breaks in skin. Fungal infections along the nail
cut, and avoid trimming cuticles.
plate are common.

Esophagitis may occur secondary to oral

Monitor reports of heartburn, dysphagia,
candidiasis, CMV, or herpes. Cryptosporidiosis is a
retrosternal pain on swallowing, increased
parasitic infection responsible for watery diarrhea
abdominal cramping, profuse diarrhea.
(often more than 15L/day).

Inspect wounds and site of invasive devices, noting Early identification and treatment of secondary
signs of local inflammation and infection. infection may prevent sepsis.

Wear gloves and gowns during direct contact with

secretions and excretions or any time there is a
break in skin of caregivers hands. Wear mask and Use of masks, gowns, and gloves is required for
protective eyewear to protect nose, mouth, and direct contact with body fluids, e.g., sputum,
eyes from secretions during procedures blood/blood products, semen, vaginal secretions.
(suctioning) or when splattering of blood may
occur.
 Nursing Interventions Rationale

Prevents accidental inoculation of caregivers. Use

of needle cutters and recapping is not to be
Dispose of needles and sharps in rigid, puncture-
practiced. Accidental needlesticks should be
resistant containers.
reported immediately, with follow-up evaluations
done per protocol.

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.

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.

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