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2 Alzheimer’s Disease Nursing Care Plans

February 1, 2012, 3:00 am
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Definition

Alzheimer’s disease (AD) is the most common form of dementia among older people. Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities.

AD usually begins after age 60. The risk goes up as you get older. Your risk is also higher if a family member has had the disease.

No treatment can stop the disease. However, some drugs may help keep symptoms from getting worse for a limited time.

Pathophysiology

AD begins slowly. It first involves the parts of the brain that control thought, memory and language. People with AD may have trouble remembering things that happened recently or names of people they know. A related problem, mild cognitive impairment (MCI), causes more memory problems than normal for people of the same age. Many, but not all, people with MCI will develop AD.

In AD, over time, symptoms get worse. People may not recognize family members or have trouble speaking, reading or writing. They may forget how to brush their teeth or comb their hair. Later on, they may become anxious or aggressive, or wander away from home. Eventually, they need total care. This can cause great stress for family members who must care for them.

Nursing Assessment

  • Activity / rest
    Signs: anxiety, helplessness, sleep pattern disturbance, lethargy and impaired motor skills.
    Symptoms: feeling melting
  • Circulation
    Symptoms: History of cerebral vascular disease / systemic, hypertension, embolic episodes
    Ego integrity
    Signs: hide incompetence, sit down and watch the other, the first activity might accumulate objects are not moving and emotional stability
    Symptoms: suspicious or afraid of the situation / person fantasies, misperceptions of the environment, loss of multiple.
  • Elimination
    Signs: Incontinence of urine / feces
    Symptoms: The urge to urinate

Nursing Diagnosis

Change the thought process related to:

  • Irreversible neuronal degeneration
  • Memory Loss
  • Psychological Conflict
  • Sleep deprivation

Changes in sensory perception related to:

  • Changes in perception, transmission and / or sensory integration
  • Limitations related to the social environment

Changes in sleep patterns related to:

  • Changes in sensory
  • Psychological pressure
  • Changes in activity patterns

The risk of trauma related to:

  • The inability to recognize / identify hazards in the environment
  • Disorientation, confusion, impaired decision making
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Nursing Care Plans

Risk for Injury

Related to:

  • Unable to recognize / identify hazards in the environment.
  • Disorientation, confusion, impaired decision making.
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Interventions

  1. Assess the degree of impaired ability of competence emergence of impulsive behavior and a decrease in visual perception.
  2. Help the people closest to identify the risk of hazards that may arise.
  3. Eliminate / minimize sources of hazards in the environment
  4. Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.

Rationale:

  1. Impairment of visual perception increase the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers more aware of the danger.
  2. An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
  3. Maintain security by avoiding a confrontation that could improve the behavior / increase the risk for injury.

Disturbed Thought Process

Related to

  • Irreversible neurodegeneration
  • Memory Loss
  • Psychological Conflict
  • Deprivation lie

Nursing Interventions

  1. Assess the level of cognitive disorders such as change to orientation to people, places and times, range, attention, thinking skills.
  2. Talk with the people closest to the usual behavior change / length of the existing problems.
  3. Maintain a nice quiet neighborhood.
  4. Face-to-face when talking with patients.
  5. Call patient by name.
  6. Use a rather low voice and spoke slowly in patients.

Rationale

  1. Provide the basis for the evaluation / comparison that will come, and influencing the choice of intervention.
  2. Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.
  3. Cause concern, especially in people with perceptual disorders.
  4. The name is a form of self-identity and lead to recognition of reality and the individual.
  5. Increasing the possibility of understanding.

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Disturbed Thought Process — AIDS (HIV Positive) Nursing Care Plan (NCP)

March 26, 2012, 4:30 am
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Disturbed Thought Process — AIDS Nursing Care PlansNursing Diagnosis: Thought Processes, disturbed

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.

Disturbed Thought Process — AIDS (HIV Positive) Nursing Care Plan (NCP)

Nursing Interventions Rationale
 Assess mental and neurological status using appropriate tools.  Establishes functional level at time of admission and provides baseline for future comparison.
 Consider effects of emotional distress, e.g., anxiety, grief, anger.  May contribute to reduced alertness, confusion, withdrawal, and hypoactivity, requiring further evaluation and intervention.
 Monitor medication regimen and usage.  Actions and interactions of various medications, prolonged drug half-life/altered excretion rates result in cumulative effects, potentiating risk of toxic reactions. Some drugs may have adverse side effects; e.g., haloperidol (Haldol) can seriously impair motor function in patients with AIDS dementia complex.
 Investigate changes in personality, response to stimuli, orientation/level of consciousness; or development of headache, nuchal rigidity, vomiting, fever, seizure activity.  Changes may occur for numerous reasons, including development/exacerbation of opportunistic diseases/CNS infection. Note: 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.  Providing normal environmental stimuli can help in maintaining some sense of reality orientation.
 Provide cues for reorientation, e.g., radio, television, calendars, clocks, room with an outside view. Use patient’s name; identify yourself. Maintain consistent personnel and structured schedules as appropriate.  Frequent reorientation to place and time may be necessary, especially during fever/acute CNS involvement. Sense of continuity may reduce associated anxiety.
 Discuss use of datebooks, lists, other devices to keep track of activities.  These techniques help patient manage problems of forgetfulness.
 Encourage family/SO to socialize and provide reorientation with current news, family events.  Familiar contacts are often helpful in maintaining reality orientation, especially if patient is hallucinating.
 Encourage patient to do as much as possible, e.g., dress and groom daily, see friends, and so forth.  Can help maintain mental abilities for longer period.
 Provide support for SO. Encourage discussion of concerns and fears  Bizarre behavior/deterioration of abilities may be very frightening for SO and makes management of care/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.  Can reduce anxiety and fear of unknown; can enhance patient’s understanding and involvement/cooperation in treatment when possible.
Reduce provocative/noxious stimuli. Maintain bedrest in quiet, darkened room if indicated. If patient is prone to agitation, violent behavior, or seizures, reducing external stimuli may be helpful.
Decrease noise, especially at night. Promotes sleep, reducing cognitive symptoms and effects of sleep deprivation.
Maintain safe environment, e.g., excess furniture out of the way, call bell within patient’s reach, bed in low position/rails up; restriction of smoking (unless monitored by caregiver/SO), seizure precautions, soft restraints if indicated. Provides sense of security/stability in an otherwise confusing situation.
Discuss causes/future expectations and treatment if dementia is diagnosed. Use concrete terms. Obtaining information that ZDV has been shown to improve cognition can provide hope and control for losses.
Administer medications as indicated:Amphotericin B (Fungizone); 

 

ZDV (Retrovir) and other antiretrovirals alone or in combination;

 

Antipsychotics, e.g., haloperidol (Haldol), and/or antianxiety agents, e.g., lorazepam (Ativan).

 Antifungal useful in treatment of cryptococcosis meningitis.Shown to improve neurological and mental functioning for undetermined period of time.

 

Cautious use may help with problems of sleeplessness, emotional lability, hallucinations, suspiciousness, and agitation.
Refer to counseling as indicated. May help patient gain control in presence of thought disturbances or psychotic symptomatology.

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Disturbed Thought Process — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP)

May 5, 2012, 3:25 am
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ED-Disturbed Thought ProcessNURSING DIAGNOSIS: Thought Processes, disturbed

May be related to

  • Severe malnutrition/electrolyte imbalance
  • Psychological conflicts, e.g., sense of low self-worth, perceived lack of control

Possibly evidenced by

  • Impaired ability to make decisions, problem-solve
  • Non–reality-based verbalizations
  • Ideas of reference
  • Altered sleep patterns, e.g., may go to bed late (stay up to binge/purge) and get up early
  • Altered attention span/distractibility
  • Perceptual disturbances with failure to recognize hunger; fatigue, anxiety, and depression

Desired Outcomes

  • Verbalize understanding of causative factors and awareness of impairment.
  • Demonstrate behaviors to change/prevent malnutrition.
  • Display improved ability to make decisions, problem-solve.

Disturbed Thought Process — Anorexia & Bulimia Nervosa Nursing Care Plan (NCP): Nursing Interventions & Rationale

Nursing Interventions Rationale
 Be aware of patient’s distorted thinking ability.  Allows caregiver to have more realistic expectations of patient and provide appropriate information and support.
Listen to/avoid challenging irrational, illogical thinking. Present reality concisely and briefly.  It is difficult to responds logically when thinking ability is physiologically impaired. Patient needs to hear reality, but challenging patient leads to distrust and frustration. Note:Even though patient may gain weight, she or he may continue to struggle with attitudes/behaviors typical of eating disorders, major depression, and/or alcohol dependence for a number of years.
Adhere strictly to nutritional regimen.  Improved nutrition is essential to improved brain functioning.
 Review electrolyte/renal function tests. Imbalances negatively affect cerebral functioning and may require correction before therapeutic interventions can begin.

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13 AIDS (HIV Positive) Nursing Care Plans

July 13, 2013, 6:45 am
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Definition

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

HIV infection is a progressive disease leading to AIDS, as defined by the CDC (January 1994): “persons with CD4 cell count of under 200 (with or without symptoms of opportunistic infection) who are HIV-positive are diagnosed as having AIDS.” Research studies in 1995 showed that HIV initially replicates rapidly on a daily basis. The half-life of the virus is 2 days, with almost complete turnover in 14 days. Therefore, the immune response is massive throughout the course of HIV disease. Evidence suggests the cellular immune response is essential in limiting replication and rate of disease progression. Controlling the replication of the virus to lower the viral load is the current focus of treatment.

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.

Diagnostic Studies

  • 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:
  • RI-PCR: The most widely used test currently can detect viral RNA levels as low as 50 copies/mL of plasma with an upper limit of 75,000 copies/mL.
  • bDNA 3.0 assay: Has a wider range of 50–500,000 copies/mL. Therapy can be initiated, or changes made in treatment approaches, based on rise of viral load or maintenance of a low viral load. This is currently the leading indicator of effectiveness of therapy.
  • T-lymphocyte cells: Total count reduced.
  • CD4+ lymphocyte count (immune system indicator that mediates several immune system processes and signals B cells to produce antibodies to foreign germs): Numbers less than 200 indicate severe immune deficiency response and diagnosis of AIDS.
  • T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of suppressor cells to helper cells (T8+ to T4+) indicates immune suppression.
  • Polymerase chain reaction (PCR) test: Detects HIV-DNA; most helpful in testing newborns of HIV-infected mothers. Infants carry maternal HIV antibodies and therefore test positive by ELISA and Western blot, even though infant is not necessarily infected.
  • STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and other common STDs may be positive.
  • Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid, lesions, sputum, and secretions may be done to identify the opportunistic infection. Some of the most commonly identified are the following:
  • Protozoal and helminthic infections: PCP, cryptosporidiosis, toxoplasmosis.
  • Fungal infections: Candida albicans (candidiasis), Cryptococcus neoformans(cryptococcosis), Histoplasma capsulatum (histoplasmosis).
  • Bacterial infections: Mycobacterium avium-intracellulare (occurs with CD4 counts less than 50), miliary mycobacterial TB, Shigella (shigellosis),Salmonella (salmonellosis).
  • Viral infections: CMV (occurs with CD4 counts less than 50), herpes simplex, herpes zoster.
  • Neurological studies, e.g., electroencephalogram (EEG), magnetic resonance imaging (MRI), computed tomography (CT) scans of the brain; electromyography (EMG)/nerve conduction studies: Indicated for changes in mentation, fever of undetermined origin, and/or changes in sensory/motor function to determine effects of HIV infection/opportunistic infections.
  • Chest x-ray: May initially be normal or may reveal progressive interstitial infiltrates secondary to advancing PCP (most common opportunistic disease) or other pulmonary complications/disease processes such as TB.
  • Pulmonary function tests: Useful in early detection of interstitial pneumonias.
  • Gallium scan: Diffuse pulmonary uptake occurs in PCP and other forms of pneumonia.
  • Biopsies: May be done for differential diagnosis of Kaposi’s 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.

Nursing Care Plans

Imbalanced Nutrition: Less Than Body Requirements

May be related to

  • Inability or altered ability to ingest, digest and/or metabolize nutrients: nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract infections, fatigue
  • Increased metabolic rate/nutritional needs (fever/infection)

Possibly evidenced by

  • Weight loss, decreased subcutaneous fat/muscle mass (wasting)
  • Lack of interest in food, aversion to eating, altered taste sensation
  • Abdominal cramping, hyperactive bowel sounds, diarrhea
  • Sore, inflamed buccal cavity
  • Abnormal laboratory results: vitamin/mineral and protein deficiencies, electrolyte imbalances

Desired Outcomes

  • Maintain weight or display weight gain toward desired goal.
  • Demonstrate positive nitrogen balance, be free of signs of malnutrition, and display improved energy level.
Nursing Interventions Rationale
 Assess ability to chew, taste, and swallow.  Lesions of the mouth, throat, and esophagus (often caused by candidiasis, herpes simplex, hairy leukoplakia, KS and 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.  Hypermotility of intestinal tract is common and is associated with vomiting and diarrhea, which may affect choice of diet/route. Note: Lactose intolerance and malabsorption (e.g., with CMV, MAC, cryptosporidiosis) contribute to diarrhea and may necessitate change in diet/supplemental formula (e.g., Advera, Resource).
 Weigh as indicated. Evaluate weight in terms of premorbid weight. Compare serial weights and anthropometric measurements.  Indicator of nutritional needs/adequacy of intake. Note:Because of immune suppression, some blood tests normally used for testing nutritional status are not useful.
 Note drug side effects.  Prophylactic and therapeutic medications can have side effects affecting nutrition, e.g., ZDV (altered taste, nausea/vomiting), Bactrim (anorexia, glucose intolerance, glossitis), Pentam (altered taste and smell, nausea/vomiting, glucose intolerance), protease inhibitors (elevated lipids and blood sugar secondary to insulin resistance).
 Plan diet with patient/SO, suggesting foods from home if appropriate. Provide small, frequent meals/snacks of nutritionally dense foods and non acidic foods and beverages, with choice of foods palatable to patient. Encourage high-calorie/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.  Including patient in planning gives sense of control of environment and may enhance intake. Fulfilling cravings for noninstitutional food may also improve intake. Note: 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/vomiting or are poorly tolerated by patient because of mouth sores/dysphagia. Avoid serving very hot liquids/foods. Serve foods that are easy to swallow, e.g., eggs, ice cream, cooked vegetables.  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.  Gastric fullness diminishes appetite and food intake.
 Encourage as much physical activity as possible.  May improve appetite and general feelings of well-being.
 Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes.  Reduces discomfort associated with nausea/vomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth may enhance appetite.
 Provide rest period before meals. Avoid stressful procedures close to mealtime.  Minimizes fatigue; increases energy available for work of eating.
 Remove existing noxious environmental stimuli or conditions that aggravate gag reflex.  Reduces stimulus of the vomiting center in the medulla.
Encourage patient to sit up for meals Facilitates swallowing and reduces risk of aspiration.
Record ongoing caloric intake. Identifies need for supplements or alternative feeding methods.
Maintain NPO status when appropriate. May be needed to reduce nausea/vomiting.
Insert/maintain nasogastric (NG) tube as indicated. May be needed to reduce vomiting or to administer tube feedings. Note: Esophageal irritation from existing infection (Candida, herpes, or KS) may provide site for secondary infections/trauma; therefore, NG tube should be used with caution.
Administer medications as indicated:Antiemetics, e.g., prochlorperazine (Compazine), promethazine (Phenergan), trimethobenzamide (Tigan);Sucralfate (Carafate) suspension; mixture of Maalox, diphenhydramine (Benadryl), and lidocaine (Xylocaine); 

Vitamin supplements;

 

 

 

 

 

Appetite stimulants, e.g., dronabinol (Marinol), megestrol (Megace), oxandrolone (Oxandrin);

 

 

 

TNF-alpha inhibitors, e.g., thalidomide;

 

 

 

 

Antidiarrheals, e.g., diphenoxylate (Lomotil), loperamide (Imodium), octreotide (Sandostatin);

 

 

 

Antibiotic therapy, e.g., ketoconazole (Nizoral), fluconazole (Diflucan).

 Reduces incidence of nausea/vomiting, possibly enhancing oral intake.Given with meals (swish and hold in mouth) to relieve mouth pain, enhance intake. Mixture may be swallowed for presence of pharyngeal/esophageal lesions. 

Corrects vitamin deficiencies resulting from decreased food intake and/or disorders of digestion and absorption in the GI system. Note:Avoid megadoses; suggested supplemental level is two times the recommended daily allowance (RDA).

 

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.

 

Reduces elevated levels of tumor necrosis factor (TNF) present in chronic illness contributing to wasting/cachexia. Studies reveal a mean weight gain of 10% over 28 wk of therapy.

 

Inhibit GI motility subsequently decreasing diarrhea. Imodium or Sandostatin areeffective treatments for secretory diarrhea (secretion of water and electrolytes by intestinal epithelium).

 

May be given to treat/prevent infections involving the GI tract.

Acute/Chronic Pain

May be related to

  • Tissue inflammation/destruction: infections, internal/external cutaneous lesions, rectal excoriation, malignancies, necrosis
  • Peripheral neuropathies, myalgias, and arthralgias
  • Abdominal cramping

Possibly evidenced by

  • Reports of pain
  • Self-focusing; narrowed focus, guarding behaviors
  • Alteration in muscle tone; muscle cramping, ataxia, muscle weakness, paresthesias, paralysis
  • Autonomic responses; restlessness

Desired Outcomes

  • Report pain relieved/controlled.
  • Demonstrate relaxed posture/facial expression.
  • Be able to sleep/rest appropriately.
Nursing Interventions Rationale
 Assess pain reports, noting location, intensity (0–10 scale), frequency, and time of onset. Note nonverbal cues, e.g., restlessness, tachycardia, grimacing.  Indicates need for/effectiveness of interventions and may signal development/resolution of complications. Note:Chronic pain does not produce autonomic changes; however, acute and chronic pain can coexist.
 Instruct/encourage patient to report pain as it develops rather then waiting until level is severe.  Efficacy of comfort measures and medications is improved with timely intervention.
Encourage verbalization of feelings.  Can reduce anxiety and fear and thereby reduce perception of intensity of pain.
 Provide diversional activities, e.g., reading, visiting, radio/television. Refocuses attention; may enhance coping abilities.
Perform palliative measures, e.g., repositioning, massage, ROM of affected joints. Promotes relaxation/decreases muscle tension.
Instruct patient in/encourage use of visualization, guided imagery, progressive relaxation, deep-breathing techniques, meditation, and mindfulness.  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. Note:Mindfulness is the skill of staying in the here and now.
 Provide oral care. (Refer to ND: Oral Mucous Membrane, impaired.)  Oral ulcerations/lesions may cause severe discomfort.
 Apply warm/moist packs to pentamidine injection/IV sites for 20 min after administration.  These injections are known to cause pain and sterile abscesses
 Administer analgesics/antipyretics, narcotic analgesics. Use patient-controlled analgesia (PCA) or provide around-the-clock analgesia with rescue doses prn.  Provides relief of pain/discomfort; reduces fever. PCA or around-the-clock medication keeps the blood level of analgesia stable, preventing cyclic undermedication or overmedication. Note: Drugs such as Ativan may be used to potentiate effects of analgesics.

Impaired Skin Integrity

Risk factors may include

  • Decreased level of activity/immobility, altered sensation, skeletal prominence, changes in skin turgor
  • Malnutrition, altered metabolic state

May be related to (actual)

  • Immunologic deficit: AIDS-related dermatitis; viral, bacterial, and fungal infections (e.g., herpes, Pseudomonas, Candida); opportunistic disease processes (e.g., KS)
  • Excretions/secretions

Possibly evidenced by

  • Skin lesions; ulcerations; decubitus ulcer formation

Desired Outcomes

  • Be free of/display improvement in wound/lesion healing.
  • Demonstrate behaviors/techniques to prevent skin breakdown/promote healing.
Nursing Interventions Rationale
 Assess skin daily. Note color, turgor, circulation, and sensation. Describe/measure lesions and observe changes.  Establishes comparative baseline providing opportunity for timely intervention.
 Maintain/instruct in good skin hygiene, e.g., wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream.  Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to dry/fragile skin. Massaging increases circulation to the skin and promotes comfort. Note: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/elbow pads, sheepskin.  Reduces stress on pressure points, improves blood flow to tissues, and promotes healing.
 Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric.  Skin friction caused by wet/wrinkled or rough sheets leads to irritation of fragile skin and increases risk for infection.
 Encourage ambulation/out of bed as tolerated.  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, e.g., zinc oxide, A & D ointment.  Prevents maceration caused by diarrhea and keeps perianal lesions dry. Note: Use of toilet paper may abrade lesions.
File nails regularly.  Long/rough nails increase risk of dermal damage.
 Cover open pressure ulcers with sterile dressings or protective barrier, e.g., Tegaderm, DuoDerm, as indicated.  May reduce bacterial contamination, promote healing.
 Provide foam/flotation/alternate pressure mattress or bed.  Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia.
 Obtain cultures of open skin lesions.  Identifies pathogens and appropriate treatment choices.
 Apply/administer topical/systemic drugs as indicated.  Used in treatment of skin lesions. Use of agents such as Prederm spray can stimulate circulation, enhancing healing process. Note: 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 (e.g., Telfa), as indicated. Protects ulcerated areas from contamination and promotes healing
Refer to physical therapy for regular exercise/activity program. Promotes improved muscle tone and skin health.

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/document all oral lesions. Note reports of pain, swelling, difficulty with chewing/swallowing.  Edema, open lesions, and crusting on oral mucous membranes and throat may cause pain and difficulty with chewing/swallowing.
 Provide oral care daily and after food intake, using soft toothbrush, nonabrasive toothpaste, nonalcohol mouthwash, floss, and lip moisturizer. Alleviates discomfort, prevents acid formation associated with retained food particles, and promotes feeling of well-being.
Rinse oral mucosal lesions with saline/dilute hydrogen peroxide or baking soda solutions.  Reduces spread of lesions and encrustations from candidiasis, and promotes comfort.
Suggest use of sugarless gum/candy or commercial salivary substitute.  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/cold smooth foods.  Abrasive foods may open healing lesions. Open lesions are painful and aggravated by salt, spice, acidic foods/beverages. Extreme cold or heat can cause pain to sensitive mucous membranes.
Encourage oral intake of at least 2500 mL/day.  Maintains hydration; prevents drying of oral cavity.
Encourage patient to refrain from smoking.  Smoke is drying and irritating to mucous membranes.
 Obtain culture specimens of lesions.  Reveals causative agents and identifies appropriate therapies.
Administer medications, as indicated, e.g., nystatin (Mycostatin), ketoconazole (Nizoral).TNF-alpha inhibitor, e.g., thalidomide. Specific drug choice depends on particular infecting organism(s), e.g.,Candida.Effective in treatment of oral lesions due to recurrent stomatitis.
 Refer for dental consultation, if appropriate.  May require additional therapy to prevent dental losses.

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
 Assess sleep patterns and note changes in thought processes/behaviors.  Multiple factors can aggravate fatigue, including sleep deprivation, emotional distress, side effects of drugs/chemotherapies, and developing CNS disease.
 Recommend scheduling activities for periods when patient has most energy. Plan care to allow for rest periods. Involve patient/SO in schedule planning.  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/conserve energy.
Establish realistic activity goals with patient.  Provides for a sense of control and feelings of accomplishment. Prevents discouragement from fatigue of overactivity.
 Encourage patient to do whatever possible, e.g., self-care, sit in chair, short walks. Increase activity level as indicated.  May conserve strength, increase stamina, and enable patient to become more active without undue fatigue and discouragement.
Identify energy conservation techniques, e.g., sitting, breaking ADLs into manageable segments. Keep travelways clear of furniture. Provide/assist with ambulation/self-care needs as appropriate.  Weakness may make ADLs almost impossible for patient to complete. Protects patient from injury during activities.
Monitor physiological response to activity, e.g., changes in BP, respiratory rate, or heart rate.  Tolerance varies greatly, depending on the stage of the disease process, nutrition state, fluid balance, and number/type of opportunistic diseases that patient has been subject to.
Encourage nutritional intake.  Adequate intake/utilization of nutrients is necessary to meet increased energy needs for activity.Note: Continuous stimulation of the immune system by HIV infection contributes to a hypermetabolic state.
 Refer to physical/occupational therapy.  Programmed daily exercises and activities help patient maintain/increase strength and muscle tone, enhance sense of well-being.
 Refer to community resources  Provides assistance in areas of individual need as ability to care for self becomes more difficult.
 Provide supplemental O2 as indicated.  Presence of anemia/hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.

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 appropriate tools.  Establishes functional level at time of admission and provides baseline for future comparison.
 Consider effects of emotional distress, e.g., anxiety, grief, anger.  May contribute to reduced alertness, confusion, withdrawal, and hypoactivity, requiring further evaluation and intervention.
 Monitor medication regimen and usage.  Actions and interactions of various medications, prolonged drug half-life/altered excretion rates result in cumulative effects, potentiating risk of toxic reactions. Some drugs may have adverse side effects; e.g., haloperidol (Haldol) can seriously impair motor function in patients with AIDS dementia complex.
 Investigate changes in personality, response to stimuli, orientation/level of consciousness; or development of headache, nuchal rigidity, vomiting, fever, seizure activity.  Changes may occur for numerous reasons, including development/exacerbation of opportunistic diseases/CNS infection. Note: 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.  Providing normal environmental stimuli can help in maintaining some sense of reality orientation.
 Provide cues for reorientation, e.g., radio, television, calendars, clocks, room with an outside view. Use patient’s name; identify yourself. Maintain consistent personnel and structured schedules as appropriate.  Frequent reorientation to place and time may be necessary, especially during fever/acute CNS involvement. Sense of continuity may reduce associated anxiety.
 Discuss use of datebooks, lists, other devices to keep track of activities.  These techniques help patient manage problems of forgetfulness.
 Encourage family/SO to socialize and provide reorientation with current news, family events.  Familiar contacts are often helpful in maintaining reality orientation, especially if patient is hallucinating.
 Encourage patient to do as much as possible, e.g., dress and groom daily, see friends, and so forth.  Can help maintain mental abilities for longer period.
 Provide support for SO. Encourage discussion of concerns and fears  Bizarre behavior/deterioration of abilities may be very frightening for SO and makes management of care/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.  Can reduce anxiety and fear of unknown; can enhance patient’s understanding and involvement/cooperation in treatment when possible.
Reduce provocative/noxious stimuli. Maintain bedrest in quiet, darkened room if indicated. If patient is prone to agitation, violent behavior, or seizures, reducing external stimuli may be helpful.
Decrease noise, especially at night. Promotes sleep, reducing cognitive symptoms and effects of sleep deprivation.
Maintain safe environment, e.g., excess furniture out of the way, call bell within patient’s reach, bed in low position/rails up; restriction of smoking (unless monitored by caregiver/SO), seizure precautions, soft restraints if indicated. Provides sense of security/stability in an otherwise confusing situation.
Discuss causes/future expectations and treatment if dementia is diagnosed. Use concrete terms. Obtaining information that ZDV has been shown to improve cognition can provide hope and control for losses.
Administer medications as indicated:Amphotericin B (Fungizone);ZDV (Retrovir) and other antiretrovirals alone or in combination;

 

Antipsychotics, e.g., haloperidol (Haldol), and/or antianxiety agents, e.g., lorazepam (Ativan).

 Antifungal useful in treatment of cryptococcosis meningitis.Shown to improve neurological and mental functioning for undetermined period of time.Cautious use may help with problems of sleeplessness, emotional lability, hallucinations, suspiciousness, and agitation.
Refer to counseling as indicated. May help patient gain control in presence of thought disturbances or psychotic symptomatology.

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
 Assure patient of confidentiality within limits of situation.  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.  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.  Can reduce anxiety and enable patient to make decisions/choices based on realities.
 Be alert to signs of denial/depression (e.g., withdrawal; angry, inappropriate remarks). Determine presence of suicidal ideation and assess potential on a scale of 1–10.  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.  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.  Acceptance of feelings allows patient to begin to deal with situation.
 Recognize and support the stage patient/family is at in the grieving process.  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.  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/interaction with family/SO.  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. Allows for better interpersonal interaction and reduction of anxiety and fear.
 Include SO as indicated when major decisions are to be made.  Ensures a support system for patient, and allows SO the chance to participate in patient’s life. Note: If patient, family, and SO are in conflict, separate care consultations and visiting times may be needed.
Discuss Advance Directives, end-of-life desires/needs. Review specific wishes and explain various options clearly. May assist patient/SO to plan realistically for terminal stages and death. Note: Many individuals do not understand medical terminology/options,
Refer to psychiatric counseling (e.g., psychiatric clinical nurse specialist, psychiatrist, social worker).Provide contact with other resources as indicated, e.g.:Spiritual advisor; 

Hospice staff.

 May require further assistance in dealing with diagnosis/prognosis, especially when suicidal thoughts are present.Provides opportunity for addressing spiritual concerns.May help relieve anxiety regarding end-of-life care and support for patient/SO.

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
 Ascertain patient’s perception of situation.  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.  Patient may experience physical isolation as a result of current medical status and some degree of social isolation secondary to diagnosis of AIDS.
 Limit/avoid use of mask, gown, and gloves when possible, e.g., when talking to patient.  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/relationship with immediate and extended family.  When patient has assistance from SO, feelings of loneliness and rejection are diminished. Note:Patient may not receive usual/needed support for coping with life-threatening illness and associated grief because of fear and lack of understanding (AIDS hysteria).
Explain isolation precautions/procedures to patient and SO.  Gloves, gowns, mask are not routinely required with a diagnosis of AIDS except when contact with secretions/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.  Participation with others can foster a feeling of belonging.
Encourage active role of contact with SO.  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/imposed isolation.  Having a plan promotes a sense of control over own life and gives patient something to look forward to/actions to accomplish.
Be alert to verbal/nonverbal cues, e.g., withdrawal, statements of despair, sense of aloneness. Ask patient if thoughts of suicide are being entertained.  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.

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
 Identify factors that contribute to patient’s feelings of powerlessness, e.g., diagnosis of a terminal illness, lack of support systems, lack of knowledge about present situation.  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, e.g., verbal/nonverbal expressions indicating lack of control (“It won’t make any difference”), flat affect, lack of communication.  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/attainable daily goals. Encourage patient control and responsibility as much as possible. Identify things that patient can and cannot control.  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.  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/assist with planning for funeral as appropriate.  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.

Deficient Knowledge

May be related to

  • Lack of exposure/recall; information misinterpretation
  • Cognitive limitation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions/request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

  • Verbalize understanding of condition/disease process and potential complications.
  • Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Correctly perform necessary procedures and explain reasons for actions.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions Rationale
 Review disease process and future expectations.  Provides knowledge base from which patient can make informed choices.
 Determine level of independence/dependence and physical condition. Note extent of care and support available from family/SO and need for other caregivers.  Helps plan amount of care and symptom management required and need for additional resources.
 Review modes of transmission of disease, especially if newly diagnosed.  Corrects myths and misconceptions; promotes safety for patient/others. Accurate epidemiological data are important in targeting prevention interventions.
 Instruct patient and caregivers concerning infection control, e.g.: using good handwashing techniques for everyone (patient, family, caregivers); using gloves when handling bedpans, dressings/soiled linens; wearing mask if patient has productive cough; placing soiled/wet linens in plastic bag and separating from family laundry, washing with detergent and hot water; cleaning surfaces with bleach/water solution of 1:10 ratio, disinfecting toilet bowl/bedpan with full-strength bleach; preparing patient’s food in clean area; washing dishes/utensils in hot soapy water (can be washed with the family dishes).  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, e.g., ointments, padding.  Healthy skin provides barrier to infection. Measures to prevent skin disruption and associated complications are critical.
 Ascertain that patient/SO can perform necessary oral and dental care. Review procedures as indicated. Encourage regular dental care.  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.  Promotes adequate nutrition necessary for healing and support of immune system; enhances feeling of well-being.
 Discuss medication regimen, interactions, and side effects  Enhances cooperation with/increases probability of success with therapeutic regimen.
 Provide information about symptom management that complements medical regimen; e.g., with intermittent diarrhea, take diphenoxylate (Lomotil) before going to social event. Provides patient with increased sense of control, reduces risk of enbarrassment, and promotes comfort.
 Stress importance of adequate rest.  Helps manage fatigue; enhances coping abilities and energy level.
 Encourage activity/exercise at level that patient can tolerate.  Stimulates release of endorphins in the brain, enhancing sense of well-being.
Stress necessity of continued healthcare and follow-up. Provides opportunity for altering regimen to meet individual/changing needs.
Recommend cessation of smoking. Smoking increases risk of respiratory infections and can further impair immune system.
Identify signs/symptoms requiring medical evaluation, e.g., persistent fever/night sweats, swollen glands, continued weight loss, diarrhea, skin blotches/lesions, headache, chest pain/dyspnea. Early recognition of developing complications and timely interventions may prevent progression to life-threatening situation.
Identify community resources, e.g., hospice/residential care centers, visiting nurse, home care services, Meals on Wheels, peer group support. Facilitates transfer from acute care setting for recovery/independence or end-of-life care.

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
 Avoid injections, rectal temperatures/rectal tubes. Administer rectal suppositories with caution.  Protects patient from procedure-related causes of bleeding; i.e., insertion of thermometers, rectal tubes can damage or tear rectal mucosa. Note: Some medications need to be given via suppository, so caution is advised.
Maintain a safe environment; e.g., keep all necessary objects and call bell within patient’s reach and keep bed in low position.  Reduces accidental injury, which could result in bleeding.
 Maintain bedrest/chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen.  Reduces possibility of injury, although activity needs to be maintained. May need to discontinue or reduce dosage of a drug. Note: Patient can have a surprisingly low platelet count without bleeding.
 Hematest body fluids, e.g., urine, stool, vomitus, for occult blood.  Prompt detection of bleeding/initiation of therapy may prevent critical hemorrhage.
Observe for/report epistaxis, hemoptysis, hematuria, nonmenstrual vaginal bleeding, or oozing from lesions/body orifices/IV insertion sites.  Spontaneous bleeding may indicate development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.
Monitor for changes in vital signs and skin color, e.g., BP, pulse, respirations, skin pallor/discoloration.  Presence of bleeding/hemorrhage may lead to circulatory failure/shock.
Evaluate change in level of consciousness.  May reflect cerebral bleeding.
 Review laboratory studies, e.g., PT, aPTT, clotting time, platelets, Hb/Hct.  Detects alterations in clotting capability; identifies therapy needs. Note: Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.
 Administer blood products as indicated.  Transfusions may be required in the event of persistent/massive spontaneous bleeding.
 Avoid use of aspirin products/NSAIDs, especially in presence of gastric lesions.  These medications reduce platelet aggregation, impairing/prolonging the coagulation process, and may cause further gastric irritation, increasing risk of bleeding.

Risk for Deficient Fluid Volume

Risk factors may include

  • Excessive losses: copious diarrhea, profuse sweating, vomiting
  • Hypermetabolic state, fever
  • Restricted intake: nausea, anorexia; lethargy

Desired outcomes

  • Maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital signs, individually adequate urinary output.
Nursing Interventions Rationale
 Monitor vital signs, including CVP if available. Note hypotension, including postural changes.  Indicators of circulating fluid volume.
 Note temperature elevation and duration of febrile episode. Administer tepid sponge baths as indicated. Keep clothing and linens dry. Maintain comfortable environmental temperature.  Fever is one of the most frequent symptoms experienced by patients with HIV infections (97%). Increased metabolic demands and associated excessive diaphoresis result in increased insensible fluid losses and dehydration.
 Assess skin turgor, mucous membranes, and thirst.  Indirect indicators of fluid status.
 Measure urinary output and specific gravity. Measure/estimate amount of diarrheal loss. Note insensible losses. Increased specific gravity/decreasing urinary output reflects altered renal perfusion/circulating volume. Note:Monitoring fluid balance is difficult in the presence of excessive GI/insensible losses.
Weigh as indicated.  Although weight loss may reflect muscle wasting, sudden fluctuations reflect state of hydration. Fluid losses associated with diarrhea can quickly create a crisis and become life-threatening.
Monitor oral intake and encourage fluids of at least 2500 mL/day.  Maintains fluid balance, reduces thirst, and keeps mucous membranes moist.
 Make fluids easily accessible to patient; use fluids that are tolerable to patient and that replace needed electrolytes  Enhances intake. Certain fluids may be too painful to consume (e.g., acidic juices) because of mouth lesions.
Eliminate foods potentiating diarrhea  May help reduce diarrhea. Use of lactose-free products helps control diarrhea in the lactose-intolerant patient.
 Encourage use of live culture yogurt or OTC Lactobacillus acidophilus(lactaid).  Antibiotic therapies disrupt normal bowel flora balance, leading to diarrhea. Note: Must be taken 2 hr before or after antibiotic to prevent inactivation of live culture.
 Administer fluids/electrolytes via feeding tube/IV, as appropriate.  May be necessary to support/augment circulating volume, especially if oral intake is inadequate, nausea/vomiting persists.
Monitor laboratory studies as indicated, e.g.:Serum/urine electrolytes;BUN/Cr;Stool specimen collection. Alerts to possible electrolyte disturbances and determines replacement needs.Evaluates renal perfusion/function.Bowel flora changes can occur with multiple or single antibiotic therapy.
Maintain hypothermia blanket if used. May be necessary when other measures fail to reduce excessive fever/insensible fluid losses.

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.
Nursing Interventions Rationale
Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen. Multiple medication regimen is difficult to maintain over a long period of time. Patients may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance.
Wash hands before and after all care contacts. Instruct patient/SO to wash hands as indicated. Reduces risk of cross-contamination.
Provide a clean, well-ventilated environment. Screen visitors/staff for signs of infection and maintain isolation precautions as indicated. Reduces number of pathogens presented to the immune system and reduces possibility of patient contracting a nosocomial infection.
Discuss extent and rationale for isolation precautions and maintenance of personal hygiene. Promotes cooperation with regimen and may lessen feelings of isolation.
Monitor vital signs, including temperature. Provides information for baseline data; frequent temperature elevations/onset of new fever indicates that the body is responding to a new infectious process or that medications are not effectively controlling incurable infections.
Assess respiratory rate/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. 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.
Investigate reports of headache, stiff neck, altered vision. Note changes in mentation and behavior. Monitor for nuchal rigidity/seizure activity. 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.
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.) Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.
Clean patient’s nails frequently. File, rather than cut, and avoid trimming cuticles. Reduces risk of transmission of pathogens through breaks in skin. Note: Fungal infections along the nail plate are common.
Monitor reports of heartburn, dysphagia, retrosternal pain on swallowing, increased abdominal cramping, profuse diarrhea. Esophagitis may occur secondary to oral candidiasis, CMV, or herpes. Cryptosporidiosis is a parasitic infection responsible for watery diarrhea (often more than 15L/day).
Inspect wounds/site of invasive devices, noting signs of local inflammation/infection. Early identification/treatment of secondary infection may prevent sepsis.
Wear gloves and gowns during direct contact with secretions/excretions or any time there is a break in skin of caregiver’s hands. Wear mask and protective eyewear to protect nose, mouth, and eyes from secretions during procedures (e.g., suctioning) or when splattering of blood may occur. 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.
Dispose of needles/sharps in rigid, puncture-resistant containers. Prevents accidental inoculation of caregivers. Use of needle cutters and recapping is not to be practiced. Note: Accidental needlesticks should be reported immediately, with follow-up evaluations done per protocol.
Label blood bags, body fluid containers, soiled dressings/ linens, and package appropriately for disposal per isolation protocol. Prevents cross-contamination and alerts appropriate personnel/departments to exercise specific hazardous materials procedures.
Clean up spills of body fluids/blood with bleach solution (1:10); add bleach to laundry. Kills HIV and controls other microorganisms on surfaces.

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7 Eating Disorders: Anorexia & Bulimia Nervosa Nursing Care Plans

July 14, 2013, 5:50 am
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Definitions

Anorexia nervosa is an illness of starvation, brought on by severe disturbance of body image and a morbid fear of obesity.

Bulimia nervosa is an eating disorder (binge-purge syndrome) characterized by extreme overeating followed by self-induced vomiting. It may include abuse of laxatives and diuretics.

Although these disorders primarily affect women, approximately 5%–10% of those afflicted are men, and both disorders can be present in the same individual.

Nursing Priorities

  1. Establish adequate/appropriate nutritional intake.
  2. Correct fluid and electrolyte imbalance.
  3. Assist patient to develop realistic body image/improve self-esteem.
  4. Provide support/involve significant other (SO), if available, in treatment program.
  5. Coordinate total treatment program with other disciplines.
  6. Provide information about disease, prognosis, and treatment to patient/SO.

Discharge Goals

  1. Adequate nutrition and fluid intake maintained.
  2. Maladaptive coping behaviors and stressors that precipitate anxiety recognized.
  3. Adaptive coping strategies and techniques for anxiety reduction and self-control implemented.
  4. Self-esteem increased.
  5. Disease process, prognosis, and treatment regimen understood.
  6. Plan in place to meet needs after discharge.

Assessment

ACTIVITY/REST

  • May report: Disturbed sleep patterns, e.g., early morning insomnia; fatigue
  • Feeling “hyper” and/or anxious
  • Increased activity/avid exerciser, participation in high-energy sports
  • Employment in positions/professions that stress/require weight control (e.g., athletics such as gymnasts, swimmers, jockeys; modeling; flight attendants)
  • May exhibit: Periods of hyperactivity, constant vigorous exercising

CIRCULATION

  • May report: Feeling cold even when room is warm
  • May exhibit: Low blood pressure (BP)
  • Tachycardia, bradycardia, dysrhythmias

EGO INTEGRITY

  • May report: Powerlessness/helplessness lack of control over eating (e.g., cannot stop eating/control what or how much is eaten [bulimia]); feeling disgusted with self, depressed or very guilty because of overeating
  • Distorted (unrealistic) body image, reports self as fat regardless of weight (denial), and sees thin body as fat; persistent overconcern with body shape and weight (fears gaining weight)
  • High self-expectations
  • Stress factors, e.g., family move/divorce, onset of puberty
  • Suppression of anger
  • May exhibit: Emotional states of depression, withdrawal, anger, anxiety, pessimistic outlook

ELIMINATION

  • May report: Diarrhea/constipation
  • Vague abdominal pain and distress, bloating
  • Laxative/diuretic abuse

FOOD/FLUID

  • May report: Constant hunger or denial of hunger; normal or exaggerated appetite that rarely vanishes until late in the disorder (anorexia)
  • Intense fear of gaining weight (females); may have prior history of being overweight (particularly males)
  • Preoccupation with food, e.g., calorie counting, gourmet cooking
  • An unrealistic pleasure in weight loss, while denying self pleasure in other areas
  • Refusal to maintain body weight over minimal norm for age/height (anorexia)
  • Recurrent episodes of binge eating; a feeling of lack of control over behavior during eating binges; a minimum average of two binge-eating episodes a week for at least 3 mo
  • Regularly engages in self-induced vomiting (binge-purge syndrome bulimia) either independently or as a complication of anorexia; or strict dieting or fasting
  • May exhibit: Weight loss/maintenance of body weight 15% or more below that expected (anorexia), or weight may be normal or slightly above or below normal (bulimia)
  • No medical illness evident to account for weight loss
  • Cachectic appearance; skin may be dry, yellowish/pale, with poor tugor (anorexia)
  • Preoccupation with food (e.g., calorie counting, hiding food, cutting food into small pieces, rearranging food on plate)
  • Irrational thinking about eating, food, and weight
  • Peripheral edema
  • Swollen salivary glands; sore, inflamed buccal cavity; continuous sore throat (bulimia)
  • Vomiting, bloody vomitus (may indicate esophageal tearing [Mallory-Weiss syndrome])
  • Excessive gum chewing

HYGIENE

  • May exhibit: Increased hair growth on body (lanugo), hair loss (axillary/pubic), hair is dull/not shiny
  • Brittle nails
  • Signs of erosion of tooth enamel, gums in poor condition, ulcerations of mucosa

NEUROSENSORY

  • May exhibit: Appropriate affect (except in regard to body and eating), or depressive affect
  • Mental changes: Apathy, confusion, memory impairment (brought on by malnutrition/
  • starvation)
  • Hysterical or obsessive personality style; no other psychiatric illness or evidence of a psychiatric thought disorder present (although a significant number may show evidence of an affective disorder)

PAIN/DISCOMFORT

  • May report: Headaches, sore throat/mouth, generalized vague complaints

SAFETY

  • May exhibit: Body temperature below normal
  • Recurrent infectious processes (indicative of depressed immune system)
  • Eczema/other skin problems, abrasions/calluses may be noted on back of hands from sticking finger down throat to induce vomiting

SEXUALITY

  • May report: Absence of at least three consecutive menstrual cycles (decreased levels of estrogen in response to malnutrition)
  • Promiscuity or denial/loss of sexual interest
  • History of sexual abuse
  • Homosexual/bisexual orientation (higher percentage in male patients than in general population)
  • May exhibit: Breast atrophy, amenorrhea

SOCIAL INTERACTION

  • May report: Middle-class or upper-class family background
  • History of being a quiet, cooperative child
  • Problems of control issues in relationships, difficult communications with others/authority figures, poor communication within family of origin
  • Engagement in power struggles
  • An emotional crisis of some sort, such as the onset of puberty or a family move
  • Altered relationships or problems with relationships (not married/divorced), withdrawal from friends/social contacts
  • Abusive family relationships
  • Sense of helplessness
  • History of legal difficulties (e.g., shoplifting)
  • May exhibit: Passive father/dominant mother, family members closely fused, togetherness prized, personal boundaries not respected

TEACHING/LEARNING

  • May report: Family history of higher than normal incidence of depression, other family members with eating disorders (genetic predisposition)
  • Onset of the illness usually between the ages of 10 and 22
  • Health beliefs/practice (e.g., certain foods have “too many” calories, use of “health” foods)
  • High academic achievement
  • Substance abuse
  • Discharge plan DRG projected mean length of inpatient stay: 6.4 days
  • considerations: Assistance with maintenance of treatment plan

Diagnostic Studies

  • Complete blood count (CBC) with differential: Determines presence of anemia, leukopenia, lymphocytosis. Platelets show significantly less than normal activity by the enzyme monoamine oxidase (thought to be a marker for depression).
  • Electrolytes: Imbalances may include decreased potassium, sodium, chloride, and magnesium.
  • Endocrine studies:
  • Thyroid function: Thyroxine (T4) levels usually normal; however, circulating triiodothyronine (T3) levels may be low.
  • Pituitary function: Thyroid-stimulating hormone (TSH) response to thyrotropin-releasing hormone (TRH) is abnormal in anorexia nervosa. Propranolol-glucagon stimulation test studies the response of human growth hormone (GH), which is depressed in anorexia. Gonadotropic hypofunction is noted.
  • Cortisol metabolism: May be elevated.
  • Dexamethasone suppression test (DST): Evaluates hypothalamic-pituitary function. Dexamethasone resistance indicates cortisol suppression, suggesting malnutrition and/or depression.
  • Luteinizing hormone (LH) secretions test: Pattern often resembles those of prepubertal girls.
  • Estrogen: Decreased.
  • MHP 6 levels: Decreased, suggestive of malnutrition/depression.
  • Serum glucose and basal metabolic rate (BMR): May be low.
  • Other chemistries: AST elevated. Hypercarotenemia, hypoproteinemia, hypercholesterolemia.
  • Urinalysis and renal function: Blood urea nitrogen (BUN) may be elevated; ketones present reflecting starvation; decreased urinary 17-ketosteroids; increased specific gravity/dehydration.
  • Electrocardiogram (ECG): Abnormal tracing with low voltage, T-wave inversion, dysrhythmias.

Nursing Care Plans

Below are 7 Nursing Care Plan (NCP) for eating disorders anorexia nervosa & bulimia nervosa.

Imbalanced Nutrition

NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements

May be related to

  • Inadequate food intake; self-induced vomiting
  • Chronic/excessive laxative use

Possibly evidenced by

  • Body weight 15% (or more) below expected, or may be within normal range (bulimia)
  • Pale conjunctiva and mucous membranes; poor skin turgor/muscle tone; edema
  • Excessive loss of hair; increased growth of hair on body (lanugo)
  • Amenorrhea
  • Hypothermia
  • Bradycardia; cardiac irregularities; hypotension

Desired Outcomes

  • Verbalize understanding of nutritional needs.
  • Establish a dietary pattern with caloric intake adequate to regain/maintain appropriate weight.
  • Demonstrate weight gain toward individually expected range.
Nursing Interventions Rationale
 Establish a minimum weight goal and daily nutritional requirements.  Malnutrition is a mood-altering condition, leading to depression and agitation and affecting cognitive function/decision making. Improved nutritional status enhances thinking ability, allowing initiation of psychological work.
 Use a consistent approach. Sit with patient while eating; present and remove food without persuasion and/or comment. Promote pleasant environment and record intake.  Patient detects urgency and may react to pressure. Any comment that might be seen as coercion provides focus on food. When staff responds in a consistent manner, patient can begin to trust staff responses. The single area in which patient has exercised power and control is food/eating, and he or she may experience guilt or rebellion if forced to eat. Structuring meals and decreasing discussions about food will decrease power struggles with patient and avoid manipulative games.
 Provide smaller meals and supplemental snacks, as appropriate.  Gastric dilation may occur if refeeding is too rapid following a period of starvation dieting. Note: Patient may feel bloated for 3–6 wk while body adjusts to food intake.
 Make selective menu available, and allow patient to control choices as much as possible.  Patient who gains confidence in self and feels in control of environment is more likely to eat preferred foods.
 Be alert to choices of low-calorie foods/beverages; hoarding food; disposing of food in various places, such as pockets or wastebaskets.  Patient will try to avoid taking in what is viewed as excessive calories and may go to great lengths to avoid eating.
Maintain a regular weighing schedule, such as Monday/ Friday before breakfast in same attire, and graph results.  Provides accurate ongoing record of weight loss/gain. Also diminishes obsessing about changes in weight.
Weigh with back to scale (depending on program protocols).  Although some programs prefer patient to see the results of the weighing, this can force the issue of trust in patient who usually does not trust others.
Avoid room checks and other control devices whenever possible.  External control reinforces feelings of powerlessness and therefore is usually not helpful.
Provide one-to-one supervision and have patient with bulimia remain in the day room area with no bathroom privileges for a specified period (e.g., 2 hr) following eating, if contracting is unsuccessful.  Prevents vomiting during/after eating. Patient may desire food and use a binge-purge syndrome to maintain weight. Note: Patient may purge for the first time in response to establishment of a weight gain program.
Monitor exercise program and set limits on physical activities. Chart activity/level of work (pacing and so on).  Moderate exercise helps in maintaining muscle tone/weight and combating depression; however, patient may exercise excessively to burn calories.
 Maintain matter-of-fact, nonjudgmental attitude if giving tube feedings, hyperalimentation, and so on.  Perception of punishment is counterproductive to patient’s self-confidence and faith in own ability to control destiny.
Be alert to possibility of patient disconnecting tube and emptying hyperalimentation if used. Check measurements, and tape tubing snugly. Sabotage behavior is common in attempt to prevent weight gain.
Provide nutritional therapy within a hospital treatment program as indicated when condition is life-threatening. Cure of the underlying problem cannot happen without improved nutritional status. Hospitalization provides a controlled environment in which food intake, vomiting/elimination, medications, and activities can be monitored. It also separates patient from SO (who may be contributing factor) and provides exposure to others with the same problem, creating an atmosphere for sharing.
Involve patient in setting up/carrying out program of behavior modification. Provide reward for weight gain as individually determined; ignore loss. Provides structured eating situation while allowing patient some control in choices. Behavior modification may be effective in mild cases or for short-term weight gain.
Provide diet and snacks with substitutions of preferred foods when available. Having a variety of foods available enables patient to have a choice of potentially enjoyable foods.
Administer liquid diet and/or tube feedings/
hyperalimentation if needed.		 When caloric intake is insufficient to sustain metabolic needs, nutritional support can be used to prevent malnutrition/death while therapy is continuing. High-calorie liquid feedings may be given as medication, at preset times separate from meals, as an alternative means of increasing caloric intake.
Blenderize and tube-feed anything left on the tray after a given period of time if indicated. May be used as part of behavior modification program to provide total intake of needed calories.
Administer supplemental nutrition as appropriate. Total parenteral nutrition (TPN) may be required for life-threatening situations; however, enteral feedings are preferred because they preserve gastrointestinal (GI) function and reduce atrophy of the gut.
Avoid giving laxatives. Use is counterproductive because they may be used by patient to rid body of food/calories.
Administer medication as indicated:Cypropheptadine (Periactin); 

 

 

Tricyclic antidepressants, e.g., amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramin); selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine (Prozac);

 

 

Antianxiety agents, e.g., alprazolam (Xanax);

 

 

Antipsychotic drugs, e.g., chlorpromazine (Thorazine);

 

 

 

Monoamine oxidase inhibitors (MAOIs), e.g., tranylcypromine sulfate (Parnate).

 A serotonin and histamine antagonist that may be used in high doses to stimulate the appetite, decrease preoccupation with food, and combat depression. Does not appear to have serious side effects, although decreased mental alertness may occur.Lifts depression and stimulates appetite. SSRIs reduce binge-purge cycles and may also be helpful in treating anorexia. Note: Use must be closely monitored because of potential side effects, although side effects from SSRIs are less significant than those associated with tricyclics.Reduces tension, anxiety/nervousness and may help patient to participate in treatment.

 

Promotes weight gain and cooperation with psychotherapeutic program; however, used only when absolutely necessary because of the possibility of extrapyramidal side effects.

 

May be used to treat depression when other drug therapy is ineffective; decreases urge to binge in bulimia.
Prepare for/assist with electroconvulsive therapy (ECT) if indicated. Discuss reasons for use and help patient understand this is not punishment. In rare and difficult cases in which malnutrition is severe/life-threatening, a short-term ECT series may enable patient to begin eating and become accessible to psychotherapy.

Deficient Fluid Volume

NURSING DIAGNOSIS: Fluid Volume actual or risk for deficient

May be related to

  • Inadequate intake of food and liquids
  • Consistent self-induced vomiting
  • Chronic/excessive laxative/diuretic use

Possibly evidenced by (actual)

  • Dry skin and mucous membranes, decreased skin turgor
  • Increased pulse rate, body temperature, decreased BP
  • Output greater than input (diuretic use); concentrated urine/decreased urine output (dehydration)
  • Weakness
  • Change in mental state
  • Hemoconcentration, altered electrolyte balance

Desired Outcomes

  • Maintain/demonstrate improved fluid balance, as evidenced by adequate urine output, stable vital signs, moist mucous membranes, good skin turgor.
  • Verbalize understanding of causative factors and behaviors necessary to correct fluid deficit.
Nursing Interventions Rationale
 Monitor vital signs, capillary refill, status of mucous membranes, skin turgor.  Indicators of adequacy of circulating volume. Orthostatic hypotension may occur with risk of falls/injury following sudden changes in position.
Monitor amount and types of fluid intake. Measure urine output accurately. Patient may abstain from all intake, with resulting dehydration; or substitute fluids for caloric intake, disturbing electrolyte balance.
Discuss strategies to stop vomiting and laxative/diuretic use. Helping patient deal with the feelings that lead to vomiting and/or laxative/diuretic use will prevent continued fluid loss. Note: Patient with bulimia has learned that vomiting provides a release of anxiety.
Identify actions necessary to regain/maintain optimal fluid balance, e.g., specific fluid intake schedule.  Involving patient in plan to correct fluid imbalances improves chances for success.
Review electrolyte/renal function test results. Fluid/electrolyte shifts, decreased renal function can adversely affect patient’s recovery/prognosis and may require additional intervention.
Administer/monitor IV, TPN; electrolyte supplements, as indicated. Used as an emergency measure to correct fluid/electrolyte imbalance and prevent cardiac dysrhythmias.

Disturbed Thought Process

NURSING DIAGNOSIS: Thought Processes, disturbed

May be related to

  • Severe malnutrition/electrolyte imbalance
  • Psychological conflicts, e.g., sense of low self-worth, perceived lack of control

Possibly evidenced by

  • Impaired ability to make decisions, problem-solve
  • Non–reality-based verbalizations
  • Ideas of reference
  • Altered sleep patterns, e.g., may go to bed late (stay up to binge/purge) and get up early
  • Altered attention span/distractibility
  • Perceptual disturbances with failure to recognize hunger; fatigue, anxiety, and depression

Desired Outcomes

  • Verbalize understanding of causative factors and awareness of impairment.
  • Demonstrate behaviors to change/prevent malnutrition.
  • Display improved ability to make decisions, problem-solve.
Nursing Interventions Rationale
 Be aware of patient’s distorted thinking ability.  Allows caregiver to have more realistic expectations of patient and provide appropriate information and support.
Listen to/avoid challenging irrational, illogical thinking. Present reality concisely and briefly.  It is difficult to responds logically when thinking ability is physiologically impaired. Patient needs to hear reality, but challenging patient leads to distrust and frustration. Note:Even though patient may gain weight, she or he may continue to struggle with attitudes/behaviors typical of eating disorders, major depression, and/or alcohol dependence for a number of years.
Adhere strictly to nutritional regimen.  Improved nutrition is essential to improved brain functioning.
 Review electrolyte/renal function tests. Imbalances negatively affect cerebral functioning and may require correction before therapeutic interventions can begin.

Disturbed Body Image

NURSING DIAGNOSIS: Body image, disturbed/Self-Esteem, chronic low

May be related to

  • Morbid fear of obesity; perceived loss of control in some aspect of life
  • Personal vulnerability; unmet dependency needs
  • Dysfunctional family system
  • Continual negative evaluation of self

Possibly evidenced by

  • Distorted body image (views self as fat even in the presence of normal body weight or severe emaciation)
  • Expresses little concern, uses denial as a defense mechanism, and feels powerless to prevent/make changes
  • Expressions of shame/guilt
  • Overly conforming, dependent on others’ opinions

Desired Outcomes

  • Establish a more realistic body image.
  • Acknowledge self as an individual.
  • Accept responsibility for own actions.
Nursing Interventions Rationale
 Have patient draw picture of self.  Provides opportunity to discuss patient’s perception of self/body image and realities of individual situation.
Involve in personal development program, preferably in a group setting. Provide information about proper application of makeup and grooming.  Learning about methods to enhance personal appearance may be helpful to long-range sense of self-esteem/image. Feedback from others can promote feelings of self-worth.
Suggest disposing of “thin” clothes as weight gain occurs. Recommend consultation with an image consultant.  Provides incentive to at least maintain and not lose weight. Removes visual reminder of thinner self. Positive image enhances sense of self-esteem.
Assist patient to confront changes associated with puberty/sexual fears. Provide sex education as necessary.  Major physical/psychological changes in adolescence can contribute to development of eating disorders. Feelings of powerlessness and loss of control of feelings (in particular sexual sensations) lead to an unconscious desire to desexualize self. Patient often believes that these fears can be overcome by taking control of bodily appearance/development/function.
Establish a therapeutic nurse/patient relationship.  Within a helping relationship, patient can begin to trust and try out new thinking and behaviors.
 Promote self-concept without moral judgment  Patient sees self as weak-willed, even though part of person may feel sense of power and control (e.g., dieting/weight loss).
States rules clearly regarding weighing schedule, remaining in sight during medication and eating times, and consequences of not following the rules. Without undue comment, be consistent in carrying out rules.  Consistency is important in establishing trust. As part of the behavior modification program, patient knows risks involved in not following established rules (e.g., decrease in privileges). Failure to follow rules is viewed as patient’s choice and accepted by staff in matter-of-fact manner so as not to provide reinforcement for the undesirable behavior.
Respond (confront) with reality when patient makes unrealistic statements such as “I’m gaining weight, so there’s nothing really wrong with me.”  Patient may be denying the psychological aspects of own situation and is often expressing a sense of inadequacy and depression.
Be aware of own reaction to patient’s behavior. Avoid arguing.  Feelings of disgust, hostility, and infuriation are not uncommon when caring for these patients. Prognosis often remains poor even with a gain in weight because other problems may remain. Many patients continue to see themselves as fat, and there is also a high incidence of affective disorders, social phobias, obsessive-compulsive symptoms, drug abuse, and psychosexual dysfunction. Nurse needs to deal with own response/feeling so they do not interfere with care of patient.
 Assist patient to assume control in areas other than dieting/weight loss, e.g., management of own daily activities, work/leisure choices.  Feelings of personal ineffectiveness, low self-esteem, and perfectionism are often part of the problem. Patient feels helpless to change and requires assistance to problem-solve methods of control in life situations.
Help patient formulate goals for self (not related to eating) and create a manageable plan to reach those goals, one at a time, progressing from simple to more complex. Patient needs to recognize ability to control other areas in life and may need to learn problem-solving skills to achieve this control. Setting realistic goals fosters success.
Note patient’s withdrawal from and/or discomfort in social settings. May indicate feelings of isolation and fear of rejection/judgment by others. Avoidance of social situations and contact with others can compound feelings of worthlessness.
Encourage patient to take charge of own life in a more healthful way by making own decisions and accepting self as she or he is at this moment (including inadequacies and strengths). Patient often does not know what she or he may want for self. Parents (mother) often make decisions for patient. Patient may also believe she or he has to be the best in everything and holds self responsible for being perfect.
Let patient know that is acceptable to be different from family, particularly mother. Developing a sense of identity separate from family and maintaining sense of control in other ways besides dieting and weight loss is a desirable goal of therapy/program.
Use cognitive-behavioral or interpersonal psychotherapy approach, rather than interpretive therapy. Although both therapies have similar results, cognitive-behavioral seems to work more quickly. Interaction between persons is more helpful for patient to discover feelings/impulses/needs from within own self. Patient has not learned this internal control as a child and may not be able to interpret or attach meaning to behavior.
Encourage patient to express anger and acknowledge when it is verbalized.  Important to know that anger is part of self and as such is acceptable. Expressing anger may need to be taught to patient because anger is generally considered unacceptable in the family, and therefore patient does not express it.
Assist patient to learn strategies other than eating for dealing with feelings. Have patient keep a diary of feelings, particularly when thinking about food. Feelings are the underlying issue, and patient often uses food instead of dealing with feelings appropriately. Patient needs to learn to recognize feelings and how to express them clearly.
Assess feelings of helplessness/hopelessness. Lack of control is a common/underlying problem for this patient and may be accompanied by more serious emotional disorders. Note: Fifty-four percent of patients with anorexia have a history of major affective disorder, and 33% have a history of minor affective disorder.
Be alert to suicidal ideation/behavior. Intense anxiety/panic about weight gain, depression, hopeless feelings may lead to suicidal attempts, particularly if patient is impulsive.
Involve in group therapy. Provides an opportunity to talk about feelings and try out new behaviors.
Refer to occupational/recreational therapy. Can develop interest and skills to fill time that has been occupied by obsession with eating. Involvement in recreational activities encourages social interactions with others and promotes fun and relaxation.

Impaired Parenting

NURSING DIAGNOSIS: Parenting, impaired

May be related to

  • Issues of control in family
  • Situational/maturational crises
  • History of inadequate coping methods

Possibly evidenced by

  • Dissonance among family members
  • Family developmental tasks not being met
  • Focus on “Identified Patient” (IP)
  • Family needs not being met
  • Family member(s) acting as enablers for IP
  • Ill-defined family rules, function, and roles

Desired Outcomes

  • Demonstrate individual involvement in problem-solving process directed at encouraging patient toward independence.
  • Express feelings freely and appropriately.
  • Demonstrate more autonomous coping behaviors with individual family boundaries more clearly defined.
  • Recognize and resolve conflict appropriately with the individuals involved.
Nursing Interventions Rationale
 Identify patterns of interaction. Encourage each family member to speak for self. Do not allow two members to discuss a third without that member’s participation.  Helpful information for planning interventions. The enmeshed, over involved family members often speak for each other and need to learn to be responsible for their own words and actions.
Discourage members from asking for approval from each other. Be alert to verbal or nonverbal checking with others for approval. Acknowledge competent actions of patient.  Each individual needs to develop own internal sense of self-esteem. Individual often is living up to others’ (family’s) expectations rather than making own choices. Acknowledgment provides recognition of self in positive ways.
Listen with regard when patient speaks.  Sets an example and provides a sense of competence and self-worth, in that patient has been heard and attended to.
Encourage individuals not to answer to everything.  Reinforces individualization and return to privacy.
Communicate message of separation, that it is acceptable for family members to be different from each other.  Individuation needs reinforcement. Such a message confronts rigidity and opens options for different behaviors.
Encourage and allow expression of feelings (e.g., crying, anger) by individuals.  Often these families have not allowed free expression of feelings and need help and permission to learn and accept this.
Prevent intrusion in dyads by other members of the family.  Inappropriate interventions in family subsystems prevent individuals from working out problems successfully.
Reinforce importance of parents as a couple who have rights of their own.  The focus on the child with anorexia is very intense and often is the only area around which the couple interact. The couple needs to explore their own relationship and restore the balance within it to prevent its disintegration.
Prevent patient from intervening in conflicts between parents. Assist parents in identifying and solving their marital differences.  Triangulation occurs in which a parent-child coalition exists. Sometimes the child is openly pressed to ally self with one parent against the other. The symptom (anorexia) is the regulator in the family system, and the parents deny their own conflicts.
Be aware and confront sabotage behavior on the part of family members.  Feelings of blame, shame, and helplessness may lead to unconscious behavior designed to maintain the status quo.
Refer to community resources such as family therapy groups, parents’ groups as indicated, and parent effectiveness classes.  May help reduce overprotectiveness, support/facilitate the process of dealing with unresolved conflicts and change.

Impaired Skin Integrity

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include

  • Altered nutritional/metabolic state; edema
  • Dehydration/cachectic changes (skeletal prominence)

Possibly evidenced by

  • [Not applicable; presence of signs and symptoms establishes and actual diagnosis.]

Desired Outcomes

  • Verbalize understanding of causative factors and absence of itching.
  • Identify and demonstrate behaviors to maintain soft, supple, intact skin.
Nursing Interventions Rationale
 Observe for reddened, blanched, excoriated areas.  Indicators of increased risk of breakdown, requiring more intensive treatment.
 Encourage bathing every other day instead of daily.  Frequent baths contribute to dryness of the skin.
 Use skin cream twice a day and after bathing. Lubricates skin and decreases itching.
 Massage skin gently, especially over bony prominences. Improves circulation to the skin, enhances skin tone.
 Discuss importance of frequent position changes, need for remaining active. Enhances circulation and perfusion to skin by preventing prolonged pressure on tissues.
 Emphasize importance of adequate nutrition/fluid intake.  Improved nutrition and hydration will improve skin condition.

Knowledge Deficit

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care and discharge needs

May be related to

  • Lack of exposure to/unfamiliarity with information about condition
  • Learned maladaptive coping skills

Possibly evidenced by

  • Verbalization of misconception of relationship of current situation and behaviors
  • Preoccupation with extreme fear of obesity and distortion of own body image
  • Refusal to eat; binging and purging; abuse of laxatives and diuretics; excessive exercising
  • Verbalization of need for new information
  • Expressions of desire to learn more adaptive ways of coping with stressors

Desired Outcomes

  • Verbalize awareness of and plan for lifestyle changes to maintain normal weight.
  • Identify relationship of signs/symptoms (weight loss, tooth decay) to behaviors of not eating/binging-purging.
  • Assume responsibility for own learning.
  • Seek out sources/resources to assist with making identified changes.
Nursing Interventions Rationale
 Determine level of knowledge and readiness to learn.  Learning is easier when it begins where the learner is.
 Note blocks to learning, e.g., physical/intellectual/emotional.  Malnutrition, family problems, drug abuse, affective disorders, and obsessive-compulsive symptoms can be blocks to learning requiring resolution before effective learning can occur.
 Provide written information for patient/SO(s).  Helpful as reminder of and reinforcement for learning.
 Discuss consequences of behavior.  Sudden death can occur because of electrolyte imbalances; suppression of the immune system and liver damage may result from protein deficiency; or gastric rupture may follow binge-eating/vomiting.
 Review dietary needs, answering questions as indicated. Encourage inclusion of high-fiber foods and adequate fluid intake.  Patient/family may need assistance with planning for new way of eating. Constipation may occur when laxative use is curtailed.
 Encourage the use of relaxation and other stress-management techniques, e.g., visualization, guided imagery, biofeedback.  New ways of coping with feelings of anxiety and fear help patient manage these feelings in more effective ways, assisting in giving up maladaptive behaviors of not eating/binging-purging.
 Assist with establishing a sensible exercise program. Caution regarding overexercise.  Exercise can assist with developing a positive body image and combats depression (release of endorphins in the brain enhances sense of well-being). However, patient may use excessive exercise as a way to control weight.
 Discuss need for information about sex and sexuality.  Because avoidance of own sexuality is an issue for this patient, realistic information can be helpful in beginning to deal with self as a sexual being.

Other Possible Nursing Diagnoses

  • Nutrition: imbalanced, risk for less than body requirements—inadequate food intake, self-induced vomiting, history of chronic laxative use.
  • Therapeutic Regimen: ineffective management—complexity of therapeutic regimen, perceived seriousness/benefits, mistrust of regimen and/or healthcare personnel, excessive demands made on individual, family conflict.

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This 50-item examination covers most concepts in Medical-Surgical Nursing. It also has a handful of questions about Emergency Nursing, HIV/AIDS, and Anemia that will test your wits about the concepts behind Medical-Surgical Nursing. Take this exam if you are preparing for your NCLEX or NLE.
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NCLEX Practice Exam 24 (50 Questions)

February 12, 2018, 8:07 am
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Learning more about Medical-Surgical Nursing often feels overwhelming. This 50-item examination has a handful of questions about Emergency Nursing, HIV/AIDS, and Anemia that will test your knowledge about the concepts behind Medical-Surgical Nursing. The key to mastering this topic is to accomplish this exam.
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NCLEX Practice Exam 25 (50 Questions)

February 18, 2018, 8:01 am
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This 50-item exam contains various questions about Medical-Surgical Nursing that covers topics of Colostomy Care, Diagnostic Tests, and several diseases.
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NCLEX Practice Exam 26 (50 Questions)

February 18, 2018, 8:02 am
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This 50-item exam contains various questions about Medical-Surgical Nursing that covers topics of Colostomy Care, Diagnostic Tests, and several diseases.
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13 AIDS (HIV Positive) Nursing Care Plans

July 13, 2013, 6:45 am
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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.

Here are 13 Nursing Care Plans (NCP) and nursing diagnosis for patients with AIDS/HIV Positive:

  1. Imbalanced Nutrition: Less Than Body Requirements
  2. Fatigue
  3. Acute/Chronic Pain
  4. Impaired Skin Integrity
  5. Impaired Oral Mucous Membrane
  6. Disturbed Thought Process
  7. Anxiety/Fear
  8. Social Isolation
  9. Powerlessness
  10. Deficient Knowledge
  11. Risk for Injury
  12. Risk for Deficient Fluid Volume
  13. Risk for Infection
  14. Other Possible Nursing Care Plans

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis

  • Imbalanced Nutrition: Less Than Body Requirements

May be related to

  • Inability or altered ability to ingest, digest and/or metabolize nutrients: nausea/vomiting, hyperactive gag reflex, intestinal disturbances, GI tract infections, fatigue
  • Increased metabolic rate/nutritional needs (fever/infection)

Possibly evidenced by

  • Weight loss, decreased subcutaneous fat/muscle mass (wasting)
  • Lack of interest in food, aversion to eating, altered taste sensation
  • Abdominal cramping, hyperactive bowel sounds, diarrhea
  • Sore, inflamed buccal cavity
  • Abnormal laboratory results: vitamin/mineral and protein deficiencies, electrolyte imbalances

Desired Outcomes

  • Maintain weight or display weight gain toward desired goal.
  • Demonstrate positive nitrogen balance, be free of signs of malnutrition, and display improved energy level.
Nursing Interventions Rationale
Assess patient’s ability to chew, taste, and swallow. 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. 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. 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. 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. 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. 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. Gastric fullness diminishes appetite and food intake.
Encourage as much physical activity as possible. May improve appetite and general feelings of well-being.
Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes. 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. 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. Reduces stimulus of the vomiting center in the medulla.
Encourage patient to sit up for meals Facilitates swallowing and reduces risk of aspiration.
Record ongoing caloric intake. Identifies need for supplements or alternative feeding methods.
Maintain NPO status when appropriate. May be needed to reduce nausea and vomiting.
Insert or maintain nasogastric (NG) tube as indicated. 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)
 Reduces incidence of nausea and vomiting, possibly enhancing oral intake.
  • Sucralfate (Carafate) suspension; mixture of Maalox, diphenhydramine (Benadryl), and lidocaine (Xylocaine);
 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
 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)
 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;
 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);
 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).
 May be given to treat and prevent infections involving the GI tract.

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
Assess sleep patterns and note changes in thought processes and behavior. 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. 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. 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. 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 travel ways clear of furniture. Provide or assist with ambulation and self-care needs as appropriate. 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. 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. 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. Programmed daily exercises and activities help patient maintain and increase strength and muscle tone, enhance sense of well-being.
Refer to community resources Provides assistance in areas of individual need as ability to care for self becomes more difficult.
Provide supplemental O2 as indicated. Presence of anemia or hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.

Acute/Chronic Pain

Nursing Diagnosis

  • Acute Pain
  • Chronic Pain

May be related to

  • Tissue inflammation/destruction: infections, internal/external cutaneous lesions, rectal excoriation, malignancies, necrosis
  • Peripheral neuropathies, myalgias, and arthralgias
  • Abdominal cramping

Possibly evidenced by

  • Reports of pain
  • Self-focusing; narrowed focus, guarding behaviors
  • Alteration in muscle tone; muscle cramping, ataxia, muscle weakness, paresthesias, paralysis
  • Autonomic responses; restlessness

Desired Outcomes

  • Report pain relieved/controlled.
  • Demonstrate relaxed posture/facial expression.
  • Be able to sleep/rest appropriately.
Nursing Interventions Rationale
Assess pain reports, noting location, intensity (0–10 scale), frequency, and time of onset. Note nonverbal cues like restlessness, tachycardia, grimacing. 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. Efficacy of comfort measures and medications is improved with timely intervention.
Encourage verbalization of feelings. Can reduce anxiety and fear and thereby reduce perception of intensity of pain.
Provide diversional activities: provide reading materials, light exercising, visiting, etc. Refocuses attention; may enhance coping abilities.
Perform palliative measures: repositioning, massage, ROM of affected joints. Promotes relaxation and decreases muscle tension.
Instruct and encourage use of visualization, guided imagery, progressive relaxation, deep-breathing techniques, meditation, and mindfulness. 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. Oral ulcerations and lesions may cause severe discomfort.
Apply warm or moist packs to pentamidine injection and IV sites for 20 min after administration. 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. 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.

Impaired Skin Integrity

Nursing Diagnosis

  • Impaired Skin Integrity

Risk factors may include

  • Decreased level of activity/immobility, altered sensation, skeletal prominence, changes in skin turgor
  • Malnutrition, altered metabolic state

May be related to (actual)

  • Immunologic deficit: AIDS-related dermatitis; viral, bacterial, and fungal infections (e.g., herpes, Pseudomonas, Candida); opportunistic disease processes (e.g., KS)
  • Excretions/secretions

Possibly evidenced by

  • Skin lesions; ulcerations; decubitus ulcer formation

Desired Outcomes

  • Be free of/display improvement in wound/lesion healing.
  • Demonstrate behaviors/techniques to prevent skin breakdown/promote healing.
Nursing Interventions Rationale
Assess skin daily. Note color, turgor, circulation, and sensation. Describe and measure lesions and observe changes. Take photographs if necessary. 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. 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. Reduces stress on pressure points, improves blood flow to tissues, and promotes healing.
Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric. 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. 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. Prevents maceration caused by diarrhea and keeps perianal lesions dry. Use of toilet paper may abrade lesions.
File nails regularly. Long and rough nails increase risk of dermal damage.
Cover open pressure ulcers with sterile dressings or protective barrier: Tegaderm, DuoDerm, as indicated. May reduce bacterial contamination, promote healing.
Provide foam, flotation, alternate pressure mattress or bed. Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia.
Obtain cultures of open skin lesions. Identifies pathogens and appropriate treatment choices.
Apply and administer medications as indicated. 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. Protects ulcerated areas from contamination and promotes healing
Refer to physical therapy for regular exercise and activity program. Promotes improved muscle tone and skin health.

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 lesions. Note reports of pain, swelling, difficulty with chewing and swallowing. 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. 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. Reduces spread of lesions and encrustations from candidiasis, and promotes comfort.
Suggest use of sugarless gum and candy. 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. 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. Maintains hydration and prevents drying of oral cavity.
Encourage patient to refrain from smoking. Smoke is drying and irritating to mucous membranes.
Obtain culture specimens of lesions. Reveals causative agents and identifies appropriate therapies.
Administer medications, as indicated:
  • nystatin (Mycostatin), ketoconazole (Nizoral).
 Specific drug choice depends on particular infecting organism(s) like Candida.
  • TNF-alpha inhibitor, e.g., thalidomide.
 Effective in treatment of oral lesions due to recurrent stomatitis.
Refer for dental consultation, if appropriate. May require additional therapy to prevent dental losses.

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 appropriate tools. Establishes functional level at time of admission and provides baseline for future comparison.
Consider effects of emotional distress. Assess for anxiety, grief, anger. May contribute to reduced alertness, confusion, withdrawal, and hypoactivity, requiring further evaluation and intervention.
Monitor medication regimen and usage. Actions and interactions of various medications, prolonged drug half-life and/or altered excretion rates result in cumulative effects, potentiating risk of toxic reactions. Some drugs may have adverse side effects: haloperidol (Haldol) can seriously impair motor function in patients with AIDS dementia complex.
Investigate changes in personality, response to stimuli, orientation and level of consciousness; or development of headache, nuchal rigidity, vomiting, fever, seizure activity. Changes may occur for numerous reasons, including development or exacerbation of opportunistic diseases or CNS infection. Early detection and treatment of CNS infection may limit permanent impairment of cognitive ability.
Maintain a pleasant environment with appropriate auditory, visual, and cognitive stimuli. 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. 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. These techniques help patient manage problems of forgetfulness.
Encourage family and SO to socialize and provide reorientation with current news, family events. 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. Can help maintain mental abilities for longer period.
Provide support for SO. Encourage discussion of concerns and fears 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. 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. If patient is prone to agitation, violent behavior, or seizures, reducing external stimuli may be helpful.
Decrease noise, especially at night. Promotes sleep, reducing cognitive symptoms and effects of sleep deprivation.
Maintain safe environment: excess furniture out of the way, call bell within patient’s reach, bed in low position and rails up; restriction of smoking (unless monitored by caregiver/SO), seizure precautions, soft restraints if indicated. 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. Obtaining information that ZDV has been shown to improve cognition can provide hope and control for losses.
Administer medications as indicated:
  • ZDV (Retrovir) and other antiretrovirals alone or in combination
 Shown to improve neurological and mental functioning for undetermined period of time.
  • Antipsychotics: haloperidol (Haldol), and/or antianxiety agents: lorazepam (Ativan).
 Cautious use may help with problems of sleeplessness, emotional lability, hallucinations, suspiciousness, and agitation.
Refer to counseling as indicated. May help patient gain control in presence of thought disturbances or psychotic symptomatology.

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
Assure patient of confidentiality within limits of situation. 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. 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. 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. 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. 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. 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. 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. 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. 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. Allows for better interpersonal interaction and reduction of anxiety and fear.
Include SO as indicated when major decisions are to be made. 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. 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). 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 Provides opportunity for addressing spiritual concerns. May help relieve anxiety regarding end-of-life care and support for patient/SO.

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
Ascertain patient’s perception of situation. 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. 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. 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. 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. 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. Participation with others can foster a feeling of belonging.
Encourage active role of contact with SO. 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. 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. 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.

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
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. 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. 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. 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. 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. 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.

Deficient Knowledge

Nursing Diagnosis

  • Deficient Knowledge

May be related to

  • Lack of exposure/recall; information misinterpretation
  • Cognitive limitation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions/request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Desired Outcomes

  • Verbalize understanding of condition/disease process and potential complications.
  • Identify relationship of signs/symptoms to the disease process and correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Correctly perform necessary procedures and explain reasons for actions.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions Rationale
Review disease process and future expectations. 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. Helps plan amount of care and symptom management required and need for additional resources.
Review modes of transmission of disease, especially if newly diagnosed. 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). 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. 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. 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. Promotes adequate nutrition necessary for healing and support of immune system; enhances feeling of well-being.
Discuss medication regimen, interactions, and side effects 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. Provides patient with increased sense of control, reduces risk of embarrassment, and promotes comfort.
Stress importance of adequate rest. Helps manage fatigue; enhances coping abilities and energy level.
Encourage activity and exercise at level that patient can tolerate. Stimulates release of endorphins in the brain, enhancing sense of well-being.
Stress necessity of continued healthcare and follow-up. Provides opportunity for altering regimen to meet individual and changing needs.
Recommend cessation of smoking. 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. 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. Facilitates transfer from acute care setting for recovery/independence or end-of-life care.

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
Avoid injections, rectal temperatures and rectal tubes. Administer rectal suppositories with caution. Protects patient from procedure-related causes of bleeding: insertion of thermometers, rectal tubes can damage or tear rectal mucosa. Some medications need to be given via suppository, so caution is advised.
Maintain a safe environment. Keep all necessary objects and call bell within patient’s reach and place bed in low position. Reduces accidental injury, which could result in bleeding.
Maintain bed rest or chair rest when platelets are below 10,000 or as individually appropriate. Assess medication regimen. Reduces possibility of injury, although activity needs to be maintained. May need to discontinue or reduce dosage of a drug. Patient can have a surprisingly low platelet count without bleeding.
Hematest body fluids: urine, stool, vomitus, for occult blood. Prompt detection of bleeding or initiation of therapy may prevent critical hemorrhage.
Observe for or report epistaxis, hemoptysis, hematuria, non menstrual vaginal bleeding, or oozing from lesions or body orifices and/or IV insertion sites. Spontaneous bleeding may indicate development of DIC or immune thrombocytopenia, necessitating further evaluation and prompt intervention.
Monitor for changes in vital signs and skin color: BP, pulse, respirations, skin pallor and discoloration. Presence of bleeding and hemorrhage may lead to circulatory failure and shock.
Evaluate change in level of consciousness. May reflect cerebral bleeding.
Review laboratory studies: PT, aPTT, clotting time, platelets, Hb/Hct. Detects alterations in clotting capability; identifies therapy needs. Many individuals (up to 80%) display platelet count below 50,000 and may be asymptomatic, necessitating regular monitoring.
Administer blood products as indicated. Transfusions may be required in the event of persistent or massive spontaneous bleeding.
Avoid use of aspirin products and NSAIDs, especially in presence of gastric lesions. These medications reduce platelet aggregation, impairing and prolonging the coagulation process, and may cause further gastric irritation, increasing risk of bleeding.

Risk for Deficient Fluid Volume

Nursing Diagnosis

  • Risk for Deficient Fluid Volume

Risk factors may include

  • Excessive losses: copious diarrhea, profuse sweating, vomiting
  • Hypermetabolic state, fever
  • Restricted intake: nausea, anorexia; lethargy

Desired outcomes

  • Maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital signs, individually adequate urinary output.
Nursing Interventions Rationale
Monitor vital signs, including CVP if available. Note hypotension, including postural changes. Indicators of circulating fluid volume.
Note temperature elevation and duration of febrile episode. Administer tepid sponge baths as indicated. Keep clothing and linens dry. Maintain comfortable environmental temperature. Around 97%, fever is one of the most frequent symptoms experienced by patients with HIV infections. Increased metabolic demands and associated excessive diaphoresis result in increased insensible fluid losses and dehydration.
Assess skin turgor, mucous membranes, and thirst. Indirect indicators of fluid status.
Measure urinary output and specific gravity. Measure and estimate amount of diarrheal loss. Note insensible losses. Increased specific gravity and decreasing urinary output reflects altered renal perfusion and circulating volume. Monitoring fluid balance is difficult in the presence of excessive GI and insensible losses.
Weigh as indicated. Although weight loss may reflect muscle wasting, sudden fluctuations reflect state of hydration. Fluid losses associated with diarrhea can quickly create a crisis and become life-threatening.
Monitor oral intake and encourage fluids of at least 2500 mL/day. Maintains fluid balance, reduces thirst, and keeps mucous membranes moist.
Make fluids easily accessible to patient; use fluids that are tolerable to patient and that replace needed electrolytes Enhances intake. Certain fluids may be too painful to consume (acidic juices) because of mouth lesions.
Eliminate foods potentiating diarrhea May help reduce diarrhea. Use of lactose-free products helps control diarrhea in the lactose-intolerant patient.
Encourage use of live culture yogurt or OTC Lactobacillus acidophilus (lactaid). Antibiotic therapies disrupt normal bowel flora balance, leading to diarrhea. Must be taken 2 hr before or after antibiotic to prevent inactivation of live culture.
Administer fluids and electrolytes via feeding tube and IV, as appropriate. May be necessary to support or augment circulating volume, especially if oral intake is inadequate, nausea and vomiting persists.
Monitor laboratory studies as indicated: Serum or urine electrolytes; BUN/Cr; Stool specimen collection. Alerts to possible electrolyte disturbances and determines replacement needs.Evaluates renal perfusion and function. Bowel flora changes can occur with multiple or single antibiotic therapy.
Maintain hypothermia blanket if used. May be necessary when other measures fail to reduce excessive fever/insensible fluid losses.

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
Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen. Multiple medication regimen is difficult to maintain over a long period of time. Patients may adjust medication regimen based on side effects experienced, contributing to inadequate prophylaxis, active disease, and resistance.
Wash hands before and after all care contacts. Instruct patient and SO to wash hands as indicated. Reduces risk of cross-contamination.
Provide a clean, well-ventilated environment. Screen visitors and staff for signs of infection and maintain isolation precautions as indicated. Reduces number of pathogens presented to the immune system and reduces possibility of patient contracting a nosocomial infection.
Discuss extent and rationale for isolation precautions and maintenance of personal hygiene. Promotes cooperation with regimen and may lessen feelings of isolation.
Monitor vital signs, including temperature. Provides information for baseline data; frequent temperature elevations and onset of new fever indicates that the body is responding to a new infectious process or that medications are not effectively controlling incurable infections.
Assess respiratory rate and depth; note 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. Respiratory congestion or distress may indicate 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.
Investigate reports of headache, stiff neck, altered vision. Note changes in mentation and behavior. Monitor for nuchal rigidity and seizure activity. Neurological abnormalities are common and may be related to HIV or secondary infections. Symptoms may vary from subtle changes in mood and 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.
Examine skin and oral mucous membranes for white patches or lesions. Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.
Clean patient’s nails frequently. File, rather than cut, and avoid trimming cuticles. Reduces risk of transmission of pathogens through breaks in skin. Fungal infections along the nail plate are common.
Monitor reports of heartburn, dysphagia, retrosternal pain on swallowing, increased abdominal cramping, profuse diarrhea. Esophagitis may occur secondary to oral candidiasis, CMV, or herpes. Cryptosporidiosis is a parasitic infection responsible for watery diarrhea (often more than 15L/day).
Inspect wounds and site of invasive devices, noting signs of local inflammation and infection. Early identification and treatment of secondary 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 caregiver’s hands. Wear mask and protective eyewear to protect nose, mouth, and eyes from secretions during procedures (suctioning) or when splattering of blood may occur. Use of masks, gowns, and gloves is required for direct contact with body fluids, e.g., sputum, blood/blood products, semen, vaginal secretions.
Dispose of needles and sharps in rigid, puncture-resistant containers. Prevents accidental inoculation of caregivers. Use of needle cutters and recapping is not to be practiced. Accidental needlesticks should be reported immediately, with follow-up evaluations done per protocol.
Label blood bags, body fluid containers, soiled dressings and linens, and package appropriately for disposal per isolation protocol. Prevents cross-contamination and alerts appropriate personnel and departments to exercise specific hazardous materials procedures.
Clean up spills of body fluids and/or blood with bleach solution (1:10); add bleach to laundry. Kills HIV and controls other microorganisms on surfaces.

Other Possible Nursing Care Plans

Other nursing diagnoses you can use for HIV/AIDS:

  • Hopelessness—related to nature of condition and poor prognosis.
  • Interrupted family process—may be related to the nature of AIDS condition, role disturbance, and uncertain future.
  • Chronic Sorrow—related to loss of body function and its effects on lifestyle.
  • Risk for Caregiver Role Strain—may be related to multiple needs of ill person and chronicity of the disease.

The following are associated with AIDS dementia: 

  • Impaired Environmental Interpretation Syndrome—may 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 Protection—may 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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See Also

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Communicable and Infectious Diseases Care Plans

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