Risk for Infection — AIDS

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

Nursing Diagnosis: 

Risk for Infection

Risk factors may include

• Inadequate primary defenses: broken skin, traumatized tissue, stasis of body fluids
• Depression of the immune system, chronic disease, malnutrition; use of antimicrobial agents
• Environmental exposure, invasive techniques

Possibly evidenced by:

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

Desired Outcomes: 

• Achieve timely healing of wounds/lesions.
• Be afebrile and free of purulent drainage/secretions and other signs of infectious conditions.
• Identify/participate in behaviors to reduce risk of infection.

AIDS Nursing Care Plan: Risk for Infection

Nursing Interventions	Rationale
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 noncurable 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.