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.

Risk for Deficient Fluid Volume — AIDS

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.

Risk for Injury — AIDS

Nursing Diagnosis: Risk for Injury (Hemorrhage)

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.

Deficient Knowledge — AIDS

Nursing Diagnosis: Deficient Knowledge regarding disease, prognosis, current therapies, and self-care needs

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.

Powerlessness — AIDS

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

Social Isolation — AIDS

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

Anxiety/Fear — AIDS

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

Disturbed Thought Process — AIDS

Nursing 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

Fatigue — AIDS

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

Impaired Oral Mucous Membrane — AIDS

Nursing Diagnosis: Oral Mucous Membrane, impaired

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.