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7 Jun 2013

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 InterventionsRationale
 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.

Impaired Skin Integrity — AIDS

Nursing Diagnosis: Skin Integrity, impaired, actual and/or risk for
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

Acute/Chronic Pain — AIDS

Nursing Diagnosis: Pain, acute/chronic
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.

Imbalanced Nutrition: Less Than Body Requirements — AIDS

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 InterventionsRationale
 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 nonacidic 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 mealsFacilitates 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.
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