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.
- Imbalanced Nutrition: Less Than Body Requirements
- Acute/Chronic Pain
- Impaired Skin Integrity
- Impaired Oral Mucous Membrane
- Disturbed Thought Process
- Social Isolation
- Deficient Knowledge
- Risk for Injury
- Risk for Deficient Fluid Volume
- Risk for Infection
- Other Possible Nursing Care Plans
Risk for Deficient Fluid Volume
- Risk for Deficient Fluid Volume
Risk factors may include
- Excessive losses: copious diarrhea, profuse sweating, vomiting
- Hypermetabolic state, fever
- Restricted intake: nausea, anorexia; lethargy
- Maintain hydration as evidenced by moist mucous membranes, good skin turgor, stable vital signs, individually adequate urinary output.
|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.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to communicable and infectious diseases: