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 and nursing diagnosis for patients with AIDS/HIV Positive:
- Imbalanced Nutrition: Less Than Body Requirements
- Fatigue
- Acute/Chronic Pain
- Impaired Skin Integrity
- Impaired Oral Mucous Membrane
- Disturbed Thought Process
- Anxiety/Fear
- Social Isolation
- Powerlessness
- Deficient Knowledge
- Risk for Injury
- Risk for Deficient Fluid Volume
- Risk for Infection
- Other Possible Nursing Care Plans
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. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- 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.
See also
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:
Very informative thumbs up 👍
Thank you! Please do check also the study guide for HIV/AIDS here.
How would I go about Citing this page as a reference