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
Impaired Skin Integrity
Nursing Diagnosis
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
Desired Outcomes
- Be free of/display improvement in wound/lesion healing.
- Demonstrate behaviors/techniques to prevent skin breakdown/promote healing.
| Nursing Interventions | Rationale |
|---|---|
| Assess skin daily. Note color, turgor, circulation, and sensation. Describe and measure lesions and observe changes. Take photographs if necessary. | Establishes comparative baseline providing opportunity for timely intervention. |
| Maintain and instruct in good skin hygiene: wash thoroughly, pat dry carefully, and gently massage with lotion or appropriate cream. | Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to dry and fragile skin. Massaging increases circulation to the skin and promotes comfort. Isolation precautions are required when extensive or open cutaneous lesions are present. |
| Reposition frequently. Use turn sheet as needed. Encourage periodic weight shifts. Protect bony prominences with pillows, heel and elbow pads, sheepskin. | Reduces stress on pressure points, improves blood flow to tissues, and promotes healing. |
| Maintain clean, dry, wrinkle-free linen, preferably soft cotton fabric. | Skin friction caused by wet or wrinkled or rough sheets leads to irritation of fragile skin and increases risk for infection. |
| Encourage ambulation as tolerated. | Decreases pressure on skin from prolonged bedrest. |
| Cleanse perianal area by removing stool with water and mineral oil or commercial product. Avoid use of toilet paper if vesicles are present. Apply protective creams: zinc oxide, A & D ointment. | Prevents maceration caused by diarrhea and keeps perianal lesions dry. Use of toilet paper may abrade lesions. |
| File nails regularly. | Long and rough nails increase risk of dermal damage. |
| Cover open pressure ulcers with sterile dressings or protective barrier: Tegaderm, DuoDerm, as indicated. | May reduce bacterial contamination, promote healing. |
| Provide foam, flotation, alternate pressure mattress or bed. | Reduces pressure on skin, tissue, and lesions, decreasing tissue ischemia. |
| Obtain cultures of open skin lesions. | Identifies pathogens and appropriate treatment choices. |
| Apply and administer medications as indicated. | Used in treatment of skin lesions. Use of agents such as Prederm spray can stimulate circulation, enhancing healing process. When multidose ointments are used, care must be taken to avoid cross-contamination. |
| Cover ulcerated KS lesions with wet-to-wet dressings or antibiotic ointment and nonstick dressing, as indicated. | Protects ulcerated areas from contamination and promotes healing |
| Refer to physical therapy for regular exercise and activity program. | Promotes improved muscle tone and skin health. |
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