NCP Aids

AIDS

Acquired immunodeficiency syndrome (AIDS) is the final result of infection with a retrovirus, the human immunodeficiency virus (HIV). HIV infection is a progressive disease leading to AIDS, as defined by the CDC (January 1994): “persons with CD4 cell count of under 200 (with or without symptoms of opportunistic infection) who are HIV-positive are diagnosed as having AIDS.” Research studies in 1995 showed that HIV initially replicates rapidly on a daily basis. The half-life of the virus is 2 days, with almost complete turnover in 14 days. Therefore, the immune response is massive throughout the course of HIV disease. Evidence suggests the cellular immune response is essential in limiting replication and rate of disease progression. Controlling the replication of the virus to lower the viral load is the current focus of treatment.

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.

CARE SETTING

Although many of the interventions listed here are appropriate at the community level, the focus of this plan of care is the acutely ill individual requiring care on an inpatient medical or subacute unit or hospice setting.

RELATED FACTORS

End of life/hospice care
Extended care
Fluid and electrolyte imbalances
HIV-positive patient
Psychosocial aspects of care
Sepsis/septicemia
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Ventilatory assistance (mechanical)

Patient Assessment Database

Data depend on the organs/body tissues involved, the current viral load, and the specific opportunistic infection (OI) or cancer.

ACTIVITY/REST

May report:
Reduced tolerance for usual activities, progressing to profound fatigue and malaise; weakness
Altered sleep patterns

May exhibit:
Muscle weakness, wasting of muscle mass
Physiological response to activity, e.g., changes in BP, HR, respiration

CIRCULATION

May report:
Slow healing (if anemic); bleeding longer with injury

May exhibit:
Tachycardia, postural BP changes
Decreased peripheral pulse volume
Pallor or cyanosis; delayed capillary refill

EGO INTEGRITY

May report:
Stress factors related to lifestyle changes, losses, e.g., family support, relationships, finances, and spiritual concerns
Concern about appearance: Alopecia, disfiguring lesions, weight loss, altered distribution of body fat (associated with protease-inhibiting drug therapy), thinning of extremities, wrinkling of skin
Denial of diagnosis; feelings of powerlessness, hopelessness, helplessness, worthlessness, guilt, loss of control, depression

May exhibit:
Denial, anxiety, depression, fear, withdrawal
Angry behaviors, dejected body posture, crying, poor eye contact
Failure to keep appointments or multiple appointments for similar symptoms

ELIMINATION

May report:
Difficult and painful elimination; rectal pain, itching
Intermittent, persistent, frequent diarrhea with or without abdominal cramping
Flank pain, burning on urination

May exhibit:
Loose-formed to watery stools with or without mucus or blood; frequent, copious diarrhea
Abdominal tenderness
Rectal, perianal lesions or abscesses
Changes in urinary output, color, character
Urinary, bowel incontinence

FOOD/FLUID

May report:
Anorexia, changes in taste of foods/food intolerance, nausea/vomiting
Rapid/progressive weight loss
Difficulty chewing and swallowing (sore mouth, tongue); dysphagia, retrosternal pain with swallowing
Food intolerance, e.g., diarrhea after dairy products, nausea, early satiation, bloating

May exhibit:
Hyperactive bowel sounds
Abdominal distension (hepatosplenomegaly)
Weight loss; thin frame; decreased subcutaneous fat/muscle mass
Poor skin turgor
Lesions of the oral cavity, white patches, discoloration; poor dental/gum health, loss of teeth
Edema (generalized, dependent)

HYGIENE

May report:
Inability to complete activities of daily living (ADLs) independently

May exhibit:
Disheveled appearance
Deficits in many or all personal care, self-care activities

NEUROSENSORY

May report:
Fainting spells/dizziness; headache; stiff neck
Changes in mental status, loss of mental acuity/ability to solve problems, forgetfulness, poor concentration
Impaired sensation or sense of position and vibration
Muscle weakness, tremors, changes in visual acuity
Numbness, tingling in extremities (feet seem to display earliest changes)
Changes in visual acuity; light flashes/floaters; photophobia

May exhibit:
Mental status changes ranging from confusion to dementia, forgetfulness, poor concentration, decreased alertness, apathy, psychomotor retardation/slowed responses; paranoid ideation, free-floating anxiety, unrealistic expectations
Abnormal reflexes, decreased muscle strength, ataxic gait
Fine/gross motor tremors, focal motor deficits; hemiparesis, seizures
Retinal hemorrhages and exudates (CMV retinitis); blindness

PAIN/DISCOMFORT

May report:
Generalized/localized pain; aching, burning in feet
Headache
Pleuritic chest pain

May exhibit:
Swelling of joints, painful nodules, tenderness
Decreased range of motion (ROM), gait changes/limp
Muscle guarding

RESPIRATION

May report:
Frequent, persistent upper respiratory infections (URIs)
Progressive shortness of breath
Cough (ranging from mild to severe); nonproductive/productive of sputum (earliest sign of PCP may be a spasmodic cough on deep breathing)
Congestion or tightness in chest
History of exposure to/prior episode of active TB

May exhibit:
Tachypnea, respiratory distress
Changes in breath sounds/adventitious breath sounds
Sputum yellow (in sputum-producing pneumonia)

SAFETY

May report:
Exposure to infectious diseases, e.g., TB, STDs
History of other immune deficiency diseases, e.g., rheumatoid arthritis, cancer
History of frequent or multiple blood/blood product transfusions (e.g., hemophilia, major vascular surgery, traumatic incident)
History of falls, burns, episodes of fainting, slow-healing wounds
Suicidal/homicidal ideation with or without a plan

May exhibit:
Recurrent fevers; low-grade, intermittent temperature elevations/spikes; night sweats
Changes in skin integrity, e.g., cuts, ulcerations, rashes (eczema, exanthems, psoriasis); discolorations; changes in size/color of moles; unexplained, easy bruising; multiple injection scars (may be infected)
Rectal, perianal lesions or abscesses
Nodules, enlarged lymph nodes in two or more areas of the body (e.g., neck, axilla, groin)
Decline in general strength, muscle tone, changes in gait

SEXUALITY

May report:
History of high-risk behavior, e.g., having sex with a partner who is HIV-positive, multiple sexual partners, unprotected sexual activity, and anal sex
Loss of libido, being too sick for sex; being afraid to engage in any sexual activities
Inconsistent use of condoms
Use of birth control pills (enhanced susceptibility to virus in women who are exposed because of increased vaginal dryness/friability)

May exhibit:
Pregnancy or risk for pregnancy (sexually active); pregnancy resulting in HIV-positive infant
Genitalia: Skin manifestations (e.g., herpes, warts); discharge

SOCIAL INTERACTION

May report:
Problems related to diagnosis and treatment, e.g., loss of family/SO, friends, support; fear of telling others; fear of rejection/loss of income
Isolation, loneliness, close friends or sexual partners who have died of or are sick with AIDS
Questioning of ability to remain independent, unable to plan for needs

May exhibit:
Changes in family/SO interaction pattern
Disorganized activities, difficulty with goal setting

TEACHING/LEARNING

May report:
Failure to comply with treatment, continued high-risk behavior (e.g., unchanged sexual behavior or injection drug use)
Injection drug use/abuse, current smoking, alcohol abuse
Evidence of failure to improve from last hospitalization

Discharge plan considerations:
DRG projected mean length of stay: 8.2 days (depending on opportunistic infection[s] present)
Usually requires assistance with finances, medications and treatments, skin/wound care, equipment/supplies; transportation, food shopping and preparation; self-care, technical nursing procedures, homemaker/maintenance tasks, child care; changes in living arrangements

Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

CBC: Anemia and idiopathic thrombocytopenia (anemia occurs in up to 85% of patients with AIDS and may be profound). Leukopenia may be present; differential shift to the left suggests infectious process (PCP), although shift to the right may be noted.
PPD: Determines exposure and/or active TB disease. Of AIDS patients, 100% of those exposed to active Mycobacterium tuberculosis will develop the disease.
Serologic: Serum antibody test: HIV screen by ELISA. A positive test result may be indicative of exposure to HIV but is not diagnostic because false-positives may occur.
Western blot test: Confirms diagnosis of HIV in blood and urine.
Viral load test:
RI-PCR: The most widely used test currently can detect viral RNA levels as low as 50 copies/mL of plasma with an upper limit of 75,000 copies/mL.
bDNA 3.0 assay: Has a wider range of 50–500,000 copies/mL. Therapy can be initiated, or changes made in treatment approaches, based on rise of viral load or maintenance of a low viral load. This is currently the leading indicator of effectiveness of therapy.
T-lymphocyte cells: Total count reduced.
CD4+ lymphocyte count (immune system indicator that mediates several immune system processes and signals B cells to produce antibodies to foreign germs): Numbers less than 200 indicate severe immune deficiency response and diagnosis of AIDS.
T8+ CTL (cytopathic suppressor cells): Reversed ratio (2:1 or higher) of suppressor cells to helper cells (T8+ to T4+) indicates immune suppression.
Polymerase chain reaction (PCR) test: Detects HIV-DNA; most helpful in testing newborns of HIV-infected mothers. Infants carry maternal HIV antibodies and therefore test positive by ELISA and Western blot, even though infant is not necessarily infected.
STD screening tests: Hepatitis B envelope and core antibodies, syphilis, and other common STDs may be positive.
Cultures: Histologic, cytologic studies of urine, blood, stool, spinal fluid, lesions, sputum, and secretions may be done to identify the opportunistic infection. Some of the most commonly identified are the following:
Protozoal and helminthic infections: PCP, cryptosporidiosis, toxoplasmosis.
Fungal infections: Candida albicans (candidiasis), Cryptococcus neoformans (cryptococcosis), Histoplasma capsulatum (histoplasmosis).
Bacterial infections: Mycobacterium avium-intracellulare (occurs with CD4 counts less than 50), miliary mycobacterial TB, Shigella (shigellosis), Salmonella (salmonellosis).
Viral infections: CMV (occurs with CD4 counts less than 50), herpes simplex, herpes zoster.
Neurological studies, e.g., electroencephalogram (EEG), magnetic resonance imaging (MRI), computed tomography (CT) scans of the brain; electromyography (EMG)/nerve conduction studies: Indicated for changes in mentation, fever of undetermined origin, and/or changes in sensory/motor function to determine effects of HIV infection/opportunistic infections.
Chest x-ray: May initially be normal or may reveal progressive interstitial infiltrates secondary to advancing PCP (most common opportunistic disease) or other pulmonary complications/disease processes such as TB.
Pulmonary function tests: Useful in early detection of interstitial pneumonias.
Gallium scan: Diffuse pulmonary uptake occurs in PCP and other forms of pneumonia.
Biopsies: May be done for differential diagnosis of Kaposi’s sarcoma (KS) or other neoplastic lesions.
Bronchoscopy/tracheobronchial washings: May be done with biopsy when PCP or lung malignancies are suspected (diagnostic confirming test for PCP).
Barium swallow, endoscopy, colonoscopy: May be done to identify opportunistic infection (e.g., Candida, CMV) or to stage KS in the GI system.

NURSING PRIORITIES

1. Prevent/minimize development of new infections.
2. Maintain homeostasis.
3. Promote comfort.
4. Support psychosocial adjustment.
5. Provide information about disease process/prognosis and treatment needs.

DISCHARGE GOALS

1. Infection prevented/resolved.
2. Complications prevented/minimized.
3. Pain/discomfort alleviated or controlled.
4. Patient dealing with current situation realistically.
5. Diagnosis, prognosis, and therapeutic regimen understood.
6. Plan in place to meet needs after discharge.