Nursing diagnosis for HIV/AIDS: Risk for infection may be related to Inadequate primary defenses: broken skin, traumatized tissue, stasis of body fluids; Depression of the immune system, chronic disease, malnutrition; use of antimicrobial agents; and Environmental exposure, invasive techniques.
1. Achieve timely healing of wounds/lesions.
2. Be afebrile and free of purulent drainage/secretions and other signs of infectious conditions.
3. Identify/participate in behaviors to reduce risk of infection.
Nursing intervention with rationale:
1.Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen.
Rationale: 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.
2. Wash hands before and after all care contacts. Instruct patient/SO to wash hands as indicated.
Rationale: Reduces risk of cross-contamination.
3. Provide a clean, well-ventilated environment. Screen visitors/staff for signs of infection and maintain isolation precautions as indicated.
Rationale: Reduces number of pathogens presented to the immune system and reduces possibility of patient contracting a nosocomial infection.
4. Discuss extent and rationale for isolation precautions and maintenance of personal hygiene.
Rationale: Promotes cooperation with regimen and may lessen feelings of isolation.
5. Monitor vital signs, including temperature.
Rationale: Provides information for baseline data; frequent temperature elevations/onset of new fever indicates that the body is responding to a new infectious process or that medications are not effectively controlling noncurable infections.
6. Assess respiratory rate/depth; note dry spasmodic cough on deep inspiration, changes in characteristics of sputum, and presence of wheezes/rhonchi. Initiate respiratory isolation when etiology of productive cough is unknown.
Rationale: Respiratory congestion/distress may indicate developing PCP (the most common opportunistic disease); however, TB is on the rise and other fungal, viral, and bacterial infections may occur that compromise the respiratory system. Note: 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.
7. Examine skin/oral mucous membranes for white patches or lesions.
Rationale: Oral candidiasis, KS, herpes, CMV, and cryptococcosis are common opportunistic diseases affecting the cutaneous membranes.
8. Inspect wounds/site of invasive devices, noting signs of local inflammation/infection.
Rationale: Early identification/treatment of secondary infection may prevent sepsis.
9. Monitor laboratory studies, e.g.: CBC/differential.
Rationale: Shifts in the differential and changes in WBC count indicate infectious process. Low WBC count or other changes in blood count may be related to treatments/medications.
10. Administer medications as indicated: Antiretrovirals.
Rationale: The antiretroviral agents approved by the FDA are aimed at blocking replication of the HIV virus at some level. The drugs are generally given in groups of three because the multidrug regimen is more effective in reducing the viral load. Individual considerations are necessary when initiating, changing, interrupting or stopping treatment, or using salvage therapies (i.e., dropping T-cell counts necessitate changes to the failing regimen). Note: Studies reveal an increasing frequency of drug-resistant strains of HIV being transmitted to others.