Last updated on April 29th, 2023 at 11:27 pm
HIV Nursing Care Plans Diagnosis and Interventions
AIDS HIV NCLEX Review and Nursing Care Plans
Acquired immunodeficiency syndrome (AIDS) is a chronic medical condition that involves damage on the immune system. AIDS is caused by human immunodeficiency virus (HIV), which is a sexually transmitted infection (STI).
Currently, HIV/AIDS has no cure yet; however, there are medications that can be administered to reduce mortality from HIV/AIDS.
Types of HIV AIDS
There are several types or phases of HIV/ AIDS. These include:
- Primary HIV Infection. Acute HIV infection or primary infection occurs within 2 to 4 weeks from the time the virus goes into the body. It is characterized by flu-like symptoms such as fever, headache, muscle and joint pain, sore throat, cough, and swollen lymph nodes, which may last for several weeks. Other symptoms may include rash, weight loss, diarrhea, and night sweats.
- Chronic HIV Infection. Also known as clinically latent HIV infection, chronic HIV infection is the phase when the virus is present in the body, particularly in the white blood cells, but symptoms may not be observed as compared to primary HIV infection. This phase can occur from six months to years.
- Symptomatic HIV Infection. Recurrent infections may occur because of the progressive damage in the immune cells. The symptoms include those of the primary HIV infection, and may also involve oral thrush, herpes zoster or shingles, fever, fatigue, or pneumonia.
- AIDS. If the HIV patient does not receive anti-viral treatments, the infection can progress to AIDS in around 8 to 10 years. AIDS is diagnosed when the immune system shows severe damage.
Signs and Symptoms of HIV AIDS
- Recurrent fevers
- Chronic diarrhea
- Swollen lymph glands
- Recurrent oral yeast infection or thrush
- Sweats and chills
- Body malaise or weakness
- Unexplained and persistent fatigue
- Skin rash or bumps
- Unexplained weight loss
Causes and Risk Factors of HIV AIDS
AIDS is caused by HIV infection. HIV is a virus that is able to destroy CD4 T-cells, which are immune cells that have a huge role in fighting disease. The virus can be spread through infected blood (such as when sharing contaminated needles or through blood transfusions), sexual contact (semen or vaginal discharge), and from the mother to her child during her pregnancy, childbirth, and breastfeeding.
It is important to note that HIV antibodies are being strictly screened in hospitals and blood banks, which makes the risk for HIV from blood transfusions very small. Also, clinics and hospitals have a single-use needle/syringe policy to prevent possible HIV transmission.
If HIV is left untreated, the immune system becomes weaker throughout the years, which may eventually lead to AIDS. Doctors diagnose AIDS when the CD4 T-cell count is lower than 200, or when the patient has a complication that strongly related to AIDS, such as cancer or serious/recurrent infection.
The risk factors of HIV/AIDS include:
- Unprotected sex
- History of sexually transmitted infections (STIs)
- Sharing IV drug paraphernalia such as needles and syringes
Complications of HIV AIDS
- Infection. AIDS patients have severely damaged immune system, making them highly vulnerable to a large number of infections. Common HIV/AIDS – related infections include candidiasis or thrush, pneumocystis pneumonia (PCP), and tuberculosis (TB). Other infections may include herpes or cytomegalovirus infection, cryptococcal meningitis, and toxoplasmosis.
- Cancer. Some types of cancer may arise due to AIDS. These include lymphoma or cancer of the white blood cells, and Kaposi’s sarcoma, or cancer in the blood vessel walls.
- Other complications. The kidneys, liver, and neurological system can be severely affected due to HIV/ AIDS. Significant weight loss or wasting syndrome is often seen in untreated HIV/ AIDS patients.
Diagnosis of HIV AIDS
- Antigen/Antibody tests. Blood tests to check for HIV antigens and antibodies from the immune system are required to detect HIV in the blood. These are done 2 to 6 weeks after contracting the virus.
- Antibody HIV tests. It can take 3 to 12 weeks from exposure to HIV to have a positive antibody test result.
- Nucleic acid tests (NATs). This tests for the viral load of HIV in the blood.
- CD4 T-cell count. This blood test counts the CD4 T-cells in the body. HIV infection has progressed to AIDS if the CD4 T-cell count is below 200.
- HIV RNA viral load
- Test for drug resistance
Prevention of HIV AIDS
- Treatment as Prevention (TasP). HIV patients should be encouraged to use TasP or to take their medications religiously, as prescribed, with regular checkups to ensure that the viral load is undetectable and their partner is safe from contracting HIV.
- Post-Exposure Prophylaxis (PEP). People who were exposed to HIV should go to the nearest emergency department or contact their doctor and take PEP within the first 72 hours of contact to reduce the risk of HIV infection. PEP medication is taken for a period of 28 days.
- Pre-Exposure Prophylaxis (PrEP). People who are at high risk for HIV infection from sex may consider PrEP drugs.
- Use of new condom every sexual encounter.
- Male circumcision. Studies show that male circumcision lowers the risk of HIV infection.
- Avoid needle sharing.
- Inform past or current sexual partner/s if you have HIV.
- Pregnant women with HIV must receive treatment immediately.
Treatment for HIV AIDS
There is currently no cure for HIV/AIDs. However, anti-retroviral therapy (ART) is widely used to control the virus and prevent complications, as well as to avoid HIV infection from progressing to AIDS. The following are classes of ART drugs that are used in combination to control HIV infection:
- Non-nucleoside reverse transcriptase inhibitors (NNRTIs) – prevent HIV to create copies of itself by turning off the protein it requires.
- Nucleoside or nucleotide reverse transcriptase inhibitors (NRTIs) – prevent HIV to create copies of itself by supplying faulty version of the protein it needs.
- Protease inhibitors (PIs) – prevent HIV to create copies of itself by inactivating the protein HIV protease.
- Integrase inhibitors – disables integrase, the protein that HIV use to introduce the genetic material into the CD4 T-cells.
- Entry or fusion inhibitors – drugs that block the entry of the virus into CD4 T-cells.
- Lifestyle changes. HIV/AIDS patients on ART are strongly recommended to avoid raw food such as raw meat and eggs. Fresh fruits and vegetables and other healthy foods are encouraged. They should also have the right vaccinations. HIV/AIDS patients should be very careful in taking care of pets which may carry infection-causing parasites.
Nursing Diagnosis for HIV
Nursing Care Plan for HIV 1
Nursing Diagnosis: Infection related to HIV/AIDS infection as evidenced by positive HIV antigen/antibody result, CD4 T-cell count is below 200, known contact with an HIV positive person, temperature of 38.2 degrees Celsius, myalgia, and fatigue
Desired Outcome: The patient will be able to avoid the development of an infection.
|HIV Nursing Interventions||Rationales|
|Assess vital signs and monitor the signs of infection.||To establish baseline observations and check the progress of the infection as the patient receives medical treatment.|
|Administer the prescribed antivirals using the antiretroviral therapy (ART) regimen.||To treat the HIV/AIDS infection.|
|Inform the patient or carer that there is no need to avoid direct social contact.||HIV can only be transmitted via sexual contact or blood. Isolation is unnecessary, unless the HIV patient develops a contagious disease due to weak immune system, such as tuberculosis.|
|Monitor the progress of the patient under ART treatment.||Tests such as nucleic acid tests (NATs) for the viral load of HIV in the blood and CD4 T-cell count to check if the CD4 T-cell count is below 200 are needed to monitor for success.|
|Provide symptomatic relief for the patient.||HIV/ AIDS patient may require treatment based on their symptoms, such as antipyretics for fever and anti-diarrheals for diarrhea.|
Nursing Care Plan for HIV 2
Nursing Diagnosis: Hyperthermia related to HIV/AIDS infection as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|HIV Nursing Interventions||Rationales|
|Assess the patient’s vital signs at least every hour. Increase the intervals between vital signs taking as the patient’s vital signs become stable.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs administered.|
|Remove excessive clothing, blankets and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed antivirals and anti-pyretic medications.||Use the antiviral for immunocompromised patients with serious HIV/AIDS infection. Use the anti-pyretic medication to stimulate the hypothalamus and normalize the body temperature.|
|Offer a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Nursing Care Plan for HIV 3
Nursing Diagnosis: Fatigue related to body weakness secondary to HIV/AIDS infection as evidenced by overwhelming lack of energy, verbalization of tiredness, generalized weakness, lack of appetite, and shortness of breath upon exertion
Desired Outcome: The patient will demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.
|HIV Nursing Interventions||Rationales|
|Assess the patient’s degree of fatigability by asking to rate his/her fatigue level (mild, moderate, or severe). Explore activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.||To create a baseline of activity levels, degree of fatigability, and mental status related to fatigue and activity intolerance.|
|Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with rest and sleep.||To gradually increase the patient’s tolerance to physical activity.|
|Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.||To allow the patient to relax while at rest. To allow enough oxygenation in the room.|
|Refer the patient to dietitian and physiotherapy / occupational therapy team as required.||To provide a more specialized care for the patient in terms of helping him/her build confidence in increasing daily physical activity and improving nutritional intake / appetite.|
Nursing Care Plan for HIV 4
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to inability to ingest, digest, or metabolize nutrients, as evidenced by weight loss, muscle wasting, diarrhea, abdominal cramping, nausea & vomiting, poor muscle tone, recurrent fevers, and lack of appetite
Desired Outcome: The patient will be able to achieve a weight within his/her normal BMI range, demonstrating healthy eating patterns and choices.
|HIV Nursing Interventions||Rationale|
|Create a daily weight chart and a food and fluid chart. Discuss with the patient the short term and long-term goals of weight gain.||To effectively monitory the patient’s daily nutritional intake and progress in weight goals.|
|Help the patient to select appropriate dietary choices to follow a high caloric diet.||Patients tend to expend a significant amount of energy by overusing respiratory muscles to breathe when battling recurrent fevers. High caloric diet may help provide the energy he/she needs and combat fatigue and weight loss.|
|Provide small, frequent meals.||To enhance oral intake, fulfil cravings, and reduce episodes of nausea.|
|Refer the patient to the dietitian.||To provide a more specialized care for the patient in terms of nutrition and diet in relation to the diagnosis.|
|Administer medications as prescribed.||Vitamin supplements – to resolve vitamin deficienciesAnti-emetics – to treat nausea/vomitingAppetite stimulantsAnti-diarrheals|
More HIV AIDS Nursing Diagnosis
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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