Description Nursing Interventions
Compiled By: Chedan B. C. BSN 4, SLU-CON B.C., Phils.
References: Johnson, Johnson, Joyce Y. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (11th ed.). Philadelphia: Lippincott Williams & Wilkins, 2008. Bartlett, John G. "Acquired Immunodeficiency Syndrome." Microsoft® Encarta® 2009 [DVD]. Redmond, WA: Microsoft Corporation,, 2008. Corporation
All information contained in this co compilation mpilation is intended only as a guide (especially for student nurses) regarding nursing interventions for patients suffering AIDS. Relevant pictures that are included here were taken from an acknowledged source. References, as presented above, may be utilized for further readings. By virtue of the saying “Knowledge is Power,” this compilation was therefore created. C.B.C.
Description
defined as the most severe form of a continuum of illnesses associated with human immunodeficiency immunodeficiency virus (HIV) infection HIV: belongs to a group of viruses known as RETROVIRUSES (type of viruses that carry their genetic material in the form of ribonucleic acid [RNA] rather than deoxyribonucleic acid [DNA]. [Picture taken from Encarta Encyclopedia]
Human Immunodeficiency Virus The human immunodeficiency virus (HIV) principally attacks CD4 T-cells, a vital part of the human immune system. As a result, the body’s ability to resist opportunistic viral, bacterial, fungal, protozoal, and other infection is greatly weakened. [Picture taken from Encarta Encyclopedia]
T-Lymphocyte Infected With HIV By infecting CD4 Tlymphocytes, a type of white blood cell, HIV weakens the immune system and leaves the infected individual open to deadly infections. The viruses gain access to a T-lymphocy T-lymphocyte te by attaching to CD4 proteins on the outer surface of the cell membrane. Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.
Pneumocystis carinii pneumonia is the leading cause of death among people with HIV infection, but the incidence of certain types of cancers such as B-cell lymphomas and Kaposi’s sarcoma is also increased. Neurological complications and dramatic weight loss, or “wasting,” are characteristic of endstage HIV disease (AIDS). HIV can be transmitted sexually; through contact with contaminated blood, tissue, or needles; and from mother to child during birth or breastfeeding. Full-blown symptoms of AIDS may not develop for more than 10 years after infection.
According to Johnson (2008), B-cell lymphomas, such as non-Hodgkin’s lymphoma, are the second most common AIDS-related cancer (the first is Kaposi’s Sarcoma). They develop outside the lymph nodes (mostly in the brain, bone marrow, and GIT), grow aggressively, affect multiple organs, and exhibit resistance to treatment, which may be complicated by severe hematologic toxicity.
According to Microsoft Encarta (2009), Kaposi’s sarcoma is a rare type of cancer of vascular tissue in the skin or internal organs. A more aggressive form occurs in about onethird of patients with acquired immunodeficiency syndrome (AIDS), primarily in homosexual or bisexual men. According to the American Cancer Society, Kaposi’s Sarcoma causes or contributes to death in h f
Magic Johnson Earvin Johnson, who played his entire National Basketball Association (NBA) career with the Los Angeles Lakers, earned the nickname Magic after an extraordinary performance in a high school game. Johnson was named NBA most valuable player in 1987, 1989, and 1990. In 1991 Johnson learned that he had been infected with the virus that causes acquired immunodeficiency syndrome (AIDS), and he started an educational campaign to raise awareness of the disease. Microsoft ® Encarta ® 2009. © 19932008 Microsoft Corporation. All rights reserved.
Greg Louganis American diver Greg Louganis is seen here in the pike the pike position during the 3meter springboard competition at the 1987 Pan American Games. His victory in this event was one of his many triumphs during the 1980s, when he dominated international diving. He also won the springboard and platform diving events at the Olympic Games in both 1984 and 1988. In 1993 he appeared in the Broadway play Jeffrey. play Jeffrey. Two years later his memoir Breaking the Surface was published, and in it he revealed that he suffered from acquired immunodeficiency syndrome (AIDS). Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation.
Nursing Interventions
Assess respiratory status, mental status, and skin color at least daily. Note and document presence of cough and quantity and characteristics of sputum; send specimen for analysis as ordered. Encourage adequate rest (this minimizes energy expenditure and prevents fatigue). Provide pulmonary therapy, such as coughing, deep breathing, postural drainage, percussion, and vibration, every 2 hours (this prevents stasis of
Assist patient into a position (high- or semi-Fowler’s) that facilitates breathing and airway clearance. Evaluate fluid volume status; encourage intake up to 3 liters daily. Provide humidified oxygen, suctioning, intubation, and mechanical ventilation as necessary. [Picture taken from Encarta Encyclopedia]
Assess skin and oral mucosa for changes in appearance, location and size of lesions, and evidence of infection and breakdown; encourage and reinforce regular oral care. Keep bed linen free of wrinkles, wr inkles, and avoid tight or restrictive clothing to reduce skin friction. [Picture taken from Encarta Encyclopedia]
Advise patients with foot lesions to wear white cotton socks and shoes that do not cause feet to perspire. Encourage patient to avoid scratching, to use nonabrasive, and nondrying soaps , and to use nonperfumed skin moisturizes on dry skin; administer antipruritic agents, antibiotic medication, analgesics, medicated lotions, ointments, and dressings as prescribed; avoid excessive use of tape. Encourage patient to balance rest and mobility whenever possible; assist
Assess
perianal region for impaired skin integrity and infection. Instruct patient to keep the area as clean as possible, to cleanse after each bowel movement, to use sitz bath or irrigation, and to dry the area thoroughly after cleaning. Assist debilitated patients in maintaining hygienic practices. Promote healing with prescribed topical ointments and lotions.
Assess
bowel patterns for diarrhea (frequency and consistency of stool, pain or cramping with bowel movements). Assess factors that increase frequency of diarrhea. Measure and document volume of liquid stool as fluid volume loss. Counsel about ways to decrease diarrhea (rest bowel, avoid foods that act as bowel irritants, including raw fruits and vegetables; encourage small, frequent feedings. Administer ordered medications: anticholinergic antispasmodics, antibiotics,
Monitor
lab values indicating presence of infection such as white blood cell count and differential. Maintain strict aseptic technique for invasive procedures. Instruct patient and caregivers to monitor for signs and symptoms of infection. Strongly urge patients and sexual partners to avoid exposure to body fluids and to use condoms for any an y sexual activities. Strongly discourage IV/injection drug use because of risk to patient of other infections and transmission of HIV
Assess
patient for quality and severity of pain, along with exacerbating and relieving factors. Encourage to use soft cushions or foam pads while sitting and topical anesthetics or ointments as prescribed. Administer NSAIDs as ordered. Use also nonpharmacologic approaches like relaxation techniques. Administer TCAs as prescribed and recommend elastic stockings as ordered in dealing with neuropathic pain.
Assess
weight, dietary intake, anthropometric measurements, serum albumin, BUN, protein, and transferrin level. Instruct about ways to supplement nutritional value of meals (eg, add eggs, butter, milk). Encourage oral hygiene before and after meals. Encourage rest before meals; do not schedule meals after painful or unpleasant
Monitor
ability to ambulate and perform
ADLs. Assist in planning daily routines to maintain balance between activity and rest. Educate about energy conservation techniques like sitting while washing or preparing a meal. Help decrease anxiety that contributes to weakness and fatigue by using measures such as relaxation and guided imagery.
Assess
for alterations in mental status. Reorient to person, place, and time as necessary; maintain and post a regular daily schedule. Give [clear] instructions, and instruct family to speak to patient, in a slow, slo w, simple, and clear manner. Provide night lights for bedroom and bathroom as necessary.
Help
patients explore and identify resources for support and mechanisms for coping. Encourage patient to maintain contact with family, friends, and coworkers and to continue usual activities whenever possible. Encourage to use local or national AIDS support groups.
