1. Acquired immunodeficiency syndrome (AIDS): the terminal stage of the disease continuum caused by human immunodeficiency virus (HIV), a retrovirus; typically progresses from asymptomatic seronegative status to asymptomatic seropositive status to subclinical immune deficiency to lymphadenopathy (early AIDS) to AIDS-related complex (middle stage with combination of symptoms) to AIDS; hallmarks of HIV infection include opportunistic infections: Pneumocystis carinii pneumonia (PCP); cytomegalovirus (CMV); Mycobacterium tuberculosis; hepatitis B; herpes simplex or zoster; candidiasis; may take 7-10 years before signs and symptoms occur.
    1. High-risk populations:
      1. Men, homosexual or bisexual (71%).
      2. Injection drug users (IDU)/heterosexual (10%).
      3. IDU/homosexual (9%).
      4. Hemophiliacs and multiple transfusion recipients (1%).
      5. Heterosexual (5%).
      6. Undetermined/other (4%).
    2. Pathophysiology: abnormal response to foreign antigen stimulation (acquired immunity) —> deficiency in cell-mediated immunity - T lymphocytes, specifically helper cells (T4 cells) and hyperactivity of the humoral system (B cells).
    3. Assessment:
      1. Subjective data:
        1. Fatigue: prolonged; associated with headache or light-headedness.
        2. Unexplained weight loss: >10%.
      2. Objective data:
        1. Fever: prolonged or night sweats >2 weeks
        2. Lymphadenopathy.
        3. Skin or mucous membrane lesions: purplish-red, nodules (Kaposi’s sarcoma).
        4. Cough: persistent, heavy, dry.
        5. Diarrhea: persistent.
        6. Tongue/mouth “thrush”; oral hairy leukoplakia.
        7. Diagnostic tests (with permission of patient): enzyme-linked immunosorbentassay (ELISA); Western blot test.
        8. Lab data: decreased - CD4 (T4) lymphocytes, hematocrit, WBC, platelets. Seropositive - syphilis, hepatitis B; ELISA - positive; Western blot test - positive (mean time for seroconversion is 6 weeks after infection).
    4. Analysis/nursing diagnosis:
      1. Risk for infection related to immunocompromised state.
      2. Fatigue related to anemia.
      3. Altered nutrition, less than body requirements, related to anorexia.
      4. Impaired skin integrity related to nonhealing viral lesions, Kaposi’s sarcoma.
      5. Diarrhea related to infection or parasites.
      6. Risk for activity intolerance related to shortness of breath.
      7. Ineffective airway clearance related to pneumonia.
      8. Visual sensory/perception alteration related to retinitis.
      9. Risk for altered body temperature (fever) related to opportunistic infections.
      10. Social isolation related to stigma attached to AIDS.
      11. Powerlessness related to inability to control disease progression.
      12. Altered thought processes related to dementia.
      13. Ineffective individual coping related to poor prognosis.
      14. Risk for violence, self-directed, related to anger, panic, or depression.
    5. Nursing care plan/implementation:
      1. Goal: reduce risk of infection; slow disease progression.
        1. Observe signs of opportunistic infections: weight loss, diarrhea, skin lesions, sore throat.
        2. Monitor vital signs (including temperature).
        3. Note secretions and excretions: changes in color, consistency, or odor indicating infection.
        4. Diet: monitor fluid and electrolytes; strict measurement; encourage adequate dietary intake (high calorie, high protein, low bulk); 5-10 times RDA for watersoluble vitamins (B complex, C); favorite foods from home; enteral feedings. Six small meals/day.
        5. Protective isolation, if indicated, for severe immunocompromise.
        6. Antiviral medications, as ordered: nucleoside reverse transcriptase inhibitors, e.g., zidovudine (Retrovir); nonnucleoside reverse transcriptase inhibitors, e.g., nevirapine (Viramune); protease inhibitors, e.g., indinavir sulfate (Crixivan); drug toxicity and numerous side effects likely (rash, GI upset); large number of pills and tight administration schedule; costly; potential for drug resistance.
      2. Goal: prevent the spread of disease.
        1. Frequent hand washing, even after wearing gloves.
        2. Avoid exposure to blood, body fluids of patient; wear gloves, gowns; proper disposal of needles, IV catheters.
      3. Goal: provide physical and psychological support.
        1. Oral care: frequent.
        2. Cooling bath: 1:10 concentration of isopropyl alcohol in tepid water; avoid plastic-backed pads with night sweats.
        3. Encourage verbalization of fears, concerns without condemnation; may suffer loss of job, lifestyle, significant other.
        4. Determine status of support network: arrange contact with support group.
        5. Observe for severe emotional symptoms (suicidal tendencies).
        6. Address issues surrounding death to ensure quality of life: advance directive prepared and on file; code blue status; reassurance of comfort and pain control.
      4. Goal: health teaching.
        1. Avoidance of environmental sources of infection (kitty litter, bird cages, tub bathing).
        2. Precautions following discharge: riskreducing behaviors; condoms (latex), limit number of sexual partners, avoid exposure to blood or semen during intercourse.
        3. Family counseling; availability of community resources.
        4. Information on disease progression and life span.
        5. Stress-reduction techniques: visualization, guided imagery, meditation.
        6. Expected side effects with drug therapy; importance of compliance.
    6. Evaluation/outcome criteria:
      1. Relief of symptoms (e.g., afebrile, gains weight).
      2. Resumes self-care activities; returns to work; improved quality of life.
      3. Accepts diagnosis; participates in support group.
      4. Progression of disease slows; improved survival probability.
      5. Retains autonomy, self-worth.
      6. Permitted to die with dignity.
TABLE 7-21 Standard Precautions