Patient Background

- Patient Name: A.D.

- Age: 37 years old

- History: A.D. has been HIV positive for 6 years. He went to the outpatient clinic with a cough

that will not go away, and SOB. He is being admitted to the unit today.

- Medications:

- EFAVIRENZ (Sustiva) 600 mg PO daily at bedtime

- Tenofovir DF and Emtricitabine (Truvada) 1 Tab PO at bedtime

Subjective Data

- Has had increasing fatigue and shortness of breath over the past week

- States ?I can?t even walk to the bathroom without stopping to catch my breath?

- Has has a nonproductive cough for two weeks and pain with coughing

- Has had lost 13 pounds over the past two months

- States he is taking his ART medications as prescribed

- Has had multiple sexual partners: is currently in monogamous relationship

- Denies tobacco use

Legend: - Has history of IV drug abuse but has not used any drugs since receiving HIV diagnosis

- Denies recent travel out of the country

- Sharing contaminated needles, syringes and other
Pathophysiology injecting equipment and drug solutions when injecting
Objective Data
drugs Physical Examination
- Blood transfusions and tissue transplantation and
medical procedures that involve unsterile cutting or - Vital signs: blood pressure 115/70, pulse 112, temperature 102 F, respiration 20
Diagnostic test piercing
- Heterosexual intercourse with an HIV infected partner - Crackles at bases of lungs, left side greater than right
- Male homosexual relations
- Heart rate rhythm regular, no murmurs
- History of IV drug abuse - HIV positiveMother to child during
Laboratory Values - Health care workers exposed to needle-stick injury pregnancy, during delivery, or through - Nonproductive cough
associated with an infected patient breast milk
- Receiving unsafe injections - Having a sexually transmitted disease - Pulse oximetry is 90% on room air
- Had multiple sex partners (STD), such as syphilis
- One anterior cervical lymph node on left side is palpable
Interventions
Diagnostic Tests

- CD4+ lymphocyte count 76 cells/l.

Signs and Symptoms - Chests x-ray shows probable pneumonia in left lower lobe

Binding and Entry:

Prognosis the virus seeks out the CD4 cell and attaches
itself to receptors on the cell?s outer membrane

Nursing Diagnosis
Fusion:
The virus fuses itself to the CD4 cell
membrane which allows HIV to enter and
Predisposing Factors release viral RNA and enzymes into it

Independent Intervention
- Assess patient?s normal bowel habits.
Precipitating Factors - Assess for diarrhea: frequent, loose stools; abdominal
Reverse Transcription: pain or cramping, volume of liquid stools, and
the virus converts its single-stranded viral exacerbating and alleviating factors.
RNA into double-stranded DNA using an Maintain fluid intake of at least 3 L/day unless
Side Effects enzyme called reverse transcriptase
contraindicated.
- Maintain fluid intake of at least 3 L/day unless
contraindicated.

Integration: Diarrhea r/t enteric pathogens or HIV Dependent Intervention

the virus integrates its newly created viral DNA
into the CD4 cell?s nucleus using an enzyme
infection - Obtain stool cultures and administer antimicrobial
called integrase; by integrating its genetic therapy as prescribed.
instructions, it commands the CD4 cell - Initiate measures to reduce hyper[activity of bowel:
a. Maintain food and fluid restrictions as prescribed.
Suggest BRAT diet (bananas, rice, apple sauce, tea
and toast).
Replication: b. Discourage smoking.
The CD4 cell starts to build new copies of the virus; c. Avoid bowel irritants such as fatty or fried foods, raw
this process can sometimes be clumsy, causing vegetables, and nuts. Offer small, frequent meals.
mutations and variations in the new virions - Administer anticholinergic antispasmodics and opioids or
other medications as prescribed.

Budding:
They then push themselves out of the cell, Independent Intervention
which is called budding, and seek out other - Monitor ability ambulate and perform ADL
CD4 cells to repeat the process - Assist in planning daily routines to maintain balance
between activity and rest
- Instruct patient in energy conservation techniques (e.g)
Activity intolerance r/t weakness sitting while washing or preparing a meal)
Maturation: and fatigue - Decrease anxiety that contributes to weakness and fatigue
the new HIV virions migrate towards the outer by using measures such as relaxation and guided imagery
membrane of the CD4 cell. An enzyme called Dependent Intervention
protease helps convert the immature virions into - Strategize with other health care team members to
mature, infectious virions. uncover and factors associated with fatigue (eg, epoetin
alfa (Epogen) for fatigue related anemia)

Primary Infection of cellls in vblood, fluids Independent Intervention

(CD4 T cell, dendritic cell, macrophages - Assess pain reports, noting location, intensity (0?10 scale), frequency, and time of onset. Note
nonverbal cues like restlessness, tachycardia, grimacing.
- Instruct and encourage patient to report pain as it develops rather than waiting until level is severe.
- Encourage verbalization of feelings.
Drainage to lymph - Provide diversional activities: provide reading materials, light exercising, visiting.
nodes, spleen
Acute Pain r/t Tissue - Perform palliative measures: repositioning, massage, ROM of affected joints.
inflammation/destruction: Infections - Instruct and encourage use of visualization, guided imagery, progressive relaxation, deep-breathing
Independent Intervention techniques, meditation, and mindfulness.
- Assess mucous membranes and document all oral lesions. Note reports of - Provide oral care.
Infection established in lymphoid Dependent Intervention
pain, swelling, difficulty with chewing and swallowing.
tissue (lymph node) - Apply warm or moist packs to pentamidine injection and IV sites for 20 min after administration.
- Provide oral care daily and after food intake, using soft toothbrush, non
- Administer analgesics and/or antipyretics, narcotic analgesics. Use patient-controlled analgesia
abrasive toothpaste, non alcohol mouthwash, floss, and lip moisturizer.
Stage 1: (PCA) or provide around-the-clock analgesia with rescue doses prn.
- Rinse oral mucosal lesions with saline and dilute hydrogen peroxide or
baking soda solutions. Viremia Acute HIV
Signs & Symptoms
- Suggest use of sugarless gum and candy. Syndrome
- Fever
- Plan diet to avoid salty, spicy, abrasive, and acidic foods or beverages. - Chills
Check for temperature tolerance of foods. Offer cool or cold smooth foods. Impaired Oral Mucous Membrane r/t Spread of infection throughout the
Mouth ulcers - Rash
- Encourage oral intake of at least 2500 mL/day. Immunologic deficit body - Night sweats
- Encourage patient to refrain from smoking.
- Muscle aches
- Sore throat
Dependent Intervention
Immune response - Fatigue
- Obtain culture specimens of lesions.
- Administer medications, as ordered:
- Chlorhexidine gluconate 2mg/mL (0.2%) mouthwash or spray
(sugar-free) used twice daily as instructed (10mL for one minute). Perform HIV RNA test (viral load)
- Benzydamine hydrochloride 1.5mg/mL (0.15%) as mouthwash or spray Anti-HIV antibodies; partial control of PLUS
(sugar-free) used four times daily as instructed (15mL as rinse or four viral replication HIV antibody/antigen screening test (ELISA)
sprays every 1.5 hours as required).

CLINICAL LATENCY

HIV RNA not detected

AND HIV RNA detected with <5000 copies/mL
HIV RNA detected with
Asymptomatic antibody/antigen nonreactive PLUS
Latent Infection >10,000 copies/mL
no serologic evidence of HIV infection
Oral Candidiasis HIV infection
Othe microbial infections suspected
Cytokines (TNF) No laboratory
Retest HIV RNA NO serologic Serologic
Hairy Leukoplakia evidence of evidence of HIV confirmation of
HIV infection infection HIV infection
Extensive viral
Lymohadenopathy replication, CD4 cell
lysis
Signs & Symptoms HIV RNA not HIV RNA - Presumptive diagnosis
- Rapid weight loss detected detected of acute HIV infection Confirmed
CD4 Lymphocyte count: - Recurring fever or profuse night sweats - Recommend ART in HIV infection.
76 cells/mm3 - Extreme and unexplained tiredness consultation with an
- Prolonged swelling of the lymph glands in experienced HIV care
Destruction of lymphoid the armpits, groin, or neck Diarrhea that provider - Nausea and vomiting,
tissue; Depletion of CD4 T lasts for more than a week - 3 weeks later, perform - Diarrhea,
cells - Sores of the mouth, anus, or genitals diagnostic testing Antiretroviral therapy - Difficulty sleeping,
Pneumonia, Red, brown, pink, or purplish according to the CDC
HIV RNA Level: 234,000 copies/ml (ART) - Dry mouth,
blotches on or under the skin or inside the HIV testing algorith
mouth, nose, or eyelids - Headache,
- Memory loss, depression, and other - Rash,
Stage 3: AIDS neurologic disorders - Dizziness,
Sustained viral
supression - Fatigue, and
- Pain
Independent Intervention
Independent Interventions
- Monitor for infection: fever, chills, and diaphoresis; cough; shortness of breath; oral pain or painful swallowing;
creamy-white patches in oral cavity; urinary frequency, urgency, or dysuria; redness, swelling, or drainage from - Assess and report signs and symptoms of altered respiratory
wounds; vesicular lesions on face, lips, or perineal area. status, tachypnea, use of accessory muscles, cough, color and Reduces risk
- Teach patient or caregiver about need to report possible infection. Instruct patient in ways to prevent infection: amount of sputum, abnormal breath sounds, dusky or cyanotic Undetectable Decreased risk
off drug
a. Clean room surfaces with disinfectants. skin color, restlessness, confusion, or somnolence. viral load of transmission
Risk for opportunistic infections r/t resistance
b. Clean hands thoroughly after exposure to body fluids. - Encourage adequate rest periods
c. Avoid exposure to others?body fluids or sharing eating utensils.
immunodeficiency
d. Turn, cough, and deep breathe, especially when activity is decreased. Dependent Interventions
e. Maintain cleanliness of perineal area - Provide pulmonary care (cough, deep breathing, postural
- Maintain strict aseptic technique for invasive procedures such as venipunctures, bladder catheterizations, and Ineffective airway clearance related drainage, and vibration) as ordered.
injections to increased secretions, decreased
- Administer antimicrobial therapy as prescribed.
ability to cough, weakness and
- Obtain sputum sample for culture prescribed
Dependent Intervention fatigue secondary to pneumonia
- Initiate measures to decrease viscosity of secretions:
- Monitor laboratory values that indicate the presence of infection, such as white blood cell count and differential
- Obtain culture specimens of skin lesions, urine, stool, sputum, mouth, and blood as ordered. a. Maintain fluid intake of at least 3 L/day unless
- Administer antiretroviral therapy as prescribed contraindicated.
b. Humidify inspired air as prescribed.
- Perform tracheal suctioning as needed.
- Administer oxygen therapy as prescribed.
- Assist with endotracheal intubation; maintain ventilator settings
Anticipatory grieving r/t changes in as prescribed.
lifestyle and roles and unfavorable
prognosis

Independent Intervention
- Help patient 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 patient to use local or national AIDS support
groups and hotlines and to identify loses and deal with
them when possible