Nursing Care Plan

1. HUMAN IMMUNO-
DEFICIENCY VIRUS

2. Retrovirus
T lymphocytes (T4 cells)
T-cell or B-cell activity
Multiple sexual partners
Bisexual partners
blood transfusions (rare)
Zidovudine (ZVD)
HIV

3. Ineffective airway clearance related to pneumocystis carinnii pneumonia,
increased bronchial secretions and decreased ability to cough related to
weakness and fatigue.
Imbalanced nutrition related to decreased oral intake.
Social isolation related to stigma of the disease, withdrawal of support systems,
isolation procedures and fear of infecting others.
Risk for infection (opportunistic) related to dysfunction of the immune system
secondary to invasion of HIV
NURSING CARE PLANS

4. INEFFECTIVE AIRWAY
CLEARANCE RELATED TO
PNEUMOCYSTIS CARINNII
PNEUMONIA, INCREASED
BRONCHIAL SECRETIONS
AND DECREASED ABILITY TO
COUGH RELATED TO
WEAKNESS AND FATIGUE.

5. DATA
Tachypnea; Use of accessory muscles; cough; color and amount of
sputum; abnormal breath sounds; dusky or cyanotic skin color;
restlessness; confusion or somnolence
OBJECTIVES
INTERVENTIONS
DIAGNOSTIC
S.T.O.
>Reports improved breathing
L.T.O
>Improved airway clearance
THERAPEUTIC EDUCATIVE
1. assess signs and
symptoms of altered
respiratory status
2. obtain sputum
sample for culture as
prescribed
3.assess sleep patterns
4. auscultate breath
sounds and assess
air movement
5.observe for signs and
symptoms of
infection
1. provide pulm onary care q2 to
4 hours
2. assist patient in attaining
semi-Fowler's position
3. perform tracheal suctioning
as needed
4. administer oxygen therapy as
prescribed
5. initiate measures to decrease
viscosity of secretions
1. encourage adequate rest
periods
2. encourage nutritional intake
3.reiterate in the use of inhalers
and other respiratory drugs as
indicated
4.urge reduction or cessation of
smoking
5. encourage deep breathing
and coughing exercises

6. IMBALANCED
NUTRITION
RELATED TO
DECREASED ORAL
INTAKE.

7. DATA
Malnutrition with: height, weight, age, BUN, serum
protein and albumin, transferrin levels, hemoglobin,
hematocrit, cutaneous anergy
OBJECTIVES
INTERVENTIONS
DIAGNOSTIC
S.T.O.
>Adequate dietary Intake
L.T.O
>Improve nutritional status
THERAPEUTIC EDUCATIVE
ability to feed self
1. assess for
m alnutrition
2. obtain dietary
history
3. assess factors that
interfere with oral
intake
4. evaluate client
5. determine older or
impaired client 's
ability to chew
1. consult with dietitian to
determine nutritional
needs
2.consult with physician and
dietitian about alternative
feeding
3. plan meals
4.serve small, frequent meals
5. consult with social worker
instruct in ways to
supplement nutrition
1. encourage to rest before
meals
2. encourage to eat meals with
SO
3. encourage to prepare simple
meals
4. instruct to lim it fluids 1hour
before and with meals
5.

8. SOCIAL ISOLATION
RELATED TO STIGMA OF
THE DISEASE,
WITHDRAWAL OF
SUPPORT SYSTEMS,
ISOLATION PROCEDURES
AND FEAR OF INFECTING
OTHERS.

9. DATA
Decreased social interaction with others; hostility;
noncompliance; sad affect; started feelings of rejection; loneliness
OBJECTIVES
S.T.O.
>Verbalize feelings and reaction to diagnosis & life changes
L.T.O
>Decrease sense of isolation
INTERVENTIONS
DIAGNOSTIC THERAPEUTIC EDUCATIVE
1. assess usual patterns
of social interaction
2. observe for behaviors
indictive of social
isolation
3. monitor medication
regimen and usage
4. assess for emotional
distress
5. determine level of
independence or
dependence and
physical condition
1. assist to identify and explore
resources for support and
positive mechanism for coping
2. allow time to be with patient
other than for medications and
procedures
3. provide an open environment
4. provide cues for reorientation
5. provide information about care
on an ongoing basis
1. encourage participation in
diversional activities
2. instruct on the modes of
transmission of HIV
3. instruct about the means of
preventing transmission of HIV
4. encourage discussion of
concerns and fears
5. encourage active role of
contact with SO

10. RISK FOR INFECTION
(OPPORTUNISTIC)
RELATED TO
DYSFUNCTION OF THE
IMMUNE SYSTEM
SECONDARY TO
INVASION OF HIV

11. DATA
Fever; chills; diaphoresis; cough; shortness of breath; oral pain;
painful swallowing; creamy white patches in oral cavity; urinary
frequency; drainage form wounds; vesicular lesions on face, lips or
perennial area
OBJECTIVES
S.T.O.
>Verbalize understanding to avoid Infection
L.T.O
>Absence of Infection
INTERVENTIONS
DIAGNOSTIC THERAPEUTIC EDUCATIVE
1. assess knowledge and
ability to maintain
opportunistic infection
prophylactic regimen
2. monitor for infection
3. monitor WBC &
differential
4.obtain cultures of wound
drainage as prescribed
5. monitor reports of
heartburn, dysphagia,
retrosternal pain on
swallowing
1. provide a clean, well-ventilated
environment
2. clean the patient's nails
frequently
3. wear protective equipment's
during direct contact or
procedure
4. proper waste disposal of soiled
dressing
5. clean up spills of blody fluids/
blood with a bleech solution
1. discuss medication regimen,
interactions, and side effects
2. discus to the extent and rationale
for isolation precautions and
maintenance of personal hygiene
3. instruct concerning infection
control
4. stress the necessity of daily skin
care
5. stress the necessity of continued
healthcare and follow-up

12. REFERENCE
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket
Guide: Diagnoses, Prioritized Interventions and Rationales.
Pillitteri, A.. (2006). Maternal & Child Health Nursing :Care of the
Childbearing & Childrearing Family (Edition 5). Philadelphia: Wolter
Kluwer.
Smeltzer, S. C. O., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010).
Brunner & Suddarth’s Textbook of Medical-surgical Nursing.
Lippincott Williams & Wilkins.