NURSING PROCESS:THE PATIENT WITH AIDS
The nursing care of patients with AIDS is challenging because of the potential for any organ system to be the target of infections or cancer. In addition, this disease is complicated by many emo-tional, social, and ethical issues. The plan of care for the patient with AIDS is individualized to meet the needs of the patient (see Plan of Nursing Care). Care includes many of the interventions and concerns cited in the supportive care section.
Nursing assessment includes identification of potential risk fac-tors, including a history of risky sexual practices and injection drug use. The patient’s physical status and psychological status are assessed. All factors affecting immune system functioning are thoroughly explored.
Nutritional status is assessed by obtaining a dietary history and identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. In addition, the patient’s ability to purchase and prepare food is as-sessed. Weight, anthropometric measurements, and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels provide objective measurements of nutritional status.
The skin and mucous membranes are inspected daily for evi-dence of breakdown, ulceration, or infection. The oral cavity is monitored for redness, ulcerations, and the presence of creamy-white patches indicative of candidiasis. Assessment of the peri-anal area for excoriation and infection in patients with profuse diarrhea is important. Wounds are cultured to identify infectious organisms.
Respiratory status is assessed by monitoring the patient for cough, sputum production, shortness of breath, orthopnea, tachypnea, and chest pain. The presence and quality of breath sounds are in-vestigated. Other measures of pulmonary function include chest x-ray results, arterial blood gas values, pulse oximetry, and pul-monary function test results.
Neurologic status is determined by assessing level of conscious-ness; orientation to person, place, and time; and memory lapses. Mental status is assessed as early as possible to provide a baseline (Chart 52-6). The patient is also assessed for sensory deficits (visual changes, headache, or numbness and tingling in the ex-tremities) and motor involvement (altered gait, paresis, or paral-ysis) and seizure activity.
Fluid and electrolyte status is assessed by examining the skin and mucous membranes for turgor and dryness. Increased thirst, de-creased urine output, low blood pressure or a decrease in systolic blood pressure between 10 and 15 mm Hg with a concurrent rise in pulse rate when the patient sits up or stands, weak and rapid pulse, and urine specific gravity of 1.025 or more may indicate dehydration. Electrolyte imbalances, such as decreased serum sodium, potassium, calcium, magnesium, and chloride, typically result from profuse diarrhea. The patient is assessed for signs and symptoms of electrolyte deficits, including decreased mental sta-tus (see Chart 52-6), muscle twitching, muscle cramps, irregular pulse, nausea and vomiting, and shallow respirations.
The patient’s level of knowledge about the disease and the modes of disease transmission is evaluated. In addition, the level of knowledge of family and friends is assessed. The patient’s psy-chological reaction to the diagnosis of HIV infection or AIDS is important to explore. Reactions vary among patients and may in-clude denial, anger, fear, shame, withdrawal from social interac-tions, and depression. It is often helpful to gain an understanding of how the patient has dealt with illness and major life stress in the past. The patient’s resources for support are also identified.
The list of potential nursing diagnoses is extensive because of the complex nature of this disease. Based on assessment data, how-ever, major nursing diagnoses for the patient may include the following:
· Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea
· Diarrhea related to enteric pathogens or HIV infection
· Risk for infection related to immunodeficiency
· Activity intolerance related to weakness, fatigue, malnutri-tion, impaired fluid and electrolyte balance, and hypoxia as-sociated with pulmonary infections
· Disturbed thought processes related to shortened attention span, impaired memory, confusion, and disorientation as-sociated with HIV encephalopathy
· Ineffective airway clearance related to PCP, increased bron-chial secretions, and decreased ability to cough related to weakness and fatigue
· Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy
· Imbalanced nutrition, less than body requirements, related to decreased oral intake
· Social isolation related to stigma of the disease, withdrawal of support systems, isolation procedures, and fear of infect-ing others
· Anticipatory grieving related to changes in lifestyle and roles and unfavorable prognosis
· Deficient knowledge related to HIV infection, means of preventing HIV transmission, and self-care
Based on the assessment data, possible complications may include the following:
· Opportunistic infections
· Impaired breathing or respiratory failure
· Wasting syndrome and fluid and electrolyte imbalance
Adverse reaction to medications
Goals for the patient may include achievement and maintenance of skin integrity, resumption of usual bowel habits, absence of in-fection, improved activity tolerance, improved thought processes, improved airway clearance, increased comfort, improved nutri-tional status, increased socialization, expression of grief, increased knowledge regarding disease prevention and self-care, and ab-sence of complications.
The skin and oral mucosa are assessed routinely for changes in ap-pearance, location and size of lesions, and evidence of infection and breakdown. The patient is encouraged to maintain a balance between rest and mobility whenever possible. Patients who are immobile are assisted to change position every 2 hours. Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Patients are encouraged to avoid scratching, to use nonabrasive, nondrying soaps, and to apply nonperfumed skin moisturizers to dry skin surfaces. Regular oral care is also encouraged.
Medicated lotions, ointments, and dressings are applied to af-fected skin surfaces as prescribed. Adhesive tape is avoided. Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Patients with foot lesions are advised to wear cotton socks and shoes that do not cause the feet to perspire. Antipruritic, anti-biotic, and analgesic agents are administered as prescribed.
The perianal region is assessed frequently for impairment of skin integrity and infection. The patient is instructed to keep the area as clean as possible. The perianal area is cleaned after each bowel movement with nonabrasive soap and water to prevent further excoriation and breakdown of the skin and infection. If the area is very painful, soft cloths or cotton sponges may prove to be less irritating than washcloths. In addition, sitz baths or gentle irrigation may facilitate cleaning and promote comfort. The area is dried thoroughly after cleaning. Topical lotions or ointments may be prescribed to promote healing. Wounds are cultured if in-fection is suspected so that the appropriate antimicrobial treat-ment can be initiated. Debilitated patients may require assistance in maintaining hygienic practices.
Bowel patterns are assessed for diarrhea. The nurse monitors the frequency and consistency of stools and reports of abdominal pain or cramping associated with bowel movements. Factors that ex-acerbate frequent diarrhea are also assessed. The quantity and vol-ume of liquid stools are measured to document fluid volume losses. Stool cultures are obtained to identify pathogenic organisms.
The patient is counseled about ways to decrease diarrhea. The physician may recommend restriction of oral intake to rest the bowel during periods of acute inflammation associated with se-vere enteric infections. As the patient’s dietary intake is increased, foods that act as bowel irritants, such as raw fruits and vegetables, popcorn, carbonated beverages, spicy foods, and foods of extreme temperatures, should be avoided. Small, frequent meals help to prevent abdominal distention. The physician may prescribe med-ications such as anticholinergic antispasmodics or opioids, which decrease diarrhea by decreasing intestinal spasms and motility. Administering antidiarrheal agents on a regular schedule may be more beneficial than administering them on an as-needed basis. Antibiotics and antifungal agents may also be prescribed to com-bat pathogens identified by stool cultures. The nurse should also assess the self-care strategies being used by the patient to control diarrhea (Henry et al., 1999).
The patient and caregivers are instructed to monitor for signs and symptoms of infection: fever; chills; night sweats; cough with or without sputum production; shortness of breath; difficulty breath-ing; oral pain or difficulty swallowing; creamy-white patches in the oral cavity; unexplained weight loss; swollen lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; headache; visual changes or memory lapses; redness, swelling, or drainage from skin wounds; and vesicular lesions on the face, lips, or perianal area. The nurse also monitors laboratory values that indicate infection, such as the white blood cell count and differential. The physician may decide to culture specimens of wound drainage, skin lesions, urine, stool, sputum, mouth, and blood to identify pathogenic organisms and the most appropriate antimicrobial therapy. The patient is instructed to avoid others with active infections such as upper respiratory infections.
Activity tolerance is assessed by monitoring the patient’s ability to ambulate and perform activities of daily living. Patients may be unable to maintain their usual levels of activity because of weakness, fatigue, shortness of breath, dizziness, and neurologic involvement. Assistance in planning daily routines that maintain a balance between activity and rest may be necessary. In addition, patients benefit from instructions about energy conservation techniques, such as sitting while washing or while preparing meals. Personal items that are frequently used should be kept within the patient’s reach. Measures such as relaxation and guided imagery may be beneficial because they decrease anxiety, which contributes to weakness and fatigue.
Collaboration with other members of the health care team may uncover other factors associated with increasing fatigue and strategies to address them. For example, if fatigue is related to anemia, administering epoetin alfa (Epogen) as prescribed may relieve fatigue and increase activity tolerance.
The patient is assessed for alterations in mental status that may be related to neurologic involvement, metabolic abnormalities, infection, side effects of treatment, and coping mechanisms. Manifestations of neurologic impairment may be difficult to dis-tinguish from psychological reactions to HIV infection, such as anger and depression.
Family members are instructed to speak to the patient in sim-ple, clear language and give the patient sufficient time to respond to questions. Family members are instructed to orient the patient to the daily routine by talking about what is taking place during daily activities. They are encouraged to provide the patient with a regular daily schedule for medication administration, grooming, meal times, bedtimes, and awakening times. Posting the schedule in a prominent area (eg, on the refrigerator), providing nightlights for the bedroom and bathroom, and planning safe leisure activi-ties allow the patient to maintain a regular routine in a safe man-ner. Activities that the patient previously enjoyed are encouraged. These should be easy to accomplish and fairly short in duration. The nurse encourages the family to remain calm and not to argue with the patient while protecting the patient from injury. Around-the-clock supervision may be necessary, and strategies can be im-plemented to prevent the patient from engaging in potentially dangerous activities, such as driving, using the stove, or mowing the lawn. Strategies for improving or maintaining functional abil-ities and for providing a safe environment are used for patients with HIV encephalopathy (Chart 52-7).
Respiratory status, including rate, rhythm, use of accessory mus-cles, and breath sounds; mental status; and skin color must be assessed at least daily. Any cough and the quantity and charac-teristics of sputum are documented. Sputum specimens are ana-lyzed for infectious organisms. Pulmonary therapy (coughing, deep breathing, postural drainage, percussion, and vibration) is provided as often as every 2 hours to prevent stasis of secretions and to promote airway clearance. Because of weakness and fa-tigue, many patients require assistance in attaining a position (such as a high Fowler’s or semi-Fowler’s position) that facilitates breathing and airway clearance. Adequate rest is essential to max-imize energy expenditure and prevent excessive fatigue. The fluid volume status is evaluated so that adequate hydration can be maintained. Unless contraindicated by renal or cardiac disease, an intake of 3 L of fluid daily is encouraged. Humidified oxygen may be prescribed, and nasopharyngeal or tracheal suctioning, in-tubation, and mechanical ventilation may be necessary to main-tain adequate ventilation.
The patient is assessed for the quality and severity of pain associ-ated with impaired perianal skin integrity, the lesions of KS, and peripheral neuropathy. In addition, the effects of pain on elimi-nation, nutrition, sleep, affect, and communication are explored, along with exacerbating and relieving factors. Cleaning the peri-anal area as previously described can promote comfort. Topical anesthetics or ointments may be prescribed. Use of soft cushions or foam pads may increase comfort while sitting. The patient is instructed to avoid foods that act as bowel irritants. Antispas-modics and antidiarrheal medications may be prescribed to re-duce the discomfort and frequency of bowel movements. If necessary, systemic analgesic agents may also be prescribed.
Pain from KS is frequently described as a sharp, throbbing pres-sure and heaviness if lymphedema is present. Pain management may include using nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids plus nonpharmacologic approaches such as relax-ation techniques. When NSAIDs are used in patients receiving zidovudine, hepatic and hematologic status must be monitored.
The patient with pain related to peripheral neuropathy fre-quently describes it as burning, numbness, and “pins and nee-dles.” Pain management measures may include opioids, tricyclic antidepressants, and elastic compression stockings to equalize pressure. Tricyclic antidepressants have been found helpful in controlling the symptoms of neuropathic pain. They also poten-tiate the actions of opioids and can be used to relieve pain with-out increasing the dose of the opioid.
Nutritional status is assessed by monitoring weight; dietary in-take; anthropometric measurements; and serum albumin, BUN, protein, and transferrin levels. The patient is also assessed for factors that interfere with oral intake, such as anorexia, oral and esophageal candidal infection, nausea, pain, weakness, fatigue, and lactose intolerance. Based on the results of assessment, the nurse can implement specific measures to facilitate oral intake. The dietitian is consulted to determine the patient’s nutritional requirements.
Control of nausea and vomiting with antiemetic medications administered on a regular basis may increase the patient’s dietary intake. Inadequate food intake resulting from pain caused by mouth sores or a sore throat may be managed by administering prescribed opioids and viscous lidocaine (the patient is instructed to rinse the mouth and swallow). Additionally, the patient is en-couraged to eat foods that are easy to swallow and to avoid rough, spicy, or sticky food items and foods that are excessively hot or cold. Oral hygiene before and after meals is encouraged.
When fatigue and weakness interfere with intake, the nurse encourages the patient to rest before meals. If the patient is hos-pitalized, meals should be scheduled so that they do not occur immediately after painful or unpleasant procedures. The patient with diarrhea and abdominal cramping is encouraged to avoid foods that stimulate intestinal motility and abdominal distention (eg, fiber-rich food or lactose if the patient is intolerant to lactose). The patient is instructed about ways to enhance the nutritional value of meals. Adding eggs, butter, margarine, and fortified milk (powdered skim milk is added to milk to increase the caloric content) to gravies, soups, or milkshakes can provide additional calories and protein. Commercial supplements such as puddings, powders, milkshakes, and Advera (a nutritional product specifi-cally designed for people with HIV infection or AIDS) may also be useful. Patients who cannot maintain their nutritional status through oral intake may require enteral feedings or parenteral nutrition.
Individuals with AIDS are at risk for double stigmatization. They have what society refers to as a “dread disease,” and they may have a lifestyle that differs from what is considered acceptable by many people. Many people with AIDS are young adults at a develop-mental stage usually associated with establishing intimate rela-tionships and personal and career goals and having and raising children. Their focus changes as they are faced with a disease that threatens their life expectancy with no cure. In addition, they may be forced to reveal hidden lifestyles or behaviors to family, friends, coworkers, and health care providers. As a result, people with HIV infection may be overwhelmed with emotions such as anxiety, guilt, shame, and fear. They also may be faced with mul-tiple losses, such as rejection by family and friends and loss of sex-ual partners, family, and friends; financial security; normal roles and functions; self-esteem; privacy; ability to control bodily func-tions; ability to interact meaningfully with the environment; and sexual functioning. Some patients may harbor feelings of guilt be-cause of their lifestyle or because they may have infected others in current or previous relationships. Other patients may feel anger toward sexual partners who transmitted the virus. Infection con-trol measures used in the hospital or at home may further con-tribute to the patient’s emotional isolation. Any or all of these stressors may cause the patient with AIDS to withdraw both physically and emotionally from social contact.
Nurses are in a key position to provide an atmosphere of acceptance and understanding of people with AIDS and their families and partners. The patient’s usual level of social inter-action is assessed as early as possible to provide a baseline for monitoring changes in behavior indicative of social isolation (eg, decreased interaction with staff or family, hostility, non-compliance). Patients are encouraged to express feelings of isola-tion and loneliness, with the assurance that these feelings are not unique or abnormal.
Providing information about how to protect themselves and others may help patients avoid social isolation. Patients, family, and friends must be assured that AIDS is not spread through ca-sual contact. Educating ancillary personnel, nurses, and physi-cians will help to reduce factors that might contribute to patients’ feelings of isolation. Patient care conferences that address the psy-chosocial issues associated with AIDS may help sensitize the health care team to patients’ needs.
The nurse can help patients verbalize feelings and explore and identify resources for support and mechanisms for coping, espe-cially when the patient is grieving about anticipated losses. Pa-tients are encouraged to maintain contact with family, friends, and coworkers and to use local or national AIDS support groups and hotlines. If possible, losses are identified and addressed. The patient is encouraged to continue usual activities whenever pos-sible. Consultations with mental health counselors are useful for many patients.
Patients who are immunosuppressed are at risk for OIs. There-fore, anti-infective agents may be prescribed and laboratory tests obtained to monitor their effect. Signs and symptoms of OIs, in-cluding fever, malaise, difficulty breathing, nausea or vomiting, diarrhea, difficulty swallowing, and any occurrences of swelling or discharge, should be reported.
Impaired breathing is a major complication that increases the pa-tient’s discomfort and anxiety and may lead to respiratory and cardiac failure. The respiratory rate and pattern are monitored and the lungs are auscultated for abnormal breath sounds. The patient is instructed to report shortness of breath and increasing difficulty in carrying out usual activities. Pulse rate and rhythm, blood pressure, and oxygen saturation are monitored. Suctioning and oxygen therapy may be prescribed to ensure an adequate air-way and to prevent hypoxia. Mechanical ventilation may be nec-essary for a patient who cannot maintain adequate ventilation as a result of pulmonary infection, fluid and electrolyte imbalance, or respiratory muscle weakness. Arterial blood gas values are used to guide ventilator settings. If the patient is intubated, a method must be established to allow communication with the nurse and others. Attention must be given to assisting the patient on me-chanical ventilation to cope with the stress associated with intu-bation and ventilator assistance. The possible need for mechanical ventilation in the future should be discussed early in the course of the disease, when the patient is able to make his or her desires about treatment known. The use of mechanical ventilation should be consistent with the patient’s decisions about end-of-life treatment.
Wasting syndrome and fluid and electrolyte disturbances, in-cluding dehydration, are common complications of HIV infec-tion and AIDS. The patient’s nutritional and electrolyte status is evaluated by monitoring weight gains or losses, skin turgor, fer-ritin levels, hemoglobin and hematocrit values, and electrolyte levels. Fluid and electrolyte status is monitored on an ongoing basis; fluid intake and output and urine specific gravity may be monitored daily if the patient is hospitalized with complications. The skin is assessed for dryness and adequate turgor. Vital signs are monitored for decreased systolic blood pressure or increased pulse rate upon sitting or standing. Signs and symptoms of elec-trolyte disturbances, such as muscle cramping, weakness, irregu-lar pulse, decreased mental status, nausea, and vomiting, are documented and reported to the physician. Serum electrolyte val-ues are monitored and abnormalities reported.
The nurse helps the patient select foods that will replenish electrolytes, such as oranges and bananas (potassium) and cheese and soups (sodium). A fluid intake of 3 L or more, unless con-traindicated, is encouraged to replace fluid lost with diarrhea, and measures to control diarrhea are initiated. If fluid and electrolyte imbalances persist, the nurse may administer IV fluids and elec-trolytes as prescribed. Effects of parenteral therapy are monitored.
Adverse reactions are of concern in patients who receive many medications to treat HIV infection or its complications. Many medications can cause severe toxic effects. Information about the purpose of the medications, correct administration, side effects, and strategies to manage or prevent side effects is provided. Pa-tients and their caregivers need to know which signs and symp-toms of side effects should be reported immediately to their primary health care provider (see Table 52-3).
In addition to medications used to treat HIV infection, other medications that may be required include opioids, tricyclics, and NSAIDs for pain relief; medications for treatment of OIs; anti-histamines (diphenhydramine) for relief of pruritus (itching); acetaminophen or aspirin for management of fever; and antiemetic agents for control of nausea and vomiting. Concurrent use of many of these medications may cause many drug interactions, in-cluding hepatic and hematologic abnormalities. Therefore, care-ful laboratory monitoring for these abnormalities is warranted.
During each contact with the patient, it is important for the nurse to ask not only about side effects but also how well the pa-tient is managing the medication regimen. The nurse may be able to assist the patient in organizing and planning the medication schedule to promote adherence to the medication regimen.
Patients, families, and friends are instructed about the routes of transmission of HIV. The nurse discusses precautions to prevent transmitting HIV, including using condoms during vaginal or anal intercourse (Chart 52-8); using dental dams or avoiding oral contact with the penis, vagina, or rectum; avoiding sexual prac-tices that might cut or tear the lining of the rectum, vagina, or penis; and avoiding sexual contact with multiple partners, indi-viduals known to be HIV infected, people who use injection drugs, and sexual partners of people who inject drugs.
Patients and their families or caregivers must receive instruc-tions about how to prevent disease transmission, including hand-washing techniques, and in methods for safely handling items soiled with body fluids. Caregivers in the home are taught how to administer medications, including IV preparations.
The medication regimens used for patients with HIV infec-tion and AIDS are often complex and expensive. Patients receiv-ing combination therapies for treatment of HIV infection and its complications require careful teaching about the importance of taking medications as prescribed and explanations and assistance in fitting the medication regimen into their lives (Chart 52-9).
Guidelines about infection and infection control, follow-up care, diet, rest, and activity are also necessary. Patient teaching also includes strategies to avoid infection. The importance of per-sonal hygiene is emphasized. Kitchen and bathroom surfaces should be cleaned regularly with disinfectants to prevent fungal and bacterial growth. Patients with pets are instructed to have an-other person clean areas soiled by animals, such as bird cages and litter boxes. If this is not possible, the patient should use gloves to clean up after pets. Patients are advised to avoid exposure to others who are sick or who have been recently vaccinated. Patients with AIDS and their sexual partners are strongly urged to avoid expo-sure to body fluids during sexual activities and to use condoms for any form of sexual intercourse. Injection drug use is strongly discouraged because of the risk to the patient of other infections and transmission of HIV infection to others. Patients infected with HIV are urged to avoid exposure to bodily fluids (through sexual contact or injection drug use) to prevent exposure to other HIV strains. The importance of avoiding smoking and main-taining a balance between diet, rest, and exercise is also emphasized.
If the patient requires enteral or parenteral nutrition, instruc-tion is provided to patients and families about how to administer nutritional therapies at home. Home care nurses provide ongoing teaching and support for the patient and family.
Patients who are HIV positive or who inject drugs are in-structed not to donate blood. Injection drug users who are un-willing to stop using drugs are advised to avoid sharing drug equipment with others.
Many people with AIDS remain in their community and con-tinue their usual daily activities, whereas others can no longer work or maintain their independence. Families or caregivers may need assistance in providing supportive care. There are many community-based organizations that provide a variety of services for people living with HIV infection and AIDS; nurses can help identify these services.
Community health nurses, home care nurses, and hospice nurses are in an excellent position to provide the support and guidance so often needed in the home setting. As hospital costs continue to rise and insurance coverage continues to decline, the complexity of home care increases. Home care nurses are key in the administration of parenteral antibiotics, chemotherapy, and nutrition in the home.
During home visits, the nurse assesses the patient’s physical and emotional status and home environment. The patient’s ad-herence to the therapeutic regimen is assessed, and strategies are suggested to assist with adherence. The patient is assessed for pro-gression of disease and for adverse side effects of medications. Pre-vious teaching is reinforced, and the importance of keeping follow-up appointments is stressed.
Complex wound care or respiratory care may be required in the home. Patients and families are often unable to meet these skilled care needs without assistance. Nurses may refer patients to community programs that offer a range of services for patients, friends, and families, including help with housekeeping, hygiene, and meals; transportation and shopping; individual and group therapy; support for caregivers; telephone networks for the home-bound; and legal and financial assistance. These services are typically provided by both professional and nonprofessional vol-unteers. A social worker may be consulted to identify sources of financial support, if needed.
Home care and hospice nurses are increasingly called on to provide physical and emotional support to patients and families as patients with AIDS enter the terminal stages of disease. This support takes on special meaning when people with AIDS lose friends and when family members fear the disease or feel anger concerning the patient’s lifestyle. The nurse encourages the pa-tient and family to discuss end-of-life decisions and to ensure that care is consistent with those decisions, all comfort measures are employed, and the patient is treated with dignity at all times.
Expected patient outcomes may include:
1) Maintains skin integrity
2) Resumes usual bowel habits
3) Experiences no infections
4) Maintains adequate level of activity tolerance
5) Maintains usual level of thought processes
6) Maintains effective airway clearance
7) Experiences increased sense of comfort, less pain
8) Maintains adequate nutritional status
9) Experiences decreased sense of social isolation
10) Progresses through grieving process
11) Reports increased understanding of AIDS and partici-pates in self-care activities as possible
12) Remains free of complications