Nursing Diagnosis of HIV...nursesoutlook

Nursing Diagnosis of HIV

1. Risk for infection related to HIV infection and subsequent immunodeficiency
2. Imbalanced nutrition less than body requirements related to diarrhoea secondary to opportunistic infection
3. Risk for deficit fluid volume related to diarrhoea secondary cryptosporidiosis
4. Anxiety related to fear of losing independence , job, and income
5. Risk for impaired skin integrity related to frequent diarrhoea

Risk for infection related to HIV infection and subsequent immunodeficiency

Intervention

• Monitor for signs and symptoms of infection (fever, chills, dyspnea, fatigue, oral lesion, dysuria). Frequent and or prolonged infections contribute to the wasting syndrome that occurs with HIV infection.


• Monitor laboratory data (WBC, CD4 count) and viral load. For monitor the progress of treatment

• Teach patient to report sigh and symptoms of infection. To assist with early detection of infection.


• Screen all visitors for communicable disease. To protect the immunocompromised patient from source of new infection.


• Culture wound drainage, mouth lesions, sputum, blood, or urine, as needed. To identify the pathogenic organism so that appropriate treatment methods can be initiated.


• Administer prescribed antimicrobial medication on time. To maintain blood levels of antimicrobial agents for maximum effectiveness.


• To teach patient way to reduce exposure to infection, such as practicing good hand washing techniques, cleaning household surfaces with disinfectant solution, maintaining personal hygiene. To decrease exposure to new infections and prevent exposing others to HIV infection.


• Ensure aseptic handing of all intravenous lines and invasive procedures, such as catheterization or injection. To decrease exposure to new, hospital-acquired infections.

Nursing Diagnosis

Imbalanced nutrition less than body requirements related to diarrhoea secondary to opportunistic infection.

Intervention

• Monitor intake and output. To determine if fluid output is excessive when compared with fluid intake so that fluid deficits can be avoided or treated early.


• Monitor hydration status. To determine adequacy of fluid intake and to initiate fluid replacement early if needed.


• Obtain daily weights and monitor trends. Weight is a clinical indicator of adequate nutrition and fluid balance. Weightless indicates the needs for nutritional supplements or total parental nutrition.


• Monitor laboratory data (blood urea nitrogen, haemoglobin). Provides objective data regarding nutritional status so that corrective action can be initiated early.


• Encourage six small meal, excluding dairy products and raw fruits and vegetable. Small meals prevent gastric distension and nausea.


• Administer intravenous fluids as prescribed. To prevent fluid volume deficit, hypovolemia, and cellular dehydration.


• Teach the patient to increase intake or high-calorie, protein-rich, carbohydrate foods. To provide calories, aid healing, and prevent wasting.

Nursing Diagnosis

Risk for deficit fluid volume related to diarrhoea secondary cryptosporidiosis

Intervention

• Monitor skin turgor and mucus membranes. Poor skin turgor and sticky mucous membranes are indication of fluid deficit.


• Monitor weight daily. Weight is a good indicator of hydration status, rapid change in the weight are usually due to changes in fluid volume.


• Monitor the vital signs. To detect changes associated with fluid deficit. Tachycardia, hypo tension, and low grade fever are associated with fluid volume deficit.


• Monitor the intake output. to determine if imbalance between intake and output exist and to determine fluid deficiency effect on renal function.


• Administer prescribed intravenous fluids. To replace fluid losses.


• Administer prescribed anti diarrhoeal  To correct the cause of the fluid loss.

Nursing Diagnosis

Activity intolerance related to decreased oxygen  transport and reduced energy reserves secondary to opportunistic infection.

Intervention

• Assess severity of fatigue and patient’s understanding of the physiology cause. To establish a baseline for later comparison and to determine effectiveness of treatment.


• Encourage patient to prioritize daily activities and let go of unessential task. Fatigue compromise one’s ability to participate in daily activity.


• Encourage patient to obtain at least 8 hours of uninterrupted sleep at night. Effective night time sleep pattern may decrease daytime fatigue.


• Encourage intake of well-balanced diet. to adequate nutrients to meet energy needs.

Nursing Diagnosis

Anxiety related to fear of losing independence , job, and income.

Intervention

• Explain all care and procedure. Decrease anxiety that often occurs when unfamiliar procedure s are scheduled.


• Encourage verbalization of fears and concern. Venting of feelings often allows the patient to put fears into perspective and may decreases in a rational manner.


• Discourage decision making until outcomes are known. Decisions based on inadequate information may cause grater stress in the future.


• Explore past effective coping strategies that were successful. Patterns of past successful coping are indicators of present resources and stenghts.

Nursing Diagnosis

Risk for impaired skin integrity related to frequent diarrhoea

Intervention

• Monitor skin for signs of breakdown. To detect skin deterioration so that treatment can be implemented as early as possible.


• Inspect skin turgor and mucous membranes daily. Dry mucous membranes and poor skin turgor indicate fluid deficit, which predisposes the patients to skin breakdown.


• Keep rectal area clan and dry. Prevents secondary infections and spread of existing micro-organisms.


• Apply topical protective cream to reddened areas as prescribed . to protect skin from wetness and acidic stool and prevent breakdown while increasing comfort.