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NURSEREVIEW.

ORG

THE INFANT OF AN HIV-POSITIVE MOTHER
Frequently, the newborn who is subsequently determined to be HIV-positive will be
asymptomatic during the nursery stay. The CDC classifies HIV-positive newborns as
indeterminate, asymptomatic, or symptomatic. Between 20% and 65% of infants born to HIV-
positive mothers are themselves infected.
This plan of care is to be used in conjunction with the previous newborn plans of care.

NEONATAL ASSESSMENT DATA BASE
As a rule, the neonate is asymptomatic at birth, although a few may show signs of
opportunistic infections within several days of birth. In addition, the effects of maternal
substance use/abuse and/or prematurity may be present.

Circulation
Prolonged bleeding, petechiae (thrombocytopenia) noted on occasion

Elimination
Diarrhea
Enlarged liver, spleen may be noted

Food/Fluid
LBW
Feeding difficulties
Oral lesions (candidiasis)

Neurosensory
Neurological deficits
Microcephaly

Respiration
Varied degree of impairment (relative maternal drug use, cesarean birth)

Safety
Swollen glands (lymphadenopathy) noted on occasion
MATERNAL FACTORS
History of high-risk behaviors, STDs
Seropositive HIV

Sexuality
MATERNAL FACTORS
History of multiple sexual partners

Teaching/learning
Prematurity
Developmental delays
MATERNAL FACTORS
History of parental drug use (mother or partner)

DIAGNOSTIC STUDIES
CBC and Total Lymphocyte Count: Provides baseline immunologic data regarding WBC and
lymphocyte counts to monitor disease progression.
Enzyme Immunoassay or Enzyme-Linked Immunosorbent Assay and Western Blot
Test (EIA/ELISA): May be positive, but invalid because test does not distinguish between
maternal and infant antibodies. (The infant may test negative by 9–15 mo of age.)
HIV Cultures (with peripheral blood mononuclear cells and, if available, plasma):
Diagnostic for infants under 15 mo of age.
Polymerase Chain Reaction Test: Detects nucleic acid in small quantities of infected
peripheral mononuclear cells.
Serum or Plasma p24 Antigen: Increased quantitative values can be indicative of
progression of infection (may not be detectable during very early stages of HIV infection)
in infants 30 days or older and who have had the second dose of hepatitis vaccine.
Quantitative Serum IgG, IgM, and IgA Determinations: Nondiagnostic in newborns, but
provide baseline immunologic data.
Blood/Lesion/Urine Cultures: Diagnostic for opportunistic infections.
X-ray: May reveal lymphoid interstitial pneumonia.

NURSING PRIORITIES
1. Prevent/minimize infections.
2. Maximize nutritional intake.
3. Promote attachment, growth, and development.
4. Provide information to parent(s)/caregivers about disease process/prognosis and treatment
needs.

DISCHARGE GOALS
1. Free of opportunistic/nosocomial infection.
2. Gaining weight appropriately.
3. Perform skills typical of age group within scope of present developmental level.
4. Parent/caregiver understands condition/prognosis and treatment needs.
5. Plan in place to meet specialized needs after discharge.

NURSING DIAGNOSIS: INFECTION, risk for
Risk Factors May Include: Immature immune system, inadequate acquired
immunity, suppressed inflammatory response, invasive
procedures, malnutrition, chronic disease (infections)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Be free of opportunistic infection.
CRITERIA—NEONATE WILL:
PARENT/CAREGIVER WILL: Verbalize understanding of individual risk factors.
Identify interventions to reduce risk of infection.
Provide safe environment for infant.
ACTIONS/INTERVENTIONS RATIONALE

Independent
Note maternal HIV status/presence of high-risk Affects care of neonate from time of delivery. Anti-
behaviors, and prenatal/intrapartal use of HIV antibodies are transmitted across the placenta
zidovudine (AZT). and are present in all infants of HIV-seropositive
mothers. Between 20% and 67% of these infants will
themselves eventually test positive for HIV. Note:
Maternal antibodies may not be cleared from infant’s
system until 9–15 mo of age.
Use mechanical suction or bulb syringe in place of Prevents exposure of healthcare provider to virus.
oral mucus extractors (e.g., DeLee trap) to clear
airways. Avoid mouth-to-mouth contact for
resuscitation.
Wash neonate at time of delivery, or as soon as Although maternal blood is contaminated, at birth
possible, using warm water and mild soap. infant may not be HIV-positive. Prompt care may
Minimize exposure to maternal blood and help reduce risk to infant.
body fluids.
Provide customary physical care of neonate (e.g., Universal precautions are routinely required for
skin care, eye care, vitamin K administration) the contact with body fluids/blood products to protect
same as for all newborns, using universal the healthcare provider from potential infection.
precautions.
Stress need for care providers/family members Reduces risk of cross-contamination and risk to
washing hands before and after contact with infant. care providers.
Wear gloves for contact with secretions (e.g.,
diapering, cord care, injections, handling of blood/
blood by-products).
Sealed soiled tissues, paper wipes/trash, and Reduces risk of cross-contamination and alerts
disposable diapers in plastic bags per protocol. appropriate personnel/departments to exercise
specific hazardous materials procedures.
Apply mittens; file infant’s nails, as indicated. Protects skin from injury that can provide additional
portals of entry for infectious agents.
Monitor temperature and secretions. Auscultate HIV-seropositive infants have increased risk for
breath sounds. Note behavioral changes, e.g., developing recurrent upper respiratory infection,
irritability, lethargy. Palpate lymph node chains. otitis media, thrush, cytomegalovirus, erythematous
rash, and lymphadenopathy. Note: Although
Pneumocystis carinii pneumonia (PCP) is common is
both infants and adults, lymphocytic interstitial
pneumonitis (LIP) is rarely seen in adults and is the
second most common indicator disease for
diagnosing AIDS in infants.
Prepare skin with soap and water and then alcohol Proper preparation and handling reduces risk of
prior to injections/heel-sticks. Notify laboratory of cross-contamination for infant and care
HIV status and mark specimens accordingly. providers/laboratory staff.
Monitor/limit contact with care providers and Reduces number of pathogens presented to the
family members, as appropriate. infant’s immune system and decreases possibility of
infant’s contracting a nosocomial infection. Note:
Depending on specific facility policy, pregnant care
providers may be excluded from caring for infant to
reduce risk of HIV contamination.
Provide for complete isolation as indicated. Presence of enteritis, congenital syphilis, CMV, or
other viral infections increases risk of cross-
contamination to other infants.
Investigate sudden fever, dyspnea, dry cough, Up to 50% of HIV-infected infants develop PCP
hypoxia, abnormal breath sounds, or use of during 1st yr of life.
accessory muscles, retractions and nasal flaring.
Observe infant for seizure activity, neck stiffness, Suggests meningitis or opportunistic CNS
muscle rigidity, irritability or lethargy, or positive infection. Note: If symptoms develop slowly over
Kernig’s sign. weeks, may reflect HIV effect on CNS rather than
acute infectious process.

Collaborative
Monitor laboratory studies as indicated:
Urine screening; Increased risk of CMV in utero or during hospital
stay necessitates routine microscopic evaluation.
Note: Once infant is discharged, exposure to CMV is
a risk in day-care setting as well.
IgG, IgM, IgA; Elevated serum immunoglobulins are a hallmark of
pediatric HIV infections and may develop before the
decrease in CD4 (T-helper cells) is noted. Note:
Polyclonal hypergammaglobulinemia occurs in
approximately 80% of infected infants, usually in
first months of life.
CD4 counts; Decline reflects immunologic compromise and need
for institution of AZT therapy. Note: CD4 counts of
3000/m3 or more are normal in healthy infants and
gradually decline to adult levels. Counts below
1500/mm3 in 1st yr place infant at increased risk of
developing PCP.
CBCD, liver function tests. Establishes baseline prior to initiation of drug
therapy to be compared with repeat studies at 2, 6,
and 12 wk of age to monitor effects of
therapy/progressions of condition.

Administer medications, as appropriate:

Zidovudine (AZT/ZVD); Useful in preventing replication of HIV in infants older
than 3 mo of age; however, side effects may limit its
usefulness. Note:Recent CDCpublications recommend
6 wk of combination therapy beginning within 12 hr of
birth for infants born to seropositive mothers.
cidobudine (CBD); trimethoprin (TMP); Given orally immediately following birth to prevent
sulfamethasoxazol (SMX) 2 divided doses; Pneumocystis carinii pneumonia
didanosine (Videx); May be used to treat HIV strains resistant to AZT.
ketoconazole (Nizoral); Effective treatment for systemic yeast infections.
trimethoprim-sulfamethoxazole (Bactrim) Instituted for symptomatic infants or
prophylaxis; asymptomatic infants with CD4 counts below
500/mm3 to prevent PCP.
Triple dye, bacitracin; Antimicrobial agents used in cord care to reduce risk
of infection.
Ganciclovir (Cytovene). Treatment of choice for CMV infection to prevent
blindness/life-threatening dissemination.

Recommend/coordinate periodic ophthalmologic Early detection of retinitis in presence of CMV
examinations as appropriate. infection allows for prompt intervention.
NURSING DIAGNOSIS: NUTRITION: altered, risk for less than body
requirements
Risk Factors May Include: Inability to ingest, digest, or absorb nutrients (e.g.,
impaired suck/swallow, GI infection, malabsorption,
diarrhea)
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Demonstrate progressive weight gain toward
CRITERIA—NEONATE WILL: goal.
Display laboratory values WNL.
Be free of signs of malnutrition/FTT.
PARENT/CAREGIVER WILL: Demonstrate understanding of feeding techniques and
infant’s specific needs.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Obtain baseline weight. Establish regular These infants are at increased risk for FTT as
schedule for weighing following discharge evidenced by weight loss or little weight gain
(e.g., three times per week). Identify resources if from birth. Early recognition provides opportunity
scale is not available in home setting. for prompt intervention. Note: If infant is eating
well, but not gaining weight, evaluate for GI
infection.

Observe coordination of sucking and Abnormal oral motor patterns may impair feeding
swallowing reflexes. ability.

Inspect oral cavity. Review procedure with Development of oral sores (e.g., thrush) impairs
caregivers. ability to feed, and, if untreated, can spread to the
esophagus, necessitating alternative feeding
techniques.

Counsel mother regarding risk of breastfeeding. HIV is present in colostrum and breast milk and
Encourage alternative feeding method. although limited, does present some risk to the
infant.

Note infant tolerance of feedings. Feeding difficulties, gastric distress, or signs of
fatigue may require small, frequent feedings for
optimal intake.

Hold infant during feedings. Provides human contact/stimulation and may
enhance intake.

Observe feeding techniques of caregivers. Provide Attention to positioning and handling may be
assistance and encouragement. required to normalize postural tone while feeding
and to maximize sucking/swallowing efforts.
Investigate presence of diarrhea. May indicate lactose intolerance requiring lactose-
free formula or reflect GI manifestations of HIV
infection (e.g., diarrhea, malabsorption, impaired
gastric motility, and liver dysfunction).

Stress importance of close monitoring for Infant is prone to parotitis, as well as frequent
infectious processes. episodes of rapid-onset pneumonia, interfering with
both appetite and feeding. In addition, presence of
infectious process greatly increases metabolic rate
and thereby nutritional needs.

Review future nutritional needs, age-appropriate Provides optimal nutrition based on individual
diet and addition of solid foods considering needs following discharge.
developmental abilities.

Collaborative
Provide enteral/parenteral feedings as appropriate. Motor impairments and/or presence of infection
may necessitate alternative feeding techniques
to meet dietary needs/prevent dehydration.
Obtain stool specimens, as indicated. Stool cultures; tests for ova/parasites,
Cryptosporidium, C. difficile (toxin produced by
bacteria), acid-fast bacillus and Gram’s stain may
identify causes for gastric distress/diarrhea
and weight loss or failure to gain.
Administer nystatin, as indicated. Effective treatment for oral yeast infection.

NURSING DIAGNOSIS: GROWTH AND DEVELOPMENT, risk for altered
Risk Factors May Include: Separation from significant others, inadequate
caretaking, inconsistent responsiveness/multiple
caretakers, environmental and stimulation deficiencies,
effects of chronic condition/disabilities
Possibly Evidenced By: [Not applicable; presence of signs/symptoms
establishes an actual diagnosis]
DESIRED OUTCOMES/EVALUATION Respond to parent/caregiver interactions.
CRITERIA—NEONATE WILL: Perform motor, social, and/or expressive skills typical of
age group, within scope of present capabilities.
PARENT/CAREGIVER WILL: Verbalize understanding of developmental status and
plans for intervention.
Demonstrate skills in handling infant needs.

ACTIONS/INTERVENTIONS RATIONALE
Independent
Determine individual status using Denver Provides baseline to note future progress/changes
Developmental or similar screening tool. and identify therapy needs. Cognitive impairments
vary, may be present at birth, or may develop as a
result of environmental deprivation or viral
infections affecting the CNS. In addition, some
infants may have delayed sensorimotor
development, while others display abnormal muscle
tone and movement patterns with delayed
development of righting and equilibrium reactions.
(Refer to CP: Deviations in Growth Patterns.)

Identify developmental milestones and Reinforces belief that infant may progress with
anticipated time frames for achievement. appropriate support and interventions. Note: Lack of
development or regression is an indicator of need for
further evaluation and may reflect effect of infectious
process.

Discuss caregiver’s perceptions of infant’s Increased frequency of illness, prolonged/recurrent
capabilities and plan for growth. hospitalizations, neglect/overprotection by
caregivers may limit sensory/movement stimuli and
motivation.

Observe infant-parent/caregiver interactions. Eye contact, reaching out of infant promotes adult
response. Effect of maternal drug use, presence of
illness, or developmental delays may prevent or limit
infant interactions, impairing bonding/attachments.

Encourage verbalization of feelings by Frequently, feelings of guilt and despair may be
parent(s)/family members. expressed as hostility, denial, or defensiveness
regarding diagnosis. Awareness of these feelings
provides opportunity to work through them and
develop a positive relationship with the infant.

Avoid confronting denial. Counsel without Parent(s) need to progress at their own rate and
lecturing, provide information without denial may be very strong especially when the
patronizing, and support and give hope infant is asymptomatic. Providing information,
without making false promises. Active-listening, and acceptance of the person in
nonjudgmental ways promotes more positive
progression to acceptance and resolution of dealing
with reality of the situation.
Encourage/support family efforts to care for infant. Personal interactions, even after a period of
abandonment, enhance the bonding process. Note:
Volunteers may be required to support staff efforts in
the absence of family participation or ineffective
family involvement.
Discuss ways to provide a normal atmosphere Enhances sense of control and provides
(e.g., spending time outdoors, using support encouragement for enjoying the present and
systems effectively). possibilities of the future.

Collaborative
Coordinate multidisciplinary team conference to Necessary to address complex issues and
include pediatrician, primary nurse, social worker, maximize infant’s potential because all areas are
nutritional support, psychologist/psychiatrist or interrelated to growth and development.
clinical specialist psychiatric nurse, physical/
occupational therapists, and speech therapists.
Stress importance of frequent screening and formal Identifies developmental delays and effectiveness
evaluations by developmental specialists. of therapy (e.g., early intervention program [EIP]).

NURSING DIAGNOSIS: KNOWLEDGE deficit [Learning Need], regarding
condition, prognosis, and treatment needs
May Be Related To: Lack of exposure, misinterpretation, unfamiliarity with
resources, lack of recall, lack of interest in learning
Possibly Evidenced By: Request for information, statement of misconceptions,
inaccurate follow-through of instructions, development
of preventable complications
DESIRED OUTCOMES/EVALUATION Verbalize understanding of condition and
CRITERIA—PARENT/CAREGIVER WILL: treatment needs.
Identify signs/symptoms requiring intervention.
Perform necessary procedures correctly and explain
reasons for the actions.
Establish plan for ongoing therapy and evaluations.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine parent(s)’/caregivers’ understanding Provides starting point for information and
of condition and prognosis. opportunity to clarify misconceptions. Incubation
period of initial HIV infection to progressive
encephalopathy varies from 2 mo to 5 yr. HIV
directly affects CNS, cardiovascular, GI, and renal
function. Median age for appearance of opportunistic
infection is 9 mo. Impaired brain growth, loss of
developmental milestones, and progressive motor
dysfunction indicate a very poor prognosis. Note:
Children rarely develop Kaposi’s sarcoma,
tuberculosis, toxoplasmosis, cryptococcosis, or
histoplasmosis.
Provide realistic, optimistic information during Enhances attachment process and reduces
each contact with parent. likelihood of abandonment. Many people have been
exposed to media information about AIDS or have
friends/lovers who have died of the disease, and
parent/caregiver may be pessimistic about outcome
for infant.
Note response to contact with infant by parent(s)/ Interactions may be affected by fear of
family, and other caregivers. Discuss individual contamination and of personal judgments
concerns. regarding suspected high-risk behaviors of parents.
Note: To date, there have been no documented cases
of individuals contracting AIDS from routine care of
infected infants when following established CDC
precautions.
Note roles of family members and availability of HIV infection is frequently a multigenerational
extended family. disease, directly affecting mothers, offspring, and
other family members. Because the mother must deal
with her own chronic illness, awareness of the role of
the father and/or grandparents is necessary in
determining family needs or necessity of alternative
placement.
Review current medication/treatment options. Research is ongoing and often openly discussed in
the media, sometimes raising false hopes that must
be clarified to enhance the decision-making process.
Current studies suggest monthly IV immunoglobulins
(IV-Ig) may reduce infections and incidence of
hospitalization. In addition, trials of experimental
vaccines for asymptomatic HIV-seropositive infants
are presently being tried in the hope of enhancing the
response of the immune system.
Discuss safe formula preparation and Reduces risk of bacterial infection and aspiration.
feeding techniques. Note: Infant should not be put to bed with
formula/juice bottle because of risk of bacterial
growth.
Recommend prompt diaper changing/perineal Reduces risk of skin irritation providing entry of
care, use of disposable gloves, and proper infectious agents. Protects others from exposure to
handling of soiled diapers/other pericare items. HIV.
Identify ways to protect infant from exposure to Impairment of immune system reduces infant’s
common infections, diseases, or contact with ability to ward off disease. Depending on infant’s
recently vaccinated individuals. immune status, placement in day care may be
contraindicated to reduce risk of cross-contamination
from other infants.
Stress importance of routine immunization Provides protection from some infectious agents.
as appropriate. Note: Infant should receive injectable (Salk) instead
of oral (Sabin) polio vaccine, which contains live
virus. In addition, asymptomatic infants do not
require influenza vaccine.
Review side effects of therapy, e.g., AZT. Nausea/vomiting, abnormalities of liver function,
and suppression of bone marrow limit therapy/drug
dosage.
Determine current living conditions, physical Mother’s lifestyle/condition may preclude her
care needs, immune status/presence of providing appropriate care for infant. Other family
opportunistic infections. members (e.g., grandparents, aunt/uncle) may be
providing care for mother and/or other involved
family members and be unable to care for infant too.
Discuss placement options as appropriate. Chronically ill/impaired mother and extended
family members who may be overtaxed with caring
for ill family members may not be able to meet the
needs of even a well infant. Residential or foster
home may be indicated at least for a period of time
until family or parent(s) are able to assume
responsibility for infant. However, many foster
homes refuse HIV-infected infants, and as a rule,
these children are not usually available for adoption,
making placement very difficult.
Stress frequency and content of follow-up care, Knowledgeable providers are better equipped to
especially with health professionals experienced deal with the complex health issues and use newly
in caring for HIV-seropositive women and infants. developed treatment options to promote optimal
outcomes for the infant/family.
Discuss significance of HIV and other testing. Regular testing to age 2 is necessary to verify HIV
status in absence of opportunistic infections. Viral
cultures, polymerase chain reaction, IgA, IgM, p24
antigen assay, and evaluation of CD4 lymphocyte
count monitor presence/progression of infection. In
addition, some resources believe all infants born to
HIV-risk women require vigilant pediatric follow-up
for early diagnosis of true HIV infection.
Identify signs/symptoms requiring notification of Prompt evaluation and intervention may limit
healthcare provider, e.g., fever, pain, altered process and progression to AIDS.
activity level, difficulty breathing, poor appetite,
weight loss, vomiting, diarrhea, skin rashes,
oral thrush, or developmental regression.
Encourage parents/caregivers to care for their own As they learn to take time for themselves,
health and to make time to meet their own needs parents/caregivers can better manage long-term
for rest and relaxation. care of a chronically ill child.
Review individual/family coping strategies. Individuals providing care for infant with complex
Discuss/encourage use of effective stress medical regimen and emotional needs are exposed
management techniques, including use of to multiple, continuous stressors that can
medication/prayer as appropriate. quickly exhaust coping abilities, increasing risk for
caregiver role strain.
Identify sources for family counseling, community Mother-infant dyads are at increased risk for
support groups, and other resources (e.g., visiting impaired bonding. Physical illness, financial
nurse services, home care agency, social services, stressors, depression, maternal drug use, and
respite care). poor support systems interfere with parenting
abilities, placing infant at risk for physical and
emotional neglect/abuse. In addition, family
members will require assistance in coping with
chronic illness and future prognosis of other family
members. Note: Recent studies suggest mothers who
provide primary care for their infant with HIV report
lower quality of life scores as compared to alternative
caregivers, reflecting need for special
attention/support of this population.