HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Human immunodeficiency virus (HIV) is species virus of Lentivirus (a subgroup of

retrovirus) that causes HIV infection and over time Acquired Immunodeficiency Syndrome
(AIDS). AIDS is a condition in humans which progressive failure of the immune system allows
life-threatening opportunistic infections and cancers to thrive. Without threatment, average
survival time after infection with HIV is estimated to be 9 to 11 years, depending on the HIV
subtype. In most cases, HIV is a sexually transmitted infection and occurs by contact with or
transfer of blood, pre-ejaculate, semen, and vaginal fluids. Non-sexual transmission can occur
from an infected mother to her infant during pregnancy, during childbirth by exposure to her
blood or vaginal fluid, and through breast milk. Within these bodily fluids, HIV is present as
both free virus particles and virus within infected immune cells.

3.1 Nursing Assessment

Based on disrupted basic needs
a) Physiologi
1) Repiration:
Symptoms : progressive shortness of breath, productive/non-productive
cough,
dam or chest tightness
Signs : tachypnea, respiratory distress, changes in breath sounds
2) Circulation
Symptoms : slow wound healing process, prolonged bleeding from injury
(rare)
Signs : tachycardia, postural blood pressure changes, decreased
peripheral
arteries, pale or cyanotic
3) Nutrition and fluids
Symptoms : anorexia, nausea/vomit, dysphagia, pain when swallowing,
weight loss
Signs : lesions in the oral cavity, white membrane, bad gum, edema
4) Elimination
 Symptoms : persistent diarrhea, pelvic pain, burning sensation when urinating
Signs : feces with or without mucus, abdominal tenderness, rectal lesions
or abscesses, changes in color, amount and characteristic of urine.

5) Activity and rest

Symptoms : easily tired, reduce tolerance to usual activity, malaise, change in
sleep patterns
Signs : muscle weakness, reduced muscle mass, changes in blood
pressure,
heart frequency, respiration rate.
6) Neurosensory
Symptoms : dizzy, headache, change in mental status, unable to remember,
concentration decreases, damage to sensations or senses, change
in visual acuity, tremor, tingling in extremities.
Signs : bad concentration, the level of consciousness decrease, dementia,
psychomotor retardation.
7) Reproduction and sexuality
Symptoms : having sex with an HIV sufferer, multiple sexual partners,
unprotected sexual activity, anal sex, reduced libido, inconsistent
use of condoms.
Signs : risk of pregnancy, pregnancy
b) Psychological
8) Pain/comfort
Symptoms : general or local pain, burning sensation in the legs, headache,
pleurisy chest pain.
Signs : swelling in the joints, pain in the gland, tenderness, decreased
range of motion, change in gait/limp.
9) Ego integrity
Symptoms : stress factors associated with loss (family support, relationships
 with others), worrying about appearances (alopecia, deformed
lessions, and weight loss), denied diagnosis, feeling helpless,
hopeless, guilty felling.
Signs : denying, anxious, depression, afraid, withdrawal, angry, crying
c) Behavior
10) Personal hygiene
Symptoms : unable to complete activity.
Signs : showing a less neat appearance, lack of self care, lack of self-care
activities.
11) Counseling and learning
Symptoms : failure to follow treatment, continuing high risk behavior
d) Relational
12) Social interaction
Symptoms : problems caused by diagnosis: loss of relatives, closest people,
friends, supporters, fear of revealing it to others, lost income,
insulation, lonely, not able to make plans.
Signs : changes in interactions with family/loved ones
e) Environment
13) Protection
Symptoms : fall history, passed out, the wound is a slow healing process,
history
of frequent or repeated blood transfusions, history of immune
deficiency disease, advanced cancer, repeated fever.
Signs : changes in skin integrity, bruises easily occur that can’t be
explaines, the emergence of nodules, widening of the lymph
glands in two areas of the body (example armpits, neck, thighs),
changes to gait.

3.2 Nursing Diagnosis

1) Clearing the airway ineffective associated with excessive secretion production
2) Hypovolemia associated with chronic diarrhea
3) Deficit of nutrition associated with lack of nutrition intake
4) Activity intolerance associated with seizures, weakness, stiffness in sitting
5) Damage to skin integrity associated with varicella zozte infection
6) Urinary elimination disorder associated with genital ulcer
7) Deficit of knowledge associated with treatment, transmission.
 Pathway

ansmitted
the virus enters the human decreased CD4
en, vaginal decreased immune system
body and infects CD4 cells cells in the body
st milk

DEFICIT OF KNOWLEDGE CD4 cells count

AIDS ≤200 µmL

neurology integument digestive reproduction

s cryptococcus varicella invade the candidiasis

infection zozter dysphagia digestive tract infection
infection
meningitis anorexia intestinal genital ulcer
herpes zoster peristalsis
increases
seizures, weakness, DEFICIT OF URINARY
stiffness in sitting NUTRITION ELIMINATION
DAMAGE TO
chronic DISORDER
SKIN INTEGRITY HYPOVOLEMIA diarrhea