languha Ngati

Med surge  

chapter 37 care plan,  HIV

12-2-2019

Correction
Case Study, Chapter 37, Management of Patients With HIV Infection and AIDS

1. The nurse is planning to provide education on HIV infection transmission and prevention

strategies at a local senior center. (Learning Objectives 1 and 4)

a. What should the nurse include in the session considering the needs of the older

population?

2. Sallie Jefferies, 28-year-old patient, is at the obstetric clinic for a pregnancy visit. The

physician informs the patient that her HIV screen test is positive. The patient has no evidence of

AIDS. The nurse provides patient education regarding what HIV is and what the clinical

management entails. (Learning Objective 5)

a. What clinical management is recommended for the patient during the pregnancy to help

decrease the risk of transmitting HIV to the unborn child?

b. The patient asks the nurse how zidovudine (Retrovir) will help her unborn child from

getting HIV. How should the nurse respond?

c. What explanation about Retrovir should the nurse provide?

d. The patient asks the nurse if it will be safe to breast-feed her infant after the delivery. The

nurse should provide what explanation?

e. The patient asks the nurse what testing schedule for the HIV antibody is needed after her

baby is born. How should the nurse respond?

     Acquired immunodeficiency syndrome is a serious secondary immunodeficiency disorder

caused by the retrovirus, human immunodeficiency virus. Both diseases are characterized by the

progressive destruction of cell-mediated (T-cell) immunity with subsequent effects on humoral

(B-cell) immunity because of the pivotal role of the CD4+helper T cells in immune reactions.

Immunodeficiency makes the patient susceptible to opportunistic infections, unusual cancers,

and other abnormalities. AIDS results from the infection of HIV which has two forms: HIV-1

and HIV-2. Both forms have the same model of transmission and similar opportunistic infections
associated with AIDS, but studies indicate that HIV-2 develops more slowly and presents with

milder symptoms than HIV-1. Transmission occurs through contact with infected blood or body

fluids and is associated with identifiable high-risk behaviors like injection drug users, children

born to an infected mother.

Signs and symptoms HIV

 Headache

 Fatigue

 Aching muscles

 Sore throat

 Swollen lymph nodes

 A red rash that doesn't itch, usually on your torso

 Fever

Head to toe assessment.

     General appearance 

 Patient is alert and oriented to person, place, time, and situation. 

 Patient is clean and well groomed,  

 Patient standing upright erect and relaxed. 

 No congenital or acquired physical deformities noted. 

 Independent and ambulatory.

o  no use of assistive device. Full range of motion present in

bilateral  upper and lower extremities. 

 Patient is can speak without any difficulties. 

     Vital signs: B/P 118/62, pulse 64, 02 98, Temp 97.0

Skin, hair, and nails:

 Patient skin is free of lesion, rashes and bruising. 

 Patient skin is warm and moist to touch. 

 No pressure area noted. 

 No edema noted 

 No lice on hair. 

 Patient Nails capillary refill less than 3 seconds bilateral and is consistent.

Head and Face

1. Scalp, hair, cranium

Head round, symmetric skull, and appropriate proposition to body size and shape. 

2. Face, stroke check

Face symmetrical, no facial skin pigmentation or abnormalities noted. Client had calm and

relaxed facial Maxillary sinuses, frontal sinuses palpation

No visible or palpable maxillary and frontal sinus swelling noted. 

               7 Facial expression, mood, and affect

Calm, cooperative, pleasant and maintain eye contact during conversation. 

 8. Speech

Clear, fluent and meaningful conversation.  

Eyes

1. Vision is good with or without glasses. 

        2       Sclera: Bilateral Sclera appears white in color.  No redness or discharges noted. 

        3 .     Cornea: Bilateral cornea clear bright smooth surface, 

        4 .      Pupils: bilateral pupils equal, round, 2 mm, reactive, accommodation to light

      

Ears

1. External ear: Bilateral external ears symmetrical, no swelling or tenderness

noted. 

2. bilateral tympanic membrane intact, shiny, and translucent, with pearly-gray

color.  

3. Hearing: Able to hear two syllable words clearly. 

Nose

1. External nose

External nose appears round symmetrical, appropriately proportioned to other facial features. No

visible nasal skin abnormality noted.  

Mouth and Throat

1. Lips and buccal mucosal

Lips and buccal mucosa are pink, moist, and free from lesion and cracks. 

2. Teeth and gums

Teeth are clean

Hard palate: pink irregular rugae present.  No visible lesion present.    

Soft Palate: Pink smooth and upwardly movable. 

4. Tonsils

Bilateral tonsils appears pink , same as oral mucus membrane. Bilateral tonsils are 1+ size at the

scale of 4+. 

5. Uvula

Pink consistent with buccal mucus membrane. Uvula Rises with phonation. 
 6. Tongue

Pink and even slightly rough at dorsal surface. No lesion or induration.

Neck

1. Symmetry, lumps, pulsations

Neck muscles symmetrical , present at midline. Full range of motion while turning left, right,

extending head backward and forward.  No lumps or skin abnormalities found. 

2. Cervical lymph nodes

Lymph nodes are bilaterally smooth, movable, discrete, soft, and nontender. 

4. Trachea

No tracheal swelling or rigidity noted. Present at midline of shoulder and neck. 

5. ROM and muscle strength

Full range of motion.NO muscles spasm, no neck rigidity noted, able to move neck left, right,

upward, and downward without any difficulty. 

Chest Anterior, Posterior, and Lateral:

Anterior and posterior chest: symmetrical bilaterally.

     Breath sounds: Respiration is regular,  breathing at a rate of 16 breaths per minute. .

2. CVA tenderness: no costal vertebral angle tenderness noted bilaterally upon percussion. 

Upper Extremities

1. ROM and muscle strength: full range of motion bilaterally and are equal strength. 

Able to circumduct, flex and extend bilateral shoulders, abduct and adduct bilateral

elbows, able to perform pronation and supination of bilateral wrists.

Fingers: full range of motion in all 10 digits. 

2. Capillary refill less than 3 seconds bilaterally.

2. Handgrips: bilateral hand grips strong and equal. 

Heart

1. Precordium: no pulsations, heaves visualized any palpable thrills present at this

time.   

2. Heart sounds x 5 cardiac landmarks:, no murmurs, no friction rub, no arterial

gallops or S4 gallops noted. S1 sound heard very prominent at apex. S2 sound was

greater at base. 

3. Denies chest pain. 

Abdomen

1. Contour, symmetry : Abdomen flat symmetrical, with no apparent masses 

Skin characteristics: abdominal skin smooth with no striae, scar, or lesion.  

Umbilicus and pulsations: Umbilicus located at the center of abdomen. Umbilicus is inverted,

clean, and free from dirt and discharges. No pulsation noted. 

 - Bowel sounds bowel sound present, no bruit.  

- Light and deep palpation: Abdomen soft and palpable,

- Patient is pregnant

Lower Extremities

- No edema present, pulses all strong on bilaterally

- Skin characteristics: Skin appears to be smooth and warm.

- Pretibial edema: no edema present at this time. 

- Toes-capillary refill: less than 3 seconds bilateral toes. 

Hips: bilateral hip symmetrical at the level of iliac crest, bilateral hip joints are stable .bilateral

hip flexion at 90 degree. 

 Knees: full range of motion present on bilaterally. Able to flex and extend smoothly. 

Ankles: full range of motion present at bilateral ankle bilaterally. Able to flex and extend

smoothly

 Feet: full range of motion present at bilateral feet Able to flex and extend smoothly. 

Skin (may assess with corresponding region)

1. Hands and nails

Bilateral upper extremities warm to touch.  Skin appears smooth, firm, and evenly surfaced.  

Nails surface are slightly curved, angled close to 160 degree.  Bilateral index figure shows

diamond shape upon touching each other.  Edges are smooth, rounded, and clean. 

2. Color and pigmentation

Skin pale and scattered senile lentiginous noted at bilateral upper arms.  Skin looks appropriate

to ethnicity and age. 

3. Temperature, moisture, texture

Skin warm to touch, appears smooth, firm, and evenly surfaced.  

4. Turgor

Elastic upon checking on skin from chest.  Pulled chest skin and released it returned to its

previous state.  

5. Any lesions

No visible lesions present. 

Neurological/Musculoskeletal.

1. Sensation

Face: Able to sense touch on her face at forehead, left cheek and her chin. . 

Arms and hands: able to feel and identify sharp and dull sensation on bilateral arms. 

Able to feel and identify known objects with bilateral hands.  

Legs and feet: able to feel and identify sharp and dull sensation bilaterally.
 - Position sense: Able to perceive direction of passive movement of index finger

bilaterally

- Stereognosis : able to feel and identify 3 known object via bilateral hands.  

- Deep tendon reflexes: she has a +2 reflex

-   Patellar : patellar reflexes present bilaterally. 

- Babinski reflex: negative Babinski reflex. 

- Romberg sign : negative

- Touch toes: able to bend and touch her bilateral toes without any difficulty.  

- ROM of spine: full range of motion against gravity present. full resistance and

normal spin  curvature. No kyphosis lordosis or scoliosis noted.  

Lab Values  

 Partial pressure of oxygen (PaO2): 75 - 100 mmHg

 Oxygen saturation (SaO2): 94 - 100%.

 Arterial blood pH: 7.38 - 7.42

 Creatinine: 0.8-1.3 mg/dL

 Glucose: 65-110 mg/dL

 Potassium: 3.5-5 mmol/L

  Uric acid: 0.18-0.48 mmol/L

 Sodium: 135-145 mmol/L

 Total calcium: 2-2.6 mmol/L

 Platelets: 150-400 x 10^9/L

 Hemoglobin: 13-17 g/dL (men), 12-15 g/dL (women)

 pH: 7.35-7.45

 White blood cells (WBC) 4-10 x 10^9/L

 Hematocrit 40%-52% (men), 36%-47%

 ESR 35

 HIV1&2 REACTIVE

 CD4 101

 Western Blott  confirm. 

 pH 7.35-7.45

 PaO2 80-100 mm Hg

 HCO3- 22 to 26 mEq/liter

 PaCO2- 35-45 mm H

 SaO2 95% to 100%

Expected lab value changes 

 CBC

 CD4
  ALT

 Creatine 

All Nanda diagnosis 

Imbalanced Nutrition: Less Than Body Requirements

Fatigue

Acute/Chronic Pain

Risk for Impaired Skin Integrity

Risk for Impaired Oral Mucous Membrane

Risk for Disturbed Thought Process

Anxiety/Fear

Risk for Social Isolation

Powerlessness

Deficient Knowledge

Risk for Injury

Risk for Deficient Fluid Volume

Risk for Infection

3 NANDA priority nursing diagnoses

- Deficient Knowledge

- Anxiety/Fear

- Risk for Social Isolation

 Goals for Deficient Knowledge

- Verbalize understanding of condition/disease process and potential complications.

- Identify relationship of signs/symptoms to the disease process and correlate

symptoms with causative factors.

- Verbalize understanding of therapeutic needs.

- Correctly perform necessary procedures and explain reasons for actions.

- Initiate necessary lifestyle changes and participate in treatment regimen

Intervention and rationale

- Review disease process and future expectations

Rationale: Provides knowledge base from which patient can make informed choices

- Determine level of independence or dependence and physical condition. Note

extent of care and support available from family.

Rationale: Helps plan amount of care and symptom management required and need for

additional resources.

- Review modes of transmission of disease, especially since she is newly

diagnosed.

Rationale: Corrects myths and misconceptions; promotes safety for patient and others.

Accurate epidemiological data are important in targeting prevention interventions.

 - Stress necessity of daily skin care, including inspecting skin folds, pressure

points, and perineum, and of providing adequate cleansing and protective measures:

ointments, padding.

Rationale: Healthy skin provides barrier to infection. Measures to prevent skin

disruption and associated complications are critical.

- Review dietary needs (high-protein and high-calorie) and ways to improve intake

when anorexia, diarrhea, weakness, depression interfere with intake.

Rationale: Promotes adequate nutrition necessary for healing and support of immune

system; enhances feeling of well-being

- Provide information about symptom management that complements medical

regimen; with intermittent diarrhea, take diphenoxylate (Lomotil) before going to social

event.

Rationale: Provides patient with increased sense of control, reduces risk of

embarrassment, and promotes comfort.

Goals for Anxiety/Fear

- Verbalize awareness of feelings and healthy ways to deal with them.

- Display appropriate range of feelings and lessened fear/anxiety.

- Demonstrate problem-solving skills.

- Use resources effectively

Intervention and Rationale

- Assure patient of confidentiality within limits of situation.

 Rationale: Provides reassurance and opportunity for patient to problem-solve solutions

to anticipated situations.

- Provide accurate, consistent information regarding prognosis. Avoid arguing

about patient’s perceptions of the situation

Rationale: Can reduce anxiety and enable patient to make decisions and choices based on

realities.

- Be alert to signs of withdrawal, anger, or inappropriate remarks as these can be

signs of indenial or depression. Determine presence of suicidal ideation and assess

potential on a scale of 1–10.

Rationale: Patient may use defense mechanism of denial and continue to hope that

diagnosis is inaccurate. Feelings of guilt and spiritual distress may cause patient to

become withdrawn and believe that suicide is a viable alternative. Although patient may

be too “sick” to have enough energy to implement thoughts, ideation must be taken

seriously and appropriate intervention initiated.

- Provide open environment in which patient feels safe to discuss feelings or to

refrain from talking.

Rationale: Helps patient feel accepted in present condition without feeling judged, and

promotes sense of dignity and control.

- Permit expressions of anger, fear, despair without confrontation. Give information

that feelings are normal and are to be appropriately expressed.

Rationale: Acceptance of feelings allows patient to begin to deal with situation.

 - Explain procedures, providing opportunity for questions and honest answers.

Arrange for someone to stay with patient during anxiety-producing procedures and

consultations

Rationale: Accurate information allows patient to deal more effectively with the

reality of the situation, thereby reducing anxiety and fear of the known.

Goals for Risk for Social Isolation

- Identify supportive individual(s).

- Use resources for assistance.

- Participate in activities/programs at level of ability/desire.

Intervention and Rationale.

- Ascertain patient’s perception of situation.

Rationale: Isolation may be partly self-imposed because patient fears rejection/reaction of

others

- Identify support systems available to patient, including presence of and/or

relationship with immediate and extended family

Rationale: When patient has assistance from SO, feelings of loneliness and rejection are

diminished. Patient may not receive usual or needed support for coping with life-threatening

illness and associated grief because of fear and lack of understanding (AIDS hysteria).

- Develop a plan of action with patient: Look at available resources; support

healthy behaviors. Help patient problem-solve solution to short-term or imposed

isolation.
 Rationale: Having a plan promotes a sense of control over own life and gives patient

something to look forward to and actions to accomplished

- Be alert to verbal or nonverbal cues: withdrawal, statements of despair, sense of

aloneness. Ask patient if thoughts of suicide are being entertained.

Rationale: Indicators of despair and suicidal ideation are often present; when these cues

are acknowledged by the caregiver, patient is usually willing to talk about thoughts of

suicide and sense of isolation and hopelessness.      

Medications 

 Nucleoside  reverse transcriptase  inhibitors

Zidovudine : Zidovudine is an antiviral medicine used to treat HIV, the virus that can cause

acquired immunodeficiency syndrome (AIDS). Zidovudine is also given during pregnancy to

prevent an HIV-infected woman from passing the virus to her baby. Zidovudine is not a cure

for HIV or AIDS. Side effects include Black, tarry stools, chills, cough, feeling of fullness,

fever, lower back or side pain, painful or difficult urination, pale skin., bone marrow

suppression.

 Protease inhibitors 

  Indinavir : Indinavir is an antiviral medicine that prevents human immunodeficiency virus

(HIV) from multiplying in your body. Side effects include nephrolithiasis, GI intolerance,

nausea, indirect hyperbilirubinemia.

 Fusion inhibitor 

   Enfuvirtide: Enfuvirtide is an antiviral medication that prevents human immunodeficiency

virus (HIV) from infecting healthy cells in your body. Side effects include nodules and cysts,

rigors, N/V.
Teaching

 Regarding zidovudine teach patient that doses should be evenly spaced around the

clock. Teach patient that zidovudine is not a cure for HIV infection nor does it

reduces the risk of transmission to others.

 With indinavir teach patient to take this medicine exactly as directed by your

doctor. Do not take more of it, do not take it more often, and do not take it for a

longer time than your doctor ordered. Also, do not stop taking this medicine without

checking first with your doctor.

 With enfuvirtide teach patient to report if injection site reaction is severe.