DIAGNO SIS Risk for infection r/t immunod eficiency

PLANNI NG Goal: After 1 hour of nursing interven tion the patient will exhibit no signs or sympto ms of infectio n.

INTERVENTION Independent:
Promote hand washing and other precautions to prevent infections. Monitor vital signs, including temperature, at least every 4 hours or per clinical condition. Monitor for signs of infection by assessing I.V. and injection sites, mucous membranes (including the rectum and vagina), and wounds or skin breaks for changes in color, texture, or sensation; swelling; pain; induration; purulent drainage; or other abnormalities. Watch closely for signs and symptoms of systemic, skin, mucocutaneous, hematologic, ophthalmologic, oral cavity, esophageal, GI, pulmonary, and central nervous system opportunistic infections. Assess pulmonary status for evidence of new pulmonary infections, checking breath sounds at least every 8 hours. Report crackles, decreased breath sounds, and other abnormal findings promptly. Collaborative: Monitor CBC daily, and report increasing leukopenia or neutropenia. Obtain cultures, as ordered, from blood, stool, urine, sputum, or wound drainage. Evaluate sensitivity results and verify the appropriateness of antibiotic therapy. Administer antibiotics and anti-infectives as ordered. Note indications of adverse effects, and report your findings.

RATIONALE

Such precautions minimize the patient's exposure to infectious organisms. Hand washing is the gold standard for infection control. Frequent observation of vital signs and temperature can detect a change in the patient's condition and prompt accurate treatment. Regular, careful, and prompt recognition of signs of infection is essential in immunocompromised patients because of the rate at which infection can spread. Early detection and treatment of neurologic infection is crucial because advanced infection is associated with a poor prognosis.

EVALUATI ON Goal met as evidenced by: The patient exhibit no signs or symptoms of infection.

Prompt recognition and treatment of pulmonary infections can be lifesaving for immunocompromised patients.

Administer antipyretics, use a hypothermia blanket, monitor for signs of dehydration, and replace fluids as needed when the patient experiences fever.

These changes indicate further compromise of the body's ability to resist or fight infection. If new signs of infection are evident, immediate cultures will identify the causative organism. Sensitivity results guide antibiotic therapy. Depending on the organism, therapy may involve several drugs simultaneously. Antibiotics may also be ordered prophylactically. Specific acute and prophylactic drug treatment may vary with the patient, depending on the effectiveness of the medication and the patient's tolerance. A hypothermia blanket reduces body temperature when antipyretics are ineffective or contraindicated. Prolonged fever increases the metabolic rate and promotes diaphoresis, contributing to dehydration.

DIAGNO SIS Impaired gas exchang e r/t respirato ry

PLANNI NG Goal: After 15 minutes of nursing

INTERVENTION Independent:
Teach coughing and deep-breathing exercises, and encourage hourly use of an incentive spirometer. Suction as needed.

RATIONALE

Deep breathing helps expand the lungs fully and prevents areas of atelectasis associated with pneumonia and bed rest. Incentive spirometry and coughing also promote lung expansion; however, exercise caution because coughing and positive-pressure breathing can cause alveolar rupture

EVALUATI ON Goal partially met as evidenced by:

implicati ons

interven tion the patient will exhibit decreas ed dyspnea as well as exhibit oximete r or arterial blood gas measur ements improve d from baseline .

Assist with self-care activities as needed. Teach energy conservation measures, such as using a shower chair, organizing activities and grouping procedures, using large muscles, avoiding activities that involve raising the arms over the head, and scheduling rest periods between activities. Collaborative:

secondary to decreased surfactant in PCP. Suctioning can provide airway clearance. Activity increases oxygen demand, and hypoxemia can worsen with exertion. Sitting requires less energy than standing. Organizing and grouping procedures reduces unnecessary exertion. Large-muscle groups are more efficient. Raising the arms over the head rapidly causes fatigue.

The patient is still having dyspnea.

Assess continuously for signs of hypoxemia. Monitor pulse oximetry and ABG results as ordered and as needed for increasing dyspnea or inadequate respiratory effort. Report abnormal findings immediately, and provide appropriate oxygen therapy or ventilatory support, as indicated by patient condition.

Monitoring respiratory status allows for rapid identification and treatment of respiratory failure. Oxygen can improve hypoxemia. Ventilatory support may be required to maintain oxygenation.

DIAGNO SIS Imbalanc ed nutrition, less than body requirem ents r/t decrease d oral intake

PLANNING Goal: After 1 hour of nursing intervention the patient will maintain adequate oral intake of foodand/ or will tolerate enteral or parenteral feedings without complicatio ns. Independent:

INTERVENTION

RATIONALE

Assess the patient's appetite. Observe what he eats and how much. Attempt to provide the patient with his food preferences. Collaborative:

Providing food that the patient likes may improve his appetite.

EVALUATI ON Goal met as evidenced by: The patient maintained adequate oral intake of food.

Administer appetite stimulants and antiemetics, as ordered; watch for adverse effects. Administer medication for oral infections, and provide frequent mouth care. Administer nasogastric tube feedings or parenteral nutrition, as ordered, if the patient is unable to tolerate adequate oral intake or has severe chronic diarrhea. Observe for tolerance and adverse effects.

Medication can help the patient with GI problems and improve his ability to eat. Improving the oral mucous membrane helps allow the patient to eat without pain, which may improve oral intake. NG tube feedings provide nutrients without as many associated complications as parenteral nutrition. However, severe diarrhea may reduce GI absorption, making parenteral nutrition necessary.

DIAGNO SIS Deficient knowledg e r/t means of preventin g disease transmis sion and self-care

PLANNING Goal: After 1 hour of nursing intervention the patient will list precautionary measures to avoid infections, list symptoms that may indicate infections or other complications, discuss appropriate home care and waste disposal guidelines, and list precautions to prevent disease.

INTERVENTION Independent:
Teach the patient and his loved ones about the disease and infection prevention measures.

RATIONALE

EVALUATION Goal met as evidenced by:

Discuss the signs and symptoms that may indicate AIDS-related complications. Review with the family the recommendations for home care and waste disposal. Teach the patient and his loved ones how the AIDS virus is spread. Discuss precautionary measures. Encourage the patient to explore treatment options with the physician, including new or experimental medications and alternatives to traditional medicine.

Providing accurate information about the disease will help the patient and family cope better with the disease process. Infection control is essential to minimize the risk of further complications. Immunosuppression renders the patient extremely susceptible to infections. Early reporting of new signs and symptoms and prompt treatment of complications that may prolong an active life. Thorough, specific teaching reduces anxiety for family members and promotes safe and effective care. The CDC recommends that caregivers use blood and body fluid precautions. Awareness of transmission factors may help the patient avoid spreading the disease to others. New or alternative therapies may offer as-yet-undocumented benefits. Such therapies may offer the patient hope, energy, and an increased sense of wellness.

The patient was able to list precautionary measures to avoid infections, listed symptoms that may indicate infections or other complications, discussed appropriate home care and waste disposal guidelines, and listed precautions to prevent disease.

Neri, Ann Nicole G. BSN 4B