HEALTHY LIVING

COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The following are the most common nursing diagnoses for clients with AIDS:

1. Risk for infection related to immunodeficiency
2. Impaired Gas Exchange related to anemia, respiratory infection or malignancy (Pneumocystis carinii pneumonia (PCP), cytomegalovirus(CMV) pneumonia, pulmonary Kaposi's sarcoma, and/or Mycobacterium infection anemia, fatigue, or pain.
3. Acute pain or chronic pain related to neuropathy, myelopathy, malignancy, or infection
4. Imbalance nutrition: Less than Body Requirements related to high metabolic need, nausea and vomiting, diarrhea, difficulty to chewing or swallowing, or anorexia.
5. Diarrhea related to infection, food intolerance, or medication.
6. Impaired skin integrity related to KS, infection, altered nutritional state, incontinence, immobility, hyperthermia, or malignancy
7. Disturbed Thought Processes related to AIDS dementia complex (ADC), central nervous system infection, or malignancy.
8. Situational low Self-Esteem or chronic low self,-esteem related to changes in body image, decreased self system, or helplessness
9. Social Isolation related to stigma virus transmissibility, infection control practices, or fear.

• Activity Intolerance related to fatigue, discomfort, CNS defect, weakness or anemia
• Risk for injury related to CNS defect,metal status changes, depression, or thrombocytopenia
• Disturbed Sensory Perception (Visual) related to CMV retinitis or blindness.
• Disturbed Sleep Pattern related to pain, discomfort, anxiety, or depression
• Ineffective coping related to the diagnosis of AIDS
• Disabled Family Coping related to the diagnosis of AIDS
• Anticipatory Grieving related to potential loss of role and function or impending death

• Monitor for systemic and localized signs and symptoms of infection
• Monitor vulnerability to infection
• Monitor absolute granulocyte count, WBC, and differential result.
• Follow neutropenic precautions, as appropriate.
• Screen all visitors for communicable disease.
• Maintain aseptic for client at risk.
• Inspect skin and mucous membranes for redness, extreme warmth, or drainage.
• Obtain cultures, as needed.
• Promote sufficient nutritional intake.
• Monitor for change in energy level/malaise.
• Instruct client to take medicine as prescribed.
• Teach the client and family members how to avoid infections.

• Place the client in a private room whenever possible. x
  
• Use good hand washing technique before touching the client or any of his or her belongings.
• Ensure that the client's room and bathroom are cleaned at least once each day.
• Do not use supplies from common areas for immunosuppressed clients. For example, keep a sleeve or box of paper cups int he client's room, and do not share this box with any other client. Other articles include drinking straws, plastic knives and fork, dressing materials, gloves and bandages.
• Limit the numbber of health care personnel entering the client's room.
• Monitor vital signs every four hours; note minor temperature elevation, which may suggest early sepsis.
• Inspect the client's mouth at least every 8 hours.
• Inspect the client's skin and mucous membranes(especially the anal area) for the presence of fissures and abscesses at least every 8 hours
• Inspect open areas, such as IV sites, every 4 hours for manifestations of infection.
• Change wound dressing daily.
• Obtain specimens of all suspicious areas for culture, and promptly notify physician.
• Assist the client in performing coughing and deep-breathing exercises.
• Encourage activity at appropriate level for the client's current health status.
• Change IV tubing daily.
• Keep frequently used equipment in the room for used by clie only (e.g., blood pressure cuff, stethoscope,thermometer).
• Limits visitors to healthy adults.
• Use strict aseptic technique for all invasive procedures.
• Monitor the white blood cell count, especially the absolute neutrophil count (ANC) daily.
• Avoid the use of indwelling urinary catheters.
• Keep fresh flowers and potted plans out of the client's room