ARELLANO UNIVERSITY

COLLEGE OF NURSING
2600 LEGARDA ST, SAMP. MANILA

SUBJECT: INP DATE: 12/06/2020

NAME: RAY EDSEL BORGONIA CI: MA’AM VIOLY DUNGCA

ACTIVITY: I CASE STUDY

CASE SCENARIO: AIDS (ACQUIRED IMMUNODEFICIENCY SYNDROME)

A. DEMOGRAPHIC DATA
a. Mr. F, 33-year old Male

B. HEALTH HISTORY
a. Past Health History
i. History of drug abuse, Hepatitis C, and HIV
ii. Previously been managed on HAART therapy but has been having
recurrent bouts of pneumonia in the last 6 months.
1. What is HAART Therapy?
a. Highly active antiretroviral therapy (HAART) are
medications used to treat HIV. These medications may also
be called antiretroviral drugs (ART), antiretrovirals
(ARVs), or anti-HIV drugs.

b. Present Health History

i. Presents to the clinic due to a complaint of weakness and fatigue,
shortness of breath and a persistent cough.
ii. He reports a 10 lb (4.5 kg) weight loss over the last 3 weeks.
iii. Patient verbalized, “I think I have pneumonia again”.
iv. Upon further questioning, patient reports fever, chills, and night sweats for
the last few days.
v. His coughing has been nonproductive.
vi. He has diffuse rhonchi through his right lung and scattered rhonchi on the
left.
1. What are RHONCHI?
a. Rhonchi are continuous low pitched, rattling lung sounds
that often resemble snoring. Obstruction or secretions in
larger airways are frequent causes of rhonchi. They can be
 heard in patients with chronic obstructive pulmonary
disease (COPD), bronchiectasis, pneumonia, chronic
bronchitis, or cystic fibrosis.
vii. Chest x-ray shows nodular consolidation on the right side and diffuse
infiltrates.
viii. Vital signs are as follows:
1. BP = 108/67 mmHg
2. HR = 100 bpm
3. RR = 20 bpm
4. Temp = 101.6° F (38.7° C)
5. SpO2 = 90%
ix. Morning after he was admitted:
1. BP = 88/47 mmHg
2. HR = 110 bpm
3. RR = 22 bpm
4. Temp = 101.8° F (38.8° C)
5. SpO2 = 92% on 4 LPM NASAL CANNULA

C. PHYSICAL ASSESSMENT
a. Flushed and warm skin
 D. PATHOPHYSIOLOGY – CONCEPT MAPPING
Subjective:
Mr. F, 33-years old Male
 Patient reports a 10
lb weight loss over Nursing Diagnosis:
the last 3 weeks.
 Patient reported that Impaired Gas Exchange
he thinks he has
pneumonia again. Risk Factors:
 Patient complains of
weakness and  Unprotected Sex
fatigue, shortness of  Usage of used
breath and a needles
persistent cough.  Drug use through
needles
Objective:
 Certain health
 Patient is weak, has problems
fever and is having  Blood products
night sweats.  Certain jobs
Signs and symptoms:
Medical
 Diagnosis:
Rapid weight loss
Acquired Immunodeficiency
 Recurring fever or
Syndromeprofuse night sweats
Medical Surgical  Extreme and
Management: unexplained
tiredness
 Lymphadenopathy  Prolonged swelling
 Thoracic Surgery of the lymph glands
 Abdominal  Diarrhea that lasts
for weeks
Lymphadenopathy
 Sores of the mouth,
and Organomegaly
anus, or genitals
 Pneumonia
Pathophysiology:
Nursing Interventions:
 Assess respirations:
note quality, rate,
rhythm, depth, use of
accessory muscles,
ease, and position
assumed for easy
breathing.
 Observe color of skin,
mucous membranes,
and nail beds, noting
presence of
peripheral cyanosis
(nail beds) or central
cyanosis (circumoral).
 Assess mental status,
restlessness, and
changes in level of
consciousness.
 Assess anxiety level
and encourage
verbalization of
feelings and
concerns.
Expected Outcomes:
 Verbalize
relief/control of
chest pain.
 Display reduced
tension, relaxed
manner, ease of
movement.
 Demonstrate use of
relaxation
techniques
 E. LABORATORY
EXAMINATION NORMAL VALUES FINDINGS ANALYSIS NURSING ALERT
 4.7-6.1 cells/mcL – 3.9 Decreased Indicates anemia and
RBC (red blood cells)
M cells/mcL affects the production of
4.2-5.4 cells/mcL – F RBC in the bone marrow

Hgb (hemoglobin) 12-18 g/dL 8.1 g/dL Decreased Indicates risk in disease
progression increases
Hct (hematocrit) 37-52 % 24.3% Decreased

WBC 3,500-10,500 7,000 Normal

cells/mcL cells/mcL

Indicates HIV may have

PLT (Platelets)
150,000- 104,000/mcL Decreased infected the bone
450,000/mcL marrow
Drugs used to treat HIV
may have damage the
bone marrow

500-1,400 cells per Less than Decreased AIDS have damaged the
CD4
cubic millimeter 10/mm3 immune system

F. NCP (2)
ASSESSMEN NURSING PLANNING INTERVENTIO RATIONAL EVALUATION
T DIAGNOSI N E
S

Subjective: Impaired Gas STG Assess respirations: Manifestations STG

Patient Exchange note quality, rate, of respiratory
complains After 1 hour of rhythm, depth, use distress are After 1 hour of
weakness and nursing of accessory dependent nursing
fatigue, intervention, the muscles, ease, and on/and intervention, the
shortness of patient will be able position assumed indicative of patient was able to:
breath and a to: for easy breathing. the degree of  Demonstr
persistent cough  Demonstr lung ate
ate involvement improved
Objective: improved and underlying ventilation
Patient has ventilation general health and
flushed and and status oxygenati
warm skin oxygenati Observe color of As on of
 on of skin, mucous oxygenation tissues
tissues membranes, and and perfusion
 Maintain nail beds, noting become LTG
optimal presence of impaired,
gas peripheral cyanosis peripheral After 8 hours of
exchange (nail beds) or tissues become nursing
central cyanosis cyanotic. intervention, the
LTG (circumoral). Cyanosis of patient was able to:
nail beds may  Participate
After 8 hours of represent in actions
nursing vasoconstrictio to
intervention, the n or the body’s maximize
patient will be able response to oxygenati
to: fever/chills on
 Participate
in actions Assess mental Restlessness,
to status, restlessness, irritation,
maximize and changes in confusion, and
oxygenati level of somnolence
on consciousness. may reflect
hypoxemia and
decreased
cerebral
oxygenation
and may
require further
intervention.

ASSESSMEN NURSING PLANNING INTERVENTIO RATIONAL EVALUATION

T DIAGNOSI N E
S

Objective: Risk for After 8 hours of Assess patient Multiple After 8 hours of
Infection nursing knowledge and medication nursing
Low CBC results intervention, the ability to maintain regimen is intervention, the
Low CD4 patient will be able opportunistic difficult to patient was able to:
to: infection prophylactic maintain over a
regimen. long period of Achieve timely
Achieve timely time. Patients healing of
healing of may adjust wounds/lesions
wounds/lesions medication
regimen Be afebrile and
Be afebrile and free of purulent
free of purulent Wash hands before Reduces risk of drainage/secretions
drainage/secretions and after all care cross- and other signs of
and other signs of contacts. Instruct contamination. infectious
infectious patient and SO to conditions
conditions wash hands as
indicated. Identify/participate
Identify/participate in behaviors to
in behaviors to Provide a clean, well- Reduces number reduce risk of
reduce risk of ventilated of pathogens infection
infection environment. Screen presented to the
visitors and staff for immune system
 signs of infection and and reduces
maintain isolation possibility of
precautions as patient
indicated. contracting a
nosocomial
infection.

Discuss extent and Promotes

rationale for isolation cooperation with
precautions and regimen and
maintenance of may lessen
personal hygiene. feelings of
isolation.

G. DISCHARGE PLANNING
Patient needs to be taught any dietary and lifestyle changes that should be made.

 Diet – low sodium, low cholesterol, avoid sugar/soda, avoid fried/processed foods.
 Exercise – 30-45 minutes of moderate activity 5-7 days a week,
o Unless instructed otherwise by cardiologist
o This will be determined by the patient’s activity tolerance – how much they can
do and still be able to breathe and be pain free
 Stop Smoking and avoid caffeine and alcohol
 Medication Instructions
o Nitroglycerin – take one SL tab at onset of chest pain. If pain does not subside
after 5 minutes, call 911 and take second dose. You can take a 3 rd dose after 5
minutes after the second if pain does not subside. Do NOT take if you have taken
Viagra in the last 24 hours.
o Aspirin – Take 81 mg baby aspirin daily
o Anticoagulant – the patient may be prescribed an anticoagulant if they had a stent
placed. They should be taught about bleeding risks.

Discharge Planning
 Medical Care
o Take your medicine exactly as directed.
 Don't take any other medicine unless your healthcare provider says it's
OK. This includes prescription medicines, over-the-counter medicines, or
vitamins or supplements. Medicine interactions can change how medicines
work. They can cause serious side effects.
  Tell your provider about any side effects
o See your healthcare provider regularly. Your provider will need to follow you
closely for the rest of your life.
o Tell all your providers that you are HIV-positive. This includes dentists and
dental hygienists.
 Reducing risk of Infection
o Follow a good diet and stay at a healthy weight. This will help protect your
immune system. Talk with your healthcare provider about seeing a dietitian to
help review your nutritional needs.
o Exercise for endurance and to boost your immune system and your mental health.
o Wash your hands often with clean, warm or cold water. If soap and water is not
available, use alcohol-based hand cleaner. Wash your hands before and after
taking care of any cuts, scrapes, or wounds.
 Help prevent spread of HIV
o Never share needles or other equipment for drug use.
o If you get tattoos or have any parts of your body pierced, be sure that the needles
are destroyed afterward.
o Don't donate blood, plasma, semen, or organs.
o If you are trying to have a baby, make sure you are taking your antiretroviral
medicine each day and your viral load is undetectable. This is important both
before conceiving and during the pregnancy.
 Follow up care
o Follow up with your healthcare provider; or as advised.
 When to get medical care
o Call your healthcare provider right away if you have any of the following:
 Blurred vision or other eye problems
 Trouble focusing
 Tiredness that gets worse
 Wheezing, trouble breathing, or shortness of breath
 Fast, irregular heartbeat
 Feeling dizzy or lightheaded
 Rash or hives
 Cut or rash that swells, turns red, feels hot or painful, or begins to ooze
 Fever of 100.4°F (38°C) or higher, or as directed by your provider
 Diarrhea that does not go away after 2 loose stools
 Pain or cramping in your belly (abdomen)
 H. REFERENCES

https://nurseslabs.com/pneumonia-nursing-care-plans/4/

http://hivinsite.ucsf.edu/InSite?page=kb-03-03-02

https://nurseslabs.com/13-aids-hiv-positive-nursing-care-plan/13/

https://www.mountnittany.org/articles/healthsheets/1961