Acquired Immunodeficiency Syndrome (HIV Infection)

Acquired immunodeficiency syndrome (AIDS) is defined as the most severe form of

a continuum of illnesses associated with human immunodeficiency virus (HIV) infe
ction. HIV belongs to a group of viruses known as retroviruses. These viruses ca
rry their genetic material in the form of ribonucleic acid (RNA) rather than deo
xyribonucleic acid (DNA). Infection with HIV occurs when it enters the host CD4
(T) cell and causes this cell to replicate viral RNA and viral proteins, which i
n turn invade other CD4 cells.
The stage of HIV disease is based on clinical history, physical examination, lab
oratory evidence of immune dysfunction, signs and symptoms, and infections and m
alignancies. The stage of primary infection is acute and spans the time from inf
ection to antibody development. Four categories of infected states have been den
oted:
Primary infection (part of CDC Category A: dramatic drop in CD4 T-cell counts fr
om normal level between 500 and 1500 cells/mm3)
HIV asymptomatic (CDC Category A: more than 500 CD4+ T lymphocytes/mm3)
HIV symptomatic (CDC Category B: 200499 CD4+ T lymphocytes/mm3)
AIDS (CDC Category C: fewer than 200 CD4+ T lymphocytes/mm3)

Risk Factors


HIV is transmitted through bodily fluids by high-risk behaviors such as heterose
xual intercourse with an HIV-infected partner, injection drug use, and male homo
sexual relations. Also at risk are people who received transfusions of blood or
blood products contaminated with HIV, children born to mothers with HIV infectio
n, breast-fed infants of HIV-infected mothers, and health care workers exposed t
o needle-stick injury associated with an infected patient.

Clinical Manifestations


Symptoms are widespread and may affect any organ system. Manifestations range fr
om mild abnormalities in immune response without overt signs and symptoms to pro
found immunosuppression, life-threatening infection, malignancy, and the direct
effect of HIV on body tissues.

Respiratory

Shortness of breath, dyspnea, cough, chest pain, and fever are associated with o
pportunistic infections, including Pneumocystis jiroveci pneumonia (PCP), the mo
st common infection, and the immune reconstitution syndromes, such as Mycobacter
ium avium complex (MAC)/Mycobacterium avium intracellulare (MAI), which is a lea
ding bacterial infection in AIDS patients. Legionella and CMV are other opportun
istic organisms.
HIV-associated tuberculosis occurs early in the course of HIV infection, often p
receding a diagnosis of AIDS.

Gastrointestinal

Loss of appetite
Nausea and vomiting
Oral and esophageal candidiasis (white patches, painful swallowing, retrosternal
pain, and possibly oral lesions)
Chronic diarrhea, possibly with devastating effects (eg, weight loss, fluid and
electrolyte imbalances, perianal skin excoriation, weakness, and inability to pe
rform activities of daily living)

WASTING SYNDROME (CACHEXIA)

Multifactorial protein-energy malnutrition
Profound involuntary weight loss exceeding 10% of baseline body weight
Chronic diarrhea, chronic weakness, and documented intermittent or constant feve
r with no concurrent illness
Anorexia, diarrhea, gastrointestinal malabsorption, lack of nutrition, and for s
ome patients a hypermetabolic state

Neurologic


Neurologic complications involve central, peripheral, and autonomic functions.
HIV encephalopathy (AIDS dementia complex [ADC]) occurs in two thirds of patient
s with AIDS. Symptoms include memory deficits, headache, lack of concentration,
progressive confusion, psychomotor slowing, apathy and ataxia, and in later stag
es global cognitive impairments, delayed verbal responses, spastic paraparesis,
hyperreflexia, psychosis, seizures, incontinence, mutism, and death.
HIV-related peripheral neuropathy is thought to be a demyelinating disorder; it
is associated with pain and numbness in the extremities, weakness, diminished de
ep tendon reflexes, orthostatic hypotension, and impotence.
Cryptococcus neoformans, a fungal infection (fever, stiff neck, nausea and vomit
ing, seizures).
Central and peripheral neuropathies, including vascular myelopathy (spastic para
paresis, ataxia, and incontinence)
Progressive multifocal leukoencephalopathy (PML), a central nervous system demye
linating disorder, can occur.
Other neurologic disorders include Toxoplasma gondii, CMV, and Mycobacterium tub
erculosis infection, with symptoms ranging from confusion to blindness, aphasia,
paresis, and death.

Integumentary

Kaposi's sarcoma (KS), herpes simplex and herpes zoster viruses, and various for
ms of dermatitis associated with painful vesicles
Folliculitis, associated with dry flaking skin or atopic dermatitis (eczema or p
soriasis)

Reproductive (Female)

Persistent recurrent vaginal candidiasis may be the first sign of HIV infection.
Ulcerative sexually transmitted diseases, such as chancroid, syphilis, and herpe
s, are more severe in women with HIV.
Venereal warts and cervical cancer/cervical intraepithelial neoplasia (CIN) may
be noted.
Women with HIV have a higher incidence of pelvic inflammatory disease (PID) and
menstrual abnormalities (amenorrhea or bleeding between periods).

Hematologic/Lymphatic


Bcell lymphomas, such as non-Hodgkin's lymphoma, are the second most common AIDS-
related cancer (the first is KS). These lymphomas usually differ from those in t
he general population because they develop outside the lymph nodes (mostly in th
e brain, bone marrow, and GI tract), grow aggressively, affect multiple organs,
and exhibit resistance to treatment, which may be complicated by severe hemotolo
gic toxicity.

Other: Chronic Illness and Cancers


Early diagnosis and treatment of opportunistic diseases and antiviral therapy ha
ve brought HIV infection into the chronic illness category. Additional clinical
manifestations follow:
Fatigue, headache, profuse night sweats, unexplained weight loss, dry cough, sho
rtness of breath, extreme weakness, diarrhea, decreased endurance, edema, blindn
ess, swallowing difficulties, and possible neurologic involvement resulting in d
ementia, hemiplegia, spastic paraparesis, painful neuropathies, proximal and dis
tal muscle weakness, and persistent lymphadenopathy
Higher than usual incidence of cancer, including KS, B-cell lymphomas, and carci
nomas of cervix, skin, stomach, pancreas, rectum, and bladder
Depressive symptoms from multiple causes, including preexisting mental illness,
neuropsychiatric disturbances, and psychosocial factors
Irrational guilt, shame, loss of self-esteem, helplessness, worthlessness, and s
uicidal ideation

Assessment and Diagnostic Methods


Confirmation of HIV antibodies is done using enzyme immunoassay (EIA; formerly e
nzyme-linked immunosorbent assay [ELISA]), Western blot assay, and viral load te
sts such as target amplification methods.

Medical Management


Currently there is no cure for HIV or AIDS, although researchers continue to wor
k on developing a vaccine. Treatment decisions for an individual patient are bas
ed on three factors: HIV RNA (viral load), CD4 T-cell counts, and the clinical c
ondition of the patient (severity of symptoms and patient's commitment to partic
ipate in lifelong therapy). The goals of treatment are maximal and durable suppr
ession of viral load, restoration and/or preservation of immunologic function, i
mprovement of quality of life, and reduction of HIV-related morbidity and mortal
ity. To determine and evaluate the treatment plan, viral load testing is recomme
nded at diagnosis and then every 3 to 4 months thereafter in the untreated perso
n. CD4+ T-cell counts should be measured at diagnosis and generally every 3 to 6
months thereafter.
Combination therapy is defined as a regimen containing at least two antiretrovir
al agents; highly active antiretroviral therapy (HAART) includes at least one nu
cleoside reverse transcriptase inhibitor plus various other drug combinations. A
s new medications are developed, the number of combinations continues to increas
e. High cost of medications, difficulties with adherence to the regimen, drug re
sistance, and drug toxicities present problems in drug therapy. Intermittent the
rapy is under investigation as an alternative regimen.

Pharmacologic Therapy


ANTIRETROVIRAL THERAPY (ART)


(For combination regimens with at least three medications)
Nucleoside/nucleotide reverse transcriptase inhibitors (NRTI)
Non-nucleoside reverse transcriptase inhibitors (NNRTI)
Protease inhibitors (PI)
Fusion inhibitors (FI)

DRUG RESISTANCE TESTING


Helps determine which antiretroviral agents to eliminate from the antiretroviral
regimen (rather than which agents should be used)

TREATMENT INTERRUPTION AND REINSTITUTION


Depending on the patient and CD4 cell count, ART may be temporarily discontinued
when immune competence recurs and stabilizes (eg, sustained CD4 count between 5
00 and 800 cells/mm3). Then, when CD4 counts fall between 350 and 400 cells/mm3,
ART should restart.

MEDICATIONS FOR HIV-RELATED INFECTIONS

PCP: trimethoprim-sulfamethoxazole (TMP-SMZ) and antibacterial agents, such as d
apsone; alternatively, pentamidine, an antiprotozoal agent
MAC: treatment for MAC infections involves use of either clarithromycin (Biaxin)
or azithromycin (Zithromax). The combination of azithromycin with rifabutin (My
cobutin) is more effective but costly, with more adverse effects and interaction
s.
Cryptococcal meningitis: intravenous amphotericin B with or without antifungal a
gents, such as fluconazole (Diflucan) or flucytosine (Ancobon).
CMV retinitis: ganciclovir, foscarnet, or cidofovir
Encephalitis: pyrimethamine (Daraprim) and sulfadiazine or clindamycin (Cleocin)
Candidiasis: clotrimazole (Mycelex), ketoconazole, or fluconazole

ANTICANCER AGENTS

KS: alpha-interferon, surgical excision of lesions, liquid nitrogen to lesions,
vinblastine injected into intraoral lesions, interferon; chemotherapy with doxor
ubicin (Adriamycin), bleomycin, and vincristine (ABV); radiation
Lymphomas: limited successful treatment; chemotherapy and radiation therapy may
be used

IMMUNOMODULATORS

Alpha-interferon
Other substances under evaluation (interleukin-2, interleukin-12, and other cyto
kines and lymphokines)

ANTIDEPRESSANTS


Psychotherapy is integrated with pharmacology (imipramine [Tofranil], desipramin
e [Norpramin], fluoxetine [Prozac], methylphenidate [Ritalin]; electroconvulsive
therapy if depression is severe).

ANTIDIARRHEAL AGENTS AND APPETITE STIMULANTS


Octreotide acetate (Sandostatin) is given to treat diarrhea and megestrol acetat
e (Megace) or dronabinol (Marinol) to stimulate appetite.

Supportive Care and Alternative Therapies

Spiritual: laughter, hypnosis, faith healing, guided imagery, positive affirmati
ons
Nutritional: Goal is to attain or maintain ideal weight and decrease risk for in
fections. Appetite stimulants (megestrol [Megace]) have been successful; dronabi
nol (Marinol), which contains synthetic tetrahydrocannabinol (THC), the active i
ngredient in marijuana, has been effective when used to relieve nausea and vomit
ing. Alternative nutritional measures include oral supplements, such as Advera,
and parenteral nutrition as well as vegetarian and macrobiotic diets, vitamin C
or beta-carotene supplements, turmeric (curcumin), and Chinese herbs.
Administration of intravenous fluid and electrolyte replacement may treat imbala
nces.
Drug and biologic: medicines not approved by the FDA; oxygen, ozone, and urine t
herapy
Physical forces and devices: acupuncture, acupressure, massage therapy, yoga, th
erapeutic touch, reflexology, crystals

NURSING PROCESS: The Patient with HIV/AIDS


Assessment


Identify potential risk factors, including sexual practices and IV/injection dru
g use history. Assess physical and psychological status. Thoroughly explore fact
ors affecting immune system functioning.

NUTRITIONAL STATUS

Obtain dietary history.
Identify factors that may interfere with oral intake, such as anorexia, nausea,
vomiting, oral pain, or difficulty swallowing.
Assess patient's ability to purchase and prepare food.
Measure nutritional status by weight, anthropometric measurements (triceps skin-
fold measurement), and blood urea nitrogen, serum protein, albumin, and transfer
rin levels.

SKIN AND MUCOUS MEMBRANES

Inspect daily for breakdown, ulceration, and infection.
Monitor oral cavity for redness, ulcerations, and creamy-white patches (candidia
sis).
Assess perianal area for excoriation and infection.
Obtain wound cultures to identify infectious organisms.

RESPIRATORY STATUS

Monitor for cough, sputum production, shortness of breath, orthopnea, tachypnea,
and chest pain; assess breath sounds.
Assess other parameters of pulmonary function (chest x-rays, arterial blood gase
s, pulmonary function tests).

NEUROLOGIC STATUS

Assess mental status as early as possible to provide a baseline. Note level of c
onsciousness and orientation to person, place, and time and the occurrence of me
mory lapses.
Observe for sensory deficits, such as visual changes, headache, and numbness and
tingling in the extremities.
Observe for motor impairments, such as altered gait and paresis.
Observe for seizure activity.

FLUID AND ELECTROLYTE STATUS

Examine skin and mucous membranes for turgor and dryness.
Assess for dehydration by observing for increased thirst, decreased urine output
, low blood pressure, weak rapid pulse, or urine specific gravity.
Monitor electrolyte imbalances (laboratory studies show low serum sodium, potass
ium, calcium, magnesium, and chloride).
Assess for signs and symptoms of electrolyte depletion, including decreased ment
al status, muscle twitching, muscle cramps, irregular pulse, nausea and vomiting
, and shallow respirations.

LEVEL OF KNOWLEDGE

Evaluate patient's knowledge of disease and transmission.
Assess level of knowledge of family and friends.
Explore patient's reaction to the diagnosis of HIV infection or AIDS.
Explore how patient has dealt with illness and major life stressors in the past.
Identify patient's resources for support.

USE OF ALTERNATIVE THERAPIES

Question patient about use of alternative therapies.
Encourage patient to report any use of alternative therapies to primary health c
are provider.
Become familiar with potential side effects of alternative therapies; if side ef
fect is suspected to result from alternative therapies, discuss with patient and
primary and alternative health care providers.
View alternative therapies with an open mind, and try to understand the importan
ce of the treatment to patient.

Diagnosis


NURSING DIAGNOSES

Impaired skin integrity related to cutaneous manifestations of HIV infection, ex
coriation, and diarrhea
Risk for infection related to immunodeficiency
Activity intolerance related to weakness, fatigue, malnutrition, impaired fluid
and electrolyte balance, and hypoxia associated with pulmonary infections
Disturbed thought processes related to shortened attention span, impaired memory
, confusion, and disorientation (HIV encephalopathy)
Ineffective airway clearance related to PCP, increased bronchial secretions, and
decreased ability to cough related to weakness and fatigue
Imbalanced nutrition: Less than body requirements related to decreased oral inta
ke
Diarrhea related to enteric pathogens or HIV infection
Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and
peripheral neuropathy
Social isolation related to stigma of the disease, withdrawal of support systems
, isolation procedures, and fear of infecting others
Anticipatory grieving related to changes in lifestyle and roles and unfavorable
prognosis
Deficient knowledge related to self-care and preventing HIV transmission

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Opportunistic infections
Impaired breathing or respiratory failure
Wasting syndrome and fluid and electrolyte imbalance
Adverse reaction to medications

Planning and Goals


Goals include improved airway clearance, achievement and maintenance of skin int
egrity, resumption of usual bowel patterns, absence of infection, relief of pain
and discomfort, improved nutritional status, activity tolerance, improved thoug
ht processes, increased socialization, expression of grief, absence of complicat
ions, and increased knowledge of disease prevention and self-care.

Nursing Interventions


IMPROVING AIRWAY CLEARANCE

At least daily, assess respiratory status, mental status, and skin color.
Note and document presence of cough and quantity and characteristics of sputum;
send specimen for analysis as ordered.
Encourage adequate rest to minimize energy expenditure and prevent fatigue.
Provide pulmonary therapy, such as coughing, deep breathing, postural drainage,
percussion, and vibration, every 2 hours to prevent stasis of secretions and pro
mote airway clearance.
Assist patient into a position (high- or semi-Fowler's) that facilitates breathi
ng and airway clearance.
Evaluate fluid volume status; encourage intake of 3 liters daily.
Provide humidified oxygen, suctioning, intubation, and mechanical ventilation as
necessary.

PROMOTING SKIN INTEGRITY

Assess skin and oral mucosa for changes in appearance, location and size of lesi
ons, and evidence of infection and breakdown; encourage regular oral care.
Encourage patient to balance rest and mobility whenever possible; assist immobil
e patients to change position every 2 hours.
Use devices such as alternating-pressure mattresses and low-air-loss beds.
Encourage patient to avoid scratching, to use nonabrasive and nondrying soaps, a
nd to use nonperfumed skin moisturizers on dry skin; administer antipruritic age
nts, antibiotic medication, analgesic agents, medicated lotions, ointments, and
dressings as prescribed; avoid excessive use of tape.
Keep bed linen free of wrinkles, and avoid tight or restrictive clothing to redu
ce friction to skin.
Advise patient with foot lesions to wear white cotton socks and shoes that do no
t cause feet to perspire.

MAINTAINING PERIANAL SKIN INTEGRITY

Assess perianal region for impaired skin integrity and infection.
Instruct patient to keep the area as clean as possible, to cleanse after each bo
wel movement, to use sitz bath or irrigation, and to dry the area thoroughly aft
er cleaning.
Assist debilitated patient in maintaining hygiene practices.
Promote healing with prescribed topical ointments and lotions.
Culture wounds if infection is suspected.

PROMOTING USUAL BOWEL HABITS

Assess bowel patterns for diarrhea (frequency and consistency of stool, pain or
cramping with bowel movements).
Assess factors that increase frequency of diarrhea.
Assess self-care strategies patient uses to control diarrhea.
Measure and document volume of liquid stool as fluid volume loss; obtain stool c
ultures.
Counsel patient about ways to decrease diarrhea (rest bowel, avoid foods that ac
t as bowel irritants, including raw fruits and vegetables); encourage small, fre
quent meals.
Administer prescribed medications, such as anticholinergic antispasmodic medicat
ions or opiates, antibiotic medications, and antifungal agents.

PREVENTING INFECTION

Instruct patient and caregivers to monitor for signs and symptoms of infection.
Recommend strategies to avoid infection (upper respiratory infections).
Monitor laboratory values that indicate the presence of infection, such as white
blood cell count and differential; assist in obtaining culture specimens as ord
ered.
Strongly urge patients and sexual partners to avoid exposure to body fluids and
to use condoms for any sexual activities.
Strongly discourage IV/injection drug use because of risk to patient of other in
fections and transmission of HIV infection.
Maintain strict aseptic technique for invasive procedures.

NURSING ALERT Observe universal precautions in all patient care. Teach colleague
s and other health care workers to apply precautions to blood and all body fluid
s, secretions, and excretions except sweat (eg, cerebrospinal fluid; synovial, p
leural, peritoneal, pericardial, amniotic, and vaginal fluids; semen). Consider
all body fluids to be potentially hazardous in emergency circumstances when diff
erentiating between fluid types is difficult.

RELIEVING PAIN AND DISCOMFORT

Assess patient for quality and severity of pain associated with impaired periana
l skin integrity, KS lesions, and peripheral neuropathy.
Explore effects of pain on elimination, nutrition, sleep, affect, and communicat
ion, along with exacerbating and relieving factors.
Encourage patient to use soft cushions or foam pads while sitting and topical an
esthetics or ointments as prescribed.
Instruct patient to avoid irritating foods and to use antispasmodic agents and a
ntidiarrheal preparations if necessary.
Administer nonsteroidal anti-inflammatory agents and opiates, and use nonpharmac
ologic approaches, such as relaxation techniques.
Administer tricyclic antidepressants and recommend elastic stockings as prescrib
ed to help alleviate neuropathic pain.

IMPROVING NUTRITIONAL STATUS

Assess weight, dietary intake, anthropometric measurements, serum albumin, blood
urea nitrogen, protein, and transferrin levels.
Instruct patient about ways to supplement nutritional value of meals (eg, add eg
gs, butter, milk).
Based on assessment of factors interfering with oral intake, implement specific
measures to facilitate oral intake; consult dietitian to determine nutritional r
equirements.
Control nausea and vomiting; encourage patient to eat easy-to-swallow foods; enc
ourage oral hygiene before and after meals.
Encourage rest before meals; do not schedule meals after painful or unpleasant p
rocedures.
Provide enteral or parenteral feedings to maintain nutritional status, as indica
ted.

IMPROVING ACTIVITY TOLERANCE

Monitor ability to ambulate and perform daily activities.
Assist in planning daily routines to maintain balance between activity and rest.
Instruct patient in energy conservation techniques (eg, sitting while washing or
preparing a meal).
Decrease anxiety that contributes to weakness and fatigue by using measures such
as relaxation and guided imagery.
Strategize with other health care team members to uncover and address factors as
sociated with fatigue (eg, epoetin alfa [Epogen] for fatigue related to anemia).

MAINTAINING THOUGHT PROCESSES

Assess for alterations in mental status.
Reorient to person, place, and time as necessary; maintain and post a regular da
ily schedule.
Give instructions, and instruct family to speak to patient, in a slow, simple, a
nd clear manner.
Provide night lights for bedroom and bathroom. Plan safe leisure activities that
patient previously enjoyed.

NURSING ALERT Provide around-the-clock supervision as necessary for patients wit
h HIV encephalopathy.

DECREASING SENSE OF SOCIAL ISOLATION

Provide an atmosphere of acceptance and understanding of AIDS patients, their fa
milies, and partners.
Assess patient's usual level of social interaction early to provide a baseline f
or monitoring changes in behavior.
Encourage patient to express feelings of isolation and aloneness; assure patient
that these feelings are not unique or abnormal.
Assure patients, family, and friends that AIDS is not spread through casual cont
act.

COPING WITH GRIEF

Help patients explore and identify resources for support and mechanisms for copi
ng.
Encourage patient to maintain contact with family, friends, and coworkers and to
continue usual activities whenever possible.
Encourage patient to use local or national AIDS support groups and hotlines and
to identify losses and deal with them when possible.

MONITORING AND MANAGING COMPLICATIONS

Respiratory failure and impaired breathing: monitor arterial blood gas values, o
xygen saturation, respiratory rate and pattern, and breath sounds; provide sucti
oning and oxygen therapy; assist patient on mechanical ventilation to cope with
associated stress.
Inform patient that signs and symptoms of opportunistic infections include fever
, malaise, difficulty breathing, nausea or vomiting, diarrhea, difficulty swallo
wing, and any occurrences of swelling or discharge. These symptoms should be rep
orted to the health care provider immediately.
Wasting syndrome and fluid and electrolyte disturbances: monitor weight gain or
loss, skin turgor and dryness, ferritin levels, hemoglobin and hematocrit, and e
lectrolytes. Assist in selecting foods that replenish electrolytes. Initiate mea
sures to control diarrhea. Provide intravenous fluids and electrolytes as prescr
ibed.
Side effects of medications: provide information about purpose, administration,
side effects (those reportable to physician), and strategies to manage or preven
t side effects of medications. Monitor laboratory test values.

Promoting Home and Community-Based Care


TEACHING PATIENTS SELF-CARE

Thoroughly discuss the disease and all fears and misconceptions; instruct patien
t, family, and friends about the transmission of AIDS.
Discuss precautions to prevent transmission of HIV: use of condoms during vagina
l or anal intercourse; using dental dam or avoiding oral contact with the penis,
vagina, or rectum; avoiding sexual practices that might cut or tear the lining
of the rectum, vagina, or penis; and avoiding sexual contact with multiple partn
ers, those known to be HIV positive, those who use illicit injectable drugs, and
those who are sexual partners of people who inject drugs.
Teach patient and family how to prevent disease transmission, including hand hyg
iene and methods of safely handling items soiled with bodily fluids.
Instruct patient not to donate blood.
Emphasize importance of taking medication as prescribed. Assist patient and care
givers in fitting the medication regimen into their lives.
Teach medication administration, including intravenous preparations.
Teach guidelines about infection, follow-up care, diet, rest, and activities.
Instruct patient and family how to administer enteral or parenteral feedings, if
applicable.
Offer support and guidance in coping with this disease.

CONTINUING CARE

Refer patient and family for home care nursing or hospice for physical and emoti
onal support.
Assist family and caregivers in providing supportive care.
Assist in administration of parenteral antibiotics, chemotherapy, nutrition, com
plicated wound care, and respiratory care.
Provide emotional support to patient and family.
Refer patient to community programs, housekeeping assistance, meals, transportat
ion, shopping, individual and group therapy, support for caregivers, telephone n
etworks for the homebound, and legal and financial assistance.
Encourage patient and family to discuss end-of-life decisions.

Evaluation


Expected Patient Outcomes

Maintains skin integrity
Resumes usual bowel habits
Experiences no infections
Maintains adequate level of activity tolerance
Maintains usual level of thought processes
Maintains effective airway clearance
Experiences increased sense of comfort, less pain
Maintains adequate nutritional status
Experiences decreased sense of social isolation
Progresses through grieving process
Reports increased understanding of AIDS and participates in self-care activities
as possible
Remains free of complications