Nursing care plan for hospitalised patients with Pneumocystis carinii pneumonia

Bill has nursed paediatric and geriatric patients and for the last five years he has nursed people with severe HIV disease.

Currently Bill is the Nursing Unit Manager of the eighteen bed inpatient HIV Diseases Unit at St. Vincent's Hospital, Sydney.

1. Potential for nutritional deficit due to:

1. nausea and vomiting (drug induced)
2. anorexia
3. breathlessness
4. change in taste sensation (drug induced)
5. increased nutritional needs.

• Ensure adequate dietary intake, evidenced by weekly weight gain.

• Dietitian referral.
• Small, frequent, easily digested meals.
• Diet supplements.
• Anti-emetic regimes.
• Try own foods (favourite foods).
• Sit out of bed for meals.
• Sweets to counter taste sensation.
• May require enteral feeding.

2. Potential for alteration in cellular nutrition due to:

1. hypoglycaemia
2. hyperglycaemia as a result of Pentamidine therapy

• Monitor and maintain blood sugar levels (BSLs), evidenced by BSLs stabilised between 3 - 5.8 mmol/L.

• 6/24 fingerprick BSLs if on pentamidine
• Monitor adequate oral intake.
• If BSL<2mmol/L give IV 50% dextrose stat and contact RMO.
• Pentamidine therapy may be given early in the day to counteract nocturnal hypoglycaemia.

• Keep patient free from other infections as evidenced by control of fevers.

• If temperature is higher than 38°C then blood cultures indicated.
• Check white cell count and differential daily.
• Change IV cannula sites as per hospital
• protocol - remove if red or inflamed.
• Wash with chlorhexidine based soap.
• Povidine-iodine to any abrasion or cut.
• Strict asepsis for any invasive procedure.

• Maintenance of body temperature at 370C per axilla.

• Record temperature 4/24.
• Document rigors.
• Antipyretics.

5. Potential for constipation due to:

1. Reduced activity
2. Diet change
3. Hypoxia.

• Prevent constipation as evidenced by regular, soft stools.

• Chart type and frequency of bowel actions.
• Aperients may need to be given. Diet may need to be modified eg high fibre.

• Absence or control of diarrhoea as evidenced by regular formed stools.

• Chart type and frequency of bowel actions.
• Any diarrhoea should have samples taken x3 for opportunistic organisms.
• Antidiarrhoeal agents may be necessary.
• Diet or enteral feeds may need to be modified.
• Fluid balance chart to measure loss vs intake.
• Daily weight.
• Request review of drug therapy eg Metoclopramide.

• Ensure adequate tissue perfusion as evidenced by O₂ saturation at 90% or over and absence of cyanosis.

• 02 to maintain peripheral 02 saturation at 90%.
• 4/24 routine 02 saturation recording if stable or more frequently if unstable.

8. Potential for fluid deficit due to high fluid loss through:

1. diaphoresis
2. vomiting
3. tachypnoea.

• Maintain fluid homeostasis, evidenced by weight stability.

• Monitor and chart fluid intake and output.
• Daily weight if possible.
• Humidified 02.
• May require intravenous fluid support.
• Control of symptoms causing fluid loss.
• Anti emetic regime.

9. Potential for fluid volume excess due to:

1. Fluid retention as a result of steroid therapy
2. Fluid overload as a result of large volume necessitated by IV Co-trimoxazole.

• Prevent fluid volume excess as evidenced by stable daily weight.

• Daily weight.
• Monitor urine output.
• Fluid restriction may be necessary.

10. Potential for alteration in circulation: decreased cardiac output as a result of:

1. Pentamidine therapy
2. Allergic drug reaction
3. Septic shock.

• Maintain cardiac output as evidenced by stable blood pressure.

• Baseline vital signs on admission.
• 4/24 blood pressure and pulse monitoring.
• Report decreased BP to RMO.
• Sit upright with support of pillows.

• Improvement of gas exchange as evidenced by improved peripheral 02 saturation via pulse oximeter.

• May require bronchodilator for relief of bronchospasm.
• 02 may be indicated.
• Change position 2/24.
• Record respiration rate 4/24.
• Record peripheral 02 saturation via pulse oximeter 4/24.

12. Potential for impairment of skin integrity due to:

1. Bed rest
2. Cachexia
3. Hypoxia.

• Maintain skin integrity, evidenced by intact, clean, dry skin on examination.

• Inspect skin each shift with particular attention to bony prominences and ears.
• Spenko mattresses.
• 2/24 turns side/back/side.
• Silicone barrier cream to areas at risk.
• Warm oil massage.
• Wrinkle free sheets.
• O₂ therapy if required.

• Prevent renal damage as evidenced by Creatinine remaining within normal range and absence of protein or blood in urine.

• Check serum creatinine once daily before administering Co-trimoxazole or Pentamidine therapy - notify RMO if creatinine rising - withhold therapy until RMO informed if Creatinine is higher than 0. 15 mmol/L.
• Daily U/A for blood, protein and pH - Alkalize urine if pH low to prevent eystaluria from co-timoxazole (particularly in patients taking large doses of ascorbic acid.)

14. Potential for social isolation due to:

1. hospitalisation
2. severity of illness
3. psychosocial impact of diagnosis of HIV disease.

• Maintenance of social contact between patients and their community, evidenced by adequate social interaction for patient's needs.

• Encourage significant others and friends to visit often.
• Educate significant others and friends about disease if appropriate.
• Encourage short frequent visits. Telephone before visiting if patient agrees. Reduce visitors to two at a time to minimise tiring. May need referral to social support agency.

15. Potential for spiritual distress due to:

1. possible death
2. guilt about HIV infection.

• Allow for spiritual guidance by informing patient of pastoral care available.

• Notify priest or chaplain if patient requests.
• Be aware of religious persuasion. Educate patient that disease is a pathological not moral infirmity.

16. Activity intolerance due to:

1. Hypoxacirda
2. Nutritional deficit.

• To preserve mobility and increase energy levels as evidenced by patient performing some activities each day.

• 02 to maintain peripheral O₂ saturation at 90% or above. Encourage frequent naps.
• Group nursing activities. Encourage high protein, high energy diet - may need enteral feeding support/ dietitian referral. Attempt to get out of bed twice each day if tolerated.
• Physiotherapy referral - simple exercise regime.

• Maintenance of hygiene, evidenced by patient stating that they feel clean and cared for.

• Daily wash in bed or shower if possible (may require portable oxygen).
• Brush hair at least once a shift.
• Inspect mouth daily using torch and tongue depressor.
• Change linen and wash after sweats. Cologne if patient wishes.
• Passive exercises, if bedridden 2/24 turns.
• Assist to the toilet if possible, otherwise bedpan and urinal by bed.
• Patient may wish to lie naked.
• Check nails each day for ragged edges and fungal infections.

• To support patient in accepting change in body image, evidenced by patient discussing these changes and coming to terms with them.

• Discuss changes with patient and reasons they occur.
• Educate re weight gain - may need dietitian referral.
• Introduce patient to others who have experienced and solved the same problem.

• To provide a realistic positive environment, evidenced by a realistic attitude to the future by the patient.

• Allow patient to ventilate these feelings and provide realistic, positive feedback. Do not extinguish hope.
• Explain to significant others what is happening, encourage the development of short term, positive, achievable goals.

20. Potential for feelings of powerlessness due to:

1. strange people and environment
2. loss of control over destiny
3. overwhelming infection
4. new toxic drug therapies
5. inability to take care of self.

• To give patient power over their environment, evidenced by patients utilizing their decision making abilities.

• Consult patient before any treatment.
• Gain informed consent.
• Respect patient's wishes regarding the treatment.
• Patient's significant others may require flexible visiting hours.
• Suggest pillows, quilts, objects etc from home.
• Give patient options from which to choose.
• If possible give patient some input into care givers.

• Improve patients' knowledge about AIDS as evidenced by their ability to explain basic disease pathology of AIDS and the precautions that they need to take.

• Simple explanation about the disease process to begin with.
• In acute stage of disease answer only questions asked - no more.
• Educate patient's primary carer extensively with repetition and reassurance.
• As patient's condition improves expand their knowledge base.

• Pain free state, evidenced by patient stating that they are pain free.

• Analgesia as required.
• Physiotherapy.
• Relaxation techniques.
• Massage.

• To relieve anxiety by providing realistic supportive care during this time, evidenced by patient expressing feelings of safety and security.

• Social work referral.
• Allow to ventilate feelings - validate those feelings.
• Answer questions or get someone who can.
• Do not answer questions not asked.
• Reassure and educate where evidence of a knowledge deficit is adding to the anxiety.

24. Fear due to:

1. Unknown future regarding:
   1. Disease process
   2. Social situation
   3. Possible loss of life
2. Pain
3. Unfamiliar environment.

• To provide a safe, secure, supportive environment at all times, evidenced by patient conveying fears and resolving them.

• Explain all procedures, drug therapies and side effects thoroughly.
• Allow time for patient to ask questions.
• Answer all questions truthfully or get someone who can.
• Involve significant others in care if patient wishes.

• To provide an environment complementary to the resolution of these issues.

• Allow patient to ventilate these feelings.
• Explain to significant others what is happening.
• Provide positive feedback during times of evaluation. Give patient time with significant others to resolve issues.