The patient and caregivers are instructed to monitor for signs and symptoms of infection: fever; chills; night sweats; cough with or without sputum production; shortness of breath; difficulty breathing; oral pain or difficulty swallowing; creamy-white patches in the oral cavity; unexplained weight loss; swollen lymph nodes; nausea; vomiting; persistent diarrhea; frequency, urgency, or pain on urination; headache; visual changes or memory lapses; redness, swelling, or drainage from skin wounds; and vesicular lesions on the face, lips, or perianal area. The nurse also monitors laboratory values that indicate infection, such as the white blood cell count and differential. The physician may decide to culture specimens of wound drainage, skin lesions, urine, stool, sputum, mouth, and blood to identify pathogenic organisms and the most appropriate antimicrobial therapy. The patient is instructed to avoid others with active infections such as upper respiratory infections

The skin and oral mucosa are assessed routinely for changes in appearance, location and size of lesions, and evidence of infection and breakdown. The patient is encouraged to maintain a balance between rest and mobility whenever possible. Patients who are immobile are assisted to change position every 2 hours. Devices such as alternating-pressure mattresses and low-air-loss beds are used to prevent skin breakdown. Patients are encouraged to avoid scratching, to use nonabrasive, nondrying soaps, and to apply nonperfumed skin moisturizers to dry skin surfaces. Regular oral care is also encouraged. Medicated lotions, ointments, and dressings are applied to affected skin surfaces as prescribed. Adhesive tape is avoided. Skin surfaces are protected from friction and rubbing by keeping bed linens free of wrinkles and avoiding tight or restrictive clothing. Patients with foot lesions are advised to wear cotton socks and shoes that do not cause the feet to perspire. Antipruritic, antibiotic, and analgesic agents are administered as prescribed. The perianal region is assessed frequently for impairment of skin integrity and infection. The patient is instructed to keep the area as clean as possible. The perianal area is cleaned after each bowel movement with nonabrasive soap and water to prevent further excoriation and breakdown of the skin and infection. If the area is very painful, soft cloths or cotton sponges may prove to be less irritating than washcloths. In addition, sitz baths or gentle irrigation may facilitate cleaning and promote comfort. The area is dried thoroughly after cleaning. Topical lotions or ointments may be prescribed to promote healing. Wounds are cultured if infection is suspected so that the appropriate antimicrobial treatment can be initiated. Debilitated patients may require assistance in maintaining hygienic practices.

Adverse reactions are of concern in patients who receive many medications to treat HIV infection or its complications. Many medications can cause severe toxic effects. Information about the purpose of the medications, correct administration, side effects, and strategies to manage or prevent side effects is provided. Patients and their caregivers need to know which signs and symptoms of side effects should be reported immediately to their primary health care provider (see Table 52-3). In addition to medications used to treat HIV infection, other medications that may be required include opioids, tricyclics, and NSAIDs for pain relief; medications for treatment of OIs; antihistamines (diphenhydramine) for relief of pruritus (itching); acetaminophen or aspirin for management of fever; and antiemetic agents for control of nausea and vomiting. Concurrent use of many of these medications may cause many drug interactions, including hepatic and hematologic abnormalities. Therefore, careful laboratory monitoring for these abnormalities is warranted. During each contact with the patient, it is important for the nurse to ask not only about side effects but also how well the patient is managing the medication regimen. The nurse may be able to assist the patient in organizing and planning the medication schedule to promote adherence to the medication regimen.

Patients, families, and friends are instructed about the routes of transmission of HIV. The nurse discusses precautions to prevent transmitting HIV, including using condoms during vaginal or anal intercourse ; using dental dams 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 partners, individuals known to be HIV infected, people who use injection drugs, and sexual partners of people who inject drugs. Patients and their families or caregivers must receive instructions about how to prevent disease transmission, including hand washing techniques, and in methods for safely handling items soiled with body fluids. Caregivers in the home are taught how to administer medications, including IV preparations. The medication regimens used for patients with HIV infection and AIDS are often complex and expensive. Patients receiving combination therapies for treatment of HIV infection and its complications require careful teaching about the importance of taking medications as prescribed and explanations and assistance in fitting the medication regimen into their lives . Guidelines about infection and infection control, follow-up care, diet, rest, and activity are also necessary. Patient teaching also includes strategies to avoid infection. The importance of personal hygiene is emphasized. Kitchen and bathroom surfaces should be cleaned regularly with disinfectants to prevent fungal and bacterial growth. Patients with pets are instructed to have another person clean areas soiled by animals, such as bird cages and litter boxes. If this is not possible, the patient should use gloves to clean up after pets. Patients are advised to avoid exposure to others who are sick or who have been recently vaccinated. Patients with AIDS and their sexual partners are strongly urged to avoid exposure to body fluids during sexual activities and to use condoms for any form of sexual intercourse. Injection drug use is strongly discouraged because of the risk to the patient of other infections and transmission of HIV infection to others. Patients infected with HIV are urged to avoid exposure to bodily fluids (through sexual contact or injection drug use) to prevent exposure to other HIV strains. The importance of avoiding smoking and maintaining a balance between diet, rest, and exercise is also emphasized. If the patient requires enteral or parenteral nutrition, instruction is provided to patients and families about how to administer nutritional therapies at home. Home care nurses provide ongoing teaching and support for the patient and family. Patients who are HIV positive or who inject drugs are instructed not to donate blood. Injection drug users who are unwilling to stop using drugs are advised to avoid sharing drug equipment with others.

Many people with HIV and AIDS remain in their community and continue their usual daily activities, whereas others can no longer work or maintain their independence. Families or caregivers may need assistance in providing supportive care. There are many community-based organizations that provide a variety of services for people living with HIV infection and AIDS; nurses can help identify these services. Community health nurses, home care nurses, and hospice nurses are in an excellent position to provide the support and guidance so often needed in the home setting. As hospital costs continue to rise and insurance coverage continues to decline, the complexity of home care increases. Home care nurses are key in the administration of parenteral antibiotics, chemotherapy, and nutrition in their homes. During home visits, the nurse assesses the patient’s physical and emotional status and home environment. The patient’s adherence to the therapeutic regimen is assessed, and strategies are suggested to assist with adherence. The patient is assessed for progression of disease and for adverse side effects of medications. Previous teaching is reinforced, and the importance of keeping follow-up appointments is stressed.