NCP
NCP
NCP
Objective: y Over whelming lack of energy y Inability to maintain usual routines y Decreased performance DIAGNOSIS Fatigue may be related to decrease metabolic energy production, increased energy requirements, overwhelming psychological and emotional demands, and altered body chemistry such as side effects of medication or insulin resistance.
(http://nursingcri b.com/nursingcareplan/nursingcare-planaidshiv/)
NURSING CARE PLAN INFERENCE Human immunodeficiency virus is a particle that has an outer envelope with special docking proteins known as gp41 and gp120 that assist in finding a host. Inside the virus have two protein coatings and the generic material with reverse transcriptase (RT) attached. The first challenge is for the HIV particle to get inside a host cell. HIV accomplishes this task by finding a way into the hosts blood stream. One of the cells that it hijacks is the CD4+ lymphocytes, also known as the CD4+ cell, helper/inducer Tcall, or T4-cell. This cell directs PLANNING INTERVENTION RATIONALE y Multiple factors can cause and aggravate fatigue, including sleep deprivation, emotional distress, side effects of drugs, and developing central nervous system disease. y Fatigue is present in variable degrees as part of HIV infection process but is often aggravated by nutritional deficiencies and side effects of certain medications. y Helpful in planning activities within tolerance levels. EVALUATION After 8 hours of nursing interventions, the patient reported improved sense of energy; participate in desired activities at level of ability and identify individual areas of control and engage in energy conservation techniques.
After 8 hours of Independent nursing y Assess sleep interventions, patterns and other the patient will factors that may be able to be aggravating report fatigue. improved sense of energy; participate in desired activities at level of ability and identify y Encourage timely individual areas evaluation of of control and fatigue if new engage in medications have energy been added to conservation regimen. techniques.
Discuss reality of patients feelings of exhaustion and identify limitations imposed by fatigue state. Assist patient in to y Patient may need set realistic activity to alter priorities goals, determining and delegate individual priorities some
immune system defenses and regulates the activity of all immune system cells. If the HIV successfully enters the CD4+ cell, it can then create more virus particles.
and responsibilities.
Discuss energy conservation techniques such as sitting instead of standing for activities, as appropriate. Encourage adequate rest periods during the day. Instruct in stress management techniques, such as breathing exercises, visualization, and music and light therapy.
responsibilities to manage fatigue and optimize performance. y Enables patient to become aware in which energy expenditures can be maximized to complete necessary tasks. y Helps patient recoup energy to managed desired activities. y Reduction of stress factors in patients life can minimize energy output.
Collaborative y Administer intravenous fluid as prescribed. y Identify available resource and support systems.
y Help to regain strength and voids dehydration. y May require outside assistance with home making and maintenance activities.