acquired immunodeficiency syndrome
(also refer to HIV positive)

risk for Infection [progression to sepsis/onset of new opportunistic infection]: risk factors may include depressed immune system, use of antimicrobial agents, inadequate primary defenses; broken skin, traumatized tissue; malnutrition; and chronic disease processes.

risk for deficient Fluid Volume: risk factors may include excessive losses: copious diarrhea, profuse sweating, vomiting, hypermetabolic state or fever; and restricted intake (nausea, anorexia; lethargy).

acute/chronic Pain may be related to tissue inflammation/destruction: infections, internal/external cutaneous lesions, rectal excoriation, malignancies, necrosis, peripheral neuropathies, myalgias, and arthralgias, possibly evidenced by verbal reports, self-focusing/narrowed focus, alteration in muscle tone, paresthesias, paralysis, guarding behaviors, changes in vital signs (acute), autonomic responses, and restlessness.

imbalanced Nutrition: less than body requirements may be related to altered ability to ingest, digest, and/or absorb nutrients (nausea/vomiting, hyperactive gag reflex, intestinal disturbances); increased metabolic activity/nutritional needs (fever, infection), possibly evidenced by weight loss, decreased subcutaneous fat/muscle mass; lack of interest in food/aversion to eating, altered taste sensation; abdominal cramping, hyperactive bowel sounds, diarrhea, sore and inflamed buccal cavity.

Fatigue may be related to decreased metabolic energy production, increased energy requirements (hypermetabolic state), overwhelming psychological/emotional demands; altered body chemistry (side effects of medication, chemotherapy), possibly evidenced by unremitting/overwhelming lack of energy, inability to maintain usual routines, decreased performance; impaired ability to concentrate, lethargy/restlessness, and disinterest in surroundings.

ineffective Protection may be related to chronic disease affecting immune and neurological systems, inadequate nutrition, drug therapies, possibly evidenced by deficient immunity, impaired healing, neurosensory alterations, maladaptive stress response, fatigue, anorexia, disorientation.

Social Isolation may be related to changes in physical appearance/mental status, state of wellness, perceptions of unacceptable social or sexual behavior/values, physical isolation, phobic fear of others (transmission of disease); possibly evidenced by expressed feelings of aloneness/rejection, absence of supportive significant other(s) (SOs), and withdrawal from usual activities.

disturbed Thought Processes/chronic Confusion may be related to physiologic changes (hypoxemia, central nervous system [CNS] infection by HIV, brain malignancies, and/or disseminated systemic opportunistic infection); altered drug metabolism/excretion, accumulation of toxic elements (renal failure, severe electrolyte imbalance, hepatic insufficiency), possibly evidenced by clinical evidence of organic impairment, altered attention span, distractibility, memory deficit, disorientation, cognitive dissonance, delusional thinking, impaired ability to make decisions/problem solve, inability to follow complex commands/mental tasks, loss of impulse control and altered personality.