Question

Leah, a 41-year-old female, came to a follow up appointment with her physician.
Three years ago, Leah was diagnosed with human immunodeficiency virus (HIV).
Her medical history includes hypertension, depression, and anxiety. She has a
substance abuse history with IV heroin and beer, but she has been sober for two
years now.
Home medications include: Paxil daily, Lisinopril twice a day, Zidovudine daily,
Tenofovir twice a day, and Xanax prn.
She recently moved back into her mother’s home after being a group home. The
relationship between her and her mother has been unstable because of Leah’s
substance abuse. She verbalized that her mother does not trust her at times. Her
closest friends are in a drug rehabilitation program or in prison.
Height: 5’6’’ Weight: 45 kg
Vital signs: T- 98.3, HR- 107, RR- 20, B/P- 145/64
Labs: CD4 count- 600 cells/microliter, Viral load count- 150,000 copies/mL
After reviewing the results with Leah, she confesses that she stopped taking
Lisinopril, Tenofovir and Zidovudine. She complains of the side effects and prefers
to take “natural stuff.”
Create a nursing care plan for this patient. Remember A.D.P.I.E
• Discuss the assessment (2 points)
• Develop two NANDA approved nursing diagnoses (2 points):
o One actual nursing diagnosis, include the etiology (“related to”) and
evidence (“as evidence by”)
o One potential (“risk for” diagnosis, include the etiology (“related to”)
• One outcome/goal for each diagnosis (total of two). Goal/outcome must be
S.M.A.R.T (2 points)

• Two independent nursing interventions for each outcome/goal
(total of four) (2 points)
• One evaluation of each goal/outcome (total of two) (2 points)

Answer 1

1. Asses the baseline data of the patient . BP 145/64 and HR is 107 . Eventhough Leah was diagnosed as HIV, CD4 count 600cells /microliter which is within normal limits.Viral load very high. It can affect CD4 count.Has history of hypertension, depression and anxiety. She is substance abuser.She has non compliance to drug.  
2. Non complaince related to deficient knowledge on the benefit of drgs

• ​​ Risk for infection related to depression of immune system as evidenced by increased viral load 150, 000copies /ml
• ​​​​​​3.Patient repirts compliance with drug administration.
• ​​​​​​​ Participate in behavior to reduce the risk of infection.
• 4.Non compliance : Assess the knowledge level of therapeutic regimen and drug intake
• Instruct the patient to the importance of drug intake.
• Risk for infection :Assess the signs and symptoms of infection
• Administer medication as prescribed by the doctor.
• Evaluation :Noncompliance : Patient display gradual healthy restoration.
• Patient viral load return to normal limits.