Care and nursing principles

What follows is practical advice on how to prevent and treat some of the common symptoms associated with HIV infection and Aids at home with only the most basic and inexpensive commonly available resources. Caregivers should look out for certain changes in the condition of the patient and seek professional help when necessary.

Fever

• Encourage the patient to drink lots of fluid, especially cool fluids. Provide plenty of water, weak tea, broth or juice.
• Remove any unnecessary clothing or blankets.
• Give sponge baths or use a fan to keep temperature down.
• Pour water on the skin, or put cloths soaked in water on the forehead or chest and fan the body with wet cloths.
• Keep the room well aerated and cool. Open the windows or doors to allow fresh air or a light breeze to penetrate.
• Use medicines that reduce fever (antipyretics) such as, for example, aspirin or paracetamol. (Don’t ever give aspirin to children or adolescents - it may cause Reyes syndrome. Rather use paracetamol)
• Make sure that the patient eats nutritious foods (a high kilojoule, high protein diet).

Seek professional help if:

• the fever is very high and continues for a long time
• it is accompanied by coughing and weight loss
• it is accompanied by symptoms such as stiff neck, severe pain, confusion, unconsciousness, a yellow colour in the eyes, sudden severe diarrhoea or convulsions
• the patient is pregnant or if she has recently had a baby
• malaria is common in the area where the patient lives, or if the fever has not gone away after one treatment with antimalarial medicine

Diarrhoea
Prevent diarrhoea by boiling water from an unsafe water supply (e.g. a dirty well or a dirty container) before it is used to prepare food or drinks. Eat only clean and safe food and make sure that stored food is reheated thoroughly at a high temperature. Avoid raw or uncooked meat and peel fruit or wash it well before eating. Always wash your hands before preparing or eating food.

There are three basic rules for treating diarrhoea:

• Drink more fluids than usual. Drink something after every stool.
• Continue to eat, even if you only consume small amounts of nutritious foods at a time.
• Recognise and treat dehydration early. Watch out for the following signs of dehydration: severe thirst, dry mouth, sunken eyes, sunken fontanelle in young children, rapid pulse and breathing, irritability, lethargy (or lack of vitality), poor urine output and a dry skin (skin going back slowly when pinched).
• Treat dehydration with an oral rehydration solution such as Oral Rehydration Salts mixed with water. Or use the following home-made rehydration fluid:
• Mix 1 litre (4 big cups) of water with 8 teaspoons of sugar and ½ teaspoon of salt. If available, add fresh orange juice for taste and potassium replacement. Adults should take 1 to 2 cups of this fluid after every diarrhoeal stool. (Or to make 1 cup of rehydration fluid, mix 1 cup of water with 2 teaspoons of sugar and a pinch of salt.)

Seek professional help if patients:

• are very thirsty
• have a fever
• cannot eat or drink properly
• do not seem to be getting better
• pass many watery stools
• see blood in the stools
• are vomiting and cannot keep fluids down
• are irritable or lethargic
• have a very dry skin

Constipation
If HIV-infected patients become constipated, the following measures can be taken:

• Encourage the intake of fluids such as water and fruit juices, as well as fresh fruits and vegetables.
• Prevent constipation by using honey, molasses, stewed prunes and grated beetroot.
• Give the patient high-fibre foods to eat if he or she can tolerate them.
• Encourage mobility and exercise.
• Check stools for blood.
• Certain medications (e.g. codeine) can cause constipation. Check the patient’s medications with the doctor or clinic.

Skin problems

• Cleaning the skin frequently with soap and water and keeping it dry between washing will prevent the most common problems.
• Itching can be reduced by cooling the skin with water, by applying lotions such as calamine, and by using effective traditional remedies that are usually available from local herbalists.
• A very dry skin can be treated by avoiding soap and by applying Vaseline, glycerine, and vegetable or plant oils (or by applying the more expensive oils and creams available in shops).
• To prevent babies (and confused adults) from scratching themselves, gloves or socks can be put over their hands, and fingernails can be kept short.
• The buttocks area of babies with diarrhoea or yeast infections need the following special care: leave the baby’s bottom exposed to air as much as possible, soak the baby’s bottom with warm water between nappy changes, change wet and soiled nappies immediately, avoid wiping the buttocks area (rather squeeze water from a cloth or pour water over the area and pat dry) and apply lotions supplied by the local clinic.
• Wash wounds with clean water (cooled boiled water if necessary) mixed with salt (one teaspoon of salt to one litre of clean water) or with a gentian violet solution (one teaspoon of gentian violet crystals in half a litre of clean water). Protect the wound by covering it with clean gauze bandages or cloth.

Seek professional help when the skin problem is associated with any of the following symptoms:

• pus, redness or fever (indicating infection)
• severe pain, difficulty in sleeping and eye problems such as blurred vision (which is often a symptom of shingles)
• allergic reactions to medication
• a bad smell, oozing of a grey or brown liquid, blackening of the skin around a wound with air bubbles or blisters (an indication of gangrene)

Mouth and throat problems

• To prevent problems in the mouth and throat, one can rinse the mouth with warm salt water (½ teaspoon of salt in 1 cup of water) or with a mouthwash solution after eating and between meals. (Do not allow the patient to swallow the mouthwash because it may cause diarrhoea and nausea.)
• Thrush can be treated by gently scrubbing the tongue and gums with a soft toothbrush, by rinsing the mouth with a mouthwash, salt water or lemon water, and by applying a gentian violet solution three to four times a day (1 teaspoon of gentian violet crystals in ½ litre of water.)
• The gentian violet solution can also be applied to herpes simplex sores (or blisters) on the lips.

Seek professional help if:

• the sick person is becoming dehydrated or is unable to swallow properly
• there are symptoms of oesophageal thrush such as a burning pain in the chest or a deep pain on swallowing

Breathing (respiratory) problems

• Help patients to cough (and to drain the lungs) by massaging or patting the back of the chest over the lungs.
• Teach patients to hold a pillow or hand tightly over the painful chest or rib area while coughing if they find it painful to cough.
• Teach people to cover their mouths when coughing because the disease-causing agents can usually be passed on to other people through the air.
• Soothe an irritating cough with remedies such as tea with sugar or honey, or use safe home-made cough syrups. If a constant cough interferes with a person’s rest at night, a cough suppressant can be prescribed. The use of a cough suppressant should, however, be discouraged during the day because it is important to cough and to get rid of mucus and disease-causing bacteria.
• When someone is experiencing difficulty in breathing, the following measures might alleviate their distress:
• Lie with pillows under the head, or with the head of the bed raised on blocks.
• Sit leaning forward with the elbows on the knees or on a low table.
• Make sure that there is always someone there with the patient. Difficulty in breathing can be very frightening and distressing.
• If a child finds it difficult to breath, clean the nose if it is congested.

Seek professional help if:

• sudden high fever develops
• the person is in severe pain or discomfort
• the colour of the sputum changes to grey, yellow or green
• the sputum has blood in it
• the person has a cough for more than three weeks - especially if the cough is also accompanied by the spitting up of blood, pain in the chest or difficulty in breathing (tuberculosis may be the cause)
• In children (particularly children below the age of five) respiratory infections can be very serious. Children should be brought to a clinic or health care professional immediately if they are:
• breathing with difficulty through the mouth or if they are breathing with an audible wheezing
• breathing faster than usual
• unable to drink because of their problems with breathing

Anorexia, nausea and vomiting

• Stop the intake of food and fluids for one to two hours if the patient is vomiting. Gradually then introduce the intake of clear fluids such as water or flat coke.
• Increase the amount of fluids as soon as the patient can tolerate it. Later the patient may eat dry toast or crackers.
• Anti-nausea medicine should be taken 30-60 minutes before mealtimes (or as prescribed).
• Advise nauseated patients not to take liquids before, during or immediately after meals.
• Eat foods that are low in fat - as well as dry, salty foods. Avoid gas-producing, greasy, spicy foods.
• Present food in an attractive and appetising way. Eliminate food odours which may nauseate the patient by keeping the windows of the room open. Serve food cold or at room temperature. Patients should eat slowly in a relaxed atmosphere.
• Encourage patients to rest after meals with their upper bodies in an elevated position.
• In order to increase appetite, encourage patients to take small, frequent meals high in protein and kilojoules throughout the day rather than three large meals. Kilojoule intake can be increased by using extra peanut butter, sugar, honey, ice cream, milk shakes and sweets. Patients should be encouraged to eat all their favourite foods and to drink lots of fluids.
• Encourage the use of nutritional supplements.
• Teach patients relaxation and breathing techniques and encourage them to use these techniques when they are nauseated.
• Thorough oral care should be encouraged to prevent thrush (because thrush makes eating difficult).
• Watch out for signs of dehydration and begin to give an oral rehydration solution, weak tea or other clear liquids to the patient to drink one or two hours after severe vomiting stopped.

Seek professional help if:

• vomiting occurs repeatedly and fluids cannot be kept down
• regular vomiting lasts more than 24 hours, particularly if it is accompanied by pain in the abdomen
• a person has a fever in addition to the vomiting
• the sick person is vomiting violently, especially if the vomit is dark green, brown, or smells like faeces
• the vomit contains blood

Note: Be very careful with vomiting children and watch them carefully for signs of dehydration. Babies can dehydrate and die within hours if vomiting and diarrhoea are neglected.

Circulation impairment

• Stimulate circulation by massaging the skin regularly with lotion.
• Encourage the patient to be active. If the patient is bedridden, passive exercises should be performed and the patient should be turned every two hours.
• Elevate extremities (e.g. the legs).
• Avoid pressure from cushions or heavy blankets on extremities, as well as tight fitting clothes.
• A bedridden child who has a severe chronic illness should be held in someone’s lap as often as possible. Not only does this improve circulation and avoid bedsores, it also gives the child the love and attention that he or she needs.

Swelling (Oedema)

• Avoid excessive salt (sodium) intake.
• Keep the swollen areas (e.g. the legs) above the level of the heart but take care not to restrict blood flow by placing pillows at pressure points such as those behind the knees.
• Avoid tight-fitting clothes and discourage the patient from crossing his or her ankles or knees.
• Examine the skin over the swollen areas regularly for circulation and skin discolourations or breakdown.

Genital problems
The caregiver should follow the principles and advice listed below when looking after a patient with a STI at home (World Health Organisation, 1993):

• Seek treatment for STIs from a health care professional or clinic immediately. Antibiotics can cure most STIs completely.
• Use a condom for every sexual contact. It is dangerous for someone who is already infected with HIV to be exposed to other STIs.
• Women with an abnormal vaginal discharge should keep the vulva and anal area clean by washing with water and a mild, non-abrasive soap.
• Women should avoid washing out or flushing the vagina (douche), or putting anything (e.g. antiseptics, leaves, herbs) inside the vagina unless advised to do so by a health care professional. The practice of “dry sex” should be avoided.
• Open genital sores should be washed with soap and water and they should be kept dry between washings.
• If herpes is diagnosed, advise the person to bathe the affected area with a salt solution (1 teaspoon of ordinary cooking salt in ½ litre of clean water) every two to three hours. Keep the area dry between bathing, and apply calamine lotion, talcum or starch powder.
• If a person suffers repeatedly from candidiasis (vaginal thrush), apply gentian violet (1 or 2 teaspoons of gentian violet crystals dissolved in 1 litre of clean water) to the affected areas.
• Plain yoghurt is very effective in the treatment of vaginal thrush. Rub plain yoghurt on any red areas or dip a tampon in the yoghurt and insert it in the vagina twice a day.
• Women with vaginal thrush should follow the ‘candida diet’ and avoid all foods containing yeast (e.g. bread) and sugar. Beer should be avoided until the oral thrush is cleared for at least three weeks.
• Women with vaginal thrush should avoid wearing tights or nylon panties (they should wear only cotton panties).
• A rash on the penis or under the foreskin can be alleviated by soaking the penis in a dilute salt and water solution. (Dissolve a teaspoonful of salt in a glass of water, pull back the foreskin, put the penis in the water and soak for five minutes. Repeat two to three times a day). If this procedure does not work, repeat by using a gentian violet solution. Ask for advice from a health care professional if the condition does not clear up in three to four days.
• Loss of menstruation and irregular bleeding often occurs in women with Aids. If a woman misses one or two periods she should go to the clinic to be examined in order to establish the cause.

Seek professional help when

• you suspect that you may have an STI
• you experience difficulty or pain in passing urine
• you have genital warts, genital ulcers, an unusual vaginal discharge that is foul-smelling, itchy, green, yellow or grey in colour
• a woman develops pain in her lower abdomen (with fever), or if her periods stop or become irregular
• there is a discharge from the penis, and if there is swelling and/or pain in the scrotum.

Pain

• Take pain medication as prescribed by the physician.
• Take pain medicine on a regular basis as prescribed (e.g. every four, six or eight hours) because this can help you to feel that you have control over your pain.
• Start with the mildest drugs first (e.g. aspirin or paracetamol) and if that does not help, go up the ladder to moderate medication (e.g. codeine).
• Keep in mind that some pain medications, such as codeine- and morphine-containing drugs, cause constipation.
• Offer comfort measures such as massages and back rubs, warm soaks for painful muscles, joints, feet or legs, ice bags for headaches and soothing music of the patient's choice.
• Encourage relaxation exercises and teach deep and regular breathing techniques.
• Maintain a quiet and restful environment, and limit the numbers of visitors.
• Keep the environment as calm as possible, talk calmly and in gentle tones to the sick person, avoid bright lights, play soft music, read to the person, apply a cool cloth on the forehead or give a light massage.

Professional advice should be sought:

• if the pain becomes unbearable or if it is associated with new symptoms such as severe headache or weakness
• if there is a sudden or recent occurrence of pain in the hands or feet
• if there is a persistent headache lasting over two weeks, a severe headache which is getting rapidly worse and which is not relieved by the usual methods of dealing with pain, a headache associated with vomiting or a headache that affects the sick person’s ability to think or move

Alteration of mental status: Confusion and dementia

• Reassure the person of your presence, especially at night, so as to alleviate his or her fears.
• Modify the patient's home environment for safety and convenience.
• Take measures to prevent accidents in the home, e.g. pay careful attention to open fires or boiling water; provide canes (walking sticks) or walkers for people who are weak or who tend to become off-balance when they walk; remove loose and potentially dangerous objects in the home; keep walkways clear; do not rearrange the furniture; store poisonous or toxic substances safely out of reach; keep medicines out of reach and only give them according to the prescribed schedule
• Install handrails or put a securely positioned and stabilised chair in a shower or bath
• Store sharp objects like knives, scissors, razors and saws safely and out of reach, and try not to leave the sick person unattended for long periods.
• Keep the person orientated to time, place and people by using clocks, a calendar, photographs, night lights and written schedules of daily routine, dates of appointments and the telephone numbers of friends.
• Ask questions that can be answered with either a “Yes” or a “No”. Be concrete and specific - and give the person enough time to respond to questions, directions or conversations.

Seek professional help when:

• there are sudden changes in a person’s ability to move or think - especially when these changes are accompanied by a high fever, headache or difficulty in breathing
• the patient begins to manifest serious mental or personality changes
• the patient becomes unmanageable at home