Human Immunodeficiency Virus
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1
Human Im mun od ef ic ie nc y Vi rus Ba si c Pri nc ipl es o f Gen etic s Transmission of HIV
Exchange of blood or other body fluids containing HIV (blood, semen,
vaginal secretions & breast milk) i.e. unprotected sex or by sharing needles
HIV- infected individuals can transmit HIV within a few days after becoming
infected; transmit ability lifelong
Sexual contact with an HIV-infected partner – 75% cases (most common
mode of transmission)
Accidental needle sticks, needle sharing among IV drug users
Perinatal Transmission (most common route for infecting children) –
HIV- infected mother to her infant occur during pregnancy in utero or at time of delivery or after birth through breastfeeding
Pathophysiology (Natural Hx of HIV) HIV
is a ribonucleic acid (RNA) virus (retroviruses – replicate in a
“backward” manner going from RNA to deoxyribonucleic acid (DNA); reverse flow of genetics)
Must have living cell to replicate; T lymphocytes (T4 or CD4 cells) (invade
living host cell)
HIV life cycle
1. HIV binds to the T cells (CD4 lymphocytes, T4 cells, Helper T cells)
2. Viral RNA is released into the host cell
3. Reverse transcriptase converts viral RNS into Viral DNA
4. Viral DNA enters the T cell’s nucleus and inserts itself into the T cell’s
DNA 5.
The T cells begins to make copies of the HIV components.
6.
Protease (enzyme) helps create new virus particles
2 7.
The new virion (virus particle is released from the T cell
Clinical Manifestations
Refer to fig 14-4, pg. 267 typical course of untreated HIV
Early Stage -First phase of HIV infection; As virus begins to replicate
person develops an acute retroviral syndrome/primary HIV infection (PHI) Period of time between initial exposure to virus & appearance of HIV
antibodies No test can detect antibodies in early stage
Fast and furious – amount of virus in peripheral blood increased greater
then 100,000 copies/ml Like Van Diesel movie fast and furious – amount of virus in peripheral
blood increased greater than 100,000 copies/ml Body starts to produce antibodies
Flu like symptoms
Second Phase of HIV infection SSx of PHI resolve
Viral load decreases
Seroconversion occurs
Chronic infection Patient seems well ( no clinical apparent disease)
Virus is busy replicating itself and spreading to uninfected cells
If no treatment – loose T cells – HIV associated infections
Symptomatic HIV infection T-cell count continues to decline
Patient develops a symptomatic infection (pneumocystis pneumonia
(PCP) or candidiasis) HIV infection Dx at this stage
3 HIV-associated illnesses appear
Acquired immunodeficiency syndrome (AIDS) Meets definition of AIDS established by US center for disease control and
prevention (CDC) HIV+ & have CD4 cell ct below 200/mm
HIV+ & have AIDS defining illness
Diagnostic Studies
Most useful screening tests are those that detect HIV-specific antibodies
Problem – median delay of 2 months after infection before antibodies can be
detected
Health care providers alerted to do HIV screening based on sexual practices,
IV drug use, receipt of blood transfusions, exposure to body fluid (needlestick)
HIV antibody testing Requires education & counseling – meaning of test & possible results
Informed consent
Privacy
Test results kept confidential
Diagnostic Studies OralQuick
Rapid HIV-1 – (2002)
Antibody test allow rapid notification of individuals
Accurate results in 20 minutes
Uni-Gold
Recombigen (Dec 2003)
Results in 10 minutes
Oral
Quick Rapid HIV – ½ Antibody test (March 2004)
99% accurate; results in 20 mins; saliva specimen
4
EIA (enzyme immunoassay) formerly ELISA (enzyme linked
immunosorbent assay) Detect serum antibodies that bind to HIV antigen
Serum & saliva
Western Blot or immunofluorescence Assay (IFA) More specifically confirms HIV
Viral Load test Measure plasma HIV RNA level
Used to track viral load & response to tx for HIV infection
CD4 T-cell count to monitor progression of the infection
WBC count, RBC count, and platelets decrease with progression of HIV
Collaborative Care (Rapidly Changing)
Protocols change often
Treat for life
Highly Active Antiretroviral Therapy (HAART) /Antiretroviral (ARV) regimen
Treatment based on HIV RNA (viral load)
CD4T cell count
Clinical condition of patient
Refer to table 14-6 & 14-7, pg. 273-275 (Lewis)
Antiretroviral regimens are complex, major side effects, adherence difficult,
carry serious potential consequences from viral resistance r/t lack of adherence or suboptimal levels of antiretroviral agents
Drug Therapy
Nonnucleoside reverse transcriptase inhibitors (NNRTIs) – attach to
the reverse transcriptase enzyme, preventing the enzyme from converting HIV RNA to DNA
Nucleoside reverse transcriptase inhibitors (NRTIs) become part of
HIV’s DNA and derail its building process. (damaged DNA can’t take control of the cell’s DNA)
5
Protease inhibitors work at later stage in replication process, preventing
the protease enzyme from cutting HIV viral proteins into the virions that infect new CD4+ cells (new copies of HIV will be defective and unable to infect other CD4+ cells.
Fusion Inhibitors – interferes with HIV’s ability to fuse with and enter the
host cell
HAART Therapy
Combining drugs from above categories allows them to block HIV at several
points in the replication, slowing its spread in the body
Strategy known as highly active (or highly aggressive) antiretroviral therapy
(HARRT)
Death rate has dropped because of HARRT
Initiated during acute HIV infection
Pregnancy
Post exposure health care worker, rape victims
Offered to all patients that are symptomatic
<350 CD4 or VL > 55,000 (low positives 10,000)
Barrier – failure to adhere to treatment
If patient doesn’t take medication as prescribed, virus will mutate
and become resistant to it
Complication & Altered Labs Protease
inhibitor class
Cause lipid abnormalities
Protease
inhibitors & NRTIs
Hyperinsulinemia and abnormal glucose metabolism
Lipodystrophy
syndrome (lipid abnormalities and /or body fat changes
Facial wasting or atrophy
Intrabdominal fat & fat at dorsocervial area/Visceral fat gain – body
6 shape changes Gynecomastia Other
- rare
complications
Common Opportunistic Infections (OIs) Pneumocystis
carinii pneumonia
Cytomegalovirus Mycobacterium
tuberculosis
Cryptosporidiosis Toxoplasmosis Candidiasis Histoplasmosis
Clinical Manifestations
Widespread and effect any organ system
Pneumocystis carinii pneumonia (PCP) Most common OI resulting in an AIDS diagnosis
Fungus – P carinii causes disease only in immunocompromised hosts,
invading and proliferating within pulmonary alveoli with resultant consolidation of the pulmonary parenchyma
Nonproductive (dry) cough, fever, chills, shortness of breath, dyspnea, occ.
chest pain, tachypnea, tachycardia
Treatment TMP-SMZ drug of choice
Pentamidine(Pentam 300, Nebu-Pent) nebulizer tx.
Dupsone – anti-infective, anti leprosy
Mepron – anti-infective, anti-protozal, antipneumocystic activity
Mycobacterium avium complex (MAC)
7
Group of acid-fast bacilli
Frequently causes GI tract problems for HIV-infected patients
SSx – chronic diarrhea, abdominal pain, fever, malaise, weight loss, anemia,
neutropenia, malabsorption syndrome, & obstructive jaundice
Treatment
clarithromycin (Biaxin)
azithromycin (Zithromax)
Rifabutin (Mycobutin) combined with azithromycin more effective but
costly
Nursing – teach about complicated drug therapy; help deal with
diarrhea
Tuberculosis Mycobacterium
tuberculosis occur in IV drug users & groups with high
preexisting high prevalence to TB infection Productive
cough, fever, night sweats, weight loss
Management complex - taking numerous meds which may interact with antituberculosis meds - expert consulted Rifampin Rifabutin INH, ethambutol
GI Manifestations Loss of appetite Nausea & vomiting Oral & esophageal candidiasis Chronic diarrhea Cryptoporidium muris Salmonella
8 Clostridium difficile Manage
chronic diarrhea - octreotide acetate (Sandostatin)
Candidiasis
- clotrimazole (Mycelex) oral troches or nystatin suspension
Kaposi’s Sarcoma (KS)
Most common HIV-related malignancy - disease involving endothelial layer
of blood and lymphatic vessels
Localized cutaneous lesions; disseminated disease involving multiple organ
systems
Brownish, pink to deep purple cutaneous lesions
Surgical
excision of lesions
application Radiation
of nitrogen
therapy - palliative to relieve pain
Alpha-interferon
HIV Encephalopathy Clinical
syndrome - progressive decline in cognitive, behavioral, and motor
functions SSx
- (early) memory deficits, headache, difficulty concentrating,
progressive confusion, psychomotor slowing, apathy and ataxia Later
stages - global cognitive impairments, delay in verbal responses, a
vacant state, spastic paraparesis, hyperreflexia,psychosis, hallucination, tremors, incontinence, seizures, mutism & death
AIDS – dementia complex (ADC)
Dementia that accompanies final stage of AIDS
Caused by HIV infection in brain, or HIV related CNS problems caused by
lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, PML, dehydration or drug SE
9
SSx – decreased ability to concentrate, apathy, depression, inattention,
forgetfulness, social withdrawal, personality changes, insomnia, confusion, hallucinations, slowed response rates, clumsiness and ataxia
Progresses – global dementia, paraplegia, incontinence and coma
Nursing intervention – focus on safety; issues r/t assistance devices, home
environment, and smoking; encourage self-care as long as possible & help caregiver
Cryptocococcal meningitis
Fungal infection
Fever, headache, malaise, stiff neck, nausea & vomiting, mental status
changes, seizures IV
amphotericin B
flucytosine
or Diflucan
Cytomegalovirus Retinitis (CMV) Leading Blurred Oral
cause of blindness - retinal lesions
or loss of vision, floaters
ganciclovir - prophylaxis with T-cell counts less than 50
foscarnet Does
(Foscavir) -
not kill the virus but control growth - requires lifelong tx
Depressive Manifestation Multifactorial May
causes
experience irrational guilt and shame, loss of self-esteem, feeling of
helplessness and worthlessness, and suicidal ideation Psychotherapy Antidepressants
imipramine (Tofranil
fluoxetine (Prozac)
10 desipramine (Norpramin)
Relieve fatigue & lethargy
Skin Manifestations OIs
- herpes zoster & herpes simplex - painful vesicles disrupt skin integrity
Seborrheic
dermatitis - indurated, diffuse, scaly rash involving scalp & face
Generalized
folliculitis - dry,flaking skin or atopic dermatitis (eczema or
psoriasis) Gynecologic Manifestations Persistent,
recurrent vaginal candidiasis - first sign in HIV infection in
women Ulcerative
STDs - chancroid syphilis, herpes more severe in women
PID
Older Adults & HIV
Seniors are a growing segment pf the HIV + population and AIDS diagnoses
among seniors are on the rise
Between 11 and 15% of U.S. AIDS cases occur in people over age 50
Referred to as an “overlooked epidemic” and “forgotten population”
Older adults do not use condom; view as means of unneeded birth control &
do not consider themselves at risk
Modes of transmission identical as for other age groups
Teach safe sex practices to prevent sexually transmitted diseases
Nursing Care Very
challenging – organ system target for infection & Cancer
Complicated
by emotional, social & ethical issues
Refer
to Table 14-10, pg. 277 (Lewis) Nursing Dx
Refer
to Table 14-11, pg. 278 (Lewis) interventions
11
Prevention of HIV Infection
Effective educational program to eliminate & reduce risk behaviors
Safer sexual practices – use of latex or non-latex condoms during vaginal &
anal intercourse, and oral contact with penis
Dental Dams used for oral contact with vagina & rectum
Avoid sexual practices that might cut, tear, lining of rectum, penis or vagina
Avoid contact with multiple partners or people know HIV infection and use
injection drugs
Avoid donating blood & sharing drug equipment
Family
planning issues need to be addressed
Estrogen in oral contraceptives increase risk of HIV infection
Use estrogen in HIV + women increase shedding in vagina & cervical
secretion IUD string serves as means to transmit HIV & causes penile abrasion
Female
condom- 1st barrier method that can be controlled by women
Transmission to Health Care Providers Standard
Precautions
Applies to all patients receiving care in hospital regardless of Dx or
presumed infection status Goal – prevent transmission of nosocominal infection
Refer to chart 52-3 pg. 1551
Transmission
Base Precautions
Used for pt with documented or suspected infections
Airborne precautions
Droplet precautions
Contact precautions
2000
Needlestick Injury & Prevention Act
12
Nursing Interventions
Promoting skin integrity Assess
Balance rest and mobility
Immobile – turn Q 2 hrs
Pressure relieving devices; low air loss beds (Clinitron)
Avoid scratching & nonabrasive soaps
Medicated lotions, ointments & dressings
Avoid adhesive tape
Regular oral care
Perianal area – clean after each BM; soft cloth or sponge less irritating;
Sitz bath or gentle irrigation Wounds cultured for infection
Promoting bowel habits
Assess for diarrhea
Monitor frequency & consistency of stools & report abdominal pain &
cramping
Measure quantity & volume of liquid stools
Obtain stool cultures
Oral fluid restriction (NPO) acute inflammation
Avoid foods that act as irritants, i.e. raw fruits & vegetables, popcorn,
carbonated beverages, spicy foods, and foods extreme temperature
Small frequent meals – prevent abdominal distention
Administer anticholinergic antispasmodics or opioids which decrease
diarrhea by decreasing intestinal spasms & motility
Antibiotics & antifungal Rx to combat pathogens (stool cultures)
Preventing Infection Monitor
for SSx infection; fever, chills, night sweats, cough with or without
13 sputum production; SOB; difficulty breathing, oral pain or difficulty swallowing… Monitor Obtain Avoid
labs, CBC with differential
culture specimens as ordered
others with active infections i.e. upper respiratory infection
Maintaining thought process
Assess alteration in mental status
Speak to patient in simple, clear language & give pt time to respond to
questions
Orient to daily routines
Provide regular daily schedule for med administration, grooming meal
times, bedtimes, and awakening
Provide nightlights
Remain calm, not to argue with the patient while protecting patient from
injury
Sitter – around the clock supervision
Activity intolerance Monitor
ability to ambulate and perform ADLs
Balance
activity & rest
Personal
items kept within pt’s reach
Relaxation
and guided imagery beneficial to decrease anxiety which
contributes to weakness and fatigue Collaborate
with Health care team
Fatigue R/T anemia – administer Epogen as ordered
Relieving pain and discomfort
Assess pain quality and severity associated with impaired perianal skin
14 integrity, KS lesions, peripheral neuropathy
Keeping perianal area clean – promote comfort
Soft cushions or foam pads
Pain from KS – described as sharp, throbbing pressure & heaviness if
lymphedema present
Pain management – NSAIDS and opioids + nonpharmacological approach
(relaxation techniques)
NSAIDS + zidovudine – monitor hepatic & hematologic status
Pain R/T peripheral neuropathy – burning, numbness, & “pins & needles” Opioids, tricyclic antidepressants, gabapentin (Neurontin), elastic
compression stockings
Nutritional Status
Monitor weight, dietary intake; anthropometric measurements, serum
albumin, BUN, protein, and transferrin levels
Control nausea & vomiting – adm antiemetic
Inadequate intake from pain caused by mouth sores or sore throat
administer Opioids; Viscous lidocaine – rinse and swallow
Eat foods easy to swallow
Provide oral care before and after eating
Encourage rest before eating
Avoid fiber rich foods or lactose if lactose intolerant
Add eggs, butter, margarine, and fortified milk to gravies, soups or
milkshakes to provide additional calories & protein
Supplement – puddings, powders, milkshakes
Advera – nutritional supplement designed for people with HIV infection or
AIDS
May require enteral or parenteral nutrition
Decreasing sense of Isolation
15
AIDS patients at risk for double stigmatization – “dread disease” & lifestyle
considered unacceptable
Overwhelmed with emotions like anxiety, guilt, shame and fear
Multiple losses
Guilt R/T lifestyle & having infected someone else
Anger toward sexual partner who transmitted virus
Infection control measures used further contribute to emotional isolation
Nurse provide atmosphere of acceptance and understanding
Nonjudegmental, establish trusting relationship
Allow verbalization of feelings of isolation and loneliness
Assure that feelings are not unique or abnormal
Therapeutic touch
Spirituality – assess spiritual needs; provide spiritual support; resources –
Chaplin, Minister
Coping with Grief Anticipatory Help
grief
patients verbalize feelings and explore and identify resources for
support and ways of coping Encourage Use
contact with family and friends, coworkers
local and national AIDS support groups and hotlines, chatline
Continue Mental
activities whenever possible
health consult
Monitor for Complications Immunosuppressed Impaired Wasting
– at risk for OIs
breathing major complication
syndrome and fluid & electrolyte imbalance & dehydration
common complication Cachexia
– state of ill health, malnutrition, wasting
Antiretroviral
drugs can cause severe toxic effects & concurrent use with
16 many other meds
Terminal Care Nursing
Care should focus on
Keeping patient comfortable
Facilitate emotional and spiritual acceptance of death
Help pt & pt significant other deal with grief and loss
Choose terminal care at home (Hospice Care)
Refer to Chapter 10 End-of-live care
Physical Care – See Table 10-8, pg. 170-171
Resources www.aidaction.org www.aidinfonet.org www.anacnet.org http://hab.hrsa.gov www.napwa.org www.nmac.org www.dhh.state.la.us www.oph.state.la.us
17
Human Im mun od ef ic ie nc y Vi rus Ba si c Pri nc ipl es o f Gen etic s Transmission of HIV
Exchange of blood or other body fluids containing HIV (blood, semen,
vaginal secretions & breast milk) i.e. unprotected sex or by sharing needles
HIV- infected individuals can transmit HIV within a few days after becoming
infected; transmit ability lifelong
Sexual contact with an HIV-infected partner – 75% cases (most common
mode of transmission)
Accidental needle sticks, needle sharing among IV drug users
Perinatal Transmission (most common route for infecting children) –
HIV- infected mother to her infant occur during pregnancy in utero or at time of delivery or after birth through breastfeeding
Pathophysiology (Natural Hx of HIV) HIV
is a ribonucleic acid (RNA) virus (retroviruses – replicate in a
“backward” manner going from RNA to deoxyribonucleic acid (DNA); reverse flow of genetics)
Must have living cell to replicate; T lymphocytes (T4 or CD4 cells) (invade
living host cell)
HIV life cycle
1. HIV binds to the T cells (CD4 lymphocytes, T4 cells, Helper T cells)
2. Viral RNA is released into the host cell
3. Reverse transcriptase converts viral RNS into Viral DNA
4. Viral DNA enters the T cell’s nucleus and inserts itself into the T cell’s
DNA 5.
The T cells begins to make copies of the HIV components.
6.
Protease (enzyme) helps create new virus particles
2 7.
The new virion (virus particle is released from the T cell
Clinical Manifestations
Refer to fig 14-4, pg. 267 typical course of untreated HIV
Early Stage -First phase of HIV infection; As virus begins to replicate
person develops an acute retroviral syndrome/primary HIV infection (PHI) Period of time between initial exposure to virus & appearance of HIV
antibodies No test can detect antibodies in early stage
Fast and furious – amount of virus in peripheral blood increased greater
then 100,000 copies/ml Like Van Diesel movie fast and furious – amount of virus in peripheral
blood increased greater than 100,000 copies/ml Body starts to produce antibodies
Flu like symptoms
Second Phase of HIV infection SSx of PHI resolve
Viral load decreases
Seroconversion occurs
Chronic infection Patient seems well ( no clinical apparent disease)
Virus is busy replicating itself and spreading to uninfected cells
If no treatment – loose T cells – HIV associated infections
Symptomatic HIV infection T-cell count continues to decline
Patient develops a symptomatic infection (pneumocystis pneumonia
(PCP) or candidiasis) HIV infection Dx at this stage
3 HIV-associated illnesses appear
Acquired immunodeficiency syndrome (AIDS) Meets definition of AIDS established by US center for disease control and
prevention (CDC) HIV+ & have CD4 cell ct below 200/mm
HIV+ & have AIDS defining illness
Diagnostic Studies
Most useful screening tests are those that detect HIV-specific antibodies
Problem – median delay of 2 months after infection before antibodies can be
detected
Health care providers alerted to do HIV screening based on sexual practices,
IV drug use, receipt of blood transfusions, exposure to body fluid (needlestick)
HIV antibody testing Requires education & counseling – meaning of test & possible results
Informed consent
Privacy
Test results kept confidential
Diagnostic Studies OralQuick
Rapid HIV-1 – (2002)
Antibody test allow rapid notification of individuals
Accurate results in 20 minutes
Uni-Gold
Recombigen (Dec 2003)
Results in 10 minutes
Oral
Quick Rapid HIV – ½ Antibody test (March 2004)
99% accurate; results in 20 mins; saliva specimen
4
EIA (enzyme immunoassay) formerly ELISA (enzyme linked
immunosorbent assay) Detect serum antibodies that bind to HIV antigen
Serum & saliva
Western Blot or immunofluorescence Assay (IFA) More specifically confirms HIV
Viral Load test Measure plasma HIV RNA level
Used to track viral load & response to tx for HIV infection
CD4 T-cell count to monitor progression of the infection
WBC count, RBC count, and platelets decrease with progression of HIV
Collaborative Care (Rapidly Changing)
Protocols change often
Treat for life
Highly Active Antiretroviral Therapy (HAART) /Antiretroviral (ARV) regimen
Treatment based on HIV RNA (viral load)
CD4T cell count
Clinical condition of patient
Refer to table 14-6 & 14-7, pg. 273-275 (Lewis)
Antiretroviral regimens are complex, major side effects, adherence difficult,
carry serious potential consequences from viral resistance r/t lack of adherence or suboptimal levels of antiretroviral agents
Drug Therapy
Nonnucleoside reverse transcriptase inhibitors (NNRTIs) – attach to
the reverse transcriptase enzyme, preventing the enzyme from converting HIV RNA to DNA
Nucleoside reverse transcriptase inhibitors (NRTIs) become part of
HIV’s DNA and derail its building process. (damaged DNA can’t take control of the cell’s DNA)
5
Protease inhibitors work at later stage in replication process, preventing
the protease enzyme from cutting HIV viral proteins into the virions that infect new CD4+ cells (new copies of HIV will be defective and unable to infect other CD4+ cells.
Fusion Inhibitors – interferes with HIV’s ability to fuse with and enter the
host cell
HAART Therapy
Combining drugs from above categories allows them to block HIV at several
points in the replication, slowing its spread in the body
Strategy known as highly active (or highly aggressive) antiretroviral therapy
(HARRT)
Death rate has dropped because of HARRT
Initiated during acute HIV infection
Pregnancy
Post exposure health care worker, rape victims
Offered to all patients that are symptomatic
<350 CD4 or VL > 55,000 (low positives 10,000)
Barrier – failure to adhere to treatment
If patient doesn’t take medication as prescribed, virus will mutate
and become resistant to it
Complication & Altered Labs Protease
inhibitor class
Cause lipid abnormalities
Protease
inhibitors & NRTIs
Hyperinsulinemia and abnormal glucose metabolism
Lipodystrophy
syndrome (lipid abnormalities and /or body fat changes
Facial wasting or atrophy
Intrabdominal fat & fat at dorsocervial area/Visceral fat gain – body
6 shape changes Gynecomastia Other
- rare
complications
Common Opportunistic Infections (OIs) Pneumocystis
carinii pneumonia
Cytomegalovirus Mycobacterium
tuberculosis
Cryptosporidiosis Toxoplasmosis Candidiasis Histoplasmosis
Clinical Manifestations
Widespread and effect any organ system
Pneumocystis carinii pneumonia (PCP) Most common OI resulting in an AIDS diagnosis
Fungus – P carinii causes disease only in immunocompromised hosts,
invading and proliferating within pulmonary alveoli with resultant consolidation of the pulmonary parenchyma
Nonproductive (dry) cough, fever, chills, shortness of breath, dyspnea, occ.
chest pain, tachypnea, tachycardia
Treatment TMP-SMZ drug of choice
Pentamidine(Pentam 300, Nebu-Pent) nebulizer tx.
Dupsone – anti-infective, anti leprosy
Mepron – anti-infective, anti-protozal, antipneumocystic activity
Mycobacterium avium complex (MAC)
7
Group of acid-fast bacilli
Frequently causes GI tract problems for HIV-infected patients
SSx – chronic diarrhea, abdominal pain, fever, malaise, weight loss, anemia,
neutropenia, malabsorption syndrome, & obstructive jaundice
Treatment
clarithromycin (Biaxin)
azithromycin (Zithromax)
Rifabutin (Mycobutin) combined with azithromycin more effective but
costly
Nursing – teach about complicated drug therapy; help deal with
diarrhea
Tuberculosis Mycobacterium
tuberculosis occur in IV drug users & groups with high
preexisting high prevalence to TB infection Productive
cough, fever, night sweats, weight loss
Management complex - taking numerous meds which may interact with antituberculosis meds - expert consulted Rifampin Rifabutin INH, ethambutol
GI Manifestations Loss of appetite Nausea & vomiting Oral & esophageal candidiasis Chronic diarrhea Cryptoporidium muris Salmonella
8 Clostridium difficile Manage
chronic diarrhea - octreotide acetate (Sandostatin)
Candidiasis
- clotrimazole (Mycelex) oral troches or nystatin suspension
Kaposi’s Sarcoma (KS)
Most common HIV-related malignancy - disease involving endothelial layer
of blood and lymphatic vessels
Localized cutaneous lesions; disseminated disease involving multiple organ
systems
Brownish, pink to deep purple cutaneous lesions
Surgical
excision of lesions
application Radiation
of nitrogen
therapy - palliative to relieve pain
Alpha-interferon
HIV Encephalopathy Clinical
syndrome - progressive decline in cognitive, behavioral, and motor
functions SSx
- (early) memory deficits, headache, difficulty concentrating,
progressive confusion, psychomotor slowing, apathy and ataxia Later
stages - global cognitive impairments, delay in verbal responses, a
vacant state, spastic paraparesis, hyperreflexia,psychosis, hallucination, tremors, incontinence, seizures, mutism & death
AIDS – dementia complex (ADC)
Dementia that accompanies final stage of AIDS
Caused by HIV infection in brain, or HIV related CNS problems caused by
lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, PML, dehydration or drug SE
9
SSx – decreased ability to concentrate, apathy, depression, inattention,
forgetfulness, social withdrawal, personality changes, insomnia, confusion, hallucinations, slowed response rates, clumsiness and ataxia
Progresses – global dementia, paraplegia, incontinence and coma
Nursing intervention – focus on safety; issues r/t assistance devices, home
environment, and smoking; encourage self-care as long as possible & help caregiver
Cryptocococcal meningitis
Fungal infection
Fever, headache, malaise, stiff neck, nausea & vomiting, mental status
changes, seizures IV
amphotericin B
flucytosine
or Diflucan
Cytomegalovirus Retinitis (CMV) Leading Blurred Oral
cause of blindness - retinal lesions
or loss of vision, floaters
ganciclovir - prophylaxis with T-cell counts less than 50
foscarnet Does
(Foscavir) -
not kill the virus but control growth - requires lifelong tx
Depressive Manifestation Multifactorial May
causes
experience irrational guilt and shame, loss of self-esteem, feeling of
helplessness and worthlessness, and suicidal ideation Psychotherapy Antidepressants
imipramine (Tofranil
fluoxetine (Prozac)
10 desipramine (Norpramin)
Relieve fatigue & lethargy
Skin Manifestations OIs
- herpes zoster & herpes simplex - painful vesicles disrupt skin integrity
Seborrheic
dermatitis - indurated, diffuse, scaly rash involving scalp & face
Generalized
folliculitis - dry,flaking skin or atopic dermatitis (eczema or
psoriasis) Gynecologic Manifestations Persistent,
recurrent vaginal candidiasis - first sign in HIV infection in
women Ulcerative
STDs - chancroid syphilis, herpes more severe in women
PID
Older Adults & HIV
Seniors are a growing segment pf the HIV + population and AIDS diagnoses
among seniors are on the rise
Between 11 and 15% of U.S. AIDS cases occur in people over age 50
Referred to as an “overlooked epidemic” and “forgotten population”
Older adults do not use condom; view as means of unneeded birth control &
do not consider themselves at risk
Modes of transmission identical as for other age groups
Teach safe sex practices to prevent sexually transmitted diseases
Nursing Care Very
challenging – organ system target for infection & Cancer
Complicated
by emotional, social & ethical issues
Refer
to Table 14-10, pg. 277 (Lewis) Nursing Dx
Refer
to Table 14-11, pg. 278 (Lewis) interventions
11
Prevention of HIV Infection
Effective educational program to eliminate & reduce risk behaviors
Safer sexual practices – use of latex or non-latex condoms during vaginal &
anal intercourse, and oral contact with penis
Dental Dams used for oral contact with vagina & rectum
Avoid sexual practices that might cut, tear, lining of rectum, penis or vagina
Avoid contact with multiple partners or people know HIV infection and use
injection drugs
Avoid donating blood & sharing drug equipment
Family
planning issues need to be addressed
Estrogen in oral contraceptives increase risk of HIV infection
Use estrogen in HIV + women increase shedding in vagina & cervical
secretion IUD string serves as means to transmit HIV & causes penile abrasion
Female
condom- 1st barrier method that can be controlled by women
Transmission to Health Care Providers Standard
Precautions
Applies to all patients receiving care in hospital regardless of Dx or
presumed infection status Goal – prevent transmission of nosocominal infection
Refer to chart 52-3 pg. 1551
Transmission
Base Precautions
Used for pt with documented or suspected infections
Airborne precautions
Droplet precautions
Contact precautions
2000
Needlestick Injury & Prevention Act
12
Nursing Interventions
Promoting skin integrity Assess
Balance rest and mobility
Immobile – turn Q 2 hrs
Pressure relieving devices; low air loss beds (Clinitron)
Avoid scratching & nonabrasive soaps
Medicated lotions, ointments & dressings
Avoid adhesive tape
Regular oral care
Perianal area – clean after each BM; soft cloth or sponge less irritating;
Sitz bath or gentle irrigation Wounds cultured for infection
Promoting bowel habits
Assess for diarrhea
Monitor frequency & consistency of stools & report abdominal pain &
cramping
Measure quantity & volume of liquid stools
Obtain stool cultures
Oral fluid restriction (NPO) acute inflammation
Avoid foods that act as irritants, i.e. raw fruits & vegetables, popcorn,
carbonated beverages, spicy foods, and foods extreme temperature
Small frequent meals – prevent abdominal distention
Administer anticholinergic antispasmodics or opioids which decrease
diarrhea by decreasing intestinal spasms & motility
Antibiotics & antifungal Rx to combat pathogens (stool cultures)
Preventing Infection Monitor
for SSx infection; fever, chills, night sweats, cough with or without
13 sputum production; SOB; difficulty breathing, oral pain or difficulty swallowing… Monitor Obtain Avoid
labs, CBC with differential
culture specimens as ordered
others with active infections i.e. upper respiratory infection
Maintaining thought process
Assess alteration in mental status
Speak to patient in simple, clear language & give pt time to respond to
questions
Orient to daily routines
Provide regular daily schedule for med administration, grooming meal
times, bedtimes, and awakening
Provide nightlights
Remain calm, not to argue with the patient while protecting patient from
injury
Sitter – around the clock supervision
Activity intolerance Monitor
ability to ambulate and perform ADLs
Balance
activity & rest
Personal
items kept within pt’s reach
Relaxation
and guided imagery beneficial to decrease anxiety which
contributes to weakness and fatigue Collaborate
with Health care team
Fatigue R/T anemia – administer Epogen as ordered
Relieving pain and discomfort
Assess pain quality and severity associated with impaired perianal skin
14 integrity, KS lesions, peripheral neuropathy
Keeping perianal area clean – promote comfort
Soft cushions or foam pads
Pain from KS – described as sharp, throbbing pressure & heaviness if
lymphedema present
Pain management – NSAIDS and opioids + nonpharmacological approach
(relaxation techniques)
NSAIDS + zidovudine – monitor hepatic & hematologic status
Pain R/T peripheral neuropathy – burning, numbness, & “pins & needles” Opioids, tricyclic antidepressants, gabapentin (Neurontin), elastic
compression stockings
Nutritional Status
Monitor weight, dietary intake; anthropometric measurements, serum
albumin, BUN, protein, and transferrin levels
Control nausea & vomiting – adm antiemetic
Inadequate intake from pain caused by mouth sores or sore throat
administer Opioids; Viscous lidocaine – rinse and swallow
Eat foods easy to swallow
Provide oral care before and after eating
Encourage rest before eating
Avoid fiber rich foods or lactose if lactose intolerant
Add eggs, butter, margarine, and fortified milk to gravies, soups or
milkshakes to provide additional calories & protein
Supplement – puddings, powders, milkshakes
Advera – nutritional supplement designed for people with HIV infection or
AIDS
May require enteral or parenteral nutrition
Decreasing sense of Isolation
15
AIDS patients at risk for double stigmatization – “dread disease” & lifestyle
considered unacceptable
Overwhelmed with emotions like anxiety, guilt, shame and fear
Multiple losses
Guilt R/T lifestyle & having infected someone else
Anger toward sexual partner who transmitted virus
Infection control measures used further contribute to emotional isolation
Nurse provide atmosphere of acceptance and understanding
Nonjudegmental, establish trusting relationship
Allow verbalization of feelings of isolation and loneliness
Assure that feelings are not unique or abnormal
Therapeutic touch
Spirituality – assess spiritual needs; provide spiritual support; resources –
Chaplin, Minister
Coping with Grief Anticipatory Help
grief
patients verbalize feelings and explore and identify resources for
support and ways of coping Encourage Use
contact with family and friends, coworkers
local and national AIDS support groups and hotlines, chatline
Continue Mental
activities whenever possible
health consult
Monitor for Complications Immunosuppressed Impaired Wasting
– at risk for OIs
breathing major complication
syndrome and fluid & electrolyte imbalance & dehydration
common complication Cachexia
– state of ill health, malnutrition, wasting
Antiretroviral
drugs can cause severe toxic effects & concurrent use with
16 many other meds
Terminal Care Nursing
Care should focus on
Keeping patient comfortable
Facilitate emotional and spiritual acceptance of death
Help pt & pt significant other deal with grief and loss
Choose terminal care at home (Hospice Care)
Refer to Chapter 10 End-of-live care
Physical Care – See Table 10-8, pg. 170-171
Resources www.aidaction.org www.aidinfonet.org www.anacnet.org http://hab.hrsa.gov www.napwa.org www.nmac.org www.dhh.state.la.us www.oph.state.la.us
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