Student Hiv 08

Slide 1

___________________________________ Human Immunodeficiency Virus

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 2

___________________________________ Transmission of HIV 

 

 

Exchange of blood or other body fluids containing HIV (blood, semen, vaginal & cervical secretions & breast milk, and cerebrospinal fluid (CSF) ) 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 (anal, vaginal, oral) with an HIVinfected 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 3

___________________________________ 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)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 4

___________________________________ Clinical Manifestations  

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  Body starts to produce antibodies  Flu like symptoms

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 5

___________________________________ Clinical Manifestations (cont.) 

Second Phase of HIV infection   



SSx of PHI resolve Viral load decreases Seroconversion occurs ( converting from HIV negative to HIV positive)

Seroconversion The process by which a newly infected person develops antibodies to HIV. These antibodies are then detectable by an HIV test. Seroconversion may occur anywhere from days to weeks or months following HIV infection. (CDC definition)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 6

___________________________________ Clinical Manifestations (cont.) 

Chronic infection  Patient

seems well ( no clinical apparent disease) is busy replicating itself and spreading to uninfected cells  If no treatment – loose T cells – HIV associated infections  Virus

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 7

___________________________________ Clinical Manifestations (cont.) 

 

 



___________________________________

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 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 or less than 14% of all lymphocytes HIV+ & have AIDS defining illness

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 8

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 9

___________________________________ Diagnostic Studies 







Antibody test allow rapid notification of individuals Accurate results in 20 minutes

Uni-Gold Recombigen (Dec 2003) 



___________________________________

OralQuick Rapid HIV-1 – (2002)

Results in 10 minutes

Oral Quick Rapid HIV – ½ Antibody test (March 2004) 

99% accurate; results in 20 mins; saliva specimen

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 10

___________________________________ Diagnostic Studies 

EIA (enzyme immunoassay) formerly ELISA (enzyme linked immunosorbent assay)



Western Blot or immunofluorescence Assay (IFA)



Viral Load test

 

  

 

Detect serum antibodies that bind to HIV antigen Serum & saliva

___________________________________ ___________________________________

More specifically confirms HIV

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

___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 11

___________________________________ 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

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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 12

___________________________________ 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) 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 13

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 14

___________________________________ Common Opportunistic Infections (OIs) 

Pneumocystis carinii pneumonia  Cytomegalovirus  Mycobacterium tuberculosis  Toxoplasmosis  Candidiasis

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 15

___________________________________ 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, breath sounds may initially be normal, sputum may be present Treatment    

TMP-SMZ drug of choice Pentamidine(Pentam 300, Nebu-Pent) nebulizer tx. Dupsone – anti-infective, anti leprosy Mepron – anti-infective, antiprotozal, antipneumocystic activity

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 16

Mycobacterium avium complex (MAC)  

 



Group of acid-fast bacilli Occurs late in course of disease CD4 count less then 50 Major cause of “wasting syndrome” Frequently causes GI tract problems for HIV-infected patients SSx – chronic diarrhea, abdominal pain, chills 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 17

___________________________________ Tuberculosis 



Mycobacterium tuberculosis occur in IV drug users & groups with high preexisting high prevalence to TB infection Productive cough, purulent sputum, fever, fatigue, night sweats, weight loss, lymphadenopathy

___________________________________ Management complex taking numerous meds which may interact with antituberculosis meds - expert consulted Rifampin Rifabutin INH, ethambutol

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 18

___________________________________ GI Manifestations Loss of appetite Nausea & vomiting Oral & esophageal candidiasis Chronic diarrhea Salmonella Clostridium difficile

___________________________________  Manage

chronic diarrhea octreotide acetate (Sandostatin)  Candidiasis clotrimazole (Mycelex) oral troches or nystatin suspension

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 19

___________________________________ Kaposi’s Sarcoma (KS) 





Most common HIVrelated 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 of nitrogen Radiation therapy - palliative to relieve pain Alpha-interferon

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 20

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 21

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 22

AIDS – dementia complex (ADC) & Neurologic Effect  



  

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 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 Sensory neuropathies – numbness, tingling and pain in lower extremities; progress to weakness and paralysis Nursing intervention – focus on safety; issues r/t assistance devices, home environment, and smoking; encourage self-care as long as possible & help caregiver

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 23

___________________________________ Cryptocococcal meningitis  

Fungal infection Fever, headache, malaise, stiff neck, nausea & vomiting, mental status changes, seizures

 

IV amphotericin B flucytosine or Diflucan

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 24

___________________________________ Cytomegalovirus Retinitis (CMV) 

 

 

Leading cause of blindness - retinal lesions Blurred or loss of vision, floaters Oral ganciclovir - prophylaxis with T-cell counts less than 50 foscarnet (Foscavir) Does not kill the virus but control growth - requires lifelong tx

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 25

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 26

___________________________________ Depressive Manifestation 



Multifactorial causes May experience irrational guilt and shame, loss of self-esteem, feeling of helplessness and worthlessness, and suicidal ideation

 

Psychotherapy Antidepressants 

 



imipramine (Tofranil fluoxetine (Prozac) desipramine (Norpramin) Relieve fatigue & lethargy

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 27

___________________________________ 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)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 28

___________________________________ Skin Manifestations

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 29

___________________________________ Gynecologic Manifestations 



 

Persistent, recurrent vaginal candidiasis - first sign in HIV infection in women Ulcerative STDs - chancroid syphilis, herpes more severe in women PID Cervical Cancer

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 30

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 31

___________________________________ Nursing Care 



___________________________________

Very challenging – organ system target for infection & Cancer Complicated by emotional, social & ethical issues

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 32

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 33

___________________________________ Prevention of HIV Infection 

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

1st

Female condombarrier method that can be controlled by women

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 34

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

Transmission Base Precautions    

Used for pt with documented or suspected infections Airborne precautions Droplet precautions Contact precautions

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 35

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 36

___________________________________ 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)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 37

___________________________________ Preventing Infection 

  

Monitor for SSx infection; fever, chills, night sweats, cough with or without sputum production; SOB; difficulty breathing, oral pain or difficulty swallowing… Monitor labs, CBC with differential Obtain culture specimens as ordered Avoid others with active infections i.e. upper respiratory infection

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 38

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 39

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 40

___________________________________ Relieving pain and discomfort 

     

Assess pain quality and severity associated with impaired perianal skin 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 41

___________________________________ 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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 42

___________________________________ Decreasing sense of Isolation            

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

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 43

___________________________________ Coping with Grief  

   

Anticipatory grief Help patients verbalize feelings and explore and identify resources for support and ways of coping Encourage contact with family and friends, coworkers Use local and national AIDS support groups and hotlines, chatline Continue activities whenever possible Mental health consult

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 44

___________________________________ Monitor for Complications   

 

Immunosuppressed – at risk for OIs Impaired breathing major complication Wasting 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 many other meds

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Slide 45

___________________________________ Terminal Care 

Nursing Care should focus on  Keeping

patient comfortable emotional and spiritual acceptance of death  Help pt & pt significant other deal with grief and loss  Choose terminal care at home (Hospice Care)  Facilitate

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________