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Chapter 52 Management of Patients With HIV Infection and AIDS. Transmission of HIV. Transmitted by body fluids containing HIV or infected CD4 lymphocytes Blood, seminal fliud, vaginal secretions, amniotic fluid, and breast milk Most prenatal infections occur during delivery
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Chapter 52Management of Patients With HIV Infection and AIDS
Transmission of HIV • Transmitted by body fluids containing HIV or infected CD4 lymphocytes • Blood, seminal fliud, vaginal secretions, amniotic fluid, and breast milk • Most prenatal infections occur during delivery • Casual contact does not cause transmission • Breaks in skin and mucosa increase risk
High-Risk Behaviors • Sharing infected injection equipment • Having sexual relations with infected individuals
Prevention • Standard precautions: see Chart 52-4 • Practice safer sex practices and safer behaviors • Abstain from sharing sexual fluids • Reduce the number of sexual partners to one • Always use latex condoms; if allergic to latex, use nonlatex condoms • See Chart 52-2 • Do not share drug injection equipment • Blood screening and treatment of blood products
Stages of HIV Disease • Primary infection • HIV asymptomatic • HIV symptomatic • AIDS • See Table 52-1
Primary Infection • Acute HIV infection/acute HIV syndrome • Part of CDC category A • Symptoms: none to flu-like syndrome • Window period: lack of HIV antibodies • Period of rapid viral replication and dissemination through the body • Viral set point: balance between amount of HIV and the immune response
HIV Asymptomatic • CDC category A • More than 500 CD4+ T lymphpocytes/mm3 • Upon reaching the viral set point, chronic asymptomatic state begins • Body has sufficient immune response to defend against pathogens
HIV Symptomatic • CDC category B • 200 to 499 CD4+ lymphpocytes/mm3 • CD4 T cells gradually fall • The patient develops symptoms or conditions related to the HIV infection that are not classified as category C conditions • Patients who are once treated for a category B condition are considered category B
AIDS • CDC category C • Less than 200 CD4+ lymphocytes/mm3 • As levels drop below 100 cells/mm3, the immune system is significantly impaired • Development of listed conditions
Treatment • Treatment and protocols are continually evolving • Antiretroviral agents: see Table 52-3 • Nucleoside reverse transcriptase inhibitors (NRTIs) • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) • Protease inhibitors (PIs) • Fusion inhibitors • Use of combination therapy • Management focuses upon the treatment of specific manifestations and conditions related to the disease
Manifestations of AIDS—Respiratory • Pneumocystis carinii pneumonia (PCP) • Most common infection • Initial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain • If untreated, progresses to pulmonary impairment and respiratory failure • Treatment: TMP-SMZ or pentamidine; prophylactic TMP-SMZ • Mycobacterium avium complex (MAC) • Tuberculosis
Manifestations of AIDS—GI • Oral candidiasis • May progress to esophagus and stomach • Treatment with Mycelex troches or nystatin and ketoconazole • Diarrhea related to HIV infection or enteric pathogens • Octreotide acetate for severe chronic diarrhea • Wasting syndrome • 10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other cause • Protein energy malnutrition • Anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute
Manifestations of AIDS—Oncologic • Kaposi's sarcoma • Cutaneous lesions but may involve multiple organ systems • Lesions cause discomfort, disfigurement, ulceration, and potential for infection • B cell lymphomas
Manifestations of AIDS—Neurologic • HIV encephalopathy • Progressive cognitive, behavioral, and motor decline • Probably directly related to the HIV infection • Cryptococcus neoformans • Other neurologic disorders • Depression
Nursing Process—Assessment of the Patient With AIDS • Assess physical and psychosocial status • Identify potential risk factors: IV drug abuse and risky sexual practices • Assess immune system function • Assess nutritional status • Assess skin integrity • Assess respiratory status and neurologic status • Assess fluid and electrolyte balance • Assess knowledge level
Nursing Process—Diagnosis of the Patient With AIDS • Impaired skin integrity • Diarrhea • Risk for infection • Activity intolerance • Disturbed thought processes • Ineffective airway clearance • Pain • Imbalanced nutrition • Social isolation • Anticipatory grieving • Deficient knowledge
Collaborative Problems/Potential Complications • Opportunistic infections • Impaired breathing or respiratory failure • Wasting syndrome • Fluid and electrolyte imbalance • Adverse reaction to medication
Nursing Process—Planning the Care of the Patient With AIDS • Goals may include: • Achievement and maintenance of skin integrity • Resumption of usual bowel patterns • Absence of infection • Improved activity tolerance • Improved thought processes • Improved airway clearance
Nursing Process—Planning the Care of the Patient With AIDS (cont.) • Goals may include (cont.) • Increased comfort • Improved nutritional status • Increased socialization • Expression of grief • Increased knowledge regarding disease prevention and self-care • Absence of complications
Skin Integrity • Conduct frequent routine assessment of skin and mucosa • Encourage patient to maintain balance between rest and activity • Reposition at least every two hours and as needed • Use pressure reduction devices • Instruct patient to avoid scratching • Use gentle, nondrying soaps or cleansers • Avoid adhesive tape • Provide perianal skin care
Promoting Usual Bowel Pattern • Assess bowel pattern and factors that may exacerbate diarrhea • Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperatures • Small, frequent meals • Administer medications as prescribed • Assess and promote self-care strategies to control diarrhea
Activity Intolerance • Maintain balance between activity and rest • Instruction regarding energy conservation techniques • Relaxation measures • Collaboration with other members of the health care team
Maintaining Thought Processes • Assess mental and neurologic status • Use clear, simple language if mental status is altered • Establish and maintain a daily routine • Use orientation techniques • Ensure patient safety and protect from injury • Implement strategies to maintain and improve functional ability • Instruct and involve family in communication and care
Nutrition • Monitor weight, I&O, dietary intake, and factors that interfere with nutrition • Provide dietary consultation • Control nausea with antiemetics • Provide oral hygiene • Treat oral discomfort • Administer dietary supplements • May require enteral feedings or parenteral nutrition
Decreasing Isolation • Promote an atmosphere of acceptance and understanding • Assess social interactions and monitor behaviors • Allow patient to express feelings • Address psychosocial issues • Provide information related to the spread of infection • Educate ancillary personnel, family, and partners
Other Interventions • Improve airway clearance • Use semi-Fowler's or high-Fowler’s position • Pulmonary therapy; coughing and deep breathing; postural drainage; percussion; and vibration • Ensure adequate rest • Pain • Administer medications as prescribed • Provide skin and perianal care