Chapter 23 pp 643-650 Chapter 52 Management of Patients With HIV Infection and AIDS

1. Inflammation Unit II Lecture 3 Lee Resurreccion Chapter 23 pp 643-650 Chapter 52Management of Patients With HIV Infection and AIDS

2. Mycobacterium Tuberculosis (TB) • Infectious disease caused by Mycobacterium tuberculosis. Usually involves lungs but it also occurs in kidneys, bones, adrenal glands, lymph nodes and meninges. • Gram positive, acid-fast bacillus • Spread via airborne droplets • Can be inhaled • Repeated close contact, not highly infectious • Bacilli are inhaled, pass down bronchial system and implant on bronchioles or alveoli (lower lungs usual site)

3. Mycobacterium Tuberculosis (TB) Clinical Manifestations Free of symptoms during early stages • Cough • Becomes frequent with mucoid or mucopurulent sputum. • Dyspnea unusual • Fatigue • Malaise • Anorexia • Weight loss (late) • Low-grade fever • Night sweats

4. Mycobacterium Tuberculosis (TB) • Tuberculin skin testing (PPD or Mantoux test)) purified protein derivative • Positive 2-12 wks after initial infection • + reaction doesn’t say if dormant or active • Response to TB skin testing decreased in the immunocompromised patient; reactions equal to or greater than 5 mm are considered positive (normally 10-15 cm) • TB sensitivity is LIFELONG! • Chest X-ray: multinodular lymph node involvement, cavitation upper lobes • Bacteriologic studies: • Sputum smear • Sputum culture (MOST ACCURATE)-takes 6-8 weeks for growth • The QuantiFERON-TB Gold (QFT-G) detects TB, and is not affected by prior BCG vaccination. Results in 24 hours

5. Mycobacterium Tuberculosis (TB) • Active TB should be managed aggressively. • Standard therapy a combination of drugs. Decreases the development of resistant strains. • 6-12 months • Five drugs used: • (****Liver Effects****) • Isoniazid (INH) • Rifampin • Pyrazinamide • Streptomycin • Ethambutol

6. 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

7. High-Risk Behaviors/Prevention • Sharing infected injection equipment • Having sexual relations with infected individuals • Prevention • Standard precautions: • 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 • Do not share drug injection equipment • Blood screening and treatment of blood products

8. Structure of HIV-1

9. Life Cycle of HIV-1

10. Stages of HIV Disease • Primary infection • HIV asymptomatic • HIV symptomatic • AIDS

11. Contributing Factors for Transmission • Duration and frequency of contact • Volume of fluid • Virulence and concentration • Viral Set Point (viral load)= amount of virus in blood • Viral Set Point in the blood, semen, vaginal secretions or breast milk of the donor is an important variable • Large amounts of viral set point first 2 to 6 months after infection and during late stages of the disease • Host immune defense capability

12. T cells • T lymphocytes are made in the bone marrow (B lymphocytes) but migrate to the Thymus, hence called “T” cells • T cells compose 70-80% of circulating lymphocytes and are primarily responsible for immunity to intracellular viruses, tumor cells and fungi • Live for a few months to lifespan (a normal CD4 T cells lifespan= 100 days, one infested with HIV=2 days) • T cytotoxic- attack antigens on cell membrane of foreign pathogens and release cytotoxic substances that destroy pathogen • T suppressor (CD8) • T helper (CD4)-regulation of cell mediated immunity abdhumoral antibody response • Normal ratio of CD4 to CD8 T cells is 2 CD4 to every 1 CD8. In Later stages of HIV this reverses. • Normal CD4+ T cells: 800 to 1200/µl • Generally, immune system will stay healthy with greater than 500 /µl.

13. Viral Set Point/Viral Load

14. Table 52-1 Brunner, p.1823 • Classification System for HIV Infection and Expanded AIDS Surveillance Case Definition for Adolescents and Adults

15. 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 • Seroconversion occurs (development of HIV-specific antibodies) • Flu like symptoms, generally mild (called “acute retroviral syndrome”) • Occurs 1 to 3 weeks after infection • Lasts 1 to 2 weeks, symptoms can continue for several months • High level of HIV in the blood • CD4 T cell counts fall temporarily but return to baseline

16. 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

17. 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

18. 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

19. 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

20. Manifestations of AIDS—Respiratory • Pneumocystiscarinii 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

21. 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

22. 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

23. Lesions of Kaposi’s Sarcoma

24. 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

25. 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

26. 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

27. Collaborative Problems/Potential Complications • Opportunistic infections • Impaired breathing or respiratory failure • Wasting syndrome • Fluid and electrolyte imbalance • Adverse reaction to medication

28. 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

29. 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

30. 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

31. 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

32. Activity Intolerance • Maintain balance between activity and rest • Instruction regarding energy conservation techniques • Relaxation measures • Collaboration with other members of the health care team

33. 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

34. 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

35. 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

36. 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