Transcript HIV/AIDS

Nursing of Adults
with
Medical & Surgical Conditions
HIV & AIDS
HIV
• Human Immunodeficiency Virus
– Type 1
• Found throughout the world
• Responsible for the majority of HIV infection cases
• Usually progresses to AIDS within 10 years
– Type 2
• Found primarily to West Africa and associated
countries
• Less virulent; does not tend to progress to AIDS as
quickly as type 1
Transmission of HIV
• HIV cannot survive very long outside of the
human body
• Transmitted from human to human
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Blood
Semen
Cervicovaginal secretions
Breast milk
Transmission of HIV
• Other body fluids contain HIV
• No evidence they are capable of
transmission
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Saliva
Urine
Tears
Feces
Transmission of HIV
• Most common modes of transmission
– Sexual Transmission
• Anal or vaginal intercourse
– Parenteral Exposure
• Contaminated injecting drug equipment and
paraphernalia
• Transfusion of blood and blood products
– 1% of adult and adolescent AIDS cases
– 5% of pediatric AIDS cases
• Occupational Exposure
– Perinatal (vertical) Transmission
• Transmission from mother to child
– may occur during pregnancy, delivery, or postpartum
breastfeeding
Pathophysiology of HIV & AIDS
• Normal immune response
– Foreign antigens interact with B cells
– B cells initiate antibody development
– B cells and T cells initiate cellular immune
response
• B cells reduce virus in blood
• T cells reduce virus in lymph nodes
Pathophysiology of HIV & AIDS
• Immune Dysfunction
– T- cells or CD4+lymphocytes are destroyed by
HIV
– HIV is then able to reproduce in the lymphatic
system and eventually “spills over” into the
blood
– Decreases resistance to life-threatening
infections
• CD4 600-1200
• CD4 200-499
• CD4 below 200
normal
minor immune problems
severe immune problems
Spectrum of HIV
• Initial Exposure
• Primary HIV Infection
– Flulike symptoms
– Develop antibodies to HIV in 2 weeks to 6 months
• Asymptomatic HIV Infection
– HIV seropositivity (seroconversion)
• positive HIV antibody test
• 95% within 3 months; 99% within 6 months
– Infectious; no illness
Spectrum of HIV
• Early HIV Disease
– S/S may not appear until 10-14 years after
exposure
– Symptomatic infection
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persistent, unexplained fever
night sweats
diarrhea
weight loss
fatigue
lymphadenopathy
• Advanced HIV Disease
– AIDS
AIDS Diagnosis
• HIV positive
AND
• CD4 (T4) count below 200
OR
• One or more AIDS-Indicator Conditions
– Page 672 (category C)
Opportunistic Infections
• Table 16-6; Pages 685-687
• Most Common Opportunistic Infections
– Pneumocystis Carinii Pneumonia (PCP)
(Most common infection)
• Symptoms
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Fever
Night sweats
Productive cough
SOB
• Treatment
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Bactrim or Septra
Pentamidine
Steroids
Wear gown, mask, and gloves during patient care
Opportunistic Infections
– Kaposi’s Sarcoma
• Symptoms
– Reddish-purple spots on the skin
» overgrowth of blood vessel cells
• Treatment
– Radiation
– Chemotherapy
• Most common neoplasm found in HIV infected
patients
Opportunistic Infections
– Cytomegalovirus (CMV)
• Symptoms
– Retinitis
» blurring of vision
» spots in visual field
– Colitis
» diarrhea
» abdomial pain
» bloating
• Treatment
– Gancyclovir
– Foscarnet
Opportunistic Infections
– Cryptococcal Meningitis
• Symptoms
– Fever
– Headache
• Treatment
– Amphotericin B
– Fluconazole
Opportunistic Infections
– Toxoplasma Encephalitis
• Symptoms
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Fever
Headache
seizures
mental changes
» lethargy
» coma
• Treatment
– Pyrimethamine & folic acid
– Sulfadiazine
– Clindamyhcin
Opportunistic Infections
– Mycobacterium (Avium Complex & Tuberculosis)
• Symptoms
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Fever
Chills
Sweats
Abdominal pain
Bone pain
Fatigue
Diarrhea
Nausea
Weight loss
• Treatment
– Rifampin
– INH
– Ciprofloxacin
Diagnostic Studies
• HIV Antibody Testing
– ELISA
• Detects the presence of HIV ANTIBODIES
• If positive, ELISA is done a second time
– Western Blot
• Done if second ELISA is positive
• More sensitive than ELISA
• CD4 Lymphocyte Count
– Normally 600-1200
– Decreases as the disease progresses
• Viral Load Monitoring
Diagnostic Studies
• Seropositive
– All three tests are positive
• ELISA x 2 and Western blot
– Does NOT mean the person has AIDS
• Seronegative
– Not an assurance that an individual is free from HIV
infection
– Seroconversion may not have occurred yet
– Assurance of seronegativity
• All three tests are negative AND no risky behavior for previous
6 months
Therapeutic Management
• Objectives of Treatment
– Monitor HIV disease progression and immune
function
– Prevent development of opportunistic
diseases
– Initiate and monitor antiretroviral therapy
– Detect and treat opportunistic diseases
– Manage symptoms
– Prevent complications of treatment
Pharmacological Management
• Opportunistic Illness Prophylaxis
– Table 16-7; Page 688-689
• Medications for HIV Disease
– Antiretrovirals
• Pages 690-691; List of medications
– Combination therapy prevents development of
resistance
– Must be given around the clock
• ie, not three times a day while awake
– Usually initiated
• CD4 count below 500, or
• Viral load greater than 10,000
Nursing Interventions
• Psychosocial Issues
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Uncertainty
Isolation
Fear
Depression
Limited financial resources
Nursing Interventions
• Assisting with Coping
– Educate about HIV
– Encourage to participate in their own care
– Face life a day at a time; live each day to the
fullest
– Listen
– Maintain sources of psychological support
Nursing Interventions
• Reducing Anxiety
– Clarification & education about HIV & AIDS
• disease process
• complications
• treatment
– Include patient and support person in planning
care
– Encourage talking about feelings or relaxation
and meditation
– Assess for suicidal ideation
– Support groups
Nursing Interventions
• Minimize Social Isolation
– Social Stigma
• associate with homosexuality, drug use, and sexual
transmission
– Sharing diagnosis with others
• need to choose carefully
– Support groups
• patients
• significant others
Nursing Interventions
• Assisting with Grieving
– Listening
– Explore feelings, fears and treatment options
– Significant others and family members
• may experience fear, anger embarrassment, and
shame
Nursing Interventions
• Confidentiality
– Diagnosis should be carefully protected
• Need to know basis
– not every health care worker needs to know diagnosis
– Universal precautions should be used on every patient
Nursing Interventions
• Duty to Treat
– Healthcare professionals may not pick and
choose their patients
– Rehabilitation Act of 1973 prohibits
discrimination against the handicapped and
the disabled
• HIV and AIDS are included
Nursing Interventions
• Early
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Good nutritional habits
Elimination of smoking and drug use
Elimination or moderation of alcohol intake
Regular exercise
Stress reduction
Avoidance of exposure to new infectious agents
Mental health counseling
Involvement in support groups
Safer sexual practices
Nursing Interventions
• Later
– Treat opportunistic diseases
– Diarrhea is often a long term problem
• Low fat, low fiber, high potassium diet
• adequate fluid intake
• good skin care
– Nutritional
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Encourage nutritional supplements
Increase protein
Enteral supplements (NG tube)
TPN
Prevention of HIV Infection
• Education
– Best means of prevention
– Counsel about HIV testing, behaviors that put
them at risk, and how to reduce or eliminate
those risks
– Nurse must be able to discuss behaviors
• forthright, relaxed, and non-judgemental
Prevention of HIV Infection
• HIV Testing and Counseling
– Pre- and Post-test counseling must be done
• Table 16-5; page 683
– Patient should not be pressured to be tested
– Informed consent must be obtained before
drawing blood
• consent laws are established by state laws
– Confidential or anonymous testing
Prevention of HIV Infection
• Risk assessment and Risk Reduction
– Minimum risk assessment (Box 16-6; Page 698)
• Have you ever had a transfusion or used clotting
factors? Was it before 1985?
• Have you ever shared needles, syringes, or other
injecting equipment with anyone?
• Have you ever had a sexual experience in which
your penis, vagina, rectum, or mouth came into
contact with another person’s penis, vagina,
rectum, or mouth?
– Positive response to any one of these
questions will require further assessment
and/or referral
Prevention of HIV Infection
• Barriers to Prevention
– Denial
• “it won’t happen to me”
– Ignoring risks
– Fear, misunderstanding, and potential for
social isolation
– Cultural and community attitudes, values and
norms
• opposed to HIV and AIDS education in schools
Prevention of HIV Infection
• Decreasing Risks Related to Sexual Transmission
– Eliminate the risk of exposure to HIV through semen
and cervicovaginal secretions
– NURSES RESPONSIBILITY IS TO COUNSEL ON SAFE
PRACTICES – NOT TO JUDGE THE CHOICE OF PRACTICES!
• Abstaining from all sexual activity
• Limit sexual behavior in which the mouth, penis, vagina, or
rectum come into contact with blood, semen, or
cervicovaginal secretions
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Massage
Masturbation; mutual masturbation
Telephone sex
Use of barriers
» condoms are not 100% effective, but reduce risk
• Chart 16-7; Page 704 and Chart 16-8; page 706
Prevention of HIV Infection
• Decreasing Risks Related to Drug Use
– Stop the use of injectable drugs
– Provide drug treatment opportunities
– If drugs are going to be injected
• use sterile needles and equipment
• Instructions on cleaning needles and equipment
– Deactivation of HIV requires a 30 second exposure to
100% bleach
» fill the syringe with bleach two times; empty two
times
» fill the syringe with clean water two times; empty two
times
Prevention of HIV Infection
• Decreasing Risks of Occupational Exposure
– Risk is very rare; only 5% of AIDS cases
– Handwashing is the single most effective
means of preventing the spread of infection
– Universal precautions and body substance
isolation
– High-risk exposure treatment
• Begin antiretroviral medications within 1-4 hours
for at least 4 weeks
• HIV testing
– Baseline, six months and twelve months
Prevention of HIV Infection
• Other Methods to Reduce Risk
– HIV-Infected person should be given the
following instructions
• Do not give blood, donate organs or donate semen
• Do not share razors, toothbrushes, or other
household items that may contain blood or other
body fluids
– shower instead of tub bath
• Avoid infecting sexual and needle-sharing partners
• Do not breastfeed