Transcript Airgas template

Chapter 52
Management of Patients
With
HIV Infection and AIDS
1
Copyright © 2008 Lippincott Williams & Wilkins.
Epidemiology
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United States
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Approx 1.1 million infected at end of 2006 (CDC)
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African Americans accounted for 44% of all cases through
2007, but make up only 12% of the population
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Minority groups disproportionately affected
Males accounted for 72% of all cases in 2003
Most common routes:
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21% undiagnosed
MSM, heterosexual contact, IVDA
Fastest growing infection rate among women, minorities and
adolescents
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Epidemiology
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Wordwide
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AIDS kills 8,000 people/day
33.4 million people infected worldwide
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22.4 million of these in Subsaharan Africa
In underdeveloped countries, heterosexual
transmission is primary route
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Transmission of HIV
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Transmitted by body fluids containing HIV or
infected CD4 lymphocytes
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Blood, seminal fliud, vaginal secretions, amniotic fluid,
and breast milk
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Most prenatal infections occur during delivery
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Risk via blood transfusion in developed countries is
very low
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Casual contact does not cause transmission
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High-Risk Behaviors (USA)
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Sharing infected injection equipment
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Having sexual relations with infected
individuals
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Gerontologic considerations
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Prevention
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Standard precautions for healthcare providers
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Practice safe activities and risk-reducing activites
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Abstain from sharing sexual fluids
Reduce the number of sexual partners to one
Always use latex condoms; if allergic to latex, use
nonlatex condoms (male or female)
Avoid sexual practices that may cause tears in mucous
membranes
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Prevention
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Practice safe activities and risk-reducing
activities
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Do not use drugs
If drugs are used, do not share equipment
Do not have sex under the influence of any
drug
Needle exchange programs
Clean equipment properly (bleach)
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See table 15-21
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Prevention
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Perinatal transmission
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Treatment during pregnancy reduces
transmission to less than 2%
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Transmission to healthcare
providers
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Standard precautions
Risk of seroconversion after needlestick
about 0.3%
Postexposure prophylaxis
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Baseline testing within 72 hours and testing at 1,
3, 6 months
If needed: start prophylaxis meds within 24 hours
of exposure
Documentation
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Structure of HIV-1 (retrovirus)
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Life Cycle of HIV-1
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Pathophysiology
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HIV is a retrovirus; it makes DNA from RNA
Replicates via reverse transcription and viral
DNA is integrated into the host DNA
Target cells
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T cells (CD4 or CD8)
B cells
Natural killer cells
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Categories
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The three CD4+ T-lymphocyte
categories are defined as follows:
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Category 1: greater than or equal to 500
cells/mL
Category 2: 200-499 cells/uL
Category 3: less than 200 cells/uL
Clinical categories
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Stages of HIV Disease
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Acute infection
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Early chronic infection
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Intermediate chronic
infection
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AIDS
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Primary Infection
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Acute HIV infection/acute HIV syndrome
Part of CDC category A
Symptoms: none to severe flu-like syndrome
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Occurs about 3 weeks after exposure, lasts 1-3 weeks
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
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Early Chronic Infection
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CD4 remains above 500
Viral load is low
Asymptomatic disease
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May have persisten generalized
lymphadenopathy, fatigue, mild symptoms
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Intermediate Chronic Infection
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CD4 drops to 200-500
Viral load increases
Symptoms may include persistent fever,
night sweats, chronic diarrhea, headaches,
fatigue, infection
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Most common infection oropharyngeal
candidiasis; also shingles, vaginal candidiasis,
increase in herpes, oral hairy leukoplakia
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AIDS - Late Chronic Infection
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CDC criteria for AIDS (table 15-10)
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CD4 <200
Certain opportunistic infection
Certain opportunistic cancers
Wasting syndrome
AIDS dementia complex
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Diagnosis
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Includes detailed history and physical exam
HIV antibody tests
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Informed consent - state specific laws
Antibodies detected within 3-12 wks of infection
ELISA performed; confirmation by Western Blot
Rapid HIV
Viral load tests
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“undetectable”
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Treatment
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Treatment and protocols are continually evolving
Most current recommendations include early,
aggressive treatment
Antiretroviral agents: see 15-14)
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Nucleoside reverse transcriptase inhibitors (NRTIs)
Non-nucleoside reverse transcriptase inhibitors
(NNRTIs)
Protease inhibitors (PIs)
Use of combination therapy
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Treatment
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Management focuses upon:
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Preservation of the immune system-maintain or
raise CD4 counts
Suppression of viral load
Improved quality of life
Reduction of HIV-associated morbidity and
mortality
Treatment of specific manifestations and
conditions related to the disease
Viral load is monitored (may become
undetectable), as well as T cell count
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Treatment
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Adverse effects vary by medication, but may
include:
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Lipodystophy syndrome
Fat redistribution syndromes
Facial wasting
Liver dysfunction
GI intolerance
Drug resistance
Immune reconstitution syndromes
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Manifestations of AIDS—
Respiratory
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Pneumocystis carinii pneumonia (PCP)
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Most common infection resulting in AIDS diagnosis
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Initial symptoms may be nonspecific and may include
nonproductive cough, fever chills, dyspnea, and chest pain
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If untreated, progresses to pulmonary impairment and
respiratory failure
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Treatment: TMP-SMZ or pentamidine; prophylactic TMPSMZ
Mycobacterium avium complex (MAC)
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May cause respiratory or GI infection
Tuberculosis
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Manifestations of AIDS—GI
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Oral candidiasis
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May progress to esophagus and stomach
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Treatment with Mycelex troches or nystatin and
ketoconazole
Diarrhea related to HIV infection or enteric pathogens
(50-90%)
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Octreotide acetate for severe chronic diarrhea
Wasting syndrome
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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
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Manifestations of AIDS—
Oncologic
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Kaposi's sarcoma
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Cutaneous lesions but may involve multiple organ
systems
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Lesions cause discomfort, disfigurement, ulceration,
and potential for infection
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Death may result from tumor progression
B cell lymphomas
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Second most common
HIV associated malignancy
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Lesions of Kaposi’s Sarcoma
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Manifestations of AIDS—
Neurologic
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HIV encephalopathy
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Progressive cognitive, behavioral, and motor decline
Probably directly related to the HIV infection
Signs/symptoms may be difficult to distinguish from
depression, fatigue/
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Includes headaches, memory deficit, apathy, confusion,
psychomotor deficits
HIV - related peripheral neuropathy
Cryptococcus neoformans (fungal infection)
Other neurologic disorders (often infectious)
Depression
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Manifestations of AIDSgynecologic
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Invasive cervical cancer
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Nursing Process—Assessment of
the Patient With AIDS
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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
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Nursing Process—Diagnosis of
the
Patient With AIDS
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Impaired skin integrity
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Diarrhea
• Imbalanced nutrition
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Risk for infection
• Social isolation
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Activity intolerance
• Pain
• Anticipatory grieving
• Deficient knowledge
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Disturbed thought
processes
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Collaborative Problems/Potential
Complications
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Opportunistic infections
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Impaired breathing or respiratory
failure
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Wasting syndrome
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Fluid and electrolyte imbalance
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Adverse reaction to medication
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Nursing Process—Planning the
Care of the Patient With AIDS
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Goals may include:
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Achievement and maintenance of skin integrity
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Resumption of usual bowel patterns
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Absence of infection
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Improved activity tolerance
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Improved thought processes
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Improved airway clearance
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Effective copingCopyright © 2008 Lippincott Williams & Wilkins.
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Nursing Process—Planning the
Care of the Patient With AIDS
(cont.)
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Goals may include (cont.)
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Increased comfort
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Improved nutritional status
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Increased socialization
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Expression of grief
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Increased knowledge regarding
disease prevention and self-care
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Absence of complications
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Skin Integrity
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Conduct frequent routine assessment of skin and
mucosa
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Encourage patient to maintain balance between rest
and activity
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Reposition at least every two hours and as needed
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Use pressure reduction devices
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Instruct patient to avoid scratching
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Use gentle, nondrying soaps or cleansers
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Avoid adhesive tape
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Provide perianalCopyright
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care
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Promoting Usual Bowel Pattern
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Assess bowel pattern and factors that may
exacerbate diarrhea
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Avoid foods that act as bowel irritants, such as raw
fruits and vegetables, carbonated beverages, spicy
foods, and foods of extreme temperatures
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Small, frequent meals
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Administer medications as prescribed
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Assess and promote self-care strategies to control
diarrhea
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Activity Intolerance
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Maintain balance between activity and
rest
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Instruction regarding energy
conservation techniques
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Relaxation measures
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Collaboration with other members of the
health care team
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Maintaining Thought Processes
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Assess mental and neurologic status
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Use clear, simple language if mental status is altered
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Establish and maintain a daily routine
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Use orientation techniques
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Ensure patient safety and protect from injury
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Implement strategies to maintain and improve functional
ability
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Instruct and involve family in communication and care
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Nutrition
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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
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Decreasing Isolation
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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
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Other Interventions
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Improve airway clearance
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Use semi-Fowler's or high-Fowler’s position
Pulmonary therapy; coughing and deep breathing;
postural drainage; percussion; and vibration
Ensure adequate rest
Pain
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Administer medications as prescribed
Provide skin and perianal care
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The Nursing Process Evaluation
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Maintains skin integrity
Resumes usual bowel habits
Experiences no infections
Maintains adequate level of activity tolerance
Maintains usual level of thought processes
Experiences increased sense of comfort
Maintains adequate nutritional status
Reports understanding of AIDS and
participates in self-care activities
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