Transcript Chapt52

Chapter 52
Management of Patients With
HIV Infection and AIDS
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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
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High-Risk Behaviors
• Sharing infected injection equipment
• Having sexual relations with infected individuals
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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
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Structure of HIV-1
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Life Cycle of HIV-1
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Stages of HIV Disease
• Primary infection
• HIV asymptomatic
• HIV symptomatic
• AIDS
• See Table 52-1
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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
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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
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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
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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
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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
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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
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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
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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
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Lesions of Kaposi’s Sarcoma
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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
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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
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Nursing Process—Diagnosis of the
Patient With AIDS
• Impaired skin integrity
• Pain
• Diarrhea
• Imbalanced nutrition
• Risk for infection
• Social isolation
• Activity intolerance
• Anticipatory grieving
• Disturbed thought processes
• Deficient knowledge
• Ineffective airway clearance
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Collaborative Problems/Potential
Complications
• Opportunistic infections
• Impaired breathing or respiratory failure
• Wasting syndrome
• Fluid and electrolyte imbalance
• Adverse reaction to medication
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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
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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
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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
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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
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Activity Intolerance
• Maintain balance between activity and rest
• Instruction regarding energy conservation
techniques
• Relaxation measures
• Collaboration with other members of the health
care team
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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
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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
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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
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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
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