interventions for clients with hiv
DESCRIPTION
TRANSCRIPT
INTERVENTIONS FOR CLIENTS WITH HIV/AIDS
Jolene Bethune, RN, MSN
Objectives Provide an overview of HIV and AIDS with
key terms you will hear in practice Provide brief outline of pathophysiology
and etiology of viral infection Describe methods of transmission Describe methods of preventing
transmission in the health care environment
Use the nursing process to describe care of the infected client
Overview Acquired immunodeficiency
syndrome (AIDS) is the late stage of a continuum of symptoms resulting from infection with the human immunodeficiency virus (HIV)
AIDS and HIV are not the same; not everyone with HIV has AIDS
Most people aren’t diagnosed at the time of infection because they don’t seek medical care when symptoms occur, or health care providers don’t take an adequate history
AIDS is seriously debilitating; eventually fatal; can occur in any age group
Key Terms
Immunodeficiency – a deficient response of the immune system d/t a missing or damaged immune component
Immunocompromised – immune system impaired, destroyed resulting in an impaired ability to neutralize, destroy or eliminate antigens
Primary, congenital – immune malfunction present from birth
Secondary, acquired – occurs in a person with a normally functioning immune system at birth; becomes immmunodeficient d/t disease, injury, exposure to toxins, medical therapy or an unknown cause
Retrovirus – have only RNA as their genetic material; differ from other viruses in their efficiency of replication/cellular infection
Reverse transcriptase (RT) – enzyme complex that increases the efficiency of viral replication once the retrovirus enters a human cell
Macrophage – largest of all the leukocytes; functions include phagocytosis, repair of injured tissues, antigen presenting/processing, and secretion of cytokines that help control the immune system
Lymphocyte – becomes sensitized to foreign cells/proteins
Lymphocytopenia – decrease in the numbers of lymphocytes
Viremia – high concentration of virus in the blood
Pathogenic infections – infections occurring in people with normally functioning immune systems
Opportunistic infections – infections caused by pathogens that are present as part of the normal environment kept in check by a normal immune systems
CD4 + T-lymphoctye (T4) – regulates activity of all immune system cells
Nonprogressors – individuals infected with HIV for more than 10 years who remain asymptomatic and have T4 lymphocyte counts within a normal range
Announced during a press conference in November, 1991, that he had HIV; remains asymptomatic today
Pathophysiology
CDC’s classification scheme combines clinical conditions associated with HIV infection and three ranges of CD4+ T-lymphocyte counts
Cell Categori
es
Clinical CategoriesA B C
1 A1 B1 C1
2 A2 B2 C2
3 A3 B3 C3Iggy, p.365, Table 22-2
Cell Categories
1. Category 1 500/microL or more
2. Category 2 200-499/microL
3. Category 3 Fewer than 200/microL
Cell Categories
Clinical CategoriesA B C
1 A1 B1 C1
2 A2 B2 C2
3 A3 B3 C3
Clinical CategoriesCategory A
Asymptomatic HIV infection Persistent lymphodenopathy Acute primary HIV infection with accompanying
symptoms (diarrhea, n/v, decreased energy) May remain in category A for an extended
period of time
Cell Categori
es
Clinical CategoriesA B C
1 A1 B1 C1
2 A2 B2 C2
3 A3 B3 C3
Category B Symptomatic conditions attributed to the HIV
infection or defect in immunity Bacterial infections Candidiasis for more than one month Fever or diarrhea lasting more than one
month Hairy leukoplakia, oral Herpes zoster – two distinct episodes Pulmonary tuberculosis
Cell Categori
es
Clinical CategoriesA B C
1 A1 B1 C1
2 A2 B2 C2
3 A3 B3 C3
Category C Conditions that are strongly associated
with severe immunodeficiency and cause serious morbidity and mortality
See Iggy, p. 365, Table 22-2
Cell Categori
es
Clinical CategoriesA B C
1 A1 B1 C1
2 A2 B2 C2
3 A3 B3 C3
Progression from HIV to AIDS can take months or years
People who have been transfused with HIV-positive blood develop AIDS more quickly
Those who become HIV-positive as a result of a single sexual encounter have a longer latency period
Other influences include frequency of re-exposure to HIV, nutritional status, pregnancy, and stress
Etiology
Retrovirus enters the body and infects the human cell
RT enzymes force the human cell’s DNA synthesis machinery to use the viral RNA as a pattern and make a piece of human DNA complementary to the viral RNA
The new piece of human DNA is then incorporated into the person’s cellular DNA, where it acts as a template to produce the virus
The new virus protein migrates to the cell surface, where it assembles the virus, which “buds’ and leaves the cell.
Viruses spread quickly throughout the lymphoid system, hiding in macrophages and in the centers of lymph nodes
Throughout the course of the infection, HIV is actively replicated by T-lymphocytes, finally exhausting the immune system
The HIV retrovirus attaches to, infects, and finally causes the destruction of those immune system cells with a CD4 (T4) surface receptor
HIV/AIDS Around the World
Methods of Transmission
Parental (Blood) Transmission Sharing contaminated needles Accidental needle sticks from an
infected person HIV+ women may transmit to their
children through perinatal transmission, breastfeeding
Exposure to an infected client’s blood through an open wound
Sexual Transmission Homosexual males
Heterosexual partners if either is infected
Any sexual activity involving exposure to bodily fluids of an infected person
Perinatal Transmission Transplacentally in utero
Intrapartally, during exposure tho blood and vaginal secretions during birth
Postpartally, through breastmilk
HIV dies quickly outside the body because it needs living tissue and moisture to survive
HIV may not be transmitted bya. Hugging, kissing, holding hands or
other nonsexual contactb. Inanimate objects (money, doorknobs,
bathtubs, toilet seats, etc.)c. Dishes, silverware, or food handled by
an infected persond. Animals or insects
After exposure to the virus, symptoms may develop within 6-12 weeks; however, symptoms may not develop for 6 months
Once infected, the client will probably harbor the virus for the rest of his life
Opportunistic infections take advantage of the suppressed immune system
Tend to resist conventional treatment Client may have multiple opportunistic
infections
Prevention of Transmission in a Health Care Setting
Maintain standard precautions
Consider all blood and bodily fluids to be contaminated
Avoid contaminating outside of container when collecting specimens
Do not recap needles and syringes
Cleanse work surface areas with appropriate germicide
Clean up spills of blood and body fluid immediately
Follow CDC recommendations for immunization of health care workers
CD4 (T4) malfunctions, suppressing the entire immune system
Results:a) Lymphocytopeniab) Abnormal T-cell functionc) Increased production of incomplete
and nonfunctional antibodiesd) Abnormally functioning macrophages
Providing care can evoke complex personal issues for nurses
a. Acknowledge your own fearb. Acknowledge any negative attitudes
regarding possible lifestyles contributing to HIV infection
c. Practice appropriate infection control techniques always
d. Provide compassionate, nonjudgmental care
ASSESSMENT
History Age, gender, occupation and residence Thoroughly assess current complaint/illness Ask when HIV was diagnosed and what
symptoms led to that diagnosis Chronology of infections/clinical problems
since diagnosis
History Health history (any blood transfusions
1978-1985?) History of STDs, infectious diseases Clotting factors, if hemophiliac Assess client’s level of knowledge
Physical AssessmentPossible signs/symptoms:
Cough Fever Night sweats Fatigue
Physical AssessmentPossible signs/symptoms:
N/V Weight loss Lymphodenopathy Diarrhea
Physical AssessmentPossible signs/symptoms:
Visual changes Headache Memory loss Confusion Seizures Personality changes
Physical AssessmentPossible signs/symptoms:
Dry skin Rashes Skin lesions Pain Discomfort
Physical Assessment
Physical Assessment – Opportunistic Infections
Protozoal Infections Pneumocystis carinii pneumonia (PNP) –
fatigue, weight loss; crackles on auscultation
Toxoplasmosis encephalitis – sudden mental, neurological changes
Cryptosporidosis – mild to severe diarrhea with wasting, electrolyte imbalance
Physical Assessment – Opportunistic Infections
Fungal Infections Candida stomatitis/esophagitis –
mouth/retrosternal pain; cottage cheese plaques; (vaginal candidiasis – plaques, pruritis, discharge, perineal irritation)
Cryptococcosis – meningitis (fever, headache, n/v, nuchal rigidity, mental/neurological changes)
Histoplasmosis – respiratory infection (dyspnea, fever, cough, weight loss)
Physical Assessment – Opportunistic Infections
Bacterial Infections MAC syndrome (systemic
mycobacterium infections of respiratory and/or gastrointestinal tracts; tuberculosis) – fever, weight loss, debility; lymphadenopathy, organ disease
Recurrent pneumonia – chest pain, productive cough, fever, dyspnea
Physical Assessment – Opportunistic InfectionsViral Infections
Cytomegalovirus (CMV) – eyes, respiratory/ gastrointestinal tracts, central nervous system
Herpes simplex virus (HSV) – painful lesions/ulcers, fever, pain, bleeding and lymph node enlargement
Varicella zoster (VZ) – shingles (pain, burning along dermatome nerve tracts, headache, low grade fever, large painful vesicles
Physical Assessment – Malignancies
Kaposi’s sarcoma
Malignant lymphomas
Physical Assessment – Other Clinical Manifestations
AIDS Dementia Complex
Wasting Syndrome
Integumentary changes
Laboratory Assessment Lymphocyte counts CD4/CD8 counts Antibody tests – enzyme-linked
immunosorbent assay (ELISA); Western blot test
Viral culture Viral load testing – measures RNA or viral
protein in client’s blood
Psychosocial Assessment Ask about client’s support system –
family, SOs, friends Protect confidentiality Activities of daily living Employment Assess client’s levels of anxiety, self
esteem Assess changes in body image Coping strategies, strengths
NURSING DIAGNOSES
Risk of infection related to immunodeficiency
Impaired gas exchange related to anemia, respiratory infection or malignancy, anemia, fatigue or pain
Acute pain or chronic pain related to neuropathy, myelopathy, malignancy or infection
Imbalanced nutrition: less than body requirements related to high metabolic need, n/v, diarrhea, difficulty chewing/swallowing, or anorexia
Diarrhea related to infection, food intolerance or medications
Impaired skin integrity related to KS, infections, altered nutritional state, incontinence, immobility, hyperthermia or malignancy
Disturbed thought processes related to AIDS dementia complex, central nervous system infection or malignancy
Situational low self-esteem or chronic low self-esteem related to changes in body image, decreased self-esteem, or helplessness
Social isolation related to stigma, virus transmissibility, infection control practices or fear
PLANNING/IMPLEMENTATION
Expected outcome: The client is expected to remain free of opportunistic diseases
Interventions: Drug therapy – antiretrovirals only inhibit viral
replication; they do not kill the virus Immune enhancement – bone marrow
transplant; lymphocyte transfusion; lymphokines
Alternative therapy – vitamins, shark cartilage; botanicals
Health promotion – the nurse teaches client to avoid exposure to infection
See Iggy, Chart 22-8, p. 378
Risk of Infection
Expected outcome: The client is expected to maintain adequate oxygenation and perfusion, and experience minimal dyspnea and discomfort
Interventions: Drug therapy Respiratory support and maintenance Comfort Rest and activity
Impaired Gas Exchange
Expected outcome: The client is expected to maintain optimal weight through adequate nutrition and hydration
Interventions: Drug therapy Diet therapy Mouth care
Imbalance nutrition: less than body requirements
Expected outcome: The client is expected to experience decreased diarrhea; maintain fluid, electrolyte and nutritional status; and minimize incontinence
Interventions: Drug therapy Diet therapy Bedside commode The nurse provides privacy, support and
understanding
Diarrhea
Expected outcome: The client is expected to have healing of any existing lesions and avoid increased skin breakdown or secondary infection
Interventions: Chemotherapy Drug therapy Wound care Make-up, concealers
Impaired Skin Integrity
Expected outcome: The client is expected to demonstrate improved mental status and sustain no injury
Interventions: Orientation Drug therapy Safety measures Support
Disturbed Thought Processes
Expected outcome: The client is expected to identify positive aspects of himself or herself and accept himself or herself
Interventions: The nurse allows for privacy, but does not
avoid, isolate the client Promote self care, independence, control
and decision-making Complementary alternative therapies
Situational Low Self-Esteem
Expected outcome: The client is expected to identify behaviors that cause social isolation and demonstrate behaviors that reduce social isolation
Interventions: Promotion of interaction Education
Social Isolation
EVALUATION
Outcomes: Expected outcomes include that the client will
Not develop opportunistic infections Demonstrate adequate respiratory
function Achieve and acceptable level of
physical comfort Attain adequate weight, nutritional and
fluid status
Maintain skin integrity Remain oriented and/or in a safe
environment Maintain self-esteem Maintain a support system and
involvement with others Comply with the appropriate and
available therapy
Other ImmunodeficienciesTherapy-induced Immunodeficiencies Drug-induced Immunodeficienciesa. Cytotoxic drugsb. Corticosteroidsc. Cyclosporine Radiation-induced Immunodeficiencies –
Collaborative management
REFERENCES All Refer (2009). Cancer. Retrieved October 25, 2009, from
http://health.allrefer.com/health/cancer-lymphoma-malignant-ct-scan.html BBC (2008). US set to spend $50bn against HIV. Retrieved October 25, 2009,
from http://news.bbc.co.uk/2/hi/7327694.stm Both Teams Play Hard (n.d.). . Retrieved October 25, 2009, from
http://www.bothteamsplayedhard.net/wp-content/uploads/2008/10/magazines-time-magicjohnson.jpg
Council Rock School District (2005). STDs, HIV & AIDS Outline. Retrieved October 25, 2009, from http://images.google.com/imgres?imgurl=http://www.crsd.org/5033092714043/lib/5033092714043/HIV.gif&imgrefurl=http://www.crsd.org/5033092714043/blank/browse.asp%3FA%3D383%26BMDRN%3D2000%26BCOB%3D0%26C%3D54173&usg=__LBtWre-1cFFVCpyIbMTj1x5hVXY=&h=404&w=402&sz=57&hl=en&start=13&sig2=BQ-IpGPifjU7sjBf5-h_yQ&um=1&tbnid=SADbWJqc8nr6vM:&tbnh=124&tbnw=123&prev=/images%3Fq%3Dhiv%2Bimages%26ndsp%3D20%26hl%3Den%26rls%3Dcom.microsoft:en-us:IE-SearchBox%26rlz%3D1I7GGLL_en%26sa%3DN%26um%3D1&ei=-dfkStTIA93Btwey0t3LCA
REFERENCES Dreamstime (n.d.). Categories. Retrieved October 25, 2009, from
http://www.dreamstime.com/stock-photos-hiv-positive-image3961133
Ignatavicius, D. D., & Workman, M. L. (2002). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (4 ed.). Philadelphia, PA: W. B. Saunders Company.
Medline Plus (2009). Primary HIV Infection. Retrieved October 25, 2009, from http://www.nlm.nih.gov/medlineplus/ency/imagepages/17268.htm
Stephanie Relfe (2008). Oil pulling amazing health for almost no cost. Retrieved October 25, 2009, from http://www.relfe.com/07/oil_pulling.html
Zerwekh, J., & Claborn, J. C. (2002). NCLEX-RN: a comprehensive study guide (5 ed.). Midlothian, TX: Nursing Education Consultants.