Med-Surg Nursing: HIV and AIDS (Ch. 37)

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Transmitted by body fluids containing HIV or infected CD4 lymphocytes

-blood, semen, vaginal secretions, amniotic fluid, breast milk

-most prenatal infections occur during delivery

casual contact does not cause transmission

breaks in skin or mucosa increase risk

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Transmission of HIV

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sharing needles

having sex with infected person

infants born/breast fed by HIV infected mothers

people who receive organ transplants, HIV infected blood, or blood products (especially between 1978 and 1985)

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Risks Associated with HIV Infection

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36 Terms

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Transmitted by body fluids containing HIV or infected CD4 lymphocytes

-blood, semen, vaginal secretions, amniotic fluid, breast milk

-most prenatal infections occur during delivery

casual contact does not cause transmission

breaks in skin or mucosa increase risk

Transmission of HIV

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sharing needles

having sex with infected person

infants born/breast fed by HIV infected mothers

people who receive organ transplants, HIV infected blood, or blood products (especially between 1978 and 1985)

Risks Associated with HIV Infection

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standard precautions

safer sex practices and safer behaviors

-abstain from sharing sexual fluids

-reduce # of sexual partners to one

-always use condoms

do not share needles

blood screening and treatment of blood products

Prevention

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hand hygiene

PPE

soiled pt care equip handling

environmental control

textiles and laundry

needles and other sharps

pt resuscitation

Prevention for Healthcare Providers

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postexposure prophylaxis

vaccination

Healthcare Provider Treatment

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1- Primary infection (high viral load)

2- CD4 200- 499

3- AIDS diagnosis <200 CD4

3 Stages of HIV

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Primary infection

HIV asymptomatic (most dangerous time)

HIV symptomatic

AIDS

Stages of HIV

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Acute HIV infection/symdrome

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 (copy machine through the lymph system)

Viral set point: balance between amount of HIV and the immune response

Primary Infection

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CDC category A

> 500 CD4+ T lymphocytes/mm3

Upon reaching viral set point, chronic asymptomatic state begins

Body has sufficient immune response to defend against infection

HIV Asymptomatic

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CDC category B

200-499 CD4+ lymphocytes/mm3

CD4 T cells gradually fall

Pt. develops symptoms or conditions related to the HIV infection, which are not classified as category C conditions

HIV Symptomatic

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CDC category C

>200 CD4+ lymphocytes/mm3

As levels drop below 100 cell/mm3 the immune system is significantly impaired

AIDS

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The first opportunistic infections that you are likely to get if you have HIV are minor fungal infections caused by an overgrowth of Candida, the fungus that causes diaper rash in babies. Candida infections commonly occur in the mouth and throat (oral candidiasis or thrush), airways and lungs, or vagina (vaginal candidiasis). This fungus typically forms white patches on your gums, tongue and lining of your mouth, and can make it so painful to swallow that you lose your appetite. An infection in your vagina will cause itching or burning, and soreness and redness accompanied by a thick white discharge.

Treatment: TMP-SMZ or pentamidine, prophylactic TMP-SMZ

(CD4 cells: around 500)

Fungal infections (Candida)

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Octreotide acetate for severe chronic diarrhea

Diarrhea Related to HIV/enteric pathogens

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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 may contribute

Wasting Syndrome

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<p>A tumour caused by a human herpes virus. The tumour usually appears as purplish lesions on the skin of your legs or face, or inside your mouth, and can spread to other parts of your body without you knowing it. If the cancer spreads to your guts or lungs, it can cause bleeding or difficulty with breathing that can be life threatening.</p><p>(CD4 count: 500 to 200)</p>

A tumour caused by a human herpes virus. The tumour usually appears as purplish lesions on the skin of your legs or face, or inside your mouth, and can spread to other parts of your body without you knowing it. If the cancer spreads to your guts or lungs, it can cause bleeding or difficulty with breathing that can be life threatening.

(CD4 count: 500 to 200)

Kaposi's sarcoma

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A type of pneumonia that severely affects the lungs and is the most common opportunistic infection in people with AIDS. Signs and symptoms of pneumocystis can include shortness of breath, fever, dry cough and chest pain. It usually takes weeks or months to develop, but can be life threatening if not treated.

(CD4 count: 200 to 100)

Pneumocystis jiroveci pneumonia

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Is everywhere and it is thought that most people throughout the world have been exposed to it, but mostly didn't notice. Nevertheless; like HIV, once you have the virus you have it for life. If you are HIV infected and have low CD4 cell counts, you should not be surprised if you get a cytomegalovirus infection in your gut, or your eyes (cytomegalovirus retinitis), where it may lead to blindness if you don't get treatment.

(CD4 count: 100-50)

Cytomegalovirus

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Exists everywhere in the environment and can infect the lungs and intestines of people with severe immunodeficiency. It can be deadly if it spreads to other parts of your body.

(CD4 count: less than 50)

Mycobacterium avium complex (MAC)

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Second most common malignancy occurring in people with AIDS. AIDS- related lymphomas tend to develop outside the lymph nodes, most commonly in the brain, bone marrow, and GI tract.

Aggressive growth and resistance to treatment

B-Cell lymphomas

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Peripheral neuropathy

HIV encephalopathy

Cryptococcus neoformans

Progressive multifocal leukoencephalopathy

Other neurologic disorders

Depression

Neurologic Manifestations of HIV/AIDS

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The amount of HIV in the pts bloodstream

When the viral load is tested, HCPs are looking for a certain number of particles in a milliliter of blood—what they call the particles copies. When a pt is being treated for HIV, the goal is to take a viral load down to the point that it is undetectable.

Anywhere between 40 to 75 copies in the sample of blood will be declared to have an "undetectable" viral load.

https://www.khanacademy.org/science/health-and-medicine/infectious-diseases/hiv-and-aids/v/what-is-hiv-and-aids

Viral Load

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1. When CD4 count is 350-500

2. Viral load is >100,000 copies

3. Pregnancy, young child, progressed to AIDS, opportunistic infection (regardless of CD4 count)

When to start HAART Treatment

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1/4 of all infected people with HIV are > 50 years old

blood transfusion before 1985 increases the risk

unprotected intercourse

reduction in immune system function

Gerontology Considerations

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EIA- antibodies detected

Western blot test- antibodies detected, used to confirm EIA

Viral load- measure HIV RNA in plasma

CD4/CD8- markers found on lymphocytes, HIV kills CD4 which reduces the numbers

OraQuick- In-home HIV test

Lab Tests for Dx and tracking HIV

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Nucleoside reverse transcriptase inhibitors (NRTIs)

Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

Protease inhibitors (PIs)

Integrate inhibitors

Use of combination therapy

Antiretroviral Agents

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Assess physical and psychosocial status

Identify potential risk factors: IV drug abuse, risky sexual practices

Immune system function

Nutritional status

Skin integrity

Respiratory status and neurologic status (pg 1012)

Fluid and electrolyte balance

Knowledge level of HIV/AIDS

(pg 1016)

Nursing Process- Assessment

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Impaired skin integrity

Diarrhea

Risk for infection

Activity Intolerance

Disturbed thought process

Ineffective airway clearance

Pain

Imbalanced Nutrition

Social Isolation

Anticipatory Grieving

Deficient Knowledge

Nursing Process- Diagnosis

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Achievement and maint. of skin integrity

Resumption of usual bowel patterns

Absence of infection

Improved activity tolerance

Improved thought process

Improved airway clearance

Increased comfort, improved nutritional status

Increased socialization

Expression of grief

Increased knowledge regarding disease prevention and self-care

Absence of complications

Nursing Process- Planning

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Frequent assessment of skin and mucosa

Encourage pt to maintain balance between rest and activity

Reposition at least every 2 hours and as needed

Pressure reduction devices

Instruct pt to avoid scratching

Use gentle, nondrying soaps and cleansers

Avoid adhesive tape

Perianal skin care

Nursing Process: Intervention- Skin

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Assess bowel pattern and factors that may exacerbate diarrhea

Avoid foods that act as bowel irritants: raw fruits and veggies, carbonated beverages, spicy foods, foods of extreme temperatures

Small frequent meals

Administer meds as prescribed

Asses and promote self-care strategies to control diarrhea

Nursing Process: Intervention- Bowels

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Maintain balance between activity and rest

Instruction regarding energy conservation technique

Relaxation measures

Collaboration with other members of the health care team

Nursing Process: Intervention- Activity

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Assess mental and neurologic status

Use clear, simple language if mental status is altered

Establish and maintain a daily routine

Orientation techniques

Ensure pt safety and protect from injury

Strategies to maintain and improve functional ability

Instruct and involve family in communication and care

Nursing Process: Intervention- Thoughts

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Monitor weight, I&O, and factors that interfere with nutrition

Dietary consult

Control of nausea with antiemetics (zofran)

Oral hygiene

Treatment of oral discomfort

Dietary supplements

May require enteral feeding or parenteral nutrition

Nursing Process: Intervention- Nutrition

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Promote an atmosphere of acceptance and understanding

Assess social interactions and monitor behaviors

Allow pt to express feelings

Address psychosocial issues

Provide information related to the spread of infection

Educate ancillary personnel, family, and partners

Nursing Process: Intervention- Isolation

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Improving airway clearance- position in semi-Fowler's or high Fowler's position, pulmonary therapy (coughing and deep breathing, postural drainage, percussion, and vibration)

ensure adequate rest

Pain- medication as prescribed, skin and perianal care

Nursing Process: Intervention- Other

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https://www.khanacademy.org/science/health-and-medicine/infectious-diseases/hiv-and-aids/a/what-is-hivaids

Brunner and Suddarth's Textbook of Medical-Surgical Nursing 13th Edition Volume 1

References