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Chapter 52 Management of Patients With HIV Infection and AIDS Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. High-Risk Behaviors • Sharing infected injection equipment • Having sexual relations with infected individuals Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. Structure of HIV-1 Copyright © 2008 Lippincott Williams & Wilkins. Life Cycle of HIV-1 Copyright © 2008 Lippincott Williams & Wilkins. Stages of HIV Disease • Primary infection • HIV asymptomatic • HIV symptomatic • AIDS • See Table 52-1 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. Lesions of Kaposi’s Sarcoma Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. Collaborative Problems/Potential Complications • Opportunistic infections • Impaired breathing or respiratory failure • Wasting syndrome • Fluid and electrolyte imbalance • Adverse reaction to medication Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. Activity Intolerance • Maintain balance between activity and rest • Instruction regarding energy conservation techniques • Relaxation measures • Collaboration with other members of the health care team Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins. 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 Copyright © 2008 Lippincott Williams & Wilkins.