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Chapter 52 Management of Patients With HIV Infection and AIDS 1 Copyright © 2008 Lippincott Williams & Wilkins. Epidemiology United States Approx 1.1 million infected at end of 2006 (CDC) African Americans accounted for 44% of all cases through 2007, but make up only 12% of the population Minority groups disproportionately affected Males accounted for 72% of all cases in 2003 Most common routes: 21% undiagnosed MSM, heterosexual contact, IVDA Fastest growing infection rate among women, minorities and adolescents Copyright © 2008 Lippincott Williams & Wilkins. 2 Copyright © 2008 Lippincott Williams & Wilkins. 3 Epidemiology Wordwide AIDS kills 8,000 people/day 33.4 million people infected worldwide 22.4 million of these in Subsaharan Africa In underdeveloped countries, heterosexual transmission is primary route Copyright © 2008 Lippincott Williams & Wilkins. 4 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 Risk via blood transfusion in developed countries is very low Casual contact does not cause transmission Copyright © 2008 Lippincott Williams & Wilkins. 5 High-Risk Behaviors (USA) Sharing infected injection equipment Having sexual relations with infected individuals Gerontologic considerations Copyright © 2008 Lippincott Williams & Wilkins. 6 Prevention Standard precautions for healthcare providers Practice safe activities and risk-reducing activites 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 Copyright © 2008 Lippincott Williams & Wilkins. 7 Prevention Practice safe activities and risk-reducing activities 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) See table 15-21 Copyright © 2008 Lippincott Williams & Wilkins. 8 Prevention Perinatal transmission Treatment during pregnancy reduces transmission to less than 2% Copyright © 2008 Lippincott Williams & Wilkins. 9 Transmission to healthcare providers Standard precautions Risk of seroconversion after needlestick about 0.3% Postexposure prophylaxis Baseline testing within 72 hours and testing at 1, 3, 6 months If needed: start prophylaxis meds within 24 hours of exposure Documentation Copyright © 2008 Lippincott Williams & Wilkins. 10 Structure of HIV-1 (retrovirus) Copyright © 2008 Lippincott Williams & Wilkins. 11 Life Cycle of HIV-1 Copyright © 2008 Lippincott Williams & Wilkins. 12 Pathophysiology HIV is a retrovirus; it makes DNA from RNA Replicates via reverse transcription and viral DNA is integrated into the host DNA Target cells T cells (CD4 or CD8) B cells Natural killer cells Copyright © 2008 Lippincott Williams & Wilkins. 13 Categories The three CD4+ T-lymphocyte categories are defined as follows: 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 Copyright © 2008 Lippincott Williams & Wilkins. 14 Stages of HIV Disease Acute infection Early chronic infection Intermediate chronic infection AIDS Copyright © 2008 Lippincott Williams & Wilkins. 15 Primary Infection Acute HIV infection/acute HIV syndrome Part of CDC category A Symptoms: none to severe flu-like syndrome 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 Copyright © 2008 Lippincott Williams & Wilkins. 16 Early Chronic Infection CD4 remains above 500 Viral load is low Asymptomatic disease May have persisten generalized lymphadenopathy, fatigue, mild symptoms Copyright © 2008 Lippincott Williams & Wilkins. 17 Intermediate Chronic Infection CD4 drops to 200-500 Viral load increases Symptoms may include persistent fever, night sweats, chronic diarrhea, headaches, fatigue, infection Most common infection oropharyngeal candidiasis; also shingles, vaginal candidiasis, increase in herpes, oral hairy leukoplakia Copyright © 2008 Lippincott Williams & Wilkins. 18 AIDS - Late Chronic Infection CDC criteria for AIDS (table 15-10) CD4 <200 Certain opportunistic infection Certain opportunistic cancers Wasting syndrome AIDS dementia complex Copyright © 2008 Lippincott Williams & Wilkins. 19 Diagnosis Includes detailed history and physical exam HIV antibody tests Informed consent - state specific laws Antibodies detected within 3-12 wks of infection ELISA performed; confirmation by Western Blot Rapid HIV Viral load tests “undetectable” Copyright © 2008 Lippincott Williams & Wilkins. 20 Treatment Treatment and protocols are continually evolving Most current recommendations include early, aggressive treatment Antiretroviral agents: see 15-14) Nucleoside reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Protease inhibitors (PIs) Use of combination therapy Copyright © 2008 Lippincott Williams & Wilkins. 21 Treatment Management focuses upon: 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 Copyright © 2008 Lippincott Williams & Wilkins. 22 Treatment Adverse effects vary by medication, but may include: Lipodystophy syndrome Fat redistribution syndromes Facial wasting Liver dysfunction GI intolerance Drug resistance Immune reconstitution syndromes Copyright © 2008 Lippincott Williams & Wilkins. 23 Manifestations of AIDS— Respiratory Pneumocystis carinii pneumonia (PCP) Most common infection resulting in AIDS diagnosis 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 TMPSMZ Mycobacterium avium complex (MAC) May cause respiratory or GI infection Tuberculosis Copyright © 2008 Lippincott Williams & Wilkins. 24 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 (50-90%) 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 25 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 Death may result from tumor progression B cell lymphomas Second most common HIV associated malignancy Copyright © 2008 Lippincott Williams & Wilkins. 26 Lesions of Kaposi’s Sarcoma Copyright © 2008 Lippincott Williams & Wilkins. 27 Manifestations of AIDS— Neurologic HIV encephalopathy Progressive cognitive, behavioral, and motor decline Probably directly related to the HIV infection Signs/symptoms may be difficult to distinguish from depression, fatigue/ Includes headaches, memory deficit, apathy, confusion, psychomotor deficits HIV - related peripheral neuropathy Cryptococcus neoformans (fungal infection) Other neurologic disorders (often infectious) Depression Copyright © 2008 Lippincott Williams & Wilkins. 28 Manifestations of AIDSgynecologic Invasive cervical cancer Copyright © 2008 Lippincott Williams & Wilkins. 29 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 Copyright © 2008 Lippincott Williams & Wilkins. 30 Nursing Process—Diagnosis of the Patient With AIDS Impaired skin integrity Diarrhea • Imbalanced nutrition Risk for infection • Social isolation Activity intolerance • Pain • Anticipatory grieving • Deficient knowledge Disturbed thought processes Copyright © 2008 Lippincott Williams & Wilkins. 31 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. 32 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 Effective copingCopyright © 2008 Lippincott Williams & Wilkins. 33 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. 34 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 perianalCopyright skin© 2008 care Lippincott Williams & Wilkins. 35 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. 36 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. 37 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. 38 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. 39 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. 40 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. 41 The Nursing Process Evaluation 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 Copyright © 2008 Lippincott Williams & Wilkins. 42