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Hiv Concepts Pptvo
 

Hiv Concepts Pptvo

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    Hiv Concepts Pptvo Hiv Concepts Pptvo Presentation Transcript

    • Human Immunodeficiency Virus Peggy D. Johndrow 2009
    • Pathophysiology
      • Retroviruses carry genetic Information in genetic material RNA instead of DNA
      • HIV uses enzyme reverse transcriptase to insert itself into cells & reprogram genetic structure; creates HIV
    •  
    • Incubation
      • Latent period: infected persons (80-90%) develop symptoms of HIV disease or AIDS within 10 years; however varies greatly individually
    • Modes of Transmission
      • Sexual
        • Genital, anal or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions
      • Parenteral
        • Sharing needles or equipment contaminated with infected blood products
        • Needle sticks acquired in healthcare settings
      • Perinatal
        • Through placenta from contact with maternal blood & body fluids during birth or from breast milk from infected mother to child
    • CDC Guidelines for Testing
      • People with STI’s
      • IV drug users
      • People who: consider themselves at risk; received a blood transfusion between 1978-1985; planning to marry; undergoing evaluation or treatment for manifestations that may be HIV related; admitted to hospitals; are in correctional institutions
      • Prostitutes and their customers
      • Women of childbearing age with identifiable risk factors
        • IV drug use, engaged in prostitution or had sexual partners who were infected, at risk or from countries with high HIV rates
    • Diagnostic Testing
      • Need informed consent to perform
      • Several tests; repeat to confirm
    • Antibody Testing
      • Antibodies develop within 3-12 weeks of exposure; can take 6-14 months (may not test positive initially)
      • Important point, may take time to test positive does not mean client is immune
    • Enzyme Linked Immunosorbent Assay (ELISA)
      • Identifies antibodies directed specifically against HIV; not establish diagnosis, indicates exposure; blood contains antibodies called seropositive
      • Window period” means that test can be negative even if person has HIV if test is performed too soon (i.e. testing one week after unprotected sex w/ith HIV + partner)
      • False (+) results can occasionally occur
    • Western Blot Assay
      • Identify HIV antibodies
        • Used to confirm seropositive
        • Positive ELISA confirmed with Western Blot Analysis
        • Detects serum antibodies to four specific HIV antigens
    • Indirect Immunofluorescence Assay (IFA)
      • Used instead of Western Blot faster & easier to perform
    • Radioimmunoprecipitation Assay (RIPA)
      • Detects HIV protein
    • Client Implication
      • Positive test antibodies present, HIV probably active, transmit, HIV + (not AIDS), not immune to AIDS
      • Negative (may not have pronounced antibodies at present); continue precautions body hasn’t produced antibodies yet; continuing present behaviors likely to result in infection with HIV
    • Diagnostic Studies
      • Lymphocyte Count
        • Leukcopenia = WBC <3500cells/mm ³
        • Lymphopenia = <1500 lymphocytes/mm³
      • CD4+ and CD8+ Counts
        • Decreased CD4+ counts & decreased CD4/CD8 ratios associated with increased manifestations of disease
        • T-helper cells = 800-1000 cells/microL
        • T-suppressor cells = 300-1000 cells/microL
        • CD4/CD8 ratio: >1
    • Viral Load Testing
      • Measures presence of HIV RNA in blood
        • Gives quantitative number
        • Indicates level of viral burden
        • Useful in monitoring disease progression & effectiveness of treatment
        • Quantitative RNA Assays
        • RT-PCR, bDNA, & NASBA: 100% specificity
        • p24 Antigen Assay
      • Higher viral load the greater risk for transmission; HAART therapy can cause viral load to decrease to undetectable levels, disease transmission risk still present
    • HIV Tracking
      • P24 antigen
      • Quantitative cell culture – viral load
    • Immune Status
      • CD4 cells
      • CD4 cell function test
      • T cells decreased ability to respond
    • Basis of Clinical Manifestations
      • Result from infections, malignancies, or direct effect of HIV in body tissue
    • Clinical Manifestations
      • Initial s/s:
        • Fever
        • Night sweats
        • Chills
        • H/A
        • Muscle aches
      • Decreased CD4+ function r/t HIV infection leads to:
        • Lymphocytopenia
        • Increased production incomplete & nonfunctional antibodies
        • Abnormally functioning macrophages
    • Respiratory Problems
      • Most common Pneumocystis Carinni pneumonia (PCP), mycobacterium avium, intracellular; legionella species
    • GI Symptoms
      • Anorexia, nausea, vomiting, diarrhea, oral esophageal candidiasis, chronic diarrhea
      • Stool cultures positive for Cryptosporidium muris, Salmonella, Isopora belli, Giardia lamblia, Clostridium difficile
    • GI Disorders
      • Effects of diarrhea
        • Profound weight loss >10% body weight, fluid & electrolyte imbalance, perianal skin excoriation, weakness, inability to perform ADL’s
      • Candidiasis
        • Creamy white patches on oral membranes, difficulty swallowing, ulcerations, dissemination to other body systems
      • Wasting syndrome
        • Defined as wt loss>10% body wt & either chronic diarrhea > 30days, chronic weakness & intermittent or constant fever & absence of disease process
      • Hypermetabolic state
        • Excessive calories burned & lean body mass lost
    • Oncology Problems
      • High incidence of cancer
      • Kaposi’s sarcoma
        • Malignancy involving blood & lymphatic vessels; cutaneous lesions on body brownish pink to deep purple lesions; confirm with biopsy
      • B cell lymphomas
        • Commonly brain, bone marrow & GI tract; aggressive growth & resistance to treatment; poor prognosis
    • Neurological Problems
      • 80% have neurological involvement
      • Central, peripheral, autonomic function
      • HIV encephalopathy: ADC(AIDS dementia complex) decline in cognitive, behavioral & motor function ; d iagnose with CT Scan or MRI, analysis of CSF, brain biopsy
      • Cryptococcus neoformans: fungal infection; meningitis; diagnose with CSF analysis
      • Demyelinating CNS disorders
      • Central & Peripheral Neuropathy Depressive disorders
    • Integumentary Problems
      • Kaposi’s Sarcoma
      • Molluscum contagiosium: viral infection with plague formation (wart like, skin tags)
      • Seborrheic dermatitis, folliculitis, eczema, psoriasis
    • Problems Specific to Women
      • Recurrent vaginal candidiasis
      • Genital warts & ulcers
      • Human papilloma virus (HPV)
      • Cervical intraepithelial neoplasia (CIN) cellular change precursor to cervical cancer
      • Women with HIV 10x more likely to develop CIN
      • Strong correlation between abnormal papanicolaou smear & HIV seropositive
      • Higher incidence of PID
      • Higher incidence of menstrual abnormalities
    • Gerontologic Considerations
      • 10% AIDS occurs in people >50
      • Under diagnosed; need education for prevention
    • HIV Classifications
      • Clinical category A HIV positive
      • Clinical category B infected with HIV
      • Clinical category C has AIDS
    • Category A
      • Positive HIV
      • May or may not be symptomatic
      • Lymphadnopathy or “flu-like” complaints
      • Sub categories
        • A1 = CD4+ ≥500/microL
        • A2 = CD4+ 200-499/microL
        • A3 = CD4+ <200/microL
    • Category B
      • One or more problems from column Table 25-1 present
      • Caused by HIV infection or indicates deficiency cell mediated immunity; complicated by HIV infection
      • Sub categories
          • B1, B2, B3
          • CD4+ counts as before
    • Category C
      • Any single problem from column C in Table 25-1
      • Meet criteria for diagnosis of AIDS per CDC guidelines
      • Sub categories
          • C1, C2, C3
          • CD4+ counts as in A&B
    • Important Facts
      • Everyone who has AIDS has HIV infection ; not everyone who has HIV infection has AIDS
      • Person with HIV infection can transmit virus to others at all stages of disease
      • Progression from HIV to AIDS range from months to years
      • Diagnosis of AIDS requires person be HIV (+) & have either a CD4 count <200 cells/microL or an opportunistic infection
      • Once AIDS diagnosed, even if CD4 count goes above 200 or infection is successfully treated, AIDS diagnosis remains & client does not return to just being HIV (+)
    • Health Promotion & Prevention
      • Education most important aspect of prevention
      • HIV: not transmitted by casual contact; easily transmitted when infected body fluids in contact with mucous membranes or non-intact skin
    • Sexual Transmission
      • Abstinence & mutually monogamous sex; only absolute safe methods of preventing HIV through sexual contact
      • Outercourse: no direct contact with blood, semen or vaginal secretions
      • Male/Female condom use
      • See Client Teaching Guidelines
    • Parental Transmission
      • Do Not share needles or equipment (aka “works”)
      • Use full strength household bleach to clean the “works”
      • Needle exchange programs
      • See Teaching Guidelines Needle exchange programs
    • Perinatal Transmission
      • All women who are pregnant or contemplating pregnancy should be counseled about HIV, informed of their choices, offered HIV testing & provided HAART
      • Refer to maternal-child course content
    • Health care Providers Transmission
      • Needle sticks primary means of HIV infection for healthcare workers
        • If needle stick occurs notify supervisor immediately
        • See Best Practice Guideline for HIV exposure
      • Contact with infected body fluids
        • Best prevention is consistent use of standard precautions
        • See prevention guidelines for healthcare workers
    • Medical Management
      • Medications : a ntiretroviral therapy with CD4+ T-cell count< 500/mm3
      • Measure CD4+ count & viral load 2x before initiating
      • HAART triple medication regimen
        • 1 protease inhibitor
        • 2 reverse transcriptase inhibitors
      • Combination therapies use 3 to 4 medications combinations
    • Treatment
      • Post exposure prophylaxis (PEP)
      • Preferred regime
      • Reverse transcriptase inhibitors zidovudine (AZT) and lamivudine (Edvir)
      • Alternate
      • Stavudine (ZERIT) and didanosine (Videx)
      • If client has a high viral load or advanced HIV add a Protease inhibitors either
      • Nelfinavir (Viracept) or indinavir (Crixivan)
    • Treatment Regimen
      • Dosage BID for 4 weeks
      • Must start within 72 hours of exposure
      • If not started renders no benefit after 72 hours
    • Medications
      • Nucleoside Analog Reverse Transcriptase Inhibitors (NRTI’s): suppress production of RT & inhibit viral DNA synthesis/replication; Retrovir, AZT (zidovudine )
      • Non-Nucleoside Analog Reverse Transcriptase Inhibitors (NNRTI’s): inhibits synthesis of RT & suppresses viral replication; Suvista (efavirenz )
          • Protease Inhibitors: block protease enzyme preventing viral replication & release of viral particles; Invirase (saquinavir)
      • Fusion Inhibitors: b lock ability of gp41 to fuse with CD4+ cell: Fuzeon( enfuvirtide); approved treatment advanced, resistant HIV infection
    • Other Therapies
      • Immune enhancement
        • In research stages
          • Hypothesis: immune system may be enhanced or replenished
            • Bone marrow transplant
            • Lymphocyte transfusion
            • Interleukin-2 infusion
      • Complementary/Alternative therapies
        • Usefulness not yet established; however, used by many clients with HIV/AIDS
          • Vitamins, shark cartilage, botanicals
    • Immunomodulator Therapy
      • Alfa-interferon (stimulate macrophages, lymphocytes & T cells)
      • Colony stimulating factor
        • Epoetin alfa recombinant/Epogen
        • Filgrastim/Neupogen
    • Other Medications
      • General infections
      • Bactrim/Septra
      • PCP pentamidine (antiprotozoal) IV slow infusion
      • Steroid
    • Medications for Specific Disorders
      • Mycobacterium avium: Biaxin, Zithromax, Rifampin, mycobutin, lamprene, Ethambutal, Cipro & Amikacin
      • Meningitis: Amphotericin B, Diflucan
      • Other infections
        • Acyclovir & Foscarent for herpes encephalitis
        • Daraprim, Sulfadiazine, Clindamycin for toxoplasmosis
        • Myclex, Nystatin for candidiasis
        • Ketoconazole, fluconazole for chronic candidiasis
    • Nursing Implications
      • See Chart 25-8 for side effects & nursing considerations
      • Antiretroviral therapy only inhibits viral replication; it does not kill virus
      • Combination therapy uses; monotherapy promotes resistance , not improve duration or quality of life
      • “ Cocktails” combination of different types of antiretroviral medications
      • HAART (highly active antiretroviral therapy) shows good results as evidenced by decreased viral load & increased CD4+ counts
    • Problems r/t Therapy
      • Expense of medications
      • Distressing side effects
      • Food & timing requirements
      • Amount of pills that must be taken daily
      • Treatment is lifelong & burdensome
    • Nursing
      • Assessment
      • History sexual practices, IV drug use, physical status, psychological status & all factors affecting immune system
      • Teaching
    • Nutritional
      • Balanced nutrition required for proper immune function
      • Diet history
      • Assess factors interfering with intake
      • Weight, BUN, serum protein, albumin, and transferrin levels
    • Skin integrity
      • Inspect daily for breakdown, excoriation and infection
      • Keep clean and dry
    • Respiratory
      • Monitor cough, sputum, dyspnea, tachypnea, chest pain
      • Evaluate CXR, PFT’s, ABG’s, O2 saturation
    • Neurological
      • LOC, orientation
      • Mental status exam
      • Motor and sensory deficits
    • Fluid and Electrolytes
      • Monitor labs, hydration, vital signs, signs and symptoms of electrolyte imbalance
      • I&O
      • Skin turgor
      • Mucus membranes
    • Health Teaching
      • Client, family, and support systems
      • About disease and transmission
      • Use of alternative therapies
      • Prevention
    • Integumentary Nursing Interventions
      • Turn q 2hrs
      • Use nonabrasive, non-drying soaps, non-perfumed moisturizers
      • Avoid adhesive tape
      • Cleanse after BM with soap and water
      • Sitz bath for comfort
    • Promote Usual Bowel Habits
      • Monitor frequency & consistency of stools
      • Measure quantity & volume of liquid stools to document fluid loss
      • Avoid bowel irritants raw fruits & vegetables, popcorn, carbonated beverages, spicy foods, extreme temperatures of foods
      • Small frequent meals
      • Anti diarrheal agents administered on regular schedule
      •  
    • Prevent Infections
      • Monitor symptoms for infection
      • Monitor labs and cultures
      • Screen visitors; avoid others with infections
      • No live plants; fresh fruits
      • All use good handwashing
      • Promote client hygiene
    • Improve Activity Tolerance
      • Assist clients to plan daily routine that maintain a balance between activity and rest
      • Teach techniques of energy conservation
      • Cluster nursing actions
    • Maintain Thought Processes
      • Teach family to speak in simple terms, clear language and give client time to respond
      • Orient to daily routine
      • Provide a regular schedule / routine
    • Improve Airway Clearance
      • Respiratory assessment
      • Postural drainage
      • Cough and deep breathe q 2hrs
      • Place HOB in semi or high fowlers
      • Adequate hydration (3L/fluid per day)
      • Suction as needed
    • Relieve Pain and Discomfort
      • Assess
      • Provide skin care
      • Assistive devices for comfort
      • Medications NSAIDS, Opioid, tricyclic antidepressants
    • Improve Nutrition Status
      • Oral care
      • Monitor daily weight & dietary intake
      • Monitor labs
      • Control nausea & vomiting with
      • anti-emetics on regular basis
      • Oral soreness opioids, viscous lidocaine
      • Bland diet, avoid temperature extremes in foods
      • Rest before meals
      • Dietary teaching,
      • supplements
    • Decrease Sense of Isolation
      • Acceptance and understanding
      • AIDS support groups and family support
      • Educate client’s families, friends and staff
    • Medications
      • Teach side effects of medication
      • Instruct on importance of taking medications as ordered
      • Explain what to report
    • Home and Community Based
      • Safe sexual practices
      • Avoid infections & infectious people
      • Kitchens & bathrooms surfaces cleansed with disinfectants
      • Avoid contact with pet waste, if necessary client must use gloves
    • Ethical
      • With appropriate techniques minimal transmission in providing care
      • Confidential information disclosure issues
      • Privacy
      • High mortality rate
      • Self-assessment & awareness of personal value & belief system regarding HIV & AIDS