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Interventions For Clients With Hiv

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  • 1. Interventions for Clients with HIV/AIDS
    Jolene Bethune, RN, MSN
  • 2. 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
  • 3. Overview
    Acquired immunodeficiency syndrome (AIDS) is the late stage of a continuum of symptoms resulting from infection with the human immunodeficiency virus (HIV)
  • 4. 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
  • 5. Key Terms
  • 6. 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
  • 7. 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
  • 8. 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
  • 9. 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
  • 10. Lymphocyte – becomes sensitized to foreign cells/proteins
    Lymphocytopenia– decrease in the numbers of lymphocytes
  • 11. Viremia– high concentration of virus in the blood
    Pathogenic infections – infections occurring in people with normally functioning immune systems
  • 12. 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
  • 13. Nonprogressors – individuals infected with HIV for more than 10 years who remain asymptomatic and have T4 lymphocyte counts within a normal range
  • 14. Announced during a press conference in November, 1991, that he had HIV; remains asymptomatic today
  • 15. Pathophysiology
  • 16. CDC’s classification scheme combines clinical conditions associated with HIV infection and three ranges of CD4+ T-lymphocyte counts
    Iggy, p.365, Table 22-2
  • 17. Cell Categories
    Category 1 500/microL or more
    Category 2 200-499/microL
    Category 3 Fewer than 200/microL
  • 18. Clinical Categories
    Category 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
  • 19. 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
  • 20. Category C
    Conditions that are strongly associated with severe immunodeficiency and cause serious morbidity and mortality
    See Iggy, p. 365, Table 22-2
  • 21. 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
  • 22. Etiology
  • 23. Retrovirus enters the body and infects the human cell
  • 24. 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
  • 25. 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
  • 26. The new virus protein migrates to the cell surface, where it assembles the virus, which “buds’ and leaves the cell.
  • 27. Viruses spread quickly throughout the lymphoid system, hiding in macrophages and in the centers of lymph nodes
  • 28. 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
  • 29. HIV/AIDS Around the World
  • 30. Methods of Transmission
  • 31. 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
  • 32. Sexual Transmission
    Homosexual males
    Heterosexual partners if either is infected
    Any sexual activity involving exposure to bodily fluids of an infected person
  • 33. Perinatal Transmission
    Transplacentally in utero
    Intrapartally, during exposure tho blood and vaginal secretions during birth
    Postpartally, through breastmilk
  • 34. HIV dies quickly outside the body because it needs living tissue and moisture to survive
    HIV may not be transmitted by
    Hugging, kissing, holding hands or other nonsexual contact
    Inanimate objects (money, doorknobs, bathtubs, toilet seats, etc.)
    Dishes, silverware, or food handled by an infected person
    Animals or insects
  • 35. 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
  • 36. Prevention of Transmission in a Health Care Setting
  • 37. 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
  • 38. 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
  • 39. CD4 (T4) malfunctions, suppressing the entire immune system
    Results:
    Lymphocytopenia
    Abnormal T-cell function
    Increased production of incomplete and nonfunctional antibodies
    Abnormally functioning macrophages
  • 40. Providing care can evoke complex personal issues for nurses
    Acknowledge your own fear
    Acknowledge any negative attitudes regarding possible lifestyles contributing to HIV infection
    Practice appropriate infection control techniques always
    Provide compassionate, nonjudgmental care
  • 41. ASSESSMENT
  • 42. 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
  • 43. History
    Health history (any blood transfusions 1978-1985?)
    History of STDs, infectious diseases
    Clotting factors, if hemophiliac
    Assess client’s level of knowledge
  • 44. Physical Assessment
    Possible signs/symptoms:
    Cough
    Fever
    Night sweats
    Fatigue
  • 45. Physical Assessment
    Possible signs/symptoms:
    N/V
    Weight loss
    Lymphodenopathy
    Diarrhea
  • 46. Physical Assessment
    Possible signs/symptoms:
    Visual changes
    Headache
    Memory loss
    Confusion
    Seizures
    Personality changes
  • 47. Physical Assessment
    Possible signs/symptoms:
    Dry skin
    Rashes
    Skin lesions
    Pain
    Discomfort
  • 48. Physical Assessment
  • 49. 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
  • 50. 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)
  • 51. 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
  • 52. Physical Assessment – Opportunistic Infections
    Viral 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
  • 53. Physical Assessment – Malignancies
    Kaposi’s sarcoma
    Malignant lymphomas
  • 54. Physical Assessment – Other Clinical Manifestations
    AIDS Dementia Complex
    Wasting Syndrome
    Integumentary changes
  • 55. 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
  • 56. 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
  • 57. NURSING DIAGNOSES
  • 58. 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
  • 59. 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
  • 60. 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
  • 61. 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
  • 62. PLANNING/IMPLEMENTATION
  • 63. Risk of Infection
    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
  • 64. Impaired Gas Exchange
    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
  • 65. Imbalance nutrition: less than body requirements
    Expected outcome: The client is expected to maintain optimal weight through adequate nutrition and hydration
    Interventions:
    Drug therapy
    Diet therapy
    Mouth care
  • 66. Diarrhea
    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
  • 67. Impaired Skin Integrity
    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
  • 68. Disturbed Thought Processes
    Expected outcome: The client is expected to demonstrate improved mental status and sustain no injury
    Interventions:
    Orientation
    Drug therapy
    Safety measures
    Support
  • 69. Situational Low Self-Esteem
    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
  • 70. Social Isolation
    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
  • 71. EVALUATION
  • 72. 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
  • 73. 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
  • 74. Other Immunodeficiencies
    Therapy-induced Immunodeficiencies
    Drug-induced Immunodeficiencies
    Cytotoxic drugs
    Corticosteroids
    Cyclosporine
    Radiation-induced Immunodeficiencies – Collaborative management
  • 75. 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
  • 76. 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.