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HIV and AIDS
Epidemiology <ul><li>CDC issued case definition of AIDS in 1982 </li></ul><ul><li>Number of people living with AIDS more t...
Transmission of HIV <ul><li>Body fluids:  Blood, semen, vaginal secretions, amniotic fluid, breast milk </li></ul><ul><li>...
Transmission to health care workers <ul><li>Standard precautions used on ALL patients </li></ul><ul><li>Post-exposure trea...
Pathophysiology <ul><li>HIV is a retrovirus </li></ul><ul><ul><li>Carry genetic material in RNA instead of DNA </li></ul><...
Stages of HIV Disease <ul><li>CDC classification system: </li></ul><ul><li>3 groups  (A, B, C) based on history, physical ...
Primary Infection (A) <ul><li>Defined as the period from infection with HIV to the development of antibodies to HIV </li><...
CDC Category A: HIV Asymptomatic <ul><li>By about 6 months, viral replication reaches lower but steady state </li></ul><ul...
CDC Category B: HIV Symptomatic <ul><li>CD4+ T-cells drop to 200 to 499 </li></ul><ul><li>Has developed a condition relate...
CDC Category C: AIDS <ul><li>CD4+ T-cell count drops below 200 </li></ul><ul><li>Once classified as category C, patient re...
Lab Tests <ul><li>EIA (enzyme immunoassay) </li></ul><ul><ul><li>Antibodies are detected (end of window period) </li></ul>...
Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G2 OraQuick Advance
Treatment of HIV <ul><li>Protocols change frequently </li></ul><ul><li>CD4 count most important consideration in starting ...
Antiretrovial Agents <ul><li>NRTIs  (nucleoside reverse transcriptase inhibitors):  Retrovir, AZT </li></ul><ul><li>NNRTIs...
HAART <ul><li>Highly active antiretroviral therapy </li></ul><ul><li>More than one antiretroviral medication taken in orde...
Medication S/E <ul><li>Nausea, vomiting, diarrhea, rash, pancreatitis, peripheral neuropathy </li></ul><ul><li>Many cause ...
Video Clip <ul><li>http://www.instruction.greenriver.edu/Kmarr/Biology100/Biol%20100%20Lecture%20Notes.htm   </li></ul><ul...
Manifestations of HIV Infection <ul><li>Sx are widespread and can involve any organ system </li></ul><ul><li>Fatigue very ...
Respiratory Infections <ul><li>Most common infection in AIDS patients is Pneumocystis pneumonia (PCP) </li></ul><ul><ul><l...
GI Symptoms <ul><li>Loss of appetite, N/V </li></ul><ul><li>Diarrhea occurs in 50-90% of AIDS pts. </li></ul><ul><ul><li>C...
Oral Candidiasis <ul><li>Occurs in almost all AIDS pts </li></ul><ul><li>May precede life-threatening infections </li></ul...
Mucocutaneous Candidiasis:   Clinical Manifestations Erythematous candidiasis  Credit: D. Greenspan, DSC, BDS, HIV InSite ...
Skin Manifestations <ul><li>Herpes zoster & simplex </li></ul><ul><li>Molluscum contagiosum (viral infection) </li></ul><u...
Wasting Syndrome <ul><li>Weight loss of more than 10% </li></ul><ul><li>Chronic diarrhea more than 1 month </li></ul><ul><...
Oncologic Manifestations <ul><li>Kaposi’s sarcoma is most common HIV related malignancy </li></ul><ul><ul><li>Skin lesions...
 
Neurologic Manifestations <ul><li>80% of AIDS patients will have neurologic involvement resulting from direct effects of H...
HIV Encephalopathy <ul><li>Formerly called “AIDS dementia complex” </li></ul><ul><li>Progressive decline in cognitive, beh...
Additional Medical Management <ul><li>Treatment of infections </li></ul><ul><ul><li>T-cell count less than 200 should rece...
Additional Medical Management <ul><li>Tx of cryptococcal meningitis with amphotericin B, with or without Diflucan </li></u...
Additional Medical Management <ul><li>Herpes infections treated with acyclovir or famciclovir </li></ul><ul><li>Oral or es...
Additional Medical Management <ul><li>Depression treated with Tofranil, Prozac </li></ul><ul><ul><li>ECT used for severe c...
Nursing Assessment <ul><li>Potential risk factors:  IV drug use, risky sexual behavior </li></ul><ul><li>Nutritional statu...
Nursing Assessment <ul><li>Respiratory Status:  cough, sputum, SOB, chest pain, pulse-ox, breath sounds, CXR </li></ul><ul...
Nursing Diagnoses for HIV/AIDS <ul><li>Risk for infection </li></ul><ul><li>Diarrhea </li></ul><ul><li>Ineffective airway ...
Nursing Interventions <ul><li>Monitor for S&S of infection </li></ul><ul><li>Balance activities with rest </li></ul><ul><l...
Nursing Interventions <ul><li>Nutritional support </li></ul><ul><ul><li>Anti-emetics, soft foods, topical Lidocaine </li><...
Nursing Interventions <ul><li>Monitoring for medication side-effects </li></ul><ul><li>Teaching self-care:  preventing tra...
Ethical Considerations  <ul><li>Must protect patient’s right to privacy </li></ul><ul><li>This sometimes conflicts with se...
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Nrsg 200 hiv

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  • Four rapid tests approved by the FDA are currently commercially available: The Uni-Gold, Multispot, Reveal, and OraQuick Advance.
  • Kaposi’s sarcoma
  • Transcript of "Nrsg 200 hiv"

    1. 1. HIV and AIDS
    2. 2. Epidemiology <ul><li>CDC issued case definition of AIDS in 1982 </li></ul><ul><li>Number of people living with AIDS more than doubled between 1998 and 2003 </li></ul><ul><li>AIDS kills more than 8000 people daily around the world </li></ul><ul><ul><li>Unsafe sex predominate mode of transmission; also infected drug injection equipment </li></ul></ul><ul><ul><li>Racial & ethnic minorities have disproportionately high rates of HIV in US, especially African-American & Hispanics </li></ul></ul>
    3. 3. Transmission of HIV <ul><li>Body fluids: Blood, semen, vaginal secretions, amniotic fluid, breast milk </li></ul><ul><li>Not transmitted via casual contact </li></ul><ul><li>Risk of transmission via transfusion virtually eliminated due to extensive testing, heat treatment & virus inactivation methods </li></ul>
    4. 4. Transmission to health care workers <ul><li>Standard precautions used on ALL patients </li></ul><ul><li>Post-exposure treatment reduces risk of HIV infection </li></ul><ul><ul><li>Immediately cleanse exposed area; report it! </li></ul></ul><ul><ul><li>Begin tx immediately after exposure, no longer than 72 hours after </li></ul></ul><ul><ul><li>Baseline testing for HIV, hep. B & C for you & pt </li></ul></ul><ul><ul><li>Follow-up testing done at 1 month, 3 & 6 mo. </li></ul></ul><ul><ul><li>Antiretroviral therapy x 4 weeks </li></ul></ul><ul><ul><ul><li>Can cost $500-$1000; may develop future resistance; S/E </li></ul></ul></ul>
    5. 5. Pathophysiology <ul><li>HIV is a retrovirus </li></ul><ul><ul><li>Carry genetic material in RNA instead of DNA </li></ul></ul><ul><ul><li>Consists of viral core containing the RNA surrounded by an envelope of glycoproteins </li></ul></ul><ul><ul><li>HIV has complex life cycle of 8 steps </li></ul></ul><ul><ul><ul><li>HIV attaches to an uninfected CD4 or CD8 cell surface </li></ul></ul></ul><ul><ul><ul><li>Enzyme “reverse transcriptase” copies the viral genetic material from RNA into DNA </li></ul></ul></ul><ul><ul><ul><li>Mutates quickly; now 12 sub-types identified </li></ul></ul></ul>
    6. 6. Stages of HIV Disease <ul><li>CDC classification system: </li></ul><ul><li>3 groups (A, B, C) based on history, physical exam, lab values, S&S, and infections and malignancies </li></ul><ul><li>See Table 52-1 on page 1823 </li></ul>
    7. 7. Primary Infection (A) <ul><li>Defined as the period from infection with HIV to the development of antibodies to HIV </li></ul><ul><ul><li>Intense viral replication </li></ul></ul><ul><ul><li>Symptoms vary from none to flu-like or “mono” </li></ul></ul><ul><ul><ul><li>Fever, enlarged lymph nodes, rash, muscle aches, H/A </li></ul></ul></ul><ul><ul><li>“ Window” period exists where infection has occurred but no antibodies are detected (lasts 3 months up to 1 year) </li></ul></ul>
    8. 8. CDC Category A: HIV Asymptomatic <ul><li>By about 6 months, viral replication reaches lower but steady state </li></ul><ul><li>CD4+ T-cell count greater than 500 </li></ul><ul><li>Few, if any, symptoms </li></ul><ul><li>8-10 years can pass before major HIV-related complication occurs </li></ul>
    9. 9. CDC Category B: HIV Symptomatic <ul><li>CD4+ T-cells drop to 200 to 499 </li></ul><ul><li>Has developed a condition related to defect in cellular immunity </li></ul><ul><ul><li>Candidiasis </li></ul></ul><ul><ul><li>Cervical dysplasia </li></ul></ul><ul><ul><li>Fever or diarrhea lasting more than 1 month </li></ul></ul><ul><ul><li>Hairy leukoplakia of the mouth </li></ul></ul><ul><ul><li>Herpes zoster </li></ul></ul><ul><ul><li>Idiopathic thrombocytopenic purpura </li></ul></ul><ul><ul><li>PID </li></ul></ul><ul><ul><li>Peripheral neuropathy </li></ul></ul>
    10. 10. CDC Category C: AIDS <ul><li>CD4+ T-cell count drops below 200 </li></ul><ul><li>Once classified as category C, patient remains in Category C (May qualify for entitlements) </li></ul><ul><ul><li>Candidiasis of esophagus or trachea </li></ul></ul><ul><ul><li>Coccidioidomycosis </li></ul></ul><ul><ul><li>Cryptosporidiosis </li></ul></ul><ul><ul><li>Cytomegalovirus </li></ul></ul><ul><ul><li>HIV-related encephalopathy </li></ul></ul><ul><ul><li>Kaposi’s sarcoma </li></ul></ul><ul><ul><li>Lymphoma </li></ul></ul><ul><ul><li>Toxoplasmosis </li></ul></ul><ul><ul><li>Pneumocystis pneumonia </li></ul></ul><ul><ul><li>Wasting syndrome </li></ul></ul>
    11. 11. Lab Tests <ul><li>EIA (enzyme immunoassay) </li></ul><ul><ul><li>Antibodies are detected (end of window period) </li></ul></ul><ul><li>Western blot </li></ul><ul><ul><li>Also detects antibodies; confirms EIA </li></ul></ul><ul><li>Viral load </li></ul><ul><ul><li>Measures HIV RNA in the plasma </li></ul></ul><ul><ul><li>Better predictor of disease progression than CD4 count </li></ul></ul><ul><li>CD4/CD8 ratio </li></ul>
    12. 12. Uni-Gold Recombigen Multispot HIV-1/HIV-2 Reveal G2 OraQuick Advance
    13. 13. Treatment of HIV <ul><li>Protocols change frequently </li></ul><ul><li>CD4 count most important consideration in starting therapy (less than 350) </li></ul><ul><li>Treatment should be offered to all patients with primary infection </li></ul><ul><li>Tx regimens are complex, have major side-effects & require adherence to avoid resistance </li></ul><ul><li>Viral load/ CD4 counts checked every 3 months </li></ul><ul><ul><li>Viral load should drop to less than 50 copies by 16-20 weeks; CD4 count should increase by 100-150 within 3 months </li></ul></ul>
    14. 14. Antiretrovial Agents <ul><li>NRTIs (nucleoside reverse transcriptase inhibitors): Retrovir, AZT </li></ul><ul><li>NNRTIs (non-nucleoside reverse transcriptase inhibitors): Sustiva </li></ul><ul><li>Protease inhibitors: Agenerase, Kaletra </li></ul><ul><li>Fusion inhibitors: Fuzeon </li></ul><ul><li>See Table 52-3 on pages 1827-28 </li></ul>
    15. 15. HAART <ul><li>Highly active antiretroviral therapy </li></ul><ul><li>More than one antiretroviral medication taken in order to achieve sustained viral suppression </li></ul>
    16. 16. Medication S/E <ul><li>Nausea, vomiting, diarrhea, rash, pancreatitis, peripheral neuropathy </li></ul><ul><li>Many cause lipodystrophy syndrome </li></ul><ul><ul><li>Pseudo-Cushing’s appearance: fat loss in arms & legs, with build-up of fat in abdomen & neck </li></ul></ul><ul><ul><li>At risk for early-onset hypercholesterolemia, heart disease & diabetes </li></ul></ul>
    17. 17. Video Clip <ul><li>http://www.instruction.greenriver.edu/Kmarr/Biology100/Biol%20100%20Lecture%20Notes.htm </li></ul><ul><li>Watch “HIV Case Study” Video </li></ul>
    18. 18. Manifestations of HIV Infection <ul><li>Sx are widespread and can involve any organ system </li></ul><ul><li>Fatigue very common </li></ul><ul><li>Opportunistic infections </li></ul><ul><li>Immune Reconstitution Syndromes </li></ul><ul><ul><li>Fever & worsening of the opportunistic infection symptoms </li></ul></ul><ul><ul><li>Develops weeks after starting antiretroviral therapy </li></ul></ul><ul><ul><ul><li>Tx with NSAIDs to alleviate inflammatory reaction </li></ul></ul></ul>
    19. 19. Respiratory Infections <ul><li>Most common infection in AIDS patients is Pneumocystis pneumonia (PCP) </li></ul><ul><ul><li>Non-productive cough, fever & chills, SOB, dyspnea, crackles, decreased O2 sats. </li></ul></ul><ul><ul><li>Will lead to resp. failure without tx </li></ul></ul><ul><li>Mycobacterium avium complex </li></ul><ul><li>TB which can disseminate to CNS, bone, stomach, peritoneum & scrotum </li></ul>
    20. 20. GI Symptoms <ul><li>Loss of appetite, N/V </li></ul><ul><li>Diarrhea occurs in 50-90% of AIDS pts. </li></ul><ul><ul><li>Cryptosporidium, Salmonella, Giardia, </li></ul></ul><ul><li>C. diff. </li></ul><ul><li> May develop profound weight loss, fluid & electrolyte imbalances, weakness, perianal excoriation </li></ul>
    21. 21. Oral Candidiasis <ul><li>Occurs in almost all AIDS pts </li></ul><ul><li>May precede life-threatening infections </li></ul><ul><li>Creamy white patches in the mouth </li></ul><ul><li>Can spread to esophagus </li></ul><ul><li>Difficulty swallowing </li></ul><ul><li>May also have oral lesions </li></ul>
    22. 22. Mucocutaneous Candidiasis: Clinical Manifestations Erythematous candidiasis Credit: D. Greenspan, DSC, BDS, HIV InSite Pseudomembranous candidiasis Credit: Pediatric AIDS Pictorial Atlas, Baylor International Pediatric AIDS Initiative
    23. 23. Skin Manifestations <ul><li>Herpes zoster & simplex </li></ul><ul><li>Molluscum contagiosum (viral infection) </li></ul><ul><li>Generalized folliculitis </li></ul>
    24. 24. Wasting Syndrome <ul><li>Weight loss of more than 10% </li></ul><ul><li>Chronic diarrhea more than 1 month </li></ul><ul><li>Chronic weakness </li></ul><ul><li>Fever </li></ul><ul><li>Hypermetabolic state with protein-energy malnutrition </li></ul><ul><li>Elevated triglycerides </li></ul>
    25. 25. Oncologic Manifestations <ul><li>Kaposi’s sarcoma is most common HIV related malignancy </li></ul><ul><ul><li>Skin lesions can occur anywhere on body </li></ul></ul><ul><ul><li>Brownish-pink to deep purple; flat or raised </li></ul></ul><ul><ul><li>Diagnosis confirmed by skin biopsy </li></ul></ul><ul><li>B-cell lymphomas are second most common; resistant to tx </li></ul><ul><li>Invasive cervical CA in females </li></ul><ul><li>Also can get CA in stomach, skin, pancreas, rectum, bladder </li></ul>
    26. 27. Neurologic Manifestations <ul><li>80% of AIDS patients will have neurologic involvement resulting from direct effects of HIV, opportunistic infections or neoplasms </li></ul><ul><li>Cryptococcus meningitis </li></ul><ul><li>Leukoencephalopathy </li></ul><ul><li>Peripheral neuropathy R/T demyelination </li></ul><ul><li>Depression </li></ul>
    27. 28. HIV Encephalopathy <ul><li>Formerly called “AIDS dementia complex” </li></ul><ul><li>Progressive decline in cognitive, behavioral and motor functions </li></ul><ul><li>Memory deficits, headache, difficulty concentrating, confusion, apathy, ataxia </li></ul><ul><li>Later stages include global cognitive impairment, delayed verbal response, vacant stare, spastic paraparesis, hyperreflexia, psychosis, tremor, hallucinations, incontinence, seizures </li></ul><ul><li>CT shows diffuse cerebral atrophy & ventricular enlargement </li></ul>
    28. 29. Additional Medical Management <ul><li>Treatment of infections </li></ul><ul><ul><li>T-cell count less than 200 should receive prophylaxis against PCP with Bactrim or Septra (TMP-SMZ) </li></ul></ul><ul><ul><li>PCP treated with Septra; pentamidine used if Septra ineffective </li></ul></ul><ul><ul><ul><li>Aerosolized pentamidine no longer used </li></ul></ul></ul><ul><ul><li>Prophylaxis against Mycobacterium avium with Biaxin or azithromycin, for T-cell counts less than 50 </li></ul></ul>
    29. 30. Additional Medical Management <ul><li>Tx of cryptococcal meningitis with amphotericin B, with or without Diflucan </li></ul><ul><ul><li>Diflucan also used for suppressive therapy </li></ul></ul><ul><li>Retinitis due to Cytomegalovirus (leading cause of blindness in AIDS patients): tx prophylactically with ganciclovir for T-cell counts less than 50 </li></ul><ul><ul><li>Tx for retinitis must be taken for life </li></ul></ul><ul><ul><li>Common adverse reaction is neutropenia </li></ul></ul><ul><ul><ul><li>May be given intravitreally </li></ul></ul></ul>
    30. 31. Additional Medical Management <ul><li>Herpes infections treated with acyclovir or famciclovir </li></ul><ul><li>Oral or esophageal Candidiasis treated with Mycelex, nystatin, Nizoral or Diflucan </li></ul><ul><li>Chronic diarrhea treated with Sandostatin </li></ul><ul><li>Kaposi’s sarcoma treated with alpha-interferon, surgical excision, liquid nitrogen, radiation </li></ul><ul><li>Lymphoma treated may be treated with chemo & radiation but usually has limited effect </li></ul>
    31. 32. Additional Medical Management <ul><li>Depression treated with Tofranil, Prozac </li></ul><ul><ul><li>ECT used for severe cases not responsive to meds </li></ul></ul><ul><li>Appetite stimulants such as Megace </li></ul><ul><li>Dronabinol (synthetic THC) used to control N/V </li></ul><ul><li>Nutritional supplements usually lactose-free: Advera specifically for AIDS </li></ul><ul><ul><li>Parenteral nutrition is final option due to risk of infections </li></ul></ul>
    32. 33. Nursing Assessment <ul><li>Potential risk factors: IV drug use, risky sexual behavior </li></ul><ul><li>Nutritional status: anorexia, N/V, oral pain, diarrhea, weight pattern, serum protein & albumin levels </li></ul><ul><li>Skin & mucous membranes: Look for breakdown, ulcerations, peri-anal excoriation </li></ul><ul><li>Fluid & electrolyte status: Turgor, V/S, urine output, electrolyte values </li></ul>
    33. 34. Nursing Assessment <ul><li>Respiratory Status: cough, sputum, SOB, chest pain, pulse-ox, breath sounds, CXR </li></ul><ul><li>Neuro Status: LOC, orientation, memory, H/A, neuropathy, seizures, visual changes, depression </li></ul><ul><li>Knowledge level: transmission, psychological reaction, ability to manage treatments </li></ul>
    34. 35. Nursing Diagnoses for HIV/AIDS <ul><li>Risk for infection </li></ul><ul><li>Diarrhea </li></ul><ul><li>Ineffective airway clearance </li></ul><ul><li>Imbalanced nutrition </li></ul><ul><li>Deficient knowledge </li></ul><ul><li>Social isolation </li></ul><ul><li>*See Care Plan pages 1838-44 </li></ul>
    35. 36. Nursing Interventions <ul><li>Monitor for S&S of infection </li></ul><ul><li>Balance activities with rest </li></ul><ul><li>Prevent skin breakdown; administer treatments as ordered </li></ul><ul><li>Promote usual bowel patterns </li></ul><ul><ul><li>Avoid bowel irritants; small frequent meals </li></ul></ul><ul><ul><li>Anti-diarrheals on routine basis </li></ul></ul><ul><li>Improve airway clearance </li></ul><ul><ul><li>Cough/ deep breathe, postural drainage </li></ul></ul>
    36. 37. Nursing Interventions <ul><li>Nutritional support </li></ul><ul><ul><li>Anti-emetics, soft foods, topical Lidocaine </li></ul></ul><ul><ul><li>Supplements & high-cal foods </li></ul></ul><ul><li>Pain management </li></ul><ul><ul><li>NSAIDs, opioids, tricyclics for neuropathy </li></ul></ul><ul><li>Social isolation: Many feel guilt, shame, suffer loss normal roles, anger </li></ul><ul><ul><li>Offer accepting attitude </li></ul></ul><ul><ul><li>Reassure that HIV not transmitted casually </li></ul></ul>
    37. 38. Nursing Interventions <ul><li>Monitoring for medication side-effects </li></ul><ul><li>Teaching self-care: preventing transmission of HIV & other infections (safe sexual practices, handling soiled items, handwashing, personal and environmental hygiene) </li></ul><ul><ul><li>Avoid exposure to sick people </li></ul></ul><ul><ul><li>Avoid alcohol, tobacco </li></ul></ul><ul><ul><li>Avoid cleaning bird cages & cat litter boxes </li></ul></ul><ul><ul><li>Medication administration </li></ul></ul><ul><ul><li>Nutrition </li></ul></ul><ul><ul><li>Importance of keeping follow-up appointments </li></ul></ul><ul><ul><li>Community resource referrals </li></ul></ul>
    38. 39. Ethical Considerations <ul><li>Must protect patient’s right to privacy </li></ul><ul><li>This sometimes conflicts with sexual or drug partners’ right to know about their exposure </li></ul><ul><li>State laws vary as to whether contacts are notified & who is responsible for notification </li></ul><ul><li>Indiana law requires that persons infected with HIV who know their status, warn past & present sexual or needle-sharing partners of their HIV status & need to seek testing </li></ul><ul><ul><li>Court can order restrictive limitations on person who presents a danger to public health </li></ul></ul>
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