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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

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