Interventions For Clients With Hiv


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Interventions For Clients With Hiv

  1. 1. Interventions for Clients with HIV/AIDS<br />Jolene Bethune, RN, MSN<br />
  2. 2. Objectives<br />Provide an overview of HIV and AIDS with key terms you will hear in practice<br />Provide brief outline of pathophysiology and etiology of viral infection<br />Describe methods of transmission<br />Describe methods of preventing transmission in the health care environment<br />Use the nursing process to describe care of the infected client<br />
  3. 3. Overview<br />Acquired immunodeficiency syndrome (AIDS) is the late stage of a continuum of symptoms resulting from infection with the human immunodeficiency virus (HIV)<br />
  4. 4. AIDS and HIV are not the same; not everyone with HIV has AIDS<br />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<br />AIDS is seriously debilitating; eventually fatal; can occur in any age group<br />
  5. 5. Key Terms<br />
  6. 6. Immunodeficiency – a deficient response of the immune system d/t a missing or damaged immune component<br />Immunocompromised – immune system impaired, destroyed resulting in an impaired ability to neutralize, destroy or eliminate antigens<br />
  7. 7. Primary, congenital – immune malfunction present from birth<br />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<br />
  8. 8. Retrovirus– have only RNA as their genetic material; differ from other viruses in their efficiency of replication/cellular infection<br />Reverse transcriptase (RT) – enzyme complex that increases the efficiency of viral replication once the retrovirus enters a human cell<br />
  9. 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<br />
  10. 10. Lymphocyte – becomes sensitized to foreign cells/proteins<br />Lymphocytopenia– decrease in the numbers of lymphocytes<br />
  11. 11. Viremia– high concentration of virus in the blood<br />Pathogenic infections – infections occurring in people with normally functioning immune systems<br />
  12. 12. Opportunistic infections – infections caused by pathogens that are present as part of the normal environment kept in check by a normal immune systems<br />CD4 + T-lymphoctye (T4) – regulates activity of all immune system cells<br />
  13. 13. Nonprogressors – individuals infected with HIV for more than 10 years who remain asymptomatic and have T4 lymphocyte counts within a normal range<br />
  14. 14. Announced during a press conference in November, 1991, that he had HIV; remains asymptomatic today<br />
  15. 15. Pathophysiology<br />
  16. 16. CDC’s classification scheme combines clinical conditions associated with HIV infection and three ranges of CD4+ T-lymphocyte counts<br />Iggy, p.365, Table 22-2<br />
  17. 17. Cell Categories<br />Category 1 500/microL or more<br />Category 2 200-499/microL<br />Category 3 Fewer than 200/microL<br />
  18. 18. Clinical Categories<br />Category A<br />Asymptomatic HIV infection<br />Persistent lymphodenopathy<br />Acute primary HIV infection with accompanying symptoms (diarrhea, n/v, decreased energy)<br />May remain in category A for an extended period of time<br />
  19. 19. Category B<br />Symptomatic conditions attributed to the HIV infection or defect in immunity<br />Bacterial infections<br />Candidiasis for more than one month<br />Fever or diarrhea lasting more than one month<br />Hairy leukoplakia, oral<br />Herpes zoster – two distinct episodes<br />Pulmonary tuberculosis<br />
  20. 20. Category C<br />Conditions that are strongly associated with severe immunodeficiency and cause serious morbidity and mortality<br />See Iggy, p. 365, Table 22-2<br />
  21. 21. Progression from HIV to AIDS can take months or years<br />People who have been transfused with HIV-positive blood develop AIDS more quickly<br />Those who become HIV-positive as a result of a single sexual encounter have a longer latency period<br />Other influences include frequency of re-exposure to HIV, nutritional status, pregnancy, and stress<br />
  22. 22. Etiology<br />
  23. 23. Retrovirus enters the body and infects the human cell<br />
  24. 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<br />
  25. 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<br />
  26. 26. The new virus protein migrates to the cell surface, where it assembles the virus, which “buds’ and leaves the cell.<br />
  27. 27. Viruses spread quickly throughout the lymphoid system, hiding in macrophages and in the centers of lymph nodes<br />
  28. 28. Throughout the course of the infection, HIV is actively replicated by T-lymphocytes, finally exhausting the immune system<br />The HIV retrovirus attaches to, infects, and finally causes the destruction of those immune system cells with a CD4 (T4) surface receptor<br />
  29. 29. HIV/AIDS Around the World<br />
  30. 30. Methods of Transmission<br />
  31. 31. Parental (Blood) Transmission<br />Sharing contaminated needles<br />Accidental needle sticks from an infected person<br />HIV+ women may transmit to their children through perinatal transmission, breastfeeding<br />Exposure to an infected client’s blood through an open wound<br />
  32. 32. Sexual Transmission<br />Homosexual males<br />Heterosexual partners if either is infected<br />Any sexual activity involving exposure to bodily fluids of an infected person<br />
  33. 33. Perinatal Transmission<br />Transplacentally in utero<br />Intrapartally, during exposure tho blood and vaginal secretions during birth<br />Postpartally, through breastmilk<br />
  34. 34. HIV dies quickly outside the body because it needs living tissue and moisture to survive<br />HIV may not be transmitted by<br />Hugging, kissing, holding hands or other nonsexual contact<br />Inanimate objects (money, doorknobs, bathtubs, toilet seats, etc.)<br />Dishes, silverware, or food handled by an infected person<br />Animals or insects<br />
  35. 35. After exposure to the virus, symptoms may develop within 6-12 weeks; however, symptoms may not develop for 6 months <br />Once infected, the client will probably harbor the virus for the rest of his life<br />Opportunistic infections take advantage of the suppressed immune system<br />Tend to resist conventional treatment<br />Client may have multiple opportunistic infections<br />
  36. 36. Prevention of Transmission in a Health Care Setting<br />
  37. 37. Maintain standard precautions<br />Consider all blood and bodily fluids to be contaminated<br />Avoid contaminating outside of container when collecting specimens<br />Do not recap needles and syringes<br />
  38. 38. Cleanse work surface areas with appropriate germicide<br />Clean up spills of blood and body fluid immediately<br />Follow CDC recommendations for immunization of health care workers<br />
  39. 39. CD4 (T4) malfunctions, suppressing the entire immune system<br />Results:<br />Lymphocytopenia<br />Abnormal T-cell function<br />Increased production of incomplete and nonfunctional antibodies<br />Abnormally functioning macrophages<br />
  40. 40. Providing care can evoke complex personal issues for nurses<br />Acknowledge your own fear<br />Acknowledge any negative attitudes regarding possible lifestyles contributing to HIV infection<br />Practice appropriate infection control techniques always<br />Provide compassionate, nonjudgmental care<br />
  41. 41. ASSESSMENT<br />
  42. 42. History<br />Age, gender, occupation and residence<br />Thoroughly assess current complaint/illness<br />Ask when HIV was diagnosed and what symptoms led to that diagnosis<br />Chronology of infections/clinical problems since diagnosis<br />
  43. 43. History<br />Health history (any blood transfusions 1978-1985?)<br />History of STDs, infectious diseases<br />Clotting factors, if hemophiliac<br />Assess client’s level of knowledge<br />
  44. 44. Physical Assessment<br />Possible signs/symptoms: <br />Cough<br />Fever<br />Night sweats<br />Fatigue<br />
  45. 45. Physical Assessment<br />Possible signs/symptoms: <br />N/V<br />Weight loss<br />Lymphodenopathy<br />Diarrhea<br />
  46. 46. Physical Assessment<br />Possible signs/symptoms: <br />Visual changes<br />Headache<br />Memory loss<br />Confusion<br />Seizures<br />Personality changes<br />
  47. 47. Physical Assessment<br />Possible signs/symptoms: <br />Dry skin<br />Rashes<br />Skin lesions<br />Pain<br />Discomfort<br />
  48. 48. Physical Assessment<br />
  49. 49. Physical Assessment – Opportunistic Infections<br />Protozoal Infections<br />Pneumocystis carinii pneumonia (PNP) – fatigue, weight loss; crackles on auscultation<br />Toxoplasmosis encephalitis – sudden mental, neurological changes<br />Cryptosporidosis – mild to severe diarrhea with wasting, electrolyte imbalance<br />
  50. 50. Physical Assessment – Opportunistic Infections<br />Fungal Infections<br />Candida stomatitis/esophagitis – mouth/retrosternal pain; cottage cheese plaques; (vaginal candidiasis – plaques, pruritis, discharge, perineal irritation)<br />Cryptococcosis – meningitis (fever, headache, n/v, nuchal rigidity, mental/neurological changes)<br />Histoplasmosis – respiratory infection (dyspnea, fever, cough, weight loss)<br />
  51. 51. Physical Assessment – Opportunistic Infections<br />Bacterial Infections<br />MAC syndrome (systemic mycobacterium infections of respiratory and/or gastrointestinal tracts; tuberculosis) – fever, weight loss, debility; lymphadenopathy, organ disease<br />Recurrent pneumonia – chest pain, productive cough, fever, dyspnea<br />
  52. 52. Physical Assessment – Opportunistic Infections<br />Viral Infections<br />Cytomegalovirus (CMV) – eyes, respiratory/ gastrointestinal tracts, central nervous system<br />Herpes simplex virus (HSV) – painful lesions/ulcers, fever, pain, bleeding and lymph node enlargement<br />Varicella zoster (VZ) – shingles (pain, burning along dermatome nerve tracts, headache, low grade fever, large painful vesicles<br />
  53. 53. Physical Assessment – Malignancies<br />Kaposi’s sarcoma<br />Malignant lymphomas<br />
  54. 54. Physical Assessment – Other Clinical Manifestations<br />AIDS Dementia Complex<br />Wasting Syndrome<br />Integumentary changes<br />
  55. 55. Laboratory Assessment<br />Lymphocyte counts<br />CD4/CD8 counts<br />Antibody tests – enzyme-linked immunosorbent assay (ELISA); Western blot test<br />Viral culture<br />Viral load testing – measures RNA or viral protein in client’s blood<br />
  56. 56. Psychosocial Assessment<br />Ask about client’s support system – family, SOs, friends<br />Protect confidentiality<br />Activities of daily living<br />Employment<br />Assess client’s levels of anxiety, self esteem<br />Assess changes in body image<br />Coping strategies, strengths<br />
  57. 57. NURSING DIAGNOSES<br />
  58. 58. Risk of infection related to immunodeficiency<br />Impaired gas exchange related to anemia, respiratory infection or malignancy, anemia, fatigue or pain<br />Acute pain or chronic pain related to neuropathy, myelopathy, malignancy or infection<br />
  59. 59. Imbalanced nutrition: less than body requirements related to high metabolic need, n/v, diarrhea, difficulty chewing/swallowing, or anorexia<br />Diarrhea related to infection, food intolerance or medications<br />
  60. 60. Impaired skin integrity related to KS, infections, altered nutritional state, incontinence, immobility, hyperthermia or malignancy<br />Disturbed thought processes related to AIDS dementia complex, central nervous system infection or malignancy<br />
  61. 61. Situational low self-esteem or chronic low self-esteem related to changes in body image, decreased self-esteem, or helplessness<br />Social isolation related to stigma, virus transmissibility, infection control practices or fear<br />
  63. 63. Risk of Infection<br />Expected outcome: The client is expected to remain free of opportunistic diseases<br />Interventions:<br />Drug therapy – antiretrovirals only inhibit viral replication; they do not kill the virus<br />Immune enhancement – bone marrow transplant; lymphocyte transfusion; lymphokines<br />Alternative therapy – vitamins, shark cartilage; botanicals<br />Health promotion – the nurse teaches client to avoid exposure to infection<br />See Iggy, Chart 22-8, p. 378<br />
  64. 64. Impaired Gas Exchange<br />Expected outcome: The client is expected to maintain adequate oxygenation and perfusion, and experience minimal dyspnea and discomfort<br />Interventions:<br />Drug therapy<br />Respiratory support and maintenance<br />Comfort<br />Rest and activity<br />
  65. 65. Imbalance nutrition: less than body requirements<br />Expected outcome: The client is expected to maintain optimal weight through adequate nutrition and hydration<br />Interventions:<br />Drug therapy<br />Diet therapy<br />Mouth care<br />
  66. 66. Diarrhea<br />Expected outcome: The client is expected to experience decreased diarrhea; maintain fluid, electrolyte and nutritional status; and minimize incontinence<br />Interventions:<br />Drug therapy<br />Diet therapy<br />Bedside commode<br />The nurse provides privacy, support and understanding<br />
  67. 67. Impaired Skin Integrity<br />Expected outcome: The client is expected to have healing of any existing lesions and avoid increased skin breakdown or secondary infection<br />Interventions:<br />Chemotherapy<br />Drug therapy<br />Wound care<br />Make-up, concealers<br />
  68. 68. Disturbed Thought Processes<br />Expected outcome: The client is expected to demonstrate improved mental status and sustain no injury<br />Interventions:<br />Orientation<br />Drug therapy<br />Safety measures<br />Support<br />
  69. 69. Situational Low Self-Esteem<br />Expected outcome: The client is expected to identify positive aspects of himself or herself and accept himself or herself<br />Interventions:<br />The nurse allows for privacy, but does not avoid, isolate the client<br />Promote self care, independence, control and decision-making<br />Complementary alternative therapies<br />
  70. 70. Social Isolation<br />Expected outcome: The client is expected to identify behaviors that cause social isolation and demonstrate behaviors that reduce social isolation<br />Interventions:<br />Promotion of interaction<br />Education<br />
  71. 71. EVALUATION<br />
  72. 72. Outcomes: Expected outcomes include that the client will<br />Not develop opportunistic infections<br />Demonstrate adequate respiratory function<br />Achieve and acceptable level of physical comfort<br />Attain adequate weight, nutritional and fluid status<br />
  73. 73. Maintain skin integrity<br />Remain oriented and/or in a safe environment<br />Maintain self-esteem<br />Maintain a support system and involvement with others<br />Comply with the appropriate and available therapy <br />
  74. 74. Other Immunodeficiencies<br />Therapy-induced Immunodeficiencies<br />Drug-induced Immunodeficiencies<br />Cytotoxic drugs<br />Corticosteroids<br />Cyclosporine<br />Radiation-induced Immunodeficiencies – Collaborative management<br />
  75. 75. REFERENCES<br />All Refer (2009). Cancer. Retrieved October 25, 2009, from<br />BBC (2008). US set to spend $50bn against HIV. Retrieved October 25, 2009, from<br />Both Teams Play Hard (n.d.). . Retrieved October 25, 2009, from<br />Council Rock School District (2005). STDs, HIV & AIDS Outline. Retrieved October 25, 2009, from<br />
  76. 76. REFERENCES<br />Dreamstime (n.d.). Categories. Retrieved October 25, 2009, from<br />Ignatavicius, D. D., & Workman, M. L. (2002). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (4 ed.). Philadelphia, PA: W. B. Saunders Company.<br />Medline Plus (2009). Primary HIV Infection. Retrieved October 25, 2009, from<br />Stephanie Relfe (2008). Oil pulling amazing health for almost no cost. Retrieved October 25, 2009, from<br />Zerwekh, J., & Claborn, J. C. (2002). NCLEX-RN: a comprehensive study guide (5 ed.). Midlothian, TX: Nursing Education Consultants.<br />