The document provides an overview of interventions for clients with HIV/AIDS. It begins with key terms related to immunodeficiency and HIV/AIDS. It then describes the pathophysiology and etiology of HIV, how it is transmitted, and methods for preventing transmission. Nursing assessments, diagnoses, outcomes, and interventions are outlined with a focus on managing infections, nutritional status, and psychosocial needs. The document concludes with references.

1. Interventions for Clients with HIV/AIDSJolene Bethune, RN, MSN

2. ObjectivesProvide an overview of HIV and AIDS with key terms you will hear in practiceProvide brief outline of pathophysiology and etiology of viral infectionDescribe methods of transmissionDescribe methods of preventing transmission in the health care environmentUse the nursing process to describe care of the infected client

3. OverviewAcquired 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 AIDSMost 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 historyAIDS 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 componentImmunocompromised – immune system impaired, destroyed resulting in an impaired ability to neutralize, destroy or eliminate antigens

7. Primary, congenital – immune malfunction present from birthSecondary, 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 infectionReverse 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/proteinsLymphocytopenia– decrease in the numbers of lymphocytes

11. Viremia– high concentration of virus in the bloodPathogenic 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 systemsCD4 + 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 countsIggy, p.365, Table 22-2

17. Cell CategoriesCategory 1 500/microL or moreCategory 2 200-499/microLCategory 3 Fewer than 200/microL

18. Clinical CategoriesCategory AAsymptomatic HIV infectionPersistent lymphodenopathyAcute primary HIV infection with accompanying symptoms (diarrhea, n/v, decreased energy)May remain in category A for an extended period of time

19. Category BSymptomatic conditions attributed to the HIV infection or defect in immunityBacterial infectionsCandidiasis for more than one monthFever or diarrhea lasting more than one monthHairy leukoplakia, oralHerpes zoster – two distinct episodesPulmonary tuberculosis

20. Category CConditions that are strongly associated with severe immunodeficiency and cause serious morbidity and mortalitySee Iggy, p. 365, Table 22-2

21. Progression from HIV to AIDS can take months or yearsPeople who have been transfused with HIV-positive blood develop AIDS more quicklyThose who become HIV-positive as a result of a single sexual encounter have a longer latency periodOther 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 systemThe 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) TransmissionSharing contaminated needlesAccidental needle sticks from an infected personHIV+ women may transmit to their children through perinatal transmission, breastfeedingExposure to an infected client’s blood through an open wound

32. Sexual TransmissionHomosexual malesHeterosexual partners if either is infectedAny sexual activity involving exposure to bodily fluids of an infected person

33. Perinatal TransmissionTransplacentally in uteroIntrapartally, during exposure tho blood and vaginal secretions during birthPostpartally, through breastmilk

34. HIV dies quickly outside the body because it needs living tissue and moisture to surviveHIV may not be transmitted byHugging, kissing, holding hands or other nonsexual contactInanimate objects (money, doorknobs, bathtubs, toilet seats, etc.)Dishes, silverware, or food handled by an infected personAnimals 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 lifeOpportunistic infections take advantage of the suppressed immune systemTend to resist conventional treatmentClient may have multiple opportunistic infections

36. Prevention of Transmission in a Health Care Setting

37. Maintain standard precautionsConsider all blood and bodily fluids to be contaminatedAvoid contaminating outside of container when collecting specimensDo not recap needles and syringes

38. Cleanse work surface areas with appropriate germicideClean up spills of blood and body fluid immediatelyFollow CDC recommendations for immunization of health care workers

39. CD4 (T4) malfunctions, suppressing the entire immune systemResults:LymphocytopeniaAbnormal T-cell functionIncreased production of incomplete and nonfunctional antibodiesAbnormally functioning macrophages

40. Providing care can evoke complex personal issues for nursesAcknowledge your own fearAcknowledge any negative attitudes regarding possible lifestyles contributing to HIV infectionPractice appropriate infection control techniques alwaysProvide compassionate, nonjudgmental care

41. ASSESSMENT

42. HistoryAge, gender, occupation and residenceThoroughly assess current complaint/illnessAsk when HIV was diagnosed and what symptoms led to that diagnosisChronology of infections/clinical problems since diagnosis

43. HistoryHealth history (any blood transfusions 1978-1985?)History of STDs, infectious diseasesClotting factors, if hemophiliacAssess client’s level of knowledge

44. Physical AssessmentPossible signs/symptoms: CoughFeverNight sweatsFatigue

45. Physical AssessmentPossible signs/symptoms: N/VWeight lossLymphodenopathyDiarrhea

46. Physical AssessmentPossible signs/symptoms: Visual changesHeadacheMemory lossConfusionSeizuresPersonality changes

47. Physical AssessmentPossible signs/symptoms: Dry skinRashesSkin lesionsPainDiscomfort

48. Physical Assessment

49. Physical Assessment – Opportunistic InfectionsProtozoal InfectionsPneumocystis carinii pneumonia (PNP) – fatigue, weight loss; crackles on auscultationToxoplasmosis encephalitis – sudden mental, neurological changesCryptosporidosis – mild to severe diarrhea with wasting, electrolyte imbalance

50. Physical Assessment – Opportunistic InfectionsFungal InfectionsCandida 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 InfectionsBacterial InfectionsMAC syndrome (systemic mycobacterium infections of respiratory and/or gastrointestinal tracts; tuberculosis) – fever, weight loss, debility; lymphadenopathy, organ diseaseRecurrent pneumonia – chest pain, productive cough, fever, dyspnea

52. Physical Assessment – Opportunistic InfectionsViral InfectionsCytomegalovirus (CMV) – eyes, respiratory/ gastrointestinal tracts, central nervous systemHerpes simplex virus (HSV) – painful lesions/ulcers, fever, pain, bleeding and lymph node enlargementVaricella zoster (VZ) – shingles (pain, burning along dermatome nerve tracts, headache, low grade fever, large painful vesicles

53. Physical Assessment – MalignanciesKaposi’s sarcomaMalignant lymphomas

54. Physical Assessment – Other Clinical ManifestationsAIDS Dementia ComplexWasting SyndromeIntegumentary changes

55. Laboratory AssessmentLymphocyte countsCD4/CD8 countsAntibody tests – enzyme-linked immunosorbent assay (ELISA); Western blot testViral cultureViral load testing – measures RNA or viral protein in client’s blood

56. Psychosocial AssessmentAsk about client’s support system – family, SOs, friendsProtect confidentialityActivities of daily livingEmploymentAssess client’s levels of anxiety, self esteemAssess changes in body imageCoping strategies, strengths

57. NURSING DIAGNOSES

58. Risk of infection related to immunodeficiencyImpaired gas exchange related to anemia, respiratory infection or malignancy, anemia, fatigue or painAcute 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 anorexiaDiarrhea related to infection, food intolerance or medications

60. Impaired skin integrity related to KS, infections, altered nutritional state, incontinence, immobility, hyperthermia or malignancyDisturbed 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 helplessnessSocial isolation related to stigma, virus transmissibility, infection control practices or fear

62. PLANNING/IMPLEMENTATION

63. Risk of InfectionExpected outcome: The client is expected to remain free of opportunistic diseasesInterventions:Drug therapy – antiretrovirals only inhibit viral replication; they do not kill the virusImmune enhancement – bone marrow transplant; lymphocyte transfusion; lymphokinesAlternative therapy – vitamins, shark cartilage; botanicalsHealth promotion – the nurse teaches client to avoid exposure to infectionSee Iggy, Chart 22-8, p. 378

64. Impaired Gas ExchangeExpected outcome: The client is expected to maintain adequate oxygenation and perfusion, and experience minimal dyspnea and discomfortInterventions:Drug therapyRespiratory support and maintenanceComfortRest and activity

65. Imbalance nutrition: less than body requirementsExpected outcome: The client is expected to maintain optimal weight through adequate nutrition and hydrationInterventions:Drug therapyDiet therapyMouth care

66. DiarrheaExpected outcome: The client is expected to experience decreased diarrhea; maintain fluid, electrolyte and nutritional status; and minimize incontinenceInterventions:Drug therapyDiet therapyBedside commodeThe nurse provides privacy, support and understanding

67. Impaired Skin IntegrityExpected outcome: The client is expected to have healing of any existing lesions and avoid increased skin breakdown or secondary infectionInterventions:ChemotherapyDrug therapyWound careMake-up, concealers

68. Disturbed Thought ProcessesExpected outcome: The client is expected to demonstrate improved mental status and sustain no injuryInterventions:OrientationDrug therapySafety measuresSupport

69. Situational Low Self-EsteemExpected outcome: The client is expected to identify positive aspects of himself or herself and accept himself or herselfInterventions:The nurse allows for privacy, but does not avoid, isolate the clientPromote self care, independence, control and decision-makingComplementary alternative therapies

70. Social IsolationExpected outcome: The client is expected to identify behaviors that cause social isolation and demonstrate behaviors that reduce social isolationInterventions:Promotion of interactionEducation

71. EVALUATION

72. Outcomes: Expected outcomes include that the client willNot develop opportunistic infectionsDemonstrate adequate respiratory functionAchieve and acceptable level of physical comfortAttain adequate weight, nutritional and fluid status

73. Maintain skin integrityRemain oriented and/or in a safe environmentMaintain self-esteemMaintain a support system and involvement with othersComply with the appropriate and available therapy

74. Other ImmunodeficienciesTherapy-induced ImmunodeficienciesDrug-induced ImmunodeficienciesCytotoxic drugsCorticosteroidsCyclosporineRadiation-induced Immunodeficiencies – Collaborative management

75. REFERENCESAll Refer (2009). Cancer. Retrieved October 25, 2009, from http://health.allrefer.com/health/cancer-lymphoma-malignant-ct-scan.htmlBBC (2008). US set to spend $50bn against HIV. Retrieved October 25, 2009, from http://news.bbc.co.uk/2/hi/7327694.stmBoth Teams Play Hard (n.d.). . Retrieved October 25, 2009, from http://www.bothteamsplayedhard.net/wp-content/uploads/2008/10/magazines-time-magicjohnson.jpgCouncil 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. REFERENCESDreamstime (n.d.). Categories. Retrieved October 25, 2009, from http://www.dreamstime.com/stock-photos-hiv-positive-image3961133Ignatavicius, 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.htmStephanie Relfe (2008). Oil pulling amazing health for almost no cost. Retrieved October 25, 2009, from http://www.relfe.com/07/oil_pulling.htmlZerwekh, J., & Claborn, J. C. (2002). NCLEX-RN: a comprehensive study guide (5 ed.). Midlothian, TX: Nursing Education Consultants.