HIV

What major antibiotic side effects do you need to monitor for in K.D.?

About 50% of AIDS patients experience the following adverse reactions when taking Bactrim: vomiting, hyponatremia, fever, rash, neutropenia, thrombocytopenia, hepatitis, and cholestatic jaundice.

K.D. is kept on trimethoprim/sulfamethoxazole (Bactrim) two tablets once daily. He asks why he has to keep taking the drug "since the pneumonia is gone." How would you respond?

Because K.D. is now at risk for opportunistic infections, Bactrim is being used prophylactically against his redeveloping further PJP and other bacterial infections.

Because of compromised immune function, K.D. is at risk for developing other opportunistic infections. List at least five.

Candidiasis, cryptosporidiosis, toxoplasmosis, Mycoplasma pneumonia, CMV, herpes simplex, histoplasmosis, tuberculosis (TB), and hepatitis

What immediate complication is K.D. at risk for experiencing?

K.D. is at risk for developing life-threatening respiratory dysfunction, including respiratory failure, pleural effusion, and pneumothorax.

What other health care team members may you involve in K.D.'s discharge planning?

K.D. would benefit from services from social services or case management, benefits counseling, nutrition counseling, and psychologic services.

Kaposi sarcoma (KS)

KS is a type of cancer found in persons with acquired immunodeficiency syndrome (AIDS). KS is frequently found on the skin but can spread to the gastrointestinal (GI) system and lungs, where it can be life threatening. It is most likely to occur with lower CD4 counts.

What is PJP?

P. jiroveci is a fungus normally found in the human lung. It rarely causes disease in healthy individuals; disease develops when the host's immune systems are critically impaired (CD4≤200 cells/mm3

To detect this complication, what will be the focus of your ongoing assessment?

Respiratory status: lung sounds, respiratory rate, oxygenation status, VS, laboratory values

Identify four problems you must manage at this time regarding K.D.

Risk for respiratory failure and inadequate oxygenation related to PJP • Risk for further or other infection related to immunosuppression • Inadequate nutrition • Anxiety and fear because of conversion to AIDS, and a cancer diagnosis • Nonadherence to medication therapy

What interventions can you use to assist K.D. in managing his depression?

Spend time with K.D. and encourage him to express his feelings and concerns. K.D. should be offered appropriate referrals, include psychiatry or counseling services. Help him identify available community support services, and encourage him to use those services after discharge. He may also be considered for antidepressant use.

K.D. was taught about disease transmission and safer sex and encouraged to maintain moderate exercise, rest, and dietary habits when he was first diagnosed as HIV positive. Give at least four additional topics that should be discussed with K.D. before he goes home.

• Because he has KS, he needs to report any symptoms of GI bleeding. • He should understand the signs and symptoms of infections and measures to reduce the risk of infections. • He should understand the importance of follow-up care. • He should be given written information about area support services. • He should be referred to a registered dietitian for medical nutrition therapy to aid in maintaining his usual body weight, preventing wasting of lean muscle mass, and addressing nausea, diarrhea, and oral pain. He has increased calorie, protein, and fluid needs. He might need a gluten- and lactose-free meal plan because of diarrhea and malabsorption. • There should be discussion and administration of pneumococcal polyvalent vaccine (Pneumovax), yearly tuberculin testing, and a yearly influenza vaccine.

K.D. has 20KS lesions on his neck, upper chest, and both upper arms, all of which are closed and painless. How will you care for the KS lesions? a. Keep each lesion covered with a clear, transparent dressing b. Place sterile, saline-soaked gauze over each lesion twice daily c. Keep the lesions dry, cleaning the affected areas gently as needed d. Apply topical antibiotic ointment twice daily to the affected areas

Answer: c There is no special treatment needed for closed lesions other than to keep them clean and dry. If the lesions were open or draining, then you would need to care for the lesions as you would an open wound, following your agency's skin care protocol, keeping them covered with a sterile dressing.

What aspects of K.D.'s care can you delegate to the licensed practical nurse (LPN)? Select all that apply. a. Providing instructions about a high-calorie, high-protein diet b Repositioning K.D. and having him deep breathe every 2 hours c. Developing a plan of care to improve K.D.'s oxygenation status d. Reinforcing teaching with K.D. about good hand washing techniques e. Administering first dose of IV trimethoprim-sulfamethoxazole (Bactrim) f. Monitoring K.D.'s pulse oximetry readings and reporting values under 95%

Answers: b, d, f The registered nurse cannot delegate any aspect of planning, including the development of comprehensive approaches to the patient's care plan, or any health teaching. An LPN can reinforce any teaching previously provided by the RN. The LPN can provide direct care by performing treatments and procedures, including repositioning and deep breathing, and reporting patient responses to the RN. The role of the LPN in IV therapy varies. Some states or institutions do not allow LPNs to administer any IV medications; when this is within the LPN's role, however, the first dose of any IV antibacterial medication must be administered by the RN.

What type of isolation precautions do you need to use when caring for K.D.? a. Droplet b. Contact c. Standard d. Airborne

C. standard. Using standard precautions for blood and body fluids is all that is necessary for K.D.

. Describe the assessment you need to perform to determine if these problems are present.

General: Any history of fever, night sweats, weight loss Skin: Look for other lesions, such as Herpes zoster or simplex lesions, dermatitis, fungal infections of the skin or nail beds Ear, nose, and throat: Candidiasis, hairy leukoplakia; cervical lymphadenopathy Cardiovascular: Friction rub, murmurs, gallops GI: Hepatomegaly, splenomegaly, change in bowel habits, anorexia, nausea, vomiting Genitourinary: Herpes lesions; candidiasis; warts; syphilitic chancres; discharge from penis or rectum; cloudy urine; complaints of frequency, urgency, or burning with urination Neurologic: Flattened affect, apathy, withdrawal, memory deficits, headache, weakness

K.D. has been seropositive for several years, yet he has been asymptomatic for acquired immunodeficiency syndrome (AIDS). What factors might have influenced K.D.'s development of PJP and KS?

He has been under considerable pressure at work, has been working long hours, and has not been eating well; such cofactors might have triggered activation of the virus, producing immunodeficiency and allowing an opportunity for P. jiroveci to cause illness. Another factor is possible reexposure to an HIV-infected person. Because he stopped taking his medications, his immune system might have declined.

What is the significance of K.D.'s developing KS and PJP?

He is now considered to have a diagnosis of AIDS. People with AIDS are HIV positive and have a CD4 count of 200 cells/mm3 or lower or an AIDS-defining condition such as KS or PJP.

What ongoing laboratory monitoring will K.D. need

Total lymphocyte count; CD4 cell count; viral load test; hepatitis A and C antibodies; hepatitis B surface antibody, core antibody, and surface antigens; CBC; platelets; and routine blood chemistries.

Recognizing that K.D. has multiple posthospital needs, you begin discharge planning. What type of assessment do you need to complete as part of K.D.'s discharge planning?

You need to evaluate what care K.D. will require on discharge and determine his ability to obtain necessary care. Assess K.D.'s support system and availability of community resources. This includes key factors, such as: Does he have significant others who will help with posthospital care? Is there someone to bring him to the hospital if necessary? Who in the community will be responsible for coordinating his care after discharge? What medical follow-up will be necessary and with whom? Can he afford the necessary care? Does he have access to counseling after discharge? What access does he have to community resources, and which may he benefit from?