HIV N112

What is the main cause for transmission between health care workers?

"sharps" injuries

attachment

- first step -HIV finds and binds with host cell (fusion)

viral replication

-A virus can not replicate on their own​ -It must attach to and enter a host cell​ -It then uses the host cell's energy to synthesize protein, DNA, and RNA

NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

-Bind directly to reverse transcriptase ​ -Prevents DNA and RNA replication and protein synthesis​ -Often used in combination with other antiretroviral agents to prevent medication resistance​ -pdelavirdine (Rescriptor), efavirenz (Sustiva) ​ Side effects: ​ Anemia and liver toxicity (most common)​ May cause birth defects and developmental problems ​ (avoid in pregnancy)​ Antacids may affect absorption ​ (take NNRTI 1 hour before or 2 hours after) ​ Report sore throat, fever, rash, blisters, bruises​ (serious adverse effect)

fusion inhibitors/ CCR5 antagonists

-Block the CCR5 receptor on CD4+ cells​ -HIV can't bind to gain entry to the cell​ -maraviroc (Selzentry) & Enfuvirtide (Fuzeon)​ -Do not chew or crush ​ - absorbed too quickly Side Effects​ Hypotension (change position slowly) ​ Liver toxicity​ Peripheral neuropathy​ localized reaction at injection site​ bacterial pneumonia, fever, chills, rash

protease inhibitors

-Blocks HIV protease enzyme, prevents viral replication and release (Stops viral DNA from final step of replication) -viral load is so low, it is not detectable Side effects: do not chew or crush​ Liver toxicity​ Increase lipid levels - ​ increased risk for CVD and pancreatitis​ Heart block, bradycardia ​ Avoid if sulfa allergy​ Avoid St. John's wort ​ (reduces effectiveness)​ ​

integrase inhibitors

-Blocks enzyme Integrase​ -Viral proteins are not made and replication is inhibited​ -Prevents apoptosis (death) of CD4 T Lymphocytes​ -Dolutgravir (TIVICAY) Side Effects: ​ diarrhea, rash, insomnia, abdominal pain​ Take with food​ Do not chew or crush​ Rhabdomyolysis​ (especially if taken with Statin drugs)​ Report muscle pain​ Increases blood glucose​ Causes birth defects

HIV progression

-Can take months to years​ -Timing depends on: -How HIV is acquired​ -Other health problems​ -Personal factors​ -Interventions​ -Frequency of re-exposure​ -Presence of other STIs​ -Nutrition status​ -Stress - makes it progress faster

immune reconstitution inflammatory syndrome (IRIS)

-Complication of effective cART in some patients whose CD4+T-cell counts rise and immunity returns to normal ​ -T-cells begin to "recognize" opportunistic infections that were present but not recognized because of reduced immunity ​ -Starts inflammatory reaction; high fever & chills ​ -IRIS may go undiagnosed and untreated b/c symptoms similar to side effects ​ -Corticosteroids to treat inflammation

fungal infections - neuro

-Cryptococcosis (cryptococcus neoformans) ​ -Can lead to debilitating Meningitis and then becomes disseminated (widespread)

***INFECTION CONTROL FOR HOME CARE

-Direct Care- Standard precautions, Do not share personal items​ -Housekeeping​ -Clean body fluids with soap and water, follow with 1:10 bleach solution - Flush solid wastes & solutions used for cleaning ​ -Soak cleaning supplies in bleach solution for 5 min​ -Wash dishes in hot soapy water (dishwasher) ​ -Clean bathroom w/ household cleaners follow w/ bleach solution. ​ -Laundry- rinse out body fluids (flush waste water)​ Launder in hot water w/ 1 cup bleach, keep soiled clothes in plastic bag​ -Waste Disposal- flush solid waste, tie contaminated trash in plastic bag - regular trash ​ -Needles and sharps in labeled puncture proof container​ -Decontaminate full containers w/bleach solution​ -Seal w/tape, place in paper bag, regular trash

Peripheral neuropathy and myopathies

-Drug SE, DM​ -Ataxia, leg weakness, muscle pain

Nucleoside Reverse Transcriptase Inhibitors (NRTIs)

-Drugs have similar structure to nucleoside bases of DNA (counterfeit or fake DNA building blocks) ​ -Trick reverse transcriptase into using counterfeit bases​ -viral DNA synthesis and replication is suppressed Side effects: ​ digestive upset​ pancreatitis (avoid fatty fried foods) ​ peripheral neuropathy​ hypersensitivity reaction(flu like symptoms) ​ liver damage (avoid ETOH)​ ​

psychological assessment

-Enormous loss and psychological stress ​ -Assess social supports ​ -Advanced directives ​ -Employment, social activities, financial, health insurance ​ -Identify strengths and coping strategies

human papilloma virus

-HIV malignancies -Cervical Cancer​ -HIV+ women need Cervical Pap smear every 6 months​ -Most common finding in women with HIV, rapidly progressing​ ​ -May also cause anal cancer - need anal pap

malignant lymphoma's

-HIV malignancies -Hodgkins and non Hodgkins B-Cell lymphomas (Burkitt's)​ -2nd most common malignancy in people with AIDS​ -May develop outside the lymph nodes in the brain, bone marrow, and GI tract​ -Symptoms: swollen lymph nodes, wt. loss, fever, night sweats

Kaposi's sarcoma

-HIV malignancies -Most common AIDS related Malignancy​ -Co-infection of HIV and human herpesvirus 8​ ​ -Small purplish brown raised lesions on skin and mucus membranes​ -may develop in lymph nodes, mouth, or throat​ -Usually not painful or itchy​ -Assess number, size, location, progression and intactness​ ​ -Diagnosed with biopsy of lesions

how would you enhance nutrition?

-Increase protein/calories​ -Supplements​ -No alcohol

Incidence and Prevalence

-More than 692,789 people have died from AIDS​ In US 1,200,000 living with HIV/ AIDS ; about 40,000 diagnosed annually ​ ​ -Perception that HIV/AIDS is only a problem for homosexual white males​ ​ -Highest new rates occur racial and ethnic minorities,​ ​ -Rates are increasing in teens and young adults​ ​ -Heterosexual Transmission is increasing​ ​ -Most US cases occur among men who have sex with men (MSM) or either gender who have used IV drugs​ ​ -Infection with HIV can occur with any age- older adult with decreased immunity increased the likelihood of infection after exposure

Wasting syndrome

-Multifactorial- diarrhea, malabsorption, oral lesions

how would you manage pain?

-NSAIDS​ -Therapy​ -heat

when assessing a patient, look for...

-Opportunistic infections​ -Malignancies​ -Endocrine complications​ -Cardiovascular complications​ -Other symptoms

evaluation

-Overall outcomes for care of patients with AIDS ​ -maintain the highest possible level of function for as long as possible, ​ -reduce infections, ​ -maintain quality of life and dignity during the course of progressive illness

fungal infections - resp

-Pneumocystis jiroveci pneumonia (PCP)- organism is a soil fungus​ -Pulmonary infection leads to respiratory insufficiency and death​ ​ -Symptoms: dyspnea, tachypnea, persistent dry cough, persistent low grade fever, fatigue, weight loss​ -Auscultate breath sounds for crackles -Histoplasmosis (histoplasma caupsulatum) begins as respiratory infection and then becomes disseminated (widespread)​ ​ -Disseminated histoplasmosis is fatal if not treated aggressively​ ​ -Assess for dyspnea, fever, cough, wt. loss- check for enlarged lymph nodes, spleen and liver​ ​

Analyze Cues and Prioritize Hypotheses

-Potential for infection​ -Inadequate gas exchange​ Pain​ -Inadequate nutrition​ -Diarrhea​ -Potential for reduced tissue integrity​ -Cognitive decline​ -Psychosocial distress

PRE-EXPOSURE PROPHYLAXIS/POSTEXPOSURE PROPHYLAXIS

-PrEP - Use of cART drugs in an uninfected person to prevent HIV infection​ -Truvada for PrEP- tenofovir/emtricitabine​ one tab oral daily​ -Population at high risk for developing HIV​ ​ -Monitor initially for HIV status, renal function, STI's, Hepatitis ​ continue to monitor HIV status and renal function every 3 months​ -EP-

generate solutions & take actions

-Preventing infection​ -Enhancing gas exchange​ -Managing pain​ -Enhancing nutrition​ -Managing diarrhea​ -Restoring skin integrity​ -Addressing psychosocial distress​ -Promote medication compliance

preventing infection

-Safe sex​ -Don't garden​ -Avoid cleaning a cats litter box​ -Hand hygiene​ -Stay away from sick people/avoid large crowds​ -Don't share needles

HIV -associated Neurocognitive disorder (HAND) and HIV-associated Dementia Complex (HADC)

-Symptoms of CNS involvement​ -Cognitive, motor impairment, behavior changes

combination drugs

-Truvada (emtricitabine, tenofovir) - common drug​ -Increased compliance ​ -Reduced number of tabs needed per day

what is the only way to prevent HIV infection through sexual contact?

-abstinence -monogamous sex with a non-infected partner

stage HIV-1

-acute response -Overt symptoms​ -Short stage - most adults progress to chronic HIV-II​ -CD4 + T-lymphocyte count: 500 cells/mm3 or more ​ -CD4 + T-lymphocyte percentage of total lymphycytes = 29% or more

Ganciclovir (Cytovene)

-antiviral drug -Used for treatment and prevention of CMV​ Also used for prevention therapy for clients who have HIV/AIDS​ -Side effects include granulocytopenia and thrombocytopenia

Acyclovir (Zovirax)

-antiviral drug -Used to treat herpes simplex and varicella-zoster viruses​ Prevents the reproduction of viral DNA and interrupts cell replication​ -Side effects include phlebitis at the site of infusion, nephrotoxicity, nausea, headache and diarrhea

mycobacterium avium complex

-bacterial -Common with later stage HIV/AIDS ​ -Affects the respiratory or GI tract then systemic ​ -Fevers, debility, wt. loss, malaise, swollen lymph glands and organs

tuberculosis

-bacterial -occurs in 2%-10%​ -50% have an extra pulmonary infection​ ​ -Symptoms: cough, dyspnea, chest pain, fever, chills, night sweats, wt. loss, and anorexia Obtain Blood analysis (NAAT), CXR, acid-fast sputum smear ​ ​ -Treat any positive PPD with isoniazid daily as prophylaxis for 9 months or with rifampin or pyrazinamide for 2 months -Maintain Airborne Isolation and standard precautions until tests other than PPD are negative​ -Those giving resp therapy should be screened for TB every 6 months

fungal infections -GI

-candidiasis: overgrowth of normal flora - may occur in mouth, stomach, bowel, vagina, skin -oral exam reveals yellow-white plaques and inflammation in mouth -vaginal itching, irritation, thick white vaginal discharge

stage HIV-2

-chronic -Asymptomatic ​ -Can last for years or even decades ​ -CD4 + T-lymphocyte count: 200-499 cells/mm3 ​ -CD4 + T-lymphocyte percentage of total lymphycytes = 14-28%

gonadal dysfunction

-endocrine complications -Low testosterone, irregular menstrual cycle, change in libido, decreased muscle mass/wt. fatigue ​ -Body shape changes​ Lipodystrophy (fat redistribution)​ -Adrenal insufficiency- r/t opportunistic infections, fatigue, hypotension wt. loss, N/V, electrolyte disturbances​ -Diabetes Mellitus​ -Elevated Cholesterol and Triglycerides - increase cardiovascular risk

Stage HIV-3

-final, most serious; known as AIDS (Acquired Immune Deficiency Syndrome)​ -Defined by: Profound reduction in immunity ​ -Adequate care and drug therapy could live for years ​ -Defining conditions: candidiasis of the esophagus, bronchi, trachea, or lungs; Herpes simplex chronic ulcers; HIV-related encephalopathy; Disseminated or extrapulmonary histoplasmosis; Kaposi's sarcoma; Burkitt's lymphoma; mycobacterium tuberculosis; pneumocystis jirovecii pneumonia; recurrent pneumonia; progressive multifocal leukoencephalopathy; recurrent salmonella septicemia; wasting syndrome attributed to HIV​ -CD4 + T-lymphocyte count: less than 200 cells/mm3 ​ -CD4 + T-lymphocyte percentage of total lymphocytes = less than 14%

how do you enhance gas exchange?

-put them on O2​ -Elevate HOB​ -Breathing treatments​ -antibiotics

other common symptoms

-skin change: diarrhea, malabsorption, oral lesions -kidney injury

protozoal infections

-toxoplasmosis encephalitis (toxoplasma gondii) -acquired through contact with cat feces or eating undercooked meat -cryptosporidiosis (cryptosporidium organisms) -from animals or from contaminated drinking water (chlorination does not kill)

Herpes Simplex Virus (HSV)

-viral -Occur in perirectal, oral, and genital areas​ -Numbness and tingling occur 24 hrs before blisters​ -Painful chronic open areas

varicella/herpes zoster virus (VSV)

-viral -Shingles infection ​ -Remains present in nerve ganglia after chicken pox ​ -In immunocompromised ​ -VSV leaves the nerve ganglia and enters the tissues causing shingles -think chicken pox/shingles (what causes them to occur)

Cytomegalovirus CMV

-viral -eyes, respiratory tract, GI tract, central nervous system​ ​ -CMV retinitis- significant cause of blindness in AIDS​ ​ -Pts have many nonspecific symptoms​ Fever, malaise, wt. loss, fatigue, swollen lymph nodes ​ ​ -Assess: vision(slight impairment to blindness), diarrhea, abdominal bloating and discomfort​ ​ -CMV may also cause encephalitis, pneumonitis, adrenalitis, hepatitis, and widespread disseminated infection

what is the HIV life cycle?

1. Binding (attachment) 2.Uncoating 3. DNA synthesis 4. Integration 5. Transcription 6. Translation 7. Cleavage 8. Budding

AIDS defining

2 ore more episodes of any type of pneumonia in 12 months

what number do you want the CD4 T-lymphocyte to be?

500

A client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday's doses. What action does the nurse recommend?​ A. "Take today's dosages as normally prescribed and continue to follow your therapy program"​ B. Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem."​ C. "Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days."​ D. "Go to the nearest emergency department and have an immediate blood test for assessment of viral load."

A. "Take today's dosages as normally prescribed and continue to follow your therapy program"​

A client with AIDS is having difficulty maintaining body weight. Which intervention will the nurse provide? ​ ​ Select all that apply.​ ​ A. Ensure regular mouth care.​ B. Provide three large meals daily.​ C. Encourage low fat food choices.​ D. Provide foods that are high in calories.​ E. Encourage drinking at least 1 L of fluid per day.​ F. Collaborate with the registered dietician nutritionist

A. ensure regular mouth care D. Provide foods that are high in calories.​ E. Encourage drinking at least 1 L of fluid per day.​ F. Collaborate with the registered dietician nutritionist

where does bacterial pneumonia often occur?

AIDS

Which dietary change does the nurse suggest for the client who has esophageal candidiasis? ​ A. "avoid drinking alcoholic beverages"​ B. "Eat soft, cool food such as pudding and smoothies"​ C. "Limit your intake of fluid to no more than 1 liter daily"​ D. "Increase your intake of cooked green leafy vegetable"

B. "Eat soft, cool food such as pudding and smoothies"​

A client reports having unprotected intercourse and is concerned about exposure to HIV. The nurse will assess whether the client has which initial symptom? A. lymphocytopenia B. Flu-like symptoms C. Opportunistic infection D. reduced numbers of CD4 + T-cells

B. Flu-like symptoms

Which statement made by the client with stage HIV-lll disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 to 400 cells/mm3 indicates to the nurse that more teaching is needed?​ A. "Now my viral load is probably lower"​ B. I am so relieved that my drug therapy is working"​ D. "this change means that I am less likely to develop an opportunistic infection"

C. "although I am still HIV positive, at least I no longer have AIDS"​

Which part of the HIV infection process is disrupted by the antiretroviral drug class protease inhibitor?​ A. Activating the viral enzyme "integrase" within the infected host's cells ​ B.Binding of the virus to the CD4+ receptor and either of the two co-receptors​ C. Clipping the newly generated viral proteins into smaller functional pieces​ D.Fusing of the newly created viral particle with the infected cell's membrane

C. Clipping the newly generated viral proteins into smaller functional pieces

. A client has been admitted to the medical-surgical floor with multiple problems. Which assessment finding does the nurse identify that is consistent with AIDS? ​ Select all that apply.​ ​ A. Persistent pain​ B. Persistent diarrhea​ C. Kaposi's sarcoma​ D. Wasting syndrome​ E. Esophageal candidiasis

C. Kaposi's sarcoma​ D. Wasting syndrome​ E. Esophageal candidiasis

What does HIV target?

CD4+ T cells

addressing psychosocial distress

DON'T -Ask HOW I got HIV - implies judgment​ ​ -Assume I am gay, or an IV drug user, or a prostitute​ ​ -Come into my room and start talking about my HIV infection in front of visitors - Not all my visitors may know of my HIV infection​ ​ -Assume that I am dying - HIV is a chronic illness, manageable

Integration

HIV uses integrate to get it's DNA into the nucleus of the host cells (blends with the host DNA)

what happens after the viral set point is reached?

HIV-positive people enter into a chronic stage in which the immune system cannot eliminate the virus despite its best efforts.

Pre-exposure prophylaxis

PrEP - Use of cART drugs in an uninfected person to prevent HIV infection​ Truvada for PrEP- tenofovir/emtricitabine​ one tab oral daily​ Population at high risk for developing HIV​ ​ Monitor initially for HIV status, renal function, STI's, Hepatitis ​ continue to monitor HIV status and renal function every 3 months

Uncoating

contents of viral core (enzymes- integrate, protease, reverse transcriptase) into host cell

Antiretroviral drugs

does not kill the virus; only controls viral replication

What client thanks the nurse for assistance, and states, "I appreciate everything, and I want you to know I am grateful for this hospital and everything the staff have done for me. I will probably die soon, so I just wanted you to know that." What is the appropriate nursing response?

educate and reassure

what symptoms occur during stage HIV-1?

fever, night sweats, chills, headache, muscle aches, may also develop sore throat and rash

budding

fuses with infected cells membrane and buds off to find another host to infected (new HIV Viron pushed out of the cell)

. The client is very weak and reports anorexia, painful swallowing, severe diarrhea, and occasional vomiting. The nurse delegates mouth care to assistive personnel (AP). What instructions will the nurse provide to the AP?

glove and mask up

what are the "docking proteins"?

gp41 and gp120

translation

mRNA makes proteins and enzymes to make new virus

Combination antiretroviral therapy (cART)

multiple drugs from different classes

what are caused by overgrowth of normal flora with decreased immunity?

opportunistic infections

cleavage

protease enzyme cuts up chain of HIV proteins

After a week, the client is being prepared for discharge to home, where the client lives with a spouse and 2 children. What teaching will the nurse provide to the family?

refer to slide about home care

what type of virus is HIV?

retrovirus

DNA synthesis

reverse transcriptase converts RNA to DNA

what is the largest risk factor for transmission of HIV?

sexual contact

which infection/stage is the most serious?

stage HIV-3

where does HIV enter?

the bloodstream

transmission

transmitted by body fluids containing HIV or infected CD4

Lipodystrophy

truncal fat is increased, but note relative atrophy of buttocks: many patients complain of discomfort when sitting for a long time

transcription

virus builds more RNA strands for new virus

Postexposure prophylaxis (PEP)

​ Occupational exposure (needle stick)​ Non occupational (consensual sexual exposure with unknown HIV status)​ Sexual assault​ Start cART ASAP (24-36 hours) ​ Treat for 28 days or until HIV status of source is determined to be negative