Care of the Patient with HIV

Opportunistic Infection: Pneumocystis jirovecil pneumonia (PCP)

*common reason for hospitalization/AIDS-defining condition -DOE -Tachypnea, dry cough, low grade fever -fatigue, weight loss -crackles -O2 supplementation tx: cotrimoxazole IV, corticosteroids

CDC recommendation for HIV routine testing

-Ages 13-63 -Beginning TB treatment -STI diagnosis -Pregnant

Goals of ART

-Increase CD4 -Decrease Viral Load -Prevent infection -prolong duration and QOL

HIV- alteration in nutrition r/t anorexia, diarrhea, oral lesions

-Nutritionally dense foods/supplements -Food/diet - easy to swallow -Mycostatin prn if oral candidiasis present -Anti-emetics for nausea r/t A.R.T.

Weakened immune system- AVOID

-Sushi or raw seafood -Raw or "over easy" eggs -Anything containing raw eggs (cookie dough, Caesar salad dressing) -"rare" or raw meats -Unpasteurized dairy products

Primary prevention- HIV

-Universal Precautions -PPE -Screening/testing -Safe Sex

What does HIV do to the body?

-When HIV enters CD4 cells, it damages the CD4 cells, rendering them ineffective, eventually killing them -HIV virus then replicates in body, causing further destruction of CD4 (T-cells), severely impairing immune system, leaving host open to many infections

Repeat HIV screening for

-high risk patients -new partners -after a high-risk exposure -if an antibody test was negative (to confirm)

cART: Adverse effects contributing to non-adherence

-lipodystrophy -facial wasting -buffalo hump

CNS OIs

-toxoplasmosis - HIV related encephalopathy -cryptococcal meningitis

A nurse is caring for four clients who have immune disorders. After receiving the hand-off report, which client should the nurse assess first? a. Client with acquired immune deficiency syndrome with a CD4+ cell count of 210/mm3 and a temp of 102.4 F (39.1 C) b. Client with Brutons agammaglobulinemia who is waiting for discharge teaching c. Client with hypogammaglobulinemia who is 1 hour post immune serum globulin infusion d. Client with selective immunoglobulin A deficiency who is on IV antibiotics for pneumonia

A A client who is this immunosuppressed and who has this high of a fever is critically ill and needs to be assessed first.

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? a. Consistent use of Standard Precautions b. Double-gloving before body fluid exposure c. Labeling charts and armbands HIV+ d. Wearing a mask within 3 feet of the client

A According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions.

The nurse is caring for a client diagnosed with human immune deficiency virus. The clients CD4+ cell count is 399/mm3. What action by the nurse is best? a. Counsel the client on safer sex practices/abstinence. b. Encourage the client to abstain from alcohol. c. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

A This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence.

A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best? a. Assess the client for support systems. b. Determine if a clergy member would help. c. Explain legal requirements to tell sex partners. d. Offer to tell the family for the client.

A This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her.

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving Truvada (emtricitabine and tenofovir). What information is most important to teach the client about this drug? a. Truvada does not reduce the need for safe sex practices. b. This drug has been taken off the market due to increases in cancer. c. Truvada reduces the number of HIV tests you will need. d. This drug is only used for postexposure prophylaxis.

A Truvada is a new drug used for pre-exposure prophylaxis and appears to reduce transmission of human immune deficiency virus (HIV) from known HIV-positive people to HIV-negative people.

A student nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. c. Macrophages stop functioning properly. d. Opportunistic infections and cancer are leading causes of death. e. People with stage 1 HIV disease are not infectious to others.

A, B, C, D In HIV, CD4+ cells begin to create new HIV particles. Antibodies the client produces are incomplete and do not function well. Macrophages also stop functioning properly. Opportunistic infections and cancer are the two leading causes of death in clients with HIV infection. People infected with HIV are infectious in all stages of the disease.

A nurse is traveling to a third-world country with a medical volunteer group to work with people who are infected with human immune deficiency virus (HIV). The nurse should recognize that which of the following might be a barrier to the prevention of perinatal HIV transmission? (Select all that apply.) a. Clean drinking water b. Cultural beliefs about illness c. Lack of antiviral medication d. Social stigma e. Unknown transmission routes

A, B, C, D Treatment and prevention of HIV is complex, and in third-world countries barriers exist that one might not otherwise think of. Mothers must have access to clean drinking water if they are to mix formula. Cultural beliefs about illness, lack of available medications, and social stigma are also possible barriers. Perinatal transmission is well known to occur across the placenta during birth, from exposure to blood and body fluids during birth, and through breast-feeding.

Which findings are AIDS-defining characteristics? (Select all that apply.) a. CD4+ cell count less than 200/mm3 or less than 14% b. Infection with Pneumocystis jiroveci c. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome e. Taking antiretroviral medications

A, B, D A diagnosis of AIDS requires that the person be HIV positive and have either a CD4+ T-cell count of less than 200 cells/mm3 or less than 14% (even if the total CD4+ count is above 200 cells/mm3) or an opportunistic infection such as Pneumocystis jiroveci and HIV wasting syndrome. Having a positive ELISA test and taking antiretroviral medications are not AIDS-defining characteristics.

Stage 3 HIV

AIDS CD4 <200+ symptoms

A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first? a. Ask the client about travel to any foreign countries. b. Assess the client for adherence to the drug regimen. c. Determine if the client has any new sexual partners. d. Request information about new living quarters or pets.

B Adherence to the complex drug regimen needed for HIV treatment can be daunting.

HIV is transmitted via

Blood, body fluids, needles, breastmilk

A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first? a. Initiate Droplet Precautions for the client. b. Notify the provider about the CD4+ results. c. Place the client under Airborne Precautions. d. Use Standard Precautions to provide care.

C Since this clients CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present.

Stage 2 HIV

CD4 count 200-499 asymptomatic

Stage 1 HIV

CD4 count 500

cART

Combination antiretroviral therapy -stops replication (does not rid HIV from the body) -must be taken every day for life (strict adherence) -slows progression

A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposis sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a. Adhering to Standard Precautions b. Assessing tolerance to dressing changes c. Performing hand hygiene before and after care d. Disposing of soiled dressings properly

D All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.

A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? a. Chooses high-protein food b. Has decreased oral discomfort c. Eats 90% of meals and snacks d. Has a weight gain of 2 pounds/1 month

D The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? a. Administer sleeping medication.b. Perform most activities for the client. c. Increase the clients oxygen during activity. d. Pace activities, allowing for adequate rest.

D This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between.

An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? a. Initiate Contact Precautions. b. Place the client on Airborne Precautions. c. Place the client on Droplet Precautions. d. Use Standard Precautions consistently.

D Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.

Kaposi's sarcoma

HIV-related cancer

opportunistic infection

Infections that occur when the body's defenses are weakened

Acute retroviral syndrome

Occurs 1-6 weeks after HIV exposure in 50-70% of infected individuals; similar to mono - pts might think they just have a virus...can be asymptomatic for years

Post exposure prophylaxis

Treatment administered to an individual after exposure to an infectious disease to prevent the disease cART

What is the most important indicator of response to ART

Viral Load Take a baseline prior to therapy

Which is a better predictor of HIV progression: CD4 or Viral load?

Viral load the lower the viral load, the longer the time to AIDS diagnosis and the longer survival time *Best method to detect response to tx of HIV

Pre-exposure prophylaxis (PrEP)

a pill containing antiretroviral drugs taken before someone is exposed to the virus to prevent HIV acquisition -Truvada

secondary immunodeficiency

acquired later in life

HIV

an ACQUIRED, transmissible retrovirus that attacks the immune system

Fungal OI

candidiasis

primary immunodeficiency

congenital; usually genetic errors

skipping doses of cART can lead to

drug resistance

Stage 0 of HIV

first Positive HIV test result

Immunodeficency can occur

in any part of immune system

Pediatric HIV is often evidenced by

lymphoid interstitial pneumonitis, pulmonary lymphoid hyperplasia, and opportunistic infections

Cancers OI

lymphomas, cervical cancers

What is the most common reason viral suppression is not achieved?

patient is not adhering to treatment plan

Respiratory OI

recurrent pneumonia, Histoplasmosis, TB

HIV clients with tuberculosis require

respiratory isolation

Viral Load

the amount of HIV present in an infected person's blood

How can you be sure you are HIV negative?

•your most recent test is after the "window period" •No potential exposure during the window period