HIV and AIDs

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D. The drug therapy is effective.

A client diagnosed with AIDS who is receiving combination antiretroviral therapy (cART) now has a CD4+ T-cell count of 525 cells/mm3. How will the nurse interpret this result? A. The client can reduce the dosages of the prescribed drugs. B. The virus is resistant to the current combination of drugs. C. The client no longer has AIDS. D. The drug therapy is effective.

A. Perinatal exposure D. Older adult woman E. Occupational exposure

A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus? SATA A. Perinatal exposure B. Pregnancy C. Monogamous sex partner D. Older adult woman E. Occupational exposure

A. Western blot B. Indirect immunofluorescence assay

A nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests and laboratory values are used to confirm HIV infection? (Select all that apply.) A. Western blot B. Indirect immunofluorescence assay C. CD4+ T-lymphocyte count D. HIV RNA quantification test E. Cerebrospinal fluid (CSF) analysis

D. "I will cook vegetables before eating them."

A nurse is completing discharge instructions with a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I will wear gloves while changing the pet litter box." B. "I will rinse raw fruits with water before eating them." C. "I will wear a mask when around family members who are ill." D. "I will cook vegetables before eating them."

A. Perform a physical assessment. B. Determine when current symptoms began. E. Obtain a sexual history.

A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Perform a physical assessment. B. Determine when current symptoms began. C. Teach the client about HIV transmission. D. Draw blood for HIV testing. E. Obtain a sexual history.

B. Brushing the client's teeth C. Emptying a Foley catheter reservoir F. Providing perineal care

With which activities does the nurse teach unlicensed assistive personnel (UAP) and nursing students caring for a client who is HIV positive to wear gloves to prevent disease transmission? Select all that apply. A. Applying lotion during a back rub B. Brushing the client's teeth C. Emptying a Foley catheter reservoir D. Feeding the client E. Filing the client's fingernails F. Providing perineal care

labeled puncture proof container, like a coffee can with a lid or empty liquid bleach bottle, using standard precautions, to avoid needlestick injuries. Decontaminate full containers by adding 1:10 bleach solution, then seal the container with tape and place it in a paper bag. Dispose of the container in the trash

Care Coordination and Home Care Management for Patients with HIV · Teaching the patient, family, and friends is a high priority when preparing for discharge · Instruct about modes of transmission and preventative behaviors · Teach how to prevent infection · Encourage patient to continue usual activities as much as possible · Stress that sexual partners and doctors should be informed of HIV diagnosis; beyond that, it is up to them. · Infection Control for Home care of the Patient with HIV/AIDS: § Follow standard precautions and good hand washing techniques § Do not share razors or toothbrushes § Wipe up feces, vomit, sputum, urine, or blood or other body fluids and the area with soap and water. Dispose of solid wastes and solutions used for cleaning by flushing them down the toilet. Disinfect the area by wiping with a 1:10 solution of bleach and water. Wear gloves during cleaning § Soak rags, mops, sponges used for cleaning in 1:10 bleach solution for 5 minutes to disinfect them § Clean bathroom surfaces with regular household cleaners and then disinfect them with a 1:10 solution of bleach § Rinse clothes, towels, and bed clothes if they get soiled with body fluids. Dispose of the soiled water by flushing it down the toilet. Launder these clothes with hot water and detergent with 1 cup of bleach added per load of laundry § Keep soiled clothes in a plastic bag § Dispose of needles and other sharps in a_____________________________________________________________ § Remove solid waste from contaminated trash (paper towels or tissues, dressings, pads, or gloves); then flush the solid waste down the toilet. Place contaminated trash items in tied plastic bags and dispose of them in the regular trash

feces, vomit, sputum, urine, or blood or other body fluids and the area with soap and water. Dispose of solid wastes and solutions used for cleaning by flushing them down the toilet. Disinfect the area by wiping with a 1:10 solution of bleach and water. Wear gloves during cleaning

Care Coordination and Home Care Management for Patients with HIV · Teaching the patient, family, and friends is a high priority when preparing for discharge · Instruct about modes of transmission and preventative behaviors · Teach how to prevent infection · Encourage patient to continue usual activities as much as possible · Stress that sexual partners and doctors should be informed of HIV diagnosis; beyond that, it is up to them. · Infection Control for Home care of the Patient with HIV/AIDS: § Follow standard precautions and good hand washing techniques § Do not share razors or toothbrushes § Wipe up_______________________________________________________________________________________________ § Soak rags, mops, sponges used for cleaning in 1:10 bleach solution for 5 minutes to disinfect them § Clean bathroom surfaces with regular household cleaners and then disinfect them with a 1:10 solution of bleach § Rinse clothes, towels, and bed clothes if they get soiled with body fluids. Dispose of the soiled water by flushing it down the toilet. Launder these clothes with hot water and detergent with 1 cup of bleach added per load of laundry § Keep soiled clothes in a plastic bag § Dispose of needles and other sharps in a labeled puncture proof container, like a coffee can with a lid or empty liquid bleach bottle, using standard precautions, to avoid needlestick injuries. Decontaminate full containers by adding 1:10 bleach solution, then seal the container with tape and place it in a paper bag. Dispose of the container in the trash § Remove solid waste from contaminated trash (paper towels or tissues, dressings, pads, or gloves); then flush the solid waste down the toilet. Place contaminated trash items in tied plastic bags and dispose of them in the regular trash

1. Buffalo humps (cervical or neck fat development 2. Large abdominal fat accumulations 3. Face, arms, and legs have wasted appearance and prominent vein patterns 4. Sunken cheeks (loss of subQ fat, or lipoatrophy)

Complications of HIV: Endocrine · Patients with HIV may have disease-related and treatment-related endocrine problems, like gonadal dysfunction, body shape changes, adrenal insufficiency, diabetes mellitus, and elevated triglycerides and cholesterol · Gonadal Dysfunction: § Many women with HIV have irregular menstrual cycles § Many men with HIV have low testosterone levels § Men and women experience a decrease in body muscle mass, a decrease in weight and change in libido, a decrease in energy, and increase in fatigue. · Body Shape Changes: § Lipodystrophy (changes from fat redistribution or fat deposition) is common in patients receiving antiretroviral therapies § Symptoms include: 1. 2. 3. 4. · Adrenal Dysfunction can result from the glands being infected by opportunistic infections, resulting in adrenal insufficiency § Fatigue, weight loss, nausea, vomiting, low BP, electrolyte disturbances

1. Small, purple, brown raised lesions on mucous membranes & skin 2. No pain, no itch 3. Lesions can develop on the back, lymph nodes, mouth and throat, intestinal tract, or lungs; Throughout Upper GI Tract

Complications of HIV: Malignancies · Malignant Lymphomas: a cancer of lymphocytes, and can be Hodgkin's, Non-Hodgkin's, immunoblastic lymphoma, and primary Brain Lymphoma § Symptoms: · Swollen Lymph Nodes · Weight Loss · Fever · Night Sweats · Kaposi's Sarcoma is the most common cancer related to AIDS infection. It is related to Co-Infection with Human herpes virus-8 1. 2. 3. § It is diagnosed by needle biopsy. Assess KS lesions for number, size, location, and whether they are intact and monitor their progression. · Cervical & Anal Cancers § Human Papilloma Virus (HPV) causes cervical and anal cancers § Vaginal PAPs q 6 months in women with HIV § Anal PAPs annually with anal intercourse

anergy

Complications of HIV: Opportunistic Infections · Opportunistic Infections are those caused by overgrowth of the patient's microbiome (normal flora), and they occur due to the HIV patient's profound reduced immunity § There can be more than one infection present at a time § These infections can result in death if not treated quickly and correctly · Mycobacterium Tuberculosis: this infection occurs in 2-10% of patients with AIDS § Signs and Symptoms: 1. Cough 2. Dyspnea 3. Chest Pain 4. Fever 5. Chills 6. Night Sweats 7. Weight Loss 8. Anorexia § The adult with TB and a CD4+T cell count below 200/mm3 may not have a positive TB skin test (PPD) because of an inability to mount an immune response to the antigen, a condition known as _______________. · Blood analysis by the NAAT test for TB with results available within 2 hours is the most sensitive and rapid test for the presence of Tuberculosis · Other diagnostics: chest x-ray, acid-fast bacilli sputum smear, sputum culture § Airborne Precautions are needed because anyone near the patient with TB is at risk for inhaling the particles and bacillus. Maintain Airborne Precautions for the AIDS patient with TB symptoms until parameters other than a skin test come back negative for TB · Healthcare members need to wear N95 When caring for TB patient · Healthcare members who give cough-inducing aerosol treatments (pentamidine isethionate) to patients with AIDS should be screened every 6 months for TB · Patients will be in NEGATIVE pressure rooms, which sucks the patient's room air outside.

NEGATIVE pressure rooms

Complications of HIV: Opportunistic Infections · Opportunistic Infections are those caused by overgrowth of the patient's microbiome (normal flora), and they occur due to the HIV patient's profound reduced immunity § There can be more than one infection present at a time § These infections can result in death if not treated quickly and correctly · Mycobacterium Tuberculosis: this infection occurs in 2-10% of patients with AIDS § Signs and Symptoms: 1. Cough 2. Dyspnea 3. Chest Pain 4. Fever 5. Chills 6. Night Sweats 7. Weight Loss 8. Anorexia § The adult with TB and a CD4+T cell count below 200/mm3 may not have a positive TB skin test (PPD) because of an inability to mount an immune response to the antigen, a condition known as anergy. · Blood analysis by the NAAT test for TB with results available within 2 hours is the most sensitive and rapid test for the presence of Tuberculosis · Other diagnostics: chest x-ray, acid-fast bacilli sputum smear, sputum culture § Airborne Precautions are needed because anyone near the patient with TB is at risk for inhaling the particles and bacillus. Maintain Airborne Precautions for the AIDS patient with TB symptoms until parameters other than a skin test come back negative for TB · Healthcare members need to wear N95 When caring for TB patient · Healthcare members who give cough-inducing aerosol treatments (pentamidine isethionate) to patients with AIDS should be screened every 6 months for TB · Patients will be in ___________________________________________________, which sucks the patient's room air outside.

Cytomegalovirus (CVM)

Complications of HIV: Opportunistic Infections · Opportunistic Infections are those caused by overgrowth of the patient's microbiome (normal flora), and they occur due to the HIV patient's profound reduced immunity § There can be more than one infection present at a time § These infections can result in death if not treated quickly and correctly · Varicella Zoster Virus (VZV) (shingles) is not a new infection for adults with AIDS. The virus causes chickenpox and then remains present in the nerve ganglia. They will experience pain/burning along the nerve tract. · ______________________________ is a viral infection that can infect many sites in adults with AIDS, including the eye (______ retinitis), respiratory and GI tract, and the CNS. § ______ infection causes many nonspecific problems, such as fever, malaise, weight loss, fatigue, and swollen lymph nodes. § ______ retinitis impairs vision, ranging from slight impairment to total blindness. § ______ can also cause diarrhea, ABD bloating and discomfort, and weight loss. § ______ can cause encephalitis, pneumonitis, adrenalitis, hepatitis, and disseminated infection.

Cryptococcosis

Candida Albicans

Cryptosporidiosis

Toxoplasmosis Encephalitis

Herpes Simplex Virus (HSV)

Pneumocystis jiroveci pneumonia

Safety Measures

Enhancing Cognition for the Patient with HIV · Neurologic changes and confusion are major areas of concern for patients with HIV disease or AIDS. These can be due to psychological stressors accompanying the disease or organic disorders caused by opportunistic infections, cancer, or encephalitis · Reorient the confused patient to person, time, and place as needed. Ensure everyone who cares for the patient reorients them. § Give simple directions § Use short, uncomplicated sentences § Explain activities in simple language § Involve the patient in daily planning § Arrange all items in the patient's environment in the same location as at home § Calendars, clocks, radios, and putting the bed close to a window can help keep them oriented · Drug Therapy is used for different conditions that cause confusion with AIDS. Psychotropic drugs, antidepressants, and anxiolytics may be used · ___________________________ are crucial to the well-being of the confused patient. They may not be aware of activities or surroundings. § Institute seizure precautions for those at risk for seizures § Assess for increased intracranial pressure (ICP): changes in LOC, vitals, pupil size or reactivity, limb strength. If any s/s are present, immediately report to provider · Support the family and friends of the patient. There is great trauma in seeing a loved one unable to care for themselves or showing childlike behavior. · IT IS VERY IMPORTANT THAT WE HAVE OUR PATIENTS GET SOMETHING IN WRITING THAT EXPLAINS WHO WILL MAKE THEIR DECISIONS FOR THEM IF THEY WERE TO DEVELOP ENCEPHALITIS OR INFECTIOUS MENINGITIS. · WE WANT THESE CLIENTS TO CONTINUE WITH ACTIVITIES AS NORMAL AS POSSIBLE. Education on resources for HIV patient, financial, home health, marriage counseling

trimethoprim with sulfamethoxazole. Many patients have reactions to this drug, including nausea, vomiting, hyponatremia, rashes, fever, leukopenia, thrombocytopenia, and hepatitis.

Enhancing Gas Exchange for Patients with HIV · The patient is expected to maintain adequate gas exchange with oxygenation and perfusion and to have minimal dyspnea, as evidenced by: rate/depth of respirations are normal; pulse oximetry is normal; absence of cyanosis or pallor and abnormal breath sounds · Drug Therapy helps maintain gas exchange for HIV patients with respiratory problems resulting from infection, such as P. jiroveci pneumonia (PCP). § Treatment for P. jiroveci pneumonia (PCP) is _____________________________________ · Pentamidine isethionate (IM or IV) is also given to treat PCP § Other drugs include bronchodilators to improve airflow · Respiratory support and maintenance help maintain gas exchange and avoid complications. § Assess RR, rhythm, and depth, breath sounds, and vitals, and monitor for cyanosis every 8 hours. § Apply O2 and humidify the room as ordered § Monitor mechanical ventilation, perform suctioning, and CPT as needed; check ABGs · Comfort can improve gas exchange. Elevate HOB, pace activities · Rest and Activity Changes are needed when gas exchange is impaired. Most patients with HIV/AIDS have fatigue, especially when respiratory problems are present. Consult the patient to pace activities and conserve energy.

1. Increased Calories & Protein 2. Calories Counts, Is/Os, Daily Weights 3. 2-3L Fluids Daily 4. Monitor: Ferritin, Albumin, Prealbumin, & Hemoglobin 5. Albumin will go DOWN if nutrition is not adequate.

Enhancing Nutrition for HIV Patients · Many patients with HIV have difficulty maintaining weight and nutrition status due to fatigue, anorexia, n/v, difficult/painful swallowing, diarrhea, intestinal malabsorption, or wasting syndrome · AIDS wasting syndrome can result in diarrhea, malabsorption, anorexia, and oral/esophageal lesions that can all contribute to weight loss and emaciated appearance § Sunken check bones § Looks emaciated § Lipoatrophy: wasting of fat · The patient is expected to maintain optimal weight through adequate nutrition and hydration, as evidenced by: selecting foods high in calories and protein, maintaining current weight or gaining weight, drinking 2-3L of fluids daily, maintaining normal blood levels of ferritin, albumin, prealbumin, and hemoglobin · Nursing Interventions: 1. 2. 3. 4. 5. · Drug Therapy § Oral Candida: · Fluconazole (Diflucan) or ketoconazole orally · Amphotericin B IV · Monitor for drug side effects, like nausea and vomiting · oral care · ice chips · remove unpleasant odors · antiemetics PRN · Nutrition Therapy: monitoring weight, intake and output, and calorie count § AVOID Dietary Fat because fat intolerance often occurs due to disease and drug side effects § Small Frequent Meals and between-meal supplements (ensure)/snacks (6 small feedings with high protein value are helpful) § Supplemental Vitamins and Fluids § Tube Feedings/TPN for patients who cannot achieve adequate nutrition through food. § Teach patient to check with doctor before using ANY complimentary therapy or herbal supplements. These can interact with HIV drugs. · Mouth Care: § No Alcohol-Based Mouthwash § Mouth rises with sodium bicarbonate with sterile water or normal saline several times a day § Use a soft toothbrush § Drink plenty of fluids § For oral pain: use analgesics or anesthetic gels/solutions

1. No Alcohol-Based Mouthwash 2. Mouth rises with sodium bicarbonate with sterile water or normal saline several times a day 3. Use a soft toothbrush 4. Drink plenty of fluids 5. For oral pain: use analgesics or anesthetic gels/solutions

Enhancing Nutrition for HIV Patients · Many patients with HIV have difficulty maintaining weight and nutrition status due to fatigue, anorexia, n/v, difficult/painful swallowing, diarrhea, intestinal malabsorption, or wasting syndrome · AIDS wasting syndrome can result in diarrhea, malabsorption, anorexia, and oral/esophageal lesions that can all contribute to weight loss and emaciated appearance § Sunken check bones § Looks emaciated § Lipoatrophy: wasting of fat · The patient is expected to maintain optimal weight through adequate nutrition and hydration, as evidenced by: selecting foods high in calories and protein, maintaining current weight or gaining weight, drinking 2-3L of fluids daily, maintaining normal blood levels of ferritin, albumin, prealbumin, and hemoglobin · Nursing Interventions: § Increased Calories & Protein § Calories Counts, Is/Os, Daily Weights § 2-3L Fluids Daily § Monitor: Ferritin, Albumin, Prealbumin, & Hemoglobin § Albumin will go DOWN if nutrition is not adequate. · Drug Therapy § Oral Candida: · Fluconazole (Diflucan) or ketoconazole orally · Amphotericin B IV · Monitor for drug side effects, like nausea and vomiting · oral care · ice chips · remove unpleasant odors · antiemetics PRN · Nutrition Therapy: monitoring weight, intake and output, and calorie count § AVOID Dietary Fat because fat intolerance often occurs due to disease and drug side effects § Small Frequent Meals and between-meal supplements (ensure)/snacks (6 small feedings with high protein value are helpful) § Supplemental Vitamins and Fluids § Tube Feedings/TPN for patients who cannot achieve adequate nutrition through food. § Teach patient to check with doctor before using ANY complimentary therapy or herbal supplements. These can interact with HIV drugs. · Mouth Care: 1. 2. 3. 4. 5.

Dietary Fat because fat intolerance often occurs due to disease and drug side effects

Enhancing Nutrition for HIV Patients · Many patients with HIV have difficulty maintaining weight and nutrition status due to fatigue, anorexia, n/v, difficult/painful swallowing, diarrhea, intestinal malabsorption, or wasting syndrome · AIDS wasting syndrome can result in diarrhea, malabsorption, anorexia, and oral/esophageal lesions that can all contribute to weight loss and emaciated appearance § Sunken check bones § Looks emaciated § Lipoatrophy: wasting of fat · The patient is expected to maintain optimal weight through adequate nutrition and hydration, as evidenced by: selecting foods high in calories and protein, maintaining current weight or gaining weight, drinking 2-3L of fluids daily, maintaining normal blood levels of ferritin, albumin, prealbumin, and hemoglobin · Nursing Interventions: § Increased Calories & Protein § Calories Counts, Is/Os, Daily Weights § 2-3L Fluids Daily § Monitor: Ferritin, Albumin, Prealbumin, & Hemoglobin § Albumin will go DOWN if nutrition is not adequate. · Drug Therapy § Oral Candida: · Fluconazole (Diflucan) or ketoconazole orally · Amphotericin B IV · Monitor for drug side effects, like nausea and vomiting · oral care · ice chips · remove unpleasant odors · antiemetics PRN · Nutrition Therapy: monitoring weight, intake and output, and calorie count § AVOID _______________________________________________ § Small Frequent Meals and between-meal supplements (ensure)/snacks (6 small feedings with high protein value are helpful) § Supplemental Vitamins and Fluids § Tube Feedings/TPN for patients who cannot achieve adequate nutrition through food. § Teach patient to check with doctor before using ANY complimentary therapy or herbal supplements. These can interact with HIV drugs. · Mouth Care: § No Alcohol-Based Mouthwash § Mouth rises with sodium bicarbonate with sterile water or normal saline several times a day § Use a soft toothbrush § Drink plenty of fluids § For oral pain: use analgesics or anesthetic gels/solutions

Stage O

HIV Classification · The adult with HIV infection can transmit the virus to others at any stage of disease, but the recently infected with high viral load and those at end stage without drug therapy can be particularly infectious. · __________________: this stage of HIV describes a patient who develops a first positive HIV test result within 6 months after a negative HIV test result (regardless of T-cell counts or AIDS related illness). § Changing the patient's status to stage 1, 2, or 3 does not occur until 6 months have elapsed since the stage 0 designation, even when CD4+T cell counts decrease or AIDS defining condition is present · HIV Progression: § The time from the beginning of HIV infection to the development of AIDS ranges from months to years § The range depends on when the infection was acquired, which additional health problems the patient has, personal factors, and interventions § EXAMPLE: adults who have been given a transfusion of HIV-contaminated blood will usually develop AIDS quickly. But for those who become HIV positive after a single sexual encounter, progression to AIDS takes much longer

Stage 3

HIV Classification · The adult with HIV infection can transmit the virus to others at any stage of disease, but the recently infected with high viral load and those at end stage without drug therapy can be particularly infectious. · __________________: this stage of HIV describes a patient with a CD4+T cell count of less than 200 cells/mm3 or a percentage less than 14%; or who has AIDs related illness (even if counts normal) § An adult who has higher CD4+T cell counts or higher percentages but who also has an AIDs defining illness meets the stage 3 criteria. § THIS IS AIDS INFECTION! · HIV Progression: § The time from the beginning of HIV infection to the development of AIDS ranges from months to years § The range depends on when the infection was acquired, which additional health problems the patient has, personal factors, and interventions § EXAMPLE: adults who have been given a transfusion of HIV-contaminated blood will usually develop AIDS quickly. But for those who become HIV positive after a single sexual encounter, progression to AIDS takes much longer

Stage 1

HIV Classification · The adult with HIV infection can transmit the virus to others at any stage of disease, but the recently infected with high viral load and those at end stage without drug therapy can be particularly infectious. · ____________________: this stage of HIV describes a patient with a CD4+T cell count of greater than 500 cells/mm3 or a percentage of 29% or greater. § An adult at this stage has no AIDS defining illness · HIV Progression: § The time from the beginning of HIV infection to the development of AIDS ranges from months to years § The range depends on when the infection was acquired, which additional health problems the patient has, personal factors, and interventions § EXAMPLE: adults who have been given a transfusion of HIV-contaminated blood will usually develop AIDS quickly. But for those who become HIV positive after a single sexual encounter, progression to AIDS takes much longer

Stage 2

HIV Classification · The adult with HIV infection can transmit the virus to others at any stage of disease, but the recently infected with high viral load and those at end stage without drug therapy can be particularly infectious. · _____________________: this stage of HIV describes a patient with a CD4+T cell count between 200-499 cells/mm3 or a percentage of 14-28% § An adult at this stage has no AIDS defining illness · HIV Progression: § The time from the beginning of HIV infection to the development of AIDS ranges from months to years § The range depends on when the infection was acquired, which additional health problems the patient has, personal factors, and interventions § EXAMPLE: adults who have been given a transfusion of HIV-contaminated blood will usually develop AIDS quickly. But for those who become HIV positive after a single sexual encounter, progression to AIDS takes much longer

Stage Unknown

HIV Classification · The adult with HIV infection can transmit the virus to others at any stage of disease, but the recently infected with high viral load and those at end stage without drug therapy can be particularly infectious. · ___________________________: this stage of HIV describes a patient with a confirmed HIV infection but no information regarding CD4+T cell counts, percentages, or AIDS defining illness. · HIV Progression: § The time from the beginning of HIV infection to the development of AIDS ranges from months to years § The range depends on when the infection was acquired, which additional health problems the patient has, personal factors, and interventions § EXAMPLE: adults who have been given a transfusion of HIV-contaminated blood will usually develop AIDS quickly. But for those who become HIV positive after a single sexual encounter, progression to AIDS takes much longer

1. Have a sexually transmitted infection 2. Use injection drugs 3. Consider yourself at risk 4. Are a woman of childbearing age with identifiable risk factors including: a. Used injection drugs b. Engaged in sex work c. Had sexual partners who were infected or at risk d. Had sexual contact with men from countries with high HIV prevalence 5. Received a transfusion between 1978 and 1985 6. Plan to get married 7. Are undergoing evaluation or treatment for symptoms that may be HIV related 8. Are in correctional institutions such as jails and prisons 9. Are a sex worker or have had sex with a sex worker · In the absence of any of the above conditions, you should be tested once: § If you are between the ages of 18-65 years old § As part of routine prenatal screening when pregnant

HIV Status and Screening · Many new transmission events come from those who are HIV positive and unaware of their diagnosis. Early identification and diagnosis allows for early treatment. Once an adult is placed on combination antiretroviral therapy (cART), reducing the viral load to undetectable levels significantly reduces the risk that HIV will be transmitted (known as treatment as prevention (TAP)). · A major health care focus for testing is to teach those who test positive to modify their behaviors to prevent transmission to others. Therefore all sexual active adults should know their HIV status · CDC Recommendations For One Time Screening And Annual Testing: · You should be tested annually for HIV if you: 1. 2. 3. 4. 5. 6. 7. 8. 9. - - - · Pretest and post-test counseling must be performed by personnel trained in HIV issues. These can be nurses, doctors, social workers, health educators, or lay educators who have specialized training. Counseling helps the patient make an informed decision about testing and provides an opportunities to teach risk-reduction behaviors. · Post-test counseling is needed to interpret the results, discuss risk reduction, provide psychological support, and provide health promotion for the patient with a positive result. · Adults who test positive should also be counseled on how to inform sexual partners and those with whom they have shared needles.

higher incidence of premature delivery, low-birth-weight infants, and transmission of the disease to the infant.

Incidence & Prevalence of HIV · 25% of New Cases Women · 50,000 U.S. Diagnosis Annually · Most Cases: Men who have sex with men or either gender IVDA · HIV & Pregnancy: Antiretrovirals during pregnancy § The effect of HIV on pregnancy includes_________________________________

infection is more easily transmitted from infected male to uninfected female than vice versa

HIV and Intercourse: Sexual Transmission · Safe Sex: A: Abstinence, B: be faithful/monogamous, C: condoms all decrease risk § The only absolute safe sex methods of preventing HIV infection from sexual contact include abstinence and mutually monogamous sex with a noninfected partner § The risk for becoming infected from a partner who is HIV positive is always present, but some sexual practices are more risky than others. § Consistently use safer sex practices: · A latex or polyurethane condom for genital and anal intercourse · An appropriate water-based lubricant with a latex condom · A condom or latex barrier over genitals or anus during oral-genital or oral-anal sexual contact · Latex gloves for finger or hand contact with the vaginal or rectum · Gender affects HIV transmission, and the __________________________________________________________ § This is because HIV is more easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin. The vagina has more mucous membranes than does the urethra of the penis § Teach women the importance of always either using a vaginal or dental dam or female condom or having male partners use a condom. · Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin are the most risk for HIV transmission. § The practice with the highest risk is anal intercourse regardless of gender (mucous membranes & risk for tearing during this form of intercourse) · Viral Load, or the amount of virus present in blood and other body fluids, affects transmission. The higher the level of HIV (viremia), the greater the risk for sexual and perinatal transmission. § cART has caused viral load to drop below detectable levels. Although there is less virus in seminal or vaginal fluids in patients receiving cART, the risk of transmission still exists. -cART and medications against HIV/AIDs DO NOT PREVENT TRANSMISSION. THEY JUST REDUCE THE RISK OF TRANSMISSION (once you have it, you always have it). The point of the medication is to DECREASE THE VIRAL LOAD and INCREASE OUR CD4 T CELL LOAD SO WE HAVE SOME IMMUNITY!

A: Abstinence, B: be faithful/monogamous, C: condoms all decrease risk

HIV and Intercourse: Sexual Transmission · Safe Sex: ____________________________________________ § The only absolute safe sex methods of preventing HIV infection from sexual contact include abstinence and mutually monogamous sex with a noninfected partner § The risk for becoming infected from a partner who is HIV positive is always present, but some sexual practices are more risky than others. § Consistently use safer sex practices: · A latex or polyurethane condom for genital and anal intercourse · An appropriate water-based lubricant with a latex condom · A condom or latex barrier over genitals or anus during oral-genital or oral-anal sexual contact · Latex gloves for finger or hand contact with the vaginal or rectum · Gender affects HIV transmission, and the infection is more easily transmitted from infected male to uninfected female than vice versa § This is because HIV is more easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin. The vagina has more mucous membranes than does the urethra of the penis § Teach women the importance of always either using a vaginal or dental dam or female condom or having male partners use a condom. · Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin are the most risk for HIV transmission. § The practice with the highest risk is anal intercourse regardless of gender (mucous membranes & risk for tearing during this form of intercourse) · Viral Load, or the amount of virus present in blood and other body fluids, affects transmission. The higher the level of HIV (viremia), the greater the risk for sexual and perinatal transmission. § cART has caused viral load to drop below detectable levels. Although there is less virus in seminal or vaginal fluids in patients receiving cART, the risk of transmission still exists. -cART and medications against HIV/AIDs DO NOT PREVENT TRANSMISSION. THEY JUST REDUCE THE RISK OF TRANSMISSION (once you have it, you always have it). The point of the medication is to DECREASE THE VIRAL LOAD and INCREASE OUR CD4 T CELL LOAD SO WE HAVE SOME IMMUNITY!

1. Sexual Transmission: genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretion 2. Parenteral: sharing of needs/equipment contaminated with infected blood or receiving contaminated blood products 3. Perinatal: from the placenta, from contact with maternal blood and body fluids during birth (amniotic fluid, vaginal secretions, blood), or from breast milk from an infected mother to child

Health Promotion and Maintenance for HIV · AIDS has High Morbidity & Mortality when untreated. · No Cure, but the use of antiretroviral therapy allows HIV patients to live long, healthy lives. · No Transmission via Casual Contact or Insects · Highest Concentrations of HIV: 1. Blood, semen, vaginal secretions (very high concentrations) 2. Amniotic Fluid 3. Breast Milk (very high concentrations) 4. Sweat 5. Urine & Feces 6. Saliva & Tears 7. Cerebrospinal Fluid 8. Corneal Tissue 9. Brain Tissue · Most common ways of HIV transmission: 1. 2. 3. · Teach all adults about the transmission routes and ways to reduce their exposure. Also stress that HIV is not transmitted by casual contact in the home, school, or workplace. Sharing household utensils, towels, and linens, and toilet facilities does not transmit HIV. HIV is not spread by mosquitos or other insects · Teach all adults, regardless of age, gender, ethnicity, or sexual orientation, that they are all susceptible to HIV infection

FALLS. SO WHEN PLANNING CARE FOR THESE CLIENTS, YOU HAVE TO THINK ABOUT SAFETY (RISK FOR INJURIES RELATED TO ENCEPHALITIS)

IF YOU HAVE A CLIENT WITH SUSPECTED ENCEPHALITIS, AND THEY HAVE ALL THESE NEURO CHANGES (UNSTEADY GAIT, ETC), WHAT ARE THEY AT RISK FOR?

chronic but manageable

Interprofessional Collaborative Care for HIV Patients · With Treatment, HIV disease is __________________. The usual disease course includes intermitted acute infections and periods of relative wellness. This period is often followed by chronic, progressive debilitation · Because of the cyclic nature of HIV disease and AIDS, the patient spends long periods at home between hospital admissions. During this time the patient must practice adequate self-care. · New strategies to promote self-care, known as mHealth, include the use of mobile devices for reminders and information. · In the acute care setting, the disease is best managed using an interprofessional team approach, including doctors, nurses, registered dieticians, infectious disease specialists, social workers, mental health professionals, and wound care specialists.

it does not mean that they have HIV or AIDS, only that they have been infected with the virus.

Laboratory Tests to Monitor of HIV-infected individuals · Antibody-Antigen Tests § Antibody tests are used to measure the patient's response to the virus (the antigen) rather than the parts of the virus. · When the body is infected with HIV, it makes an antibody to the virus, usually within 3 weeks to 3 months after infection occurs · These are indirect tests. If an adult has a positive test result for HIV antibodies, ____________________________________ § ELISA: Enzyme-linked immunosorbent assay (ELISA) tests a patient's blood sample for antibodies. HIV antibodies can be measured using this test and the Western blot analysis, which is an older testing algorithm. This algorithm was the gold standard for many years and, while it is highly accurate, it is more time consuming and expensive than fourth-generation testing. Normally takes a long time to get results back § Western Blot: Separates blood proteins & detects HIV antibodies. · Used to confirm a positive ELISA. · Combined tests 99.9% accurate. § HIV antibodies are not detected for at least 21 days after exposure, and the Western blot requires an additional 7 days before results can confirm infection. This time frame is known as the window period (in which an adult is first infected with the virus and when viral replication is occurring but the immune system has not yet started making antibodies) · Therefore, if a patient has unprotected sex with an HIV positive adult one night and comes in for testing a week later, the ELISA will be negative, even though the patient may have active HIV. Thus, testing during the window period does not provide useful information.

at least 21 days after exposure, and the Western blot requires an additional 7 days before results can confirm infection. This time frame is known as the window period (in which an adult is first infected with the virus and when viral replication is occurring but the immune system has not yet started making antibodies)

Laboratory Tests to Monitor of HIV-infected individuals · Antibody-Antigen Tests § Antibody tests are used to measure the patient's response to the virus (the antigen) rather than the parts of the virus. · When the body is infected with HIV, it makes an antibody to the virus, usually within 3 weeks to 3 months after infection occurs · These are indirect tests. If an adult has a positive test result for HIV antibodies, it does not mean that they have HIV or AIDS, only that they have been infected with the virus. § ELISA: Enzyme-linked immunosorbent assay (ELISA) tests a patient's blood sample for antibodies. HIV antibodies can be measured using this test and the Western blot analysis, which is an older testing algorithm. This algorithm was the gold standard for many years and, while it is highly accurate, it is more time consuming and expensive than fourth-generation testing. Normally takes a long time to get results back § Western Blot: Separates blood proteins & detects HIV antibodies. · Used to confirm a positive ELISA. · Combined tests 99.9% accurate. § HIV antibodies are not detected for _________________________________________________________________________________________________________ · Therefore, if a patient has unprotected sex with an HIV positive adult one night and comes in for testing a week later, the ELISA will be negative, even though the patient may have active HIV. Thus, testing during the window period does not provide useful information.

the greater chance of transmission of HIV.

Laboratory Tests to Monitor of HIV-infected individuals · HIV RNA Quantification (Viral Load Testing): this directly measures the actual amount of HIV viral RNA particles present in 1mL of blood. § An uninfected adult has no viral load for HIV § A positive viral load test can measure as few as 40 particles/mL, while higher viral loads can measure as high as 80,000 particles/mL § The higher the viral load, ______________________________________________________________________________ -!! You have an HIV/AIDs client comes in, all of a sudden from one lab study to the next, their viral load has increased. What do you ask them? ARE YOU COMPLIANT, ARE YOU AHDERING TO YOUR DRUG REGIMEN? § In a newly infected adult, viral loads can be detected about 10 days after infection, and processed in as little as 24 hours. If positive, this is a clear diagnosis of HIV infection · One caution is that some patient's immune systems are strong enough to control viral replication to an undetectable viral load. Thus, a forth gen test should be done · If a viral load test and a fourth generation test are both negative, the specimen is truly negative. § At home saliva tests can be used. The patient place a device against the gum and cheek for 2 minutes, then the pad is placed in a solution; and a positive result will show. Total testing time is about 20 minutes. If results are positive, it is recommended to get a blood test for confirmation · HIV IgG Antibodies: Immunoglobulin G most common antibody in blood § HIV is associated with elevated Ig G Antibodies · Other Lab Tests to Monitor patient's overall health: CBC, electrolytes, toxoplasmosis antibody titer, LFTs, serologic tests for syphilis (STS), cervical and Pap testing · Other Diagnostic Tests: often performed on basis of patient's symptoms, such as testing stool for ova and parasites; biopsies of skin, lymph nodes, lungs, liver, GI tract, or brain; chest x-ray; gallium scans; bronchoscopy; endoscopy; or colonoscopy; liver and spleen scans; pulmonary function tests; and ABGs

leukopenic (WBC less than 3,500) and lymphopenic (lymphocyte less than 1500); may also be anemic and thrombocytopenic (platelets less than 150,000)

Laboratory Tests to Monitor of HIV-infected individuals · Lymphocyte Counts: this is done as part of a CBC with differential § Normal WBC count: 5,000-10,000 cells/mm3 with differential of 30-40% lymphocytes (1500-4500) § Patients with AIDS are often ______________________________________________________ · Immunity Profile: counts CD4+T cells and CD8+T cells § Normal CD4+T cell to CD8+T cell ratio: 2:1 § In HIV/AIDS patients, the ratio is low, with low CD4+T cells · Rapid Antibody Test - Initial Testing

pressure-relieving mattress pads, warm baths, hydrotherapy, massage, heat/cold application. Use lift sheets to avoid pulling or grasping the patient with joint pain.

Managing pain for HIV Patients · The patient is expected to achieve an acceptable level of comfort and pain reduction, as evidenced by: reporting pain is controlled to an acceptable level, absence of indicators of pain (high HR and BP), absence of facial grimacing/teeth clenching, and willingness to move and participate in self-care · Comfort measures: ___________________________________ · Drug Therapy: § For arthralgia and myalgia, NSAIDs may reduce inflammation and increase comfort. § Pregabalin may provide some relief from muscle and joint pain § Neuropathic pain may respond to TCAs (amitriptyline) or anticonvulsants (gabapentin, phenytoin, carbamazepine) § When opioids are used, assess for respiratory depression

Antidiarrheals

Minimizing Diarrhea for HIV Patients · Patients with AIDS often suffer from diarrhea. Sometimes it is caused by infection (giardia), which can be treated, but sometimes no treatment is available for some causes. § HIV worsens lactose intolerance!!!! § Diarrhea may occur due to drug side effects · The patient is expected to have decreased diarrhea, to maintain fluid/electrolyte/nutrition status, and to reduce incontinence, as evidenced by: has a stool amount and character that are appropriate for the diet; recognizes urge to defecate; maintains control of stool passage · Nursing Interventions/Treatment: · _____________________: give on regular schedule § Loperamide (Imodium) · Send a C. Diff culture to lab before starting this. Because if they have it, you want them to poop the C. Diff out so you won't give loperamide (immodium) § Diphenoxylate hydrochloride · IV Fluids · Assess Perianal Skin every 8-12 hours. Report redness, rashes, blisters, or open areas · Bedside Commode/Bedpan · Keep Perineal Clean & Dry and wear gloves during peri-care · Consult registered dietician § Avoid: Roughage, fatty foods, spicy foods, sugary foods, alcohol, & caffeine § Some patients obtain relief when they eliminate dairy products or eat smaller amounts of food more often and drink plenty of fluids

AIDS wasting syndrome

Other Complications of Symptoms of HIV · HIV associated neurocognitive disorder (HAND) and AIDS dementia complex refer to symptoms of CNS involvement. It is a result of infection of cells in the CNS § S/S: cognitive and motor impairment, behavioral changes, ranging from barely noticeable to severe dementia · ________________________ can result in diarrhea, malabsorption, anorexia, and oral/esophageal lesions that can all contribute to weight loss and emaciated appearance · SKIN CHANGES include dry, itchy skin and rashes § Folliculitis, eczema, or psoriasis may occur · Kidney Problems, including HIV-associated nephropathy (HIVAN) include problems ranging from discrete glomerular injury to acute and chronic kidney diseases. Psychosocial Impacts of HIV · Ask about patient's support system (family, friends) · Offer resources to help with disclosure to sexual partners or significant others · Ask about ADLs and any changes that have occurred since diagnosis. · Monitor the patient's feelings, thoughts, and behaviors · As disease progresses, the patient gets more fatigued. So, pace interviews, assessments, and interventions to match their energy level. When the patient is greatly fatigued, postpone or eliminate nonurgent tests or care activities

carry a small container with this bleach solution whenever sharing needles or to participate in community needle-exchange programs if available.

Parenteral Transmission of HIV · Preventative practices to reduce transmission among injection drug users (IDUs) include the use of proper cleaning of "works" (needles, syringes, other drug paraphernalia). § Instruct IDUs to clean a used needle and syringe by first filling and flushing them with clear water. Next the syringe should be filled with ordinary household bleach. The bleach-filled syringe should be shaken for 30-60 seconds. § Advise IDUs to _____________________________________________________________ · The risk for HIV transmission through transfusion of banked blood and blood products is very low. All donated blood in North America is screened for the HIV antibody, and blood that tests positive is not used for transmission purposes. § Because of the time lag in antibody production after exposure to HIV, infected blood can test negative for HIV antibodies. § Inform patients that there is a small but real possibility of HIV transmission through blood and blood products

viral genetic material the same as human DNA. HIV then uses its enzyme integrase to get its DNA into the nucleus of the host's cell and inert it into the host's DNA. This action completes infection of the Cd4+T cell.

Pathophysiology · Human Immunodeficiency Virus (HIV) infection and disease can progress to Acquired Immunodeficiency Syndrome (AIDs). § The cause of HIV is a virus. It is an intracellular parasite because it must use the infected cell's resources to reproduce. § HIV can infect a cell and take over its functions to force the cell to make more copies of the virus (viral particles). The new viral particles can infect more cells, repeating the cycle as long as there are new host cells to infect. · The Process of HIV Infection: 1. Viral particle features include an outer envelope with special docking proteins (gp41 and gp120), which help find a host. 2. Inside, the virus has genetic material along with the enzymes reverse transcriptase (RT) and integrase. 3. To infect, HIV must first enter the bloodstream and "hijack" certain cells, the CD4+T cells (helper T-cells). This cell directs immunity and regulates the activity of all immune system cells. 4. Virus-host interactions are needed after infection for disease development. When an adult is infected with HIV, the virus randomly "bumps" into many cells. The docking proteins on the HIV must find special receptors on a host cell to which the virus can bind and enter the cell. HIV particles recognize the receptors on the CD4-T cell a. For the virus to enter the cell, both the gp120 and the gp41 must bind to the receptors b. Viral binding to the CD4 receptor and to either co-receptors is needed to enter the cell 5. After entering a host cell, HIV inserts its genetic material into the host cell's DNA. HIV is a retrovirus, which is able to insert its single-stranded RNA genetic material into the host's DNA. 6. The HIV enzyme reverse transcriptase (RT) converts HIV's RNA into DNA, which makes the _______________________________________________________________________ 7. HIV particles are made in the infected cell. The new virus particle is made in the form of one long protein strand. The strand is clipped by the enzyme HIV protease into smaller functional pieces. These pieces are formed into a new finished viral particle. Once the new virus particle is finished, it fuses with the infected cell's membrane and buds off in search of other CD4+T cell. 8. Effects of HIV infection are related to the new genetic instructions that now direct Cd4+T cells to change their role in immune system defenses. Their new role is to be an "HIV factory", making up to 10 billion new viral particles daily. The immune system is made weaker by removing some CD4+T cells from circulation. 9. In early HIV infection before HIV is evident, the immune system can still attack and destroy most of the new viral particles. But with time, the number of HIV particles overwhelms the immune system, CD4+T cell numbers gradually fall, viral load increases, and (without treatment) the patient dies of opportunistic infection or cancer. 10. Everyone who has AIDs has an HIV infection; however, not everyone who has HIV has AIDS. a. The distinction is the # of CD4+T cells and whether any opportunistic infections have occurred. b. A healthy adult usually has 800-1000 CD4+T cells per mm3 of blood. This number is reduced in HIV disease.

1. Fever 2. Night Sweats 3. Chills 4. Headaches 5. Muscle Weakness/Aches 6. Sore Throat 7. Rash 8. With time, these symptoms cease, and the patient feels well again, although a "war" is going on between HIV and the immune system 9. Even in this early phase of disease, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible.

1. Lymphocytopenia: Decreased Lymphocytes 2. Increased Production of Incomplete and Nonfunctional Antibodies 3. Increased Abnormally Functioning Macrophages 4. Increased Risk for bacterial, fungal, & viral infections 5. Increased Risk for Cancer

Pathophysiology · Human Immunodeficiency Virus (HIV) infection and disease can progress to Acquired Immunodeficiency Syndrome (AIDs). · Acute Infection can occur within 4 wks of being infected. Symptoms of Acute HIV Infection include: 1. Fever 2. Night Sweats 3. Chills 4. Headaches 5. Muscle Weakness/Aches 6. Sore Throat 7. Rash 8. With time, these symptoms cease, and the patient feels well again, although a "war" is going on between HIV and the immune system 9. Even in this early phase of disease, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible. · As Time Progresses, More CD4+ T-cells infected and taken out of immune system service. The count decreases, and those that remain function poorly. · Poor CD4+T Cell Function Results In: 1. 2. 3. 4. 5. · Opportunistic Infections are those caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity. The profound reduced immunity in the adult with AIDS allows these usually harmless organisms to overgrow and cause infection · A Diagnosis of AIDS requires that the adult be HIV positive and have either a CD4+T cell count of less than 200 cells/mm3 or less than 14%, or an opportunistic infection. Once AIDS is diagnosed, even if the CD4+T count rises above 200 or if percentage rises above 14%, or if the infection is successfully treated, the AIDs diagnosis remains.

HIV positive and have either a CD4+T cell count of less than 200 cells/mm3 or less than 14%, or an opportunistic infection. Once AIDS is diagnosed, even if the CD4+T count rises above 200 or if percentage rises above 14%, or if the infection is successfully treated, the AIDs diagnosis remains.

Pathophysiology · Human Immunodeficiency Virus (HIV) infection and disease can progress to Acquired Immunodeficiency Syndrome (AIDs). · Acute Infection can occur within 4 wks of being infected. Symptoms of Acute HIV Infection include: 1. Fever 2. Night Sweats 3. Chills 4. Headaches 5. Muscle Weakness/Aches 6. Sore Throat 7. Rash 8. With time, these symptoms cease, and the patient feels well again, although a "war" is going on between HIV and the immune system 9. Even in this early phase of disease, the viral numbers in the bloodstream and genital tract are high and sexual transmission is possible. · As Time Progresses, More CD4+ T-cells infected and taken out of immune system service. The count decreases, and those that remain function poorly. · Poor CD4+T Cell Function Results In: 1. Lymphocytopenia: Decreased Lymphocytes 2. Increased Production of Incomplete and Nonfunctional Antibodies 3. Increased Abnormally Functioning Macrophages 4. Increased Risk for bacterial, fungal, & viral infections 5. Increased Risk for Cancer · Opportunistic Infections are those caused by organisms that are present as part of the body's microbiome and usually are kept in check by normal immunity. The profound reduced immunity in the adult with AIDS allows these usually harmless organisms to overgrow and cause infection · A Diagnosis of AIDS requires that the adult be ____________________________________________________________________________________

REDUCES RISK of HIV transmission

Perinatal Transmission of HIV · HIV transmission can occur across the placenta during pregnancy, with infant exposure to blood and vaginal secretions during birth, or with exposure after birth through breast milk · Inform women of childbearing age with HIV infection about the risks for perinatal transmission. · The risk for transmission to infants from pregnant women with HIV infection who are NOT using HIV drug therapy is about 25% § It is about 8% for women who are using HIV drug therapy § It doesn't PREVENT, instead it _________________________________

1. "Bleeding" the wound 2. Washing would for 1 full minute 3. Immediately Contact ED or Employee Health to begin documentation and testing 4. Start 3 Drug Therapy within 2 hours if possible (best outcome to prevent HIV infection) 5. The Window of Opportunity for best outcome closes when prophylaxis is started after 72 hours. Thus, the exposed health care worker is started on cART before all test results are known. 6. Get HIV testing at 1, 3, & 6 months and electrolytes, creatinine, and CBCs 2 weeks after starting cART

Post-Exposure Prophylaxis (PEP) · Post-Exposure Prophylaxis (PEP): using cART as PEP generally falls into one of 3 exposure categories for adults. · Three Exposure Categories: 1. Occupational Exposure: contact between blood, tissue, or selected body fluids (blood, CSF, pleural fluid, synovial fluid, peritoneal fluid, pericardial fluid, breast milk, amniotic fluid, semen, vaginal secretions) from a patient who is HIV positive (source patient) and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances are not considered infectious for HIV unless obviously bloody (feces, nasal secretions, sputum, saliva, sweat, tears, urine, vomit) do not require prophylaxis. § Accidental needle stick is the most common occurrence needed PEP. The other common exposure is direct contact with mucous membranes (eyes, nose, mouth) § For sharps injuries, initial steps include: 1. 2. 3. 4. 5. 6. 2. Non-Occupational Exposure: This usually refers to consensual sexual exposure with an adult of unknown HIV status (other types can include sharing of needles and inadvertent percutaneous or mucosal contact in the home) 3. Sexual Assault: 1. Check for STIs and HIV infection 2. Plan B within 72 hours 3. Start 3 day regimen of antiretrovirals 4. within 24-36 hours & use for 28 days · IN ALL CASES, starting PEP cART as soon as possible after HIV exposure(preferrable within the first 24-36 hours of exposure) is critical to preventing HIV infection. § The current recommendation is that significant exposures should be treated with the same three-drug regimen for 28 days until the HIV status of the sources has been determined to be negative.

1. Check for STIs and HIV infection 2. Plan B within 72 hours 3. Start 3 day regimen of antiretrovirals 4. within 24-36 hours & use for 28 days

Post-Exposure Prophylaxis (PEP) · Post-Exposure Prophylaxis (PEP): using cART as PEP generally falls into one of 3 exposure categories for adults. · Three Exposure Categories: 1. Occupational Exposure: contact between blood, tissue, or selected body fluids (blood, CSF, pleural fluid, synovial fluid, peritoneal fluid, pericardial fluid, breast milk, amniotic fluid, semen, vaginal secretions) from a patient who is HIV positive (source patient) and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances are not considered infectious for HIV unless obviously bloody (feces, nasal secretions, sputum, saliva, sweat, tears, urine, vomit) do not require prophylaxis. § Accidental needle stick is the most common occurrence needed PEP. The other common exposure is direct contact with mucous membranes (eyes, nose, mouth) § For sharps injuries, initial steps include: 1. "Bleeding" the wound 2. Washing would for 1 full minute 3. Immediately Contact ED or Employee Health to begin documentation and testing 4. Start 3 Drug Therapy within 2 hours if possible (best outcome to prevent HIV infection) 5. The Window of Opportunity for best outcome closes when prophylaxis is started after 72 hours. Thus, the exposed health care worker is started on cART before all test results are known. 6. Get HIV testing at 1, 3, & 6 months and electrolytes, creatinine, and CBCs 2 weeks after starting cART 2. Non-Occupational Exposure: This usually refers to consensual sexual exposure with an adult of unknown HIV status (other types can include sharing of needles and inadvertent percutaneous or mucosal contact in the home) 3. Sexual Assault: 1. 2. 3. 4. · IN ALL CASES, starting PEP cART as soon as possible after HIV exposure(preferrable within the first 24-36 hours of exposure) is critical to preventing HIV infection. § The current recommendation is that significant exposures should be treated with the same three-drug regimen for 28 days until the HIV status of the sources has been determined to be negative.

same three-drug regimen for 28 days until the HIV status of the sources has been determined to be negative.

Post-Exposure Prophylaxis (PEP) · Post-Exposure Prophylaxis (PEP): using cART as PEP generally falls into one of 3 exposure categories for adults. · Three Exposure Categories: 1. Occupational Exposure: contact between blood, tissue, or selected body fluids (blood, CSF, pleural fluid, synovial fluid, peritoneal fluid, pericardial fluid, breast milk, amniotic fluid, semen, vaginal secretions) from a patient who is HIV positive (source patient) and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances are not considered infectious for HIV unless obviously bloody (feces, nasal secretions, sputum, saliva, sweat, tears, urine, vomit) do not require prophylaxis. § Accidental needle stick is the most common occurrence needed PEP. The other common exposure is direct contact with mucous membranes (eyes, nose, mouth) § For sharps injuries, initial steps include: 1. "Bleeding" the wound 2. Washing would for 1 full minute 3. Immediately Contact ED or Employee Health to begin documentation and testing 4. Start 3 Drug Therapy within 2 hours if possible (best outcome to prevent HIV infection) 5. The Window of Opportunity for best outcome closes when prophylaxis is started after 72 hours. Thus, the exposed health care worker is started on cART before all test results are known. 6. Get HIV testing at 1, 3, & 6 months and electrolytes, creatinine, and CBCs 2 weeks after starting cART 2. Non-Occupational Exposure: This usually refers to consensual sexual exposure with an adult of unknown HIV status (other types can include sharing of needles and inadvertent percutaneous or mucosal contact in the home) 3. Sexual Assault: 1. Check for STIs and HIV infection 2. Plan B within 72 hours 3. Start 3 day regimen of antiretrovirals 4. within 24-36 hours & use for 28 days · IN ALL CASES, starting PEP cART as soon as possible after HIV exposure(preferrable within the first 24-36 hours of exposure) is critical to preventing HIV infection. § The current recommendation is that significant exposures should be treated with the ______________________________________________________________

This usually refers to consensual sexual exposure with an adult of unknown HIV status (other types can include sharing of needles and inadvertent percutaneous or mucosal contact in the home)

Post-Exposure Prophylaxis (PEP) · Post-Exposure Prophylaxis (PEP): using cART as PEP generally falls into one of 3 exposure categories for adults. · Three Exposure Categories: 1. Occupational Exposure: contact between blood, tissue, or selected body fluids (blood, CSF, pleural fluid, synovial fluid, peritoneal fluid, pericardial fluid, breast milk, amniotic fluid, semen, vaginal secretions) from a patient who is HIV positive (source patient) and the blood, broken skin, or mucous membranes of a health care professional. Bodily substances are not considered infectious for HIV unless obviously bloody (feces, nasal secretions, sputum, saliva, sweat, tears, urine, vomit) do not require prophylaxis. § Accidental needle stick is the most common occurrence needed PEP. The other common exposure is direct contact with mucous membranes (eyes, nose, mouth) § For sharps injuries, initial steps include: 1. "Bleeding" the wound 2. Washing would for 1 full minute 3. Immediately Contact ED or Employee Health to begin documentation and testing 4. Start 3 Drug Therapy within 2 hours if possible (best outcome to prevent HIV infection) 5. The Window of Opportunity for best outcome closes when prophylaxis is started after 72 hours. Thus, the exposed health care worker is started on cART before all test results are known. 6. Get HIV testing at 1, 3, & 6 months and electrolytes, creatinine, and CBCs 2 weeks after starting cART 2. Non-Occupational Exposure: ______________________________________________________________ 3. Sexual Assault: 1. Check for STIs and HIV infection 2. Plan B within 72 hours 3. Start 3 day regimen of antiretrovirals 4. within 24-36 hours & use for 28 days · IN ALL CASES, starting PEP cART as soon as possible after HIV exposure(preferrable within the first 24-36 hours of exposure) is critical to preventing HIV infection. § The current recommendation is that significant exposures should be treated with the same three-drug regimen for 28 days until the HIV status of the sources has been determined to be negative.

4 days of consistent dosing leading to a steady-state blood drug level 1. Once initial protection period is completed, one dose can be missed, and protection is still adequate 2. However, 2 consecutively missed doses significantly reduces protection. The patient needs to start over (before being exposed to HIV) with another 4 day lead in period until a new steady state can be achieved. 3. Tenofovir 300mg/Emtricitabine 300 mg (Truvada) has no protection against other STIs

Pre-Exposure Prophylaxis (PrEP) · Pre-Exposure Prophylaxis (PrEP) to HIV is the use of HIV specific anti-retroviral drugs in an HIV uninfected adult for the purpose of preventing HIV infection § Tenofovir 300mg/Emtricitabine 300 mg (Truvada) § 1 Tab Daily for High-Risk § PrEP is for a select population that is at high risk for airing HIV infection, including: · Men who have sex with men · Heterosexually active men and women · Injection drug users · Those in serodiscordant relationships (one partner HIV positive, one HIV negative) · After an adult has been identified as at risk (has screened positive for increased risk of getting HIV infection), specific blood and urine tests are done to make sure that it is safe to use PrEP. § First ensure that the adult is HIV negative before starting PrEP § Other tests include Renal Function tests: estimated GFR § Tests for other STIs, like syphilis, gonorrhea, chlamydia, Hepatitis A, B, and C serologies · If adult is positive for hepatitis B, do not initiate PrEP, but refer to an infectious disease specialist · After starting Tenofovir 300mg/Emtricitabine 300 mg (Truvada), ongoing tests of renal function and HIV infection is performed at specific intervals (q3months) · The person using Tenofovir 300mg/Emtricitabine 300 mg (Truvada) is not protected until ________________________________________________________________________________ 1. 2. 3. · PRE-EXPOSURE PROPHYLAXIS DOES NOT REPLACE THE STANDARD SAFER SEX PRACTICES RECOMMENDED TO PREVENT HIV TRANSMISSION. If this drug is used in patients who become infected with HIV, the risk for developing drug resistance greatly increases. Therefore, remind patients prescribed Truvada to use the safer sex practices and to adhere to every 3 month HIV testing along with monitoring for side effects of the drug.

HIV negative before starting PrEP

Pre-Exposure Prophylaxis (PrEP) · Pre-Exposure Prophylaxis (PrEP) to HIV is the use of HIV specific anti-retroviral drugs in an HIV uninfected adult for the purpose of preventing HIV infection § Tenofovir 300mg/Emtricitabine 300 mg (Truvada) § 1 Tab Daily for High-Risk § PrEP is for a select population that is at high risk for airing HIV infection, including: · Men who have sex with men · Heterosexually active men and women · Injection drug users · Those in serodiscordant relationships (one partner HIV positive, one HIV negative) · After an adult has been identified as at risk (has screened positive for increased risk of getting HIV infection), specific blood and urine tests are done to make sure that it is safe to use PrEP. § First ensure that the adult is _______________________________ § Other tests include Renal Function tests: estimated GFR § Tests for other STIs, like syphilis, gonorrhea, chlamydia, Hepatitis A, B, and C serologies · If adult is positive for hepatitis B, do not initiate PrEP, but refer to an infectious disease specialist · After starting Tenofovir 300mg/Emtricitabine 300 mg (Truvada), ongoing tests of renal function and HIV infection is performed at specific intervals (q3months) · The person using Tenofovir 300mg/Emtricitabine 300 mg (Truvada) is not protected until 4 days of consistent dosing leading to a steady-state blood drug level § Once initial protection period is completed, one dose can be missed, and protection is still adequate § However, 2 consecutively missed doses significantly reduces protection. The patient needs to start over (before being exposed to HIV) with another 4 day lead in period until a new steady state can be achieved. § Tenofovir 300mg/Emtricitabine 300 mg (Truvada) has no protection against other STIs · PRE-EXPOSURE PROPHYLAXIS DOES NOT REPLACE THE STANDARD SAFER SEX PRACTICES RECOMMENDED TO PREVENT HIV TRANSMISSION. If this drug is used in patients who become infected with HIV, the risk for developing drug resistance greatly increases. Therefore, remind patients prescribed Truvada to use the safer sex practices and to adhere to every 3 month HIV testing along with monitoring for side effects of the drug.

new-onset muscle pain or weakness because these drugs can cause muscle breakdown (rhabdomyolysis), especially in adults taking a statin

archiving

Preventing Infection for Patients with HIV · Drug Therapy: All antiretroviral drugs only inhibit viral replication; they do not kill the virus. Treatment with only one antiretroviral drug promotes drug resistance and does not improve lifespan, so multiple drugs from different classes are used in combination (combination antiretroviral therapy, cART) · HIV Drugs are Expensive · HIV Drugs require Specific food & timing requirements · Numerous daily drugs, they don't just take one pill. · HIV Drug Therapy is Lifelong and Burdensome · HIV Drugs have Numerous side effects · Homeopathic/botanical agents can effect HIV drugs: always check with md & pharmacy · combination antiretroviral therapy (cART) reduces viral load, improves CD4+T cell counts, and slows disease progression. Patients MUST take these drugs correctly 90% of the time (make sure than 9 out of 10 doses are taken on time and correctly), known as the 90% rule § If/When resistance develops, viral replication is no longer suppressed by the drugs, and the most common cause of this is missed doses of drugs. § Once a patient has an HIV with resistant mutations, the resistant virus is stored in the body indefinitely, a process known as _____________. In this case, the drugs which the virus is resistant to are no longer used (even years later, if the drug to which the HIV showed resistance to is tried again, the virus with the resistant mutation comes out of archival storage to defeat the drug). § ENSURE THAT CART DRUGS ARE NOT MISSED, DELAYED, OR ADMINISTERED IN LOWER-THAN-PRESCRIBED DOSES IN THE INPATIENT SETTING. Teach patients the importance of taking these drugs exactly as prescribed to maintain effectiveness. Even a few missed doses per month can promote drug resistance. § A complication of effective cART in some patients whose CD4+T cell counts rise and immunity returns to normal is the development of Immune Reconstitution Inflammatory Syndrome (IRIS). As the drug works and T4 counts rise, T4 cells recognize several opportunistic infections that were present before but not recognized due to immunosuppression. The T4 cells generate an inflammatory reaction with high fever, chills, and (depending on what infections there are), worsening disease · Very common with co-infected HIV and TB. TB symptoms usually get worse after starting cART · Treatment: corticosteroids

private room when possible

Preventing Infection for Patients with HIV · The patient is expected to remain free of opportunistic diseases and other infections, as evidenced by: normal WBC count, and no chills, fever, temp instability, purulent drainage/sputum, diarrhea, chest-x-ray infiltration · Care of Hospitalized Patients with Reduced Immunity (Chart 19-5): § Place the patient in a _________________ § Use good handwashing technique or alcohol based hand rubs before touching patient or their belongings § Inspect the patient's mouth at least every 8 hours § Inspect the patient's skin and mucous membranes (especially anal area) for the presence of fissures and abscesses at least every 8 hours § Inspect open areas, like IV sites, every 4 hours for s/s of infection § Avoid use of indwelling urinary catheters (risk of CAUTI) § Ensure the patient's room/bathroom are cleaned at least daily § Do not use supplies from common areas for neutropenic patients. Keep a dedicated box of disposable gloves in their room and don't share it with other patients. Provide single-use food products, individually wrapped gauze, or other individual items. § Limit the # of people entering the patient's room § Monitor vitals, including temp, every 4 hours § Change gauze-containing wound dressings daily § Obtain specimens of all suspicious areas for culture and notify doctor § Help the patient perform coughing and deep breathing exercises § Encourage activity at a level appropriate for the patient's current health status § Keep frequently used equipment in the room for use with this patient only (BP cuff, stethoscope, thermometer) § Limit visitors to healthy adults § Keep fresh flowers and potted plants out of the patient's room § Teach the patient to eat a low-bacteria diet (no raw fruits/veggies, undercooked meats/eggs/fish, pepper and paprika)

change pet litter boxes due to risk of toxoplasmosis. If unavoidable, use gloves and wash hands immediately

Preventing Infection for Patients with HIV · The patient is expected to remain free of opportunistic diseases and other infections, as evidenced by: normal WBC count, and no chills, fever, temp instability, purulent drainage/sputum, diarrhea, chest-x-ray infiltration · Patient Education on Prevention of Infection (Chart 19-4): § Take all prescribed drugs § Do not dig in the garden or work with houseplants § Wear a condom when having sex. If you are a woman having sex with a male partner, ensure he wears a condom or use a vaginal sheath. § Avoid travel to areas with poor sanitation or less than adequate health care facilities § Do not share personal toilet articles like toothbrushes, toothpaste, washcloths, or deodorant sticks § Wash hands thoroughly with antimicrobial soap because eating/drinking, after touching a pet, after shaking hands with someone, as soon as you get home from an outing, and after using the toilet. § Wash dishes between use with hot, sudsy water or use a dishwasher § Do not _____________________________________ § Avoid turtles and reptiles as pets § Avoid crowds and other large gatherings of people who might be ill § Bathe daily using antimicrobial soap. If total bathing is not possible, was armpits, groin, genitals, and anal area twice a day with antimicrobial soap § Clean toothbrush at least twice weekly either by running it through the dishwasher or rinsing it in liquid laundry bleach (then rinsing out bleach with hot water) § Avoid eating salads; raw fruits and vegetables; undercooked meats, fish, or eggs; and pepper and paprika (per textbook). WASH any fruits and vegetables (per Cortese) § Do not drink water, milk, juice, or other cold liquids that have been standing for longer than an hour § Do not reuse cups and glasses without washing § Do not feed pets raw or undercooked meats § Take your temperature daily and when you don't feel well § Immediately report: temp greater than 100F, persistent cough (with/without sputum), pus/foul-smelling drainage from any lesion or opening, presence of a boil or abscess, urine that is cloudy/foul-smelling or that causes burning on urination

Potential for infection due to reduced immunity

Priority Problems for Patients with AIDS: 1. ____________________ 2. Inadequate gas exchange due to anemia, respiratory infection, pulmonary Kaposi's sarcoma 3. Pain due to neuropathy, myelopathy, cancer, or infection 4. Inadequate nutrition due to increased metabolic need, nausea, vomiting, diarrhea, difficulty chewing or swallowing, or anorexia 5. Diarrhea due to infection, food intolerance, or drugs 6. Potential for reduced tissue integrity due to KS, infection, reduced nutrition, incontinence, immobility, hyperthermia, or cancer 7. Cognitive decline due to AIDS dementia complex, CNS infection, or cancer 8. Potential for distress due to living with a life-threatening chronic disease that affects all aspects of life

B. Binding the virus to the CD4+ receptor and either of the two co-receptors

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding 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 the newly created viral particle with the infected cell's membrane

Kaposi's sarcoma

Restoring Skin Integrity for Patients with HIV · Impaired Tissue Integrity in AIDS may be related to ___________. § Lesions may be localized or widespread. Large lesions can cause pain, restrict movement, and impede circulation, causing open, weeping, painful lesions. · Impaired Tissue Integrity in AIDS may be related to skin infection with Herpes Simplex Virus (HSV) or Varicella Zoster Virus (VZV) · Nursing Interventions and Treatment: · Kaposi's sarcoma often response well to antiretroviral drug therapy. With time and cART, lesions disappear. For lesions that don't disappear, KS can be treated with local radiation, intralesional or systemic chemotherapy, systemic interferon, cryotherapy, or topical retinoids § Treatment of painful KS lesions includes analgesics and comfort measures. · Keep open, weeping KS lesions clean and dressed to prevent infection. § Many patients are upset with KS lesion appearance. (If lesions are closed) Teach them about makeup, wearing long-sleeves, or wearing hats · For Herpes Simplex Virus (HSV), provide good skin care. Keep skin clean and dry. Lesions are painful, and need analgesics, assistance with position, and other comfort measures. § Modified Burow's solution soaks promote healing for some patients. § HSV is treated with acyclovir or valacyclovir

b. reduces risk of LBW and preterm delivery

SAMPLE EXAM QUESTION: An HIV positive pregnant lady asks the nurse, "I'm scared of the HIV medicine, what is it going to do?". What should the nurse say to her? a. it will prevent perinatal transmission (FALSE. It REDUCES (not prevents) b. reduces risk of LBW and preterm delivery c. it prevents me and my partner from having to have safe sex d. It prevents something else (he said it was not right answer)

HIV infection

Signs and Symptoms of HIV · History: § Age, gender, occupation, location of home § Current illness, when it started, severity of symptoms, associated problems, and interventions § Ask when HIV infection was diagnosed and which symptoms led to diagnosis § Ask for chronologic history of infections and problems since diagnosis § Ask about sex practices, STIs, major infectious diseases (TB, hepatitis) § If patient has hemophilia, ask about treatment with clotting factors § Risk factors for HIV: unprotected sex, multiple partners, occupational exposure, perinatal exposure, blood transfusions, IV drug use, old adults · Signs and Symptoms of HIV: § May have either few symptoms/problems or have problems that are acute rather than chronic § Manifestations occur within 2-4 weeks after infection, and are similar to those of influenza (rash, sore throat) § S/S of acute _______________________________________: 1. Fever 2. Night sweats 3. Chills 4. Headaches 5. Muscle aches 6. Sore throat 7. Rash 8. Findings are temporary and resolve with the client returning to previous level of health*

AIDS

Signs and Symptoms of HIV · Key Features of ____________: 1. Immunologic S/S: a. Low WBC counts: i. CD4+/CD8+ ratio <2 ii. CD4+ count less than 200/mm3 b. Hypergammaglobulinemia c. Opportunistic infections d. Lymphadenopathy e. Fatigue 2. Integumentary S/S: a. Dry skin b. Poor wound healing c. Skin lesions d. Night sweats 3. Respiratory S/S: a. Cough b. Shortness of breath 4. GI S/S: a. Diarrhea b. Weight loss c. Nausea and vomiting 5. CNS S/S: a. Confusion b. Dementia c. Headache d. Fever e. Visual changes f. Memory loss g. Personality changes h. Pain i. Seizures 6. Opportunistic infections: a. Protozoal infections: toxoplasmosis, cryptosporidiosis, isosporiasis, microsporidiosis, strongyloidiasis, giardiasis b. Fungal Infections: candidiasis, Pneumocystis jiroveci pneumonia, cryptococcosis, histoplasmosis, coccidioidomycosis c. Bacterial infections: mycobacterium avium complex infection, tuberculosis, nocardiosis d. Viral infections: cytomegalovirus infection, herpes simplex virus infection, varicella-zoster virus infection 7. Malignancies: a. Kaposi's sarcoma b. Non-Hodgkin's lymphoma c. Hodgkin's lymphoma d. Invasive cervical carcinoma

§ Wear gloves when in contact with patients' mucous membranes or nonintact skin. § Infected workers with weeping dermatitis or open lesions must wear gloves or not perform direct patient care

Transmission of HIV and Health Care Workers · Needlesticks or "sharps" injuries are the main means of occupation-related HIV infection for health care workers · In addition, health care workers can be infected through exposure of nonintact skin and mucous membranes to blood and body fluids · Best Prevention for HCPs: Use Standard Precautions for ALL patients -______________________________________ -______________________________________ · Recommendations for Preventing HIV Transmission by Health Care Workers 1. Adhere to standard precautions 2. Workers with exudative lesions or weeping dermatitis should not perform direct patient care or handle patient care equipment and devices used in invasive procedures 3. Workers must follow guidelines for disinfection and sterilization of reusable equipment used in invasive procedures 4. Workers infected with HIV are not restricted from practice of non-exposure-prone procedures, as long as they comply with standard precautions and sterilization/disinfection recommendations 5. Workers who perform exposure-prone procedures should now their HIV status 6. Workers who are infected with HIV should seek advice from an expert review panel before performing exposure-prone procedures to determine under which circumstances they may continue to practice these procedures. These circumstances would include notification of prospective patients of HIV positivity.

B. URINE OUTPUT IS 50ML/HR (BC IT IS MEASURABLE)

§ NCLEX/TEST SAMPLE QUESTION: HOW DO WE KNOW THAT FLUID RESUSCITATION WAS SUCCESSFUL? A. PATIENT VOIDS 5 TIMES A DAY B. URINE OUTPUT IS 50ML/HR C. PATIENT HAS LESS EDEMA

C. PATIENT HAS GAINED 2 POUNDS IN ONE MONTH (BC THIS IS MEASURABLE)

§ NCLEX/TEST SAMPLE QUESTION: IF IT ASKS YOU ABOUT MEASURING THE OUTCOMES OF HIV PATIENT WITH WASTING SYNDROME DIET: A. PATIENT CHOSES HIGH PROTEIN SNACK B. PATIENT EATS 4 SMALL MEALS PER DAY C. PATIENT HAS GAINED 2 POUNDS IN ONE MONTH D. PATIENT CHOOSE ENSURE BETWEEN MEALS

HIV and AIDs

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