Nursing Management: HIV and AIDS
What are the GI manifestations of HIV?
- Anorexia, nausea, and vomiting • Oral and esophageal candidiasis or thrush - Chronic diarrhea - causing profound weight loss, fluid and electrolyte imbalances, perianal skin excoriation, weakness, and inability to perform activities of daily living
What are the neurologic manifestations of AIDS?
- HIV encephalopathy - HIV-associated dementia - HIV-related peripheral neuropathy
What are the risk factors for acquiring HIV?
- High-risk behaviors such as sexual intercourse with an HIV-infected partner or injection drug use • Blood transfusion or blood products contaminated with HIV • Children born to mothers with HIV infection, breastfed infants of HIV-infected mothers • Health care workers exposed to needle-stick injury or transmucosal contamination from an infected patient • Potentially infected body fluids, including blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk • Estrogen and progesterone may increase a woman's risk for HIV infection through changes in the cervical mucosa.
Assessment for patients with AIDS
- Identify potential risk factors, including sexual practices and IV/ injection drug use history. • Assess physical and psychological status and explore factors affecting immune system functioning.
What are the integumentary manifestations of HIV?
- KS, herpes simplex, herpes zoster viruses, and various forms of dermatitis • Folliculitis, atopic dermatitis including eczema or psoriasis
What are the oncologic manifestations of patients with AIDS?
- Kaposi's sarcoma -- is the most common - B-cell lymphomas - second most common
What are the S/S of wasting syndrome (cachexia)?
- Multifactorial protein- energy malnutrition; - Profound involuntary weight loss - Either chronic diarrhea for more than 30 days or chronic weakness and documented intermittent or constant fever with no concurrent illness • Anorexia, diarrhea, gastrointestinal (GI) malabsorption, lack of nutrition
What are the gynecologic manifestations of HIV?
- Persistent recurrent vaginal candidiasis may be the first sign of HIV infection. • Ulcerative sexually transmitted diseases, such as chancroid, syphilis, and herpes, are more severe in women with HIV. - HPV - cervical intraepithelial neoplasia - pelvic inflammatory disease - menstrual abnormalities
What are the prolong side effects of pharmacologic therapy?
- lipodystrophy syndrome - risk for early-onset hypercholesterolemia, heart disease, and diabetes. - Fat redistribution syndrome,
HIV symptomatic
200 to 499 CD4 + T lymphocytes/ mm3
AIDS
< 200 CD4 + T lymphocytes/ mm3
HIV asymptomatic
> 500 CD4 + T lymphocytes/ mm3
Maintaining Thought Processes
• Assess for alterations in mental status. • Reorient to person, place, and time as necessary - maintain and post a regular daily schedule. • Give instructions, and instruct family to speak to the patient in a slow, simple, and clear manner. • Provide night lights for bedroom and bathroom. Plan safe leisure activities that patient previously enjoyed.
Improving Airway Clearance
• Assess respiratory rate, rhythm, use of accessory muscles, cough and breath sounds; mental status, and skin color daily. • Provide oxygen, suctioning, or mechanical ventilation as needed. • Obtain sputum specimens as indicated. • Encourage intake of 3 L of fluid if no renal or cardiac complications are present.
What are the respiratory manifestations of HIV?
Dyspnea, cough, chest pain, and fever
Dx of HIV
Enzyme immunoassay Western blot assay confirms seropositivity. Viral load tests
Primary infection is associated with...
High levels of HIV in the blood are accompanied by dramatic drops in CD4 + T-cell counts, normally between 500 and 1,500 cells/ mm3.
What are the immunological manifestation of HIV?
Immune reconstitution inflammatory syndromes (IRIS) is characterized by fever and worsening of clinical manifestations of opportunistic infections, or the appearance of new manifestations.
Promoting Usual Bowel Patterns
• Assess bowel patterns for diarrhea - assess frequency and consistency of stool, abdominal pain or cramping with bowel movements. • Assist patient in avoiding factors that exacerbate diarrhea. • Measure and document volume of liquid stool as fluid volume loss; obtain stool cultures. • To decrease diarrhea, recommend restricting oral intake for bowel rest and to avoid bowel irritants including raw fruits and vegetables, popcorn, carbonated beverages, and spicy food - encourage small, frequent meals. • Administer antidiarrheal agents, anticholinergics, antispasmodics, opiates, antibiotics, and antifungal agents.
Acquired Immunodeficiency Syndrome
is defined as the most severe form of a continuum of illnesses associated with the retroviral human immunodeficiency virus (HIV) infection
What are the symptoms of HIV encephalopathy?
memory deficits headache difficulty concentrating progressive confusion psychomotor slowing apathy ataxia global cognitive impairments delayed verbal responses a vacant stare spastic paraparesis hyperreflexia psychosis hallucinations tremor incontinence seizures mutism death
Pharmacologic therapy of HIV
nucleoside/ nucleotide reverse transcriptase inhibitors (NRTI) non-nucleoside reverse transcriptase inhibitors (NNRTI) protease inhibitors fusion inhibitors integrase inhibitors entry inhibitors.
S/S of HIV-related peripheral neuropathy
pain and numbness in the extremities weakness diminished DTR orthostatic hypotension impotence.
Nursing interventions
promoting skin integrity promoting usual bowel patterns preventing infection improving activity tolerance maintaining though processes improving airway clearance relieving pain and discomfort improving nutritional status decreasing sense of social isolation coping with grief monitoring and managing potential complications
Effective medication regimen contains at least ...
three antiretroviral medications from at least two classes.
Promoting skin integrity
• Assess skin and oral mucosa for changes in appearance, location and size of lesions, and evidence of infection and breakdown; encourage regular oral care. • Encourage patient to balance rest and mobility whenever possible; assist immobile patients to change position every 2 hours. • Use devices such as alternating-pressure mattresses and low-air-loss beds, keeping linens wrinkle free. • Encourage patient to avoid scratching, to use nonabrasive and nondrying soaps, and to use nonperfumed skin moisturizers on dry skin - administer antipruritic agents, antibiotic medication, analgesic agents, medicated lotions, ointments, and dressings as prescribed - avoid adhesive tape. • Advise patient with foot lesions to wear cotton socks and shoes that do not cause feet to perspire - avoid tight or restrictive clothing. • Assess perianal region for impaired skin integrity and infection. • Instruct patient to keep the area as clean as possible, to cleanse after each bowel movement, to use sitz bath or irrigation, and to dry the area thoroughly after cleaning. • Assist debilitated patient in maintaining hygiene practices. • Promote healing with prescribed topical ointments and lotions. • Culture wounds if infection is suspected.
Assessment of level of knowledge
• Evaluate patient's knowledge of disease and transmission. • Assess level of knowledge of family and friends. • Explore patient's reaction to the diagnosis of HIV infection or AIDS, which may include denial, anger, fear, shame, withdrawal from social interactions, and depression. • Identify patient's resources for support.
Assessment of F&E status
• Examine skin and mucous membranes for turgor and dryness. • Assess for dehydration by observing for increased thirst, decreased urine output, postural hypotension, weak and/ or rapid pulse, or elevated urine specific gravity. • Monitor for serum sodium, potassium, calcium, magnesium, and chloride imbalances, typically from diarrhea. • Assess for signs and symptoms of electrolyte deficits, including decreased mental status, muscle twitching, muscle cramps, irregular pulse, nausea and vomiting, and shallow respirations.
Assessment of skin and mucous membranes
• Inspect daily for redness, breakdown, ulceration, and infection. • Monitor oral cavity for and creamy-white patches (candidiasis). • Assess perianal area for excoriation and infection. • Obtain wound cultures to identify infectious organisms.
Preventing infection
• Instruct patient and caregivers to monitor for signs and symptoms of infection: fever, chills, night sweats, cough, sputum production, difficulty breathing, creamy-white patches in the oral cavity, swollen lymph nodes, nausea, vomiting - persistent diarrhea - frequency, urgency, or pain on urination - drainage from skin wounds. - Avoid others with active infections. • Monitor WBC count and differential - culture wound drainage, skin lesions, urine, stool, sputum, mouth, and blood as ordered
Improving Activity Tolerance
• Monitor ability to ambulate and perform daily activities. • Assist in planning daily routines to maintain balance between activity and rest. • Instruct patient in energy conservation techniques (eg, sitting while washing or preparing a meal). • Decrease anxiety that contributes to weakness and fatigue by using measures such as relaxation and guided imagery. • Collaborate with other health care team members to uncover and address factors associated with fatigue - administer epoetin alfa [Epogen] for fatigue related to anemia.
Assessment of respiratory status
• Monitor for cough, sputum production, shortness of breath, orthopnea, tachypnea, and chest pain; assess breath sounds. • Assess other parameters of pulmonary function including chest X-rays, arterial blood gases (ABGs), pulse oximetry, pulmonary function tests.
Assessment for nutritional status for patients with AIDS
• Obtain dietary history, identifying factors that may interfere with oral intake, such as anorexia, nausea, vomiting, oral pain, or difficulty swallowing. • Assess patient's ability to purchase and prepare food. • Measure nutritional status by weight, anthropometric measurements (triceps skinfold measurement), and blood urea nitrogen (BUN), serum protein, albumin, and transferrin levels.
Monitoring and Managing Potential Complication
• Opportunistic infections: Report signs and symptoms including fever, malaise, difficulty breathing, nausea or vomiting, diarrhea, difficulty swallowing, and any occurrences of swelling or discharge to the health care provider. Teach patients to report these symptoms immediately. • Respiratory failure: Monitor respiratory rate, pattern, and breath sounds, ABGs, and oxygen saturation; provide suctioning and oxygen therapy. Perform early assessment of patient wishes regarding mechanical ventilation; assess response to stress of intubation and mechanical ventilation. • Cachexia and wasting: Monitor weight gain or loss, skin turgor and dryness, ferritin levels, hemoglobin and hematocrit, fluid and electrolyte balance. Assist in selecting foods that replenish electrolytes. Initiate measures to control diarrhea. Provide IV fluids and electrolytes as prescribed. • Side effects of medications: Provide information about purpose, correct administration, side effects to report to physician, and strategies to manage or prevent side effects. Monitor laboratory test values and observe for drug interactions
Assessment of neurologic status
• Perform baseline assessment of mental status as early as possible. - Note level of consciousness and orientation to person, place, and time, and memory lapses. • Observe for sensory deficits, such as visual changes, headache, and numbness and tingling in the extremities. • Observe for motor impairments, such as altered gait, paresis, or paralysis. • Observe for seizure activity.
Patient Education
• Teach patient how to prevent disease transmission, including hand washing, delegating cleaning soiled pet areas to others, techniques and methods for safely handling and disposal of items soiled with body fluids. • Discuss precautions to prevent transmission of HIV: Use of condoms during vaginal or anal intercourse; using dental dam or avoiding oral contact with the penis, vagina, or rectum; avoiding sexual practices that might tear the lining of the rectum, vagina, or penis. • Teach patient and family to clean kitchen and bathroom surfaces regularly with disinfectants to prevent growth of fungi and bacteria. • Emphasize the importance of avoiding smoking, alcohol, and over-the-counter and street drugs. Instruct patients who are HIV positive or who inject drugs not to donate blood. Injection drug users who are unwilling to stop using should avoid sharing drug equipment with others. • Teach medication administration, any IV preparation, techniques for enteral or parenteral therapies.