Med Surg 2, Chapter 20, HIV and AIDS
How long after infection do HIV antibodies begin to appear in the body?
(there are 2 different answers found thru out the chapter...) On page 365, it says it may take up to 3-6 months. On page 371, it says 3 weeks - 3 months or longer... **Testing for these antibodies is what diagnoses HIV. The time between infection and the developing antibodies is called the WINDOW PERIOD**
Name some complications that may result from HIV/AIDS.
AIDS wasting syndrome, HIV-associated neurocognitive disorder, and opportunistic infections/cancers
Medications have been developed not to cure HIV/AIDS but to SLOW the progression of HIV/AIDS. There are 2 types: ARV and HAART. What do these stand for?
ARV: Anti-retroviral agents HAART: Highly-active anti retroviral therapy.
Anal sex has the highest risk of spreading HIV. Why? Females are a higher risk than men to contract HIV . Why?
Anal sex: the anal mucosa is thin and prone to tearing which allows HIV/AIDS a portal of entry into the body Women: the vagina has a greater area of mucous membranes than the penis and there is a greater amount of HIV found in semen compared with vaginal secretions.
HIV has 2 stages: asymptomatic stage (also called the clinical latency stage) and the symptomatic stage. Explain the difference (include the sx) What is acute retroviral syndrome?
Asymptomatic stage: there are usually no sx and virus remains in the lymph nodes, liver, spleen, and reproduces. If left untreated, a decline in CD4+ T lymphocytes AND even B lymphocytes can be seen. (B and T cells work together to fight infection). *Sx may not appear after infection until up to 8-12 years!* Symptomatic stage: This is when the person starts to exhibit sx of HIV which can include SOB, fever, wt loss, fatigue, night sweats, persistent diarrhea, oral or vaginal candidiasis ulcers, dry skin, skin lesions, shingles, seizures, dementia. acute retroviral syndrome: Remember that during the asymptomatic stage, people usually do not have any sx BUT some can have acute retroviral syndrome which is when they have nonspecific sx such as fever, headache, extreme fatigue, enlarged lymph nodes, diarrhea, sore throat. These sx mimic a cold or flu and people usually do not connect this to HIV and therefore remain untreated.
One of the many opportunistic infections related to HIV/AIDS includes PCP (pneumocystis pneumonia). What are some meds that are used to treat PCP?
Bactrim (trimethoprim-sulfamethoxazole)
More older adults are starting to contract HIV. About 11% of new cases and 24% of all persons living with HIV/AIDS are over 50. Why is it that there has been an increase in older adults contracting the virus? What are the signs and sx of HIV in older adults that may not be seen in the average person?
Because HIV/AIDS are thought to be a younger-person disease and so older adults are usually not educated on the disease. Like the younger people, older adults can have multiple sex partners as well and older adults are actually less likely to use protection. A decline in the older adult's immune system, along with older females' decrease in vaginal secretions contribute to a higher risk of contracting HIV/AIDs. Sx include: confusion (remember that HIV/AIDS can infect the brain and cause dementia. This may be mistaken for "normal" dementia and aging in the older patient).
Along with promoting a healthy and adequate diet, why would exercise be equally important for a patient with HIV/AIDS?
Because exercise helps to maintain and build muscle mass, promotes relaxation, aids sleep, and gives the patient a sense of control and well-being.
It is extremely important for patients with HIV/AIDS to report to their MD immediately if they start to experience signs and sx of an opportunistic infection. Give some examples of those signs and sx that they should report.
Body temp higher than 100, SOB, cough, chest tightness, signs of CNS impairments such as difficulty with speech/walking/visual changes/weakness of the arm or leg/ changes in mood or memory. Foul-smelling drainage/pus. Cloudy or foul smelling urine. Diarrhea lasting more than 2 days or more than 6 stools day. Rashes. Sore mouth or tongue, difficulty swallowing, white patches in the mouth or throat. Worsening fatigue, unintended wt loss, etc.
A person suspected or has HIV/AIDS should stay on top of routine bloodwork. Name some examples of bloodwork that would be ordered and briefly why it would be needed.
CBC: patients with HIV/AIDS are prone having abnormal blood counts such as anemia, thrombocytopenia, leukopenia, etc. Their lymphocyte has to be monitored, as well. *Should be done every 3-4months* CD4+/ CD8+ T Lymphocyte count: in healthy adults, the CD4+ levels should be about 500-1600. People with HIV/AIDS start to drop in their CD4+ cells but their CD8+ cells remain the same. The bigger the ratio between the 2, the more sick the person is. *Should be done every 3 months, very important for those on ARV therapy* Viral load testing: measures how much of the virus the person has. This is important when determining if treatment is working. The goal is to get a result of "an undetectable viral load" *Should be done every 3 months* Genotyping: determines what kind of strain or type the HIV is and also determines what kind of treatment would work best. other tests: includes testing for syphilis, Hep A, B, C, and liver panels. This is because people who have HIV have a high incidence of coinfections . *Coinfections can affect the course of HIV and the treatment options*
Explain the pathophysiology of HIV.
HIV is a retrovirus (which means it ONLY has RNA for its genetic material). It likes to attack cells with CD4 receptors and the cells that have CD4 receptors are *WBCs* (such as the CD4+ T lymphocytes, T4 lymphocytes, helper T lymphocytes, and macrophages). Its *FAVORITE* white blood cell to attack is the *CD4+ T lymphocytes*. Once it binds to the CD4 receptor, the virus uses an enzyme called *REVERSE TRANSCRIPTASE* to force the human cell form a new piece of DNA from the viral RNA. Then the enzyme *INTEGRASE* integrates the new DNA into the host cell. Now the human cell starts to produce more and more VIRAL DNA. The virus can then bud (or be released) from the cell to infect other human cells. **The invasion and destruction of the WBCs causes the immune system to go own and cancers and infections can easily take over**
There are 2 strains of HIV: HIV-1 and HIV-2. What is the difference? Is it possible to be infected with both?
HIV-1 is found world-wide. HIV-2 is found only in a small area in West Africa. **both have the same sx, can be spread the same way, and both are incurable, and can progress to AIDS** yes
Define what HIV stands for. Define what AIDS stands for. True or false: HIV causes AIDS.
HIV: Human immunodeficiency virus AIDS: acquired immunodeficiency syndrome FALSE: HIV does not CAUSE AIDS. AIDS is the last stage of HIV.
HIV/AIDS weakens the immune system, therefore, patients are more prone to contracting opportunistic infections. One of those infections includes CMV (cytomegalovirus). Explain what cytomegalovirus is (CMV). Include its signs and sx.
It can be serious infection for those with a CD4+ T lymphocyte count below 100. It can cause retinitis (which can result in blindness). Sx include: fever, fatigue, diarrhea, GI upset, and hepatitis.
HIV/AIDS weakens the immune system, therefore, patients are more prone to contracting opportunistic infections. One of those infections includes TB (tuberculosis). Explain what TB is and its signs and sx.
It is a bacterial infection caused by the organism called mycobacterium tuberculosis. sx: dyspnea, cough, chest pain, fever, night sweats, wt loss, bloody sputum. **Patients with HIV/AIDs should get a TB test at least every year. An induration of 5 mm or more is considered positive for TB**
HIV/AIDS weakens the immune system, therefore, patients are more prone to contracting opportunistic infections such as candida albicans, TB, pneumocystis pneumonia, etc. Explain what candida albicans is (include its signs and sx)
It is a fungus that can infect the mouth, esophagus, and the vagina. The most common found in people with AIDS is the oral and esophageal kind. Sx include: dysphagia, yellow-white plaques that look like cottage cheese in the mouth and throat, and esophageal pain. Vaginal candidiasis: severe itching, white discharge.
HIV/AIDS weakens the immune system, therefore, patients are more prone to contracting opportunistic infections. One of those infections includes MAC (mycobacterium avium complex). What is MAC? Include its signs and sx.
It is a serious bacterial infection that occurs in patients with AIDS when CD4+ T lymphocytes fall below 50. **It is found in water, soil, and food. So it is hard to prevent**. sx: fever, night sweats, wt loss, abd pain, tiredness, diarrhea. **Prophylactic treatments includes antibx such as azithromycin, clarithromycin, etc for pts who have a CD4+ T lymphocyte count below 50 should be given to prevent mycobacterium avium complex.** **treatment: uses the same antibx as prevention**
The complications associated with HIV/AIDS is AIDS wasting syndrome, HIV-associated neurocognitive disorders, and opportunistic infections/cancer. What is is AIDs wasting syndrome?
It is the involuntary loss of 10% or more baseline body weight plus chronic weakness or fever or chronic diarrhea that lasts more than 30 days. There are several factors that can contribute to this syndrome: medications side effects, diarrhea, decreased appetite, oral lesions, malabsorption, GI infections, cognitive impairments, etc.
It is important for HIV/AIDS patients to report to their MD any side effects of their medications. For a person with a compromised immune system, some of these med side effects can be serious and/or life threatening. Some patients with very low CD4+ cell counts who are on anti retroviral therapy for HIV/AIDS may get a syndrome called immune reconstitution syndrome. Explain what this is.
Prior to treatment, the immune system of a person with HIV/AIDS may be too weak to show any sx of infections. But once they start treatment and their immune system gets stronger, they can begin to display sx of infections including opportunistic infections that they may have already had in their body . This can be a serious and sometimes fatal condition that can occur a few weeks after ARV therapy.
Some people are get infected with HIV will go thru something called acute retroviral syndrome. What is this?
Remember that in the asymptomatic stage, the pt usually has no sx. BUT some do go thru something called acute retroviral syndrome which exhibits cold/flu like sx such as fever, headache, diarrhea, fatigue, sore throat, and enlarged lymph nodes These sx can occur 6-12 weeks after HIV infection and can last for a few days - weeks.
Once HIV progresses to the symptomatic stage, what are some signs and sx would you see?
SOB, fever, wt loss, fatigue, night sweats, persistent diarrhea, oral/vaginal candidiasis ulcers, dry skin, skin lesions, shingles, peripheral neuropathy, seizures, dementia.
There are several medications that have been developed to slow down the progression of the HIV/AIDS virus. What are some ways these meds work?
Some can prevent the virus from attaching to the CD4+ receptor sites on white blood cells. Some stop the reverse transcriptase (which is an enzyme that the virus uses to force the human host cell to make a DNA copy of the virus) Some stops the enzyme called protease (which the virus uses to integrate its DNA into the human host cell) Some stops the virus from "budding" or coming out of the human host cell to infect other human cells. **other ways these drugs work are listed on pages 372-373**
True or false: It is not the HIV that ultimately causes death. It is the compromised immune system and the invasion of an opportunistic infection or disease that the body is unable to fight off.
TRUE
When is a person who has HIV considered positive for AIDS?
There are 3 times: When their CD4+ T-lymphocyt count falls BELOW 200 **This is the only one Mrs. Green wanted us to know for her exam** or if the CD4+ T-lymphocytes fall below 14 percent of the total lymphocytes or the presence of one or more of the following conditions: Candidiasis of the bronchi/lung/trachea/esophagus, invasive cervical cancer, herpes simplex with ulcers lasting more than a month, Kaposi's sarcoma, recurrent pneumonia, recurrent, salmonella septicemia, wasting syndrome, etc (For the entire list, refer to page 363).
One of the many opportunistic infections related to HIV/AIDS includes herpes simplex, herpes zoster (shingles), and varicella zoster (chicken pox). Name some meds that are used to treat these conditions.
These are treated with antiVIRALS such as: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir
How is HIV spread? Name some ways that HIV cannot be spread.
Thru infected blood, semen, vaginal secretions, breast milk, and bodily fluids contaminated witih blood. It needs a portal of entry into the body such as thru the mucous membranes (such as oral sex) or nonintact skin (such as from a cut) or access to the bloodstream (such as from a needlestick). It cannot be spread thru casual touching such as hugging, closed mouth kissing, shaking hands, sharing eating utensils. It cannot be spread thru mosquito bites, air, water, or food.
One of the many opportunistic infections related to HIV/AIDS includes MAC (mycobacterium avium complex). Name some meds that are used to treat MAC.
Treated with antibx such as : azithromycin, clarithromycin, and ethambutol
There are 6 different classes of HIV treatments available. True or false: At least 3 meds in at least 2 classes of treatment categories are used .
True! (Refer to page 373-374 to see the list of meds used)
True or false: PrEP (pre-exposure prophylaxis) with the use of an ARV (anti retroviral agent) can help prevent HIV transmission for those who are at high risk of contracting the virus.
True! It is a daily pill that should be taken and used along with appropriate other HIV transmission precautions.
The complications seen with HIV/AIDS include AIDS wasting syndrome, HIV-associated neurocognitive disorder, and opportunistic infections/cancer. Explain what HIV-associated neurocognitive disorder is.
When HIV infects the brain or other parts of the central nervous system , it can cause sx that range from mild to severe. Sx include memory impairment, personality changes, halluncinations, leg weakness, loss of balance, slower responses, etc **Safety is a concern in these patients**
Your patient who is on ARV therapy to treat HIV/AIDS called the office and states he forgot to take his medication this morning at 9 AM.It is now 12 PM. His next dose is scheduled for 6PM. Can he take his missed dose now?
Yes. If a dose is missed, it should be taken as soon as possible. **But do not take it if it is close to the next dose. as doses should NOT be doubled** **Missing doses can cause therapy failure as it brings up the viral load and the virus can become resistant to the medication**
How can pregnant women reduce their risk to 1% of spreading HIV/AIDS to their fetus? True or false: At the time of labor, women who have not been tested for HIV/AIDS have to get tested as there are rapid HIV tests available. After delivery of a baby who has an HIV-infected mother, what kind of medication should be given to the baby ? And for how long ?
by taking ARV therapy during pregnancy, labor, and delivery (A medication called AZT which is also called zidovudine is usually used) FALSE. Pregnant women who have not been tested for HIV/AIDS DO NOT have to get tested. It is their choice if they want to get tested or not. But rapid HIV testing SHOULD be offered AZT (zidovudine), 6 weeks
The complications seen with HIV/AIDS include AIDS wasting syndrome, HIV-associated neurocognitive disorder, and opportunistic infections/cancer. Name some examples of opportunistic infections .
candida albicans, cytomegalovirus (CMV), mycobacterium avium complex (MAC), pneumocystis pneumonia (PCP), and tuberculosis (TB).
HIV/AIDS weakens the immune system, therefore, patients are more prone to contracting opportunistic infections. One of those infections includes PCP (pneumocystis pneumonia). Explain what PCP is and include its signs and sx.
caused by a *FUNGUS* called pneumocystis jiroveci. As the name suggests, it affects the lungs Sx develop slowly: SOB, dry cough, fever. **For those who have a CD4+ T lymphocyte count of less than 350, should be given prophylactic treatment with Bactrim (trimethoprim-sulfamethoxazole).** **treatments include: o2 , Bactrim, and steroids can help reduce lung inflammation**
Some patients with HIV experience fatigue. What are some other causes of fatigue?
depression, med side effects, malnutrition, infections, anemia, dehydration, etc.
Give some examples of nursing dx that you can use when taking care of a patient with HIV/AIDS
ineffective protection (related to decreased immune function), impaired gas exchange (related to respiratory infections), fatigue (related to HIV infection and or side effects of meds), imbalanced nutrition, risk for injury (related to fatigue, weakness, sedation), diarrhea (related to medications or infection), social isolation, deficient knowledge, ineffective coping, etc **refer to pg. 375 for more examples**
What are some reasons a person with HIV/AIDS would be malnourished?
nausea/vomiting from med side effects, they may have painful oral lesions that prevents them from eating, persistent diarrhea, malabsorption issues, **Patients with HIV/AIDS need 10-15 % more energy per day and 50-100% more protein than the normal healthy person. So promoting a high calorie and high protein diet is preferred!**
You are caring for a patient with HIV/AIDS. The person currently just got diagnosed with HIV/AIDS wasting syndrome. What are some therapeutic interventions that you can do as a nurse to help this patient?
promote small, frequent meals. Encourage high calorie and high protein meals and snacks. Eat low-residue diet if pt has diarrhea. Consult MD regarding use of antiemetics and/or meds that induce appetite. Control odors if pt has nausea. Incorporate the pt's fav foods to entice them to eat. Use simple and easy foods if pt has fatigue. Avoid spicy foods and really hot foods for those who have oral sores/lesions. Encourage supplements such as vitamins/minerals and drinking Boost or Ensure. Use artificial saliva for those with dry mouth. Offer popsicles and ice chips.
One of the many opportunistic infections related to HIV/AIDS includes candidiasis. Name examples of drugs that can treat candidiasis.
treated with antifungals such as : nystatin, Diflucan (fluconazole), Nizoral (ketoconazole)
What bodily fluids can be used to test for HIV? Explain the steps involved in traditional HIV antibody testing.
urine (even though it is least accurate), serum blood, blood from a fingerstick, oral fluids (involves a swab of the upper and lower outer gums). 1.) ELISA test is done (enzyme-linked immunosorbent assay test) 2.) if positive, ELISA test is done again 3.) If still positive, a Western Blot is done (this test detects 4 major HIV antigens. If at least 2 is present, the test is considered positive) 4.) If all tests are positive, then the patient is HIV-antibody positive. **If the test is negative, the person is HIV negative OR they can also be in the window period**
You should be aware of your facility's occupational exposure to potentially contaminated bodily fluids. What should you do if you become exposed ?
wash the exposure site with soap and water immediately. If mucous membranes have been exposed such as your eyes or mouth, flush with water and then report to the ER!
The least expensive disinfectant is using a mixture of ______ and _______. How much of each should be used to make this disinfectant? True or false: You should teach your patients who have HIV/AIDS to wash their linens separately with bleach if they have been soiled with feces,urine,blood, or semen. True or false: People with HIV/AIDS cannot use the same dishes and silverware as others.
water and bleach. 10 parts water and 1 part bleach true! False. They do not require separate dishes/silverware. Just make sure these are cleaned after use by using soap and hot water or placed in the dishwasher
True or false: It is ok if the patient routinely misses a dose of his/her HIV/AIDS medication.
FALSE. Missing even one dose out of 10 doses decreases effectiveness by about 80%!! Encourage the patient to be compliant with meds!!
What are some things you can teach your patient who has HIV/AIDS to prevent opportunistic infections? **Remember that infections from bacteria,viruses, fungus, parasites, etc can spread via food, soil, water, contact with animals).
HAND HYGIENE especially before and after eating, bathe regularly, avoid sharing personal items, wash off dishes between uses, avoid contact with soil and animal feces (wear gloves and mask if they have to garden or take care of animals). Avoid eating raw foods such as raw eggs/meats/vegetables/seafood.Avoid cross contamination of uncooked foods. Avoid eating leftovers, meat spreads, deli foods. Avoid drinking water from bodies of water. Use a safe water supply or boil water for at least 1 min. Do not share needles or reuse needles (if they have to, teach them to clean with bleach and water). All pets should be vaccinated. **For more, refer to page 376-378**