Nursing Care for HIV
Practice question: True or false, An individual with a positive result with the ELISA is not considered HIV-antibody positive until confirmed with a repeat positive ELISA and positive Western Blot or Immunoflorescence Essay (IFA testing)?
True
Meds: PIs
stop the enzyme "protease"—which HIV uses to cut out and assemble new viral parts -Although new viral parts may be produced, the parts don't go together properly -The defective virus cannot go on to infect other cells
HIV medications
*All anti-HIV medications attack the virus inside the CD4 cell where the virus is trying to make copies of itself -called enzyme inhibitors: work by blocking the enzymes used by HIV *3 types 1. NRTIs- nucleoside reverse transcriptase inhibitors 2. NNRTIs- non-nucleoside reverse transcriptase inhibitors 3. PIs- protease inhibitors
HIV diagnosis
*HIV antibody test -positive 6 weeks to 3 months after exposure- sometimes as long as 6 months 1. Elisa test first- cheaper- 5 bucks -uses spectrophotometry to detect serum antibody reactions to specific HIV viral proteins *has a lot of false positives *may have you come back and do another one 2. Western Blot 2nd- 30 bucks- detects antibody formation *confirms Elisa test 3. PCR - Polymerace Chain Reaction- expensive, not often used
Diagnostic criteria for AIDS
*Person has to have at least 1 of these things to be diagnosed 1. CD4 below 200 2. Development of an opportunistic infection 3. Development of an opportunistic cancer 4. Presence of wasting syndrome 5. Development of dementia
Who is appropriate for antiretroviral med therapy?
*Recommended for the following patients infected with HIV: -history of AIDS-defining illness- such as tuberculosis -CD4+ T-cell count <200 cells/uL or between 200 and 350 cells/uL -pregnant women -persons with HIV-associated nephropathy -persons co-infected with hepatitis B
HIV transmission
*blood, semen, vaginal, breastmilk *Most common modes of transmission are: -unprotected sex w/infected partner -sharing needles w/ infected person *Almost eliminated as risks for transmission are: -infected mother to fetus -infection from blood products *Need a gallon of spit to get it- won't transmit it via saliva -Not in feces or urine *Need to know how much of it is in the blood- viral load: -lower=transmission lower -also helps evaluate effectiveness of medication therapy *Seroconversion in 2-4 weeks
Practice question: Treatment with two nucleoside reverse transcriptase inhibitors and a protease inhibitor is prescribed for a patient with HIV infection who has a CD4 and T cell count of <400. The patient asks why three drugs are necessary for treatment. The nurse explains that the primary rationale for combination therapy is that:
-Combinations of antiretroviral drugs decrease the potential for development of antiretroviral-resistant HIV variants. *The use of potent combination antiretroviral therapy limits the potential for selection of antiretroviral-resistant HIV variants, the major factor limiting the ability of antiretroviral drugs to inhibit virus replication and delay disease progression.
Practice Question: The nurse is caring for a patient who is receiving antiretroviral therapy (ART) for treatment of AIDS. Which assessment best indicates that the patient's condition is improving?
-Decreased viral load *Rationale: Goals of antiretroviral therapy (ART) in the treatment of a patient with HIV are to decrease the viral load and maintain or increase CD4+ T-cell counts.
HIV facts
-Dependent on living cells to survive -HIV likes T-cells- wants to be with them: attaches to T4 cell- interacts with the CD4 glycoprotein on the membrane *CD4=T-cells -Looks like a T-cell on the outside but is a virus on the inside -Retrovirus: replicates backwards- RNA is transformed into viral DNA -Causes immunosuppression making persons susceptible to infections -5 types identified: HIV-1 is the predominate cause of AIDS in the USA -HIV doesn't have to be documented- must be full blown AIDS
Nursing Evaluations for HIV
-Free of Secondary Infection, temperature normal, skin intact, lungs clear Regains weight -Pt. & Family supportive -Takes medication appropriately -Maintains self-care -Maintains Social interactions
Nutrition for HIV
-High calorie, high protein, low fat, high vitamins/minerals, low microbial diet. -Small frequent meals 6x/day -Rest
Importance of compliance with HIV meds
-If you miss a dose of your NRTI or NNRTI, HIV can enter some new CD4 cells -If you miss a dose of your PI, then HIV can make good copies of itself to attack more cells -Although missing a single dose is not a disaster, the more you miss, the more HIV will copy itself in you
Complications of HIV
-Infections -Cancers -Side effects of Medications: Diarrhea, G.I. Upset, Bone marrow suppression, Hepatotoxicity, Peripheral Jaundice, Sclera Icterus, Steven Johnson Syndrome -Deficits in Nutrition -Depression -Isolation **Endless possible complications
Progression of HIV
-Initial infection- first 6 weeks- may see flu-like symptoms, T-cells rapidly dropping -HIV positive- at 3 weeks to 3 months -Intermediate chronic infection at 8-10 years -at 10-12 years the HIV is detectable as viral replication continues to increase- late chronic infection (AIDS) -Viral Replication increases decreasing the T4 lymphocytes - body's defenses are progressively weakened. -Infections that you would not see with health immune system begin to happen. **Lifestyle modification comes first- nutrition, getting enough sleep
HIV diagnostics: labs
-WBC & differential -ESR: more fibrinogen (inflamm response), faster rate -CRP - C-reactive Protein: measures an abnormal protein found 18 to 24 hours after certain inflammatory processes. -T & B Cells - Protein Electrophoresis - analyze plasma protein content -Immunoeletrophoresis - identifies specific immunoglobulins. Shows quantities.
Nutrition for fungal infection in the mouth
-decrease acidic foods -add yogurt or acidophilus -no regular mouthwash! Only medicinal (nystatin)
Normal T-cell
-special cells that help the body's immune system protect you against germs and viruses that can make you sick -job is to kill infected cells that we don't want to reproduce, respond to a specific antigen
Meds: NRTIs & NNRTIs
-stop the enzyme "reverse transcriptase"—the enzyme HIV uses to change itself and enter the CD4 cell -Unable to change, HIV cannot get into the cell's command center -HIV is unable to make new copies of itself -NRTI examples: Zidovudine (Retrovir), Didanosine (Videx)- side effect= liver failure/GI, Zalcitibine (Hivid)- not used as much, Stavudine (Zerit), Lamivudine (Epivir), Abacavir (Ziagen)
Teaching around anti-retrovirals
1. 3 types at a time is recommended 2. Know what you are taking and how to take them. i.e. w/ or w/o food etc. 3. Take full dose on schedule, if you can't for some reason, notify health provider 4. Drug interactions are common- don't start anything new w/o consulting provider 5. Goal is to get viral load to undetectable level- viral load is initially tested and then 2-4 weeks after initiating therapy to see if the meds are working 6. An undetectable viral load does not mean the virus is gone- protect partners etc
How HIV works inside the body
1. HIV invades healthy CD4 (T) cell 2. HIV has the key to unlock the cell- a special chemical 3. HIV disguises itself: uses another chemical, the enzyme known as reverse transcriptase, to change so it can gain entry into the cell's command center 4. HIV gets inside of the command center- uses another enzyme known as integrase 5. HIV now takes control, inserting its own codes into the command center so that the reprogrammed CD4 cell will make new virus 6. The infected CD4 cell is now an HIV factory, pumping out new viral parts- protease cuts and assembles 7. New copies of the virus leave the cell ready to seek out more and more CD4 cells to invade
Spectrum of HIV infection
1. HIV positive: CD4 & T cells count above 500 cells/ml 2. ARC- Aids-related complex: CD4 & T cells count drops 200-499 3. AIDS- Acquired Immune Deficiency Syndrome: CD4 & T cell count drops less than 200
Examples of opportunistic infections
1. Viruses herpes simplex EBV CMV- blindness 2. Protozoa's - pneumocystis carinii Fever Dyspnea non-productive cough 3. Fungi Histoplasma cryptococcus toxoplasma 4. Mycobacteria Tuberculosis: productive cough * pulmonary infections are often the first manifestation of HIV infections
Clinical manifestations of HIV
Chills & fever Night Sweats Dry Productive cough Dyspnea Lethargy Confusion Stiff Neck Seizures Headache Fatigue Oral lesions Skin rashes G.I. Discomfort Wt. Loss Lymphadenopathy Generalized edema
Medical Management of HIV
Diagnostic tests Medications Diet/Nutrition Activity Referral/Consultation
Practice question: True or false, The progression of HIV infection is monitored with the use of Western Blot or Immunoflorescence Assay (IFA)?
False: CD4 count and Viral Load & Lymphocyte Percentage
Additional meds that may be added to regimen
G.I. Medications for nausea and vomiting as well as diarrhea. Antibiotics Antiviral- acyclovir Antifungal- nystatin Antiprotozoian- flagyl Antimicrobials Vitamins Supplements
Populations most at risk for HIV
Homosexual men Heterosexual women and their children IV drug abusers *African-American & Hispanic-Americans are at greater risk than White Americans
Nursing goals for HIV
Improving Nutrition Promoting Communication Promoting Home Maintenance Maintaining Social Interactions Preventing Infections Promoting Self Care Decreasing Fear Decreasing Fatigue
Examples of opportunistic cancers
Kaposi's sarcoma (KS) Non-Hodgkin's lymphoma Cervical Carcinoma Lymphoma
Nursing Diagnoses with HIV
Risk for infection Inadequate Nutrition Ineffective Coping Fatigue Self Care Deficits Social Isolation Fear Impaired Skin Integrity (diarrhea, skin cancer) Grieving Knowledge deficit Non-Compliance
