Interventions For Clients With Hiv

INTERVENTIONS FOR CLIENTS WITH HIV/AIDS

Jolene Bethune, RN, MSN

Objectives Provide an overview of HIV and AIDS with

key terms you will hear in practice Provide brief outline of pathophysiology

and etiology of viral infection Describe methods of transmission Describe methods of preventing

transmission in the health care environment

Use the nursing process to describe care of the infected client

Overview Acquired immunodeficiency

syndrome (AIDS) is the late stage of a continuum of symptoms resulting from infection with the human immunodeficiency virus (HIV)

AIDS and HIV are not the same; not everyone with HIV has AIDS

Most people aren’t diagnosed at the time of infection because they don’t seek medical care when symptoms occur, or health care providers don’t take an adequate history

AIDS is seriously debilitating; eventually fatal; can occur in any age group

Key Terms

Immunodeficiency – a deficient response of the immune system d/t a missing or damaged immune component

Immunocompromised – immune system impaired, destroyed resulting in an impaired ability to neutralize, destroy or eliminate antigens

Primary, congenital – immune malfunction present from birth

Secondary, acquired – occurs in a person with a normally functioning immune system at birth; becomes immmunodeficient d/t disease, injury, exposure to toxins, medical therapy or an unknown cause

Retrovirus – have only RNA as their genetic material; differ from other viruses in their efficiency of replication/cellular infection

Reverse transcriptase (RT) – enzyme complex that increases the efficiency of viral replication once the retrovirus enters a human cell

Macrophage – largest of all the leukocytes; functions include phagocytosis, repair of injured tissues, antigen presenting/processing, and secretion of cytokines that help control the immune system

Lymphocyte – becomes sensitized to foreign cells/proteins

Lymphocytopenia – decrease in the numbers of lymphocytes

Viremia – high concentration of virus in the blood

Pathogenic infections – infections occurring in people with normally functioning immune systems

Opportunistic infections – infections caused by pathogens that are present as part of the normal environment kept in check by a normal immune systems

CD4 + T-lymphoctye (T4) – regulates activity of all immune system cells

Nonprogressors – individuals infected with HIV for more than 10 years who remain asymptomatic and have T4 lymphocyte counts within a normal range

Announced during a press conference in November, 1991, that he had HIV; remains asymptomatic today

Pathophysiology

CDC’s classification scheme combines clinical conditions associated with HIV infection and three ranges of CD4+ T-lymphocyte counts

Cell Categori

es

Clinical CategoriesA B C

1 A1 B1 C1

2 A2 B2 C2

3 A3 B3 C3Iggy, p.365, Table 22-2

Cell Categories

1. Category 1 500/microL or more

2. Category 2 200-499/microL

3. Category 3 Fewer than 200/microL

Cell Categories

Clinical CategoriesA B C

1 A1 B1 C1

2 A2 B2 C2

3 A3 B3 C3

Clinical CategoriesCategory A

Asymptomatic HIV infection Persistent lymphodenopathy Acute primary HIV infection with accompanying

symptoms (diarrhea, n/v, decreased energy) May remain in category A for an extended

period of time

Cell Categori

es

Clinical CategoriesA B C

1 A1 B1 C1

2 A2 B2 C2

3 A3 B3 C3

Category B Symptomatic conditions attributed to the HIV

infection or defect in immunity Bacterial infections Candidiasis for more than one month Fever or diarrhea lasting more than one

month Hairy leukoplakia, oral Herpes zoster – two distinct episodes Pulmonary tuberculosis

Cell Categori

es

Clinical CategoriesA B C

1 A1 B1 C1

2 A2 B2 C2

3 A3 B3 C3

Category C Conditions that are strongly associated

with severe immunodeficiency and cause serious morbidity and mortality

See Iggy, p. 365, Table 22-2

Cell Categori

es

Clinical CategoriesA B C

1 A1 B1 C1

2 A2 B2 C2

3 A3 B3 C3

Progression from HIV to AIDS can take months or years

People who have been transfused with HIV-positive blood develop AIDS more quickly

Those who become HIV-positive as a result of a single sexual encounter have a longer latency period

Other influences include frequency of re-exposure to HIV, nutritional status, pregnancy, and stress

Etiology

Retrovirus enters the body and infects the human cell

RT enzymes force the human cell’s DNA synthesis machinery to use the viral RNA as a pattern and make a piece of human DNA complementary to the viral RNA

The new piece of human DNA is then incorporated into the person’s cellular DNA, where it acts as a template to produce the virus

The new virus protein migrates to the cell surface, where it assembles the virus, which “buds’ and leaves the cell.

Viruses spread quickly throughout the lymphoid system, hiding in macrophages and in the centers of lymph nodes

Throughout the course of the infection, HIV is actively replicated by T-lymphocytes, finally exhausting the immune system

The HIV retrovirus attaches to, infects, and finally causes the destruction of those immune system cells with a CD4 (T4) surface receptor

HIV/AIDS Around the World

Methods of Transmission

Parental (Blood) Transmission Sharing contaminated needles Accidental needle sticks from an

infected person HIV+ women may transmit to their

children through perinatal transmission, breastfeeding

Exposure to an infected client’s blood through an open wound

Sexual Transmission Homosexual males

Heterosexual partners if either is infected

Any sexual activity involving exposure to bodily fluids of an infected person

Perinatal Transmission Transplacentally in utero

Intrapartally, during exposure tho blood and vaginal secretions during birth

Postpartally, through breastmilk

HIV dies quickly outside the body because it needs living tissue and moisture to survive

HIV may not be transmitted bya. Hugging, kissing, holding hands or

other nonsexual contactb. Inanimate objects (money, doorknobs,

bathtubs, toilet seats, etc.)c. Dishes, silverware, or food handled by

an infected persond. Animals or insects

After exposure to the virus, symptoms may develop within 6-12 weeks; however, symptoms may not develop for 6 months

Once infected, the client will probably harbor the virus for the rest of his life

Opportunistic infections take advantage of the suppressed immune system

Tend to resist conventional treatment Client may have multiple opportunistic

infections

Prevention of Transmission in a Health Care Setting

Maintain standard precautions

Consider all blood and bodily fluids to be contaminated

Avoid contaminating outside of container when collecting specimens

Do not recap needles and syringes

Cleanse work surface areas with appropriate germicide

Clean up spills of blood and body fluid immediately

Follow CDC recommendations for immunization of health care workers

CD4 (T4) malfunctions, suppressing the entire immune system

Results:a) Lymphocytopeniab) Abnormal T-cell functionc) Increased production of incomplete

and nonfunctional antibodiesd) Abnormally functioning macrophages

Providing care can evoke complex personal issues for nurses

a. Acknowledge your own fearb. Acknowledge any negative attitudes

regarding possible lifestyles contributing to HIV infection

c. Practice appropriate infection control techniques always

d. Provide compassionate, nonjudgmental care

ASSESSMENT

History Age, gender, occupation and residence Thoroughly assess current complaint/illness Ask when HIV was diagnosed and what

symptoms led to that diagnosis Chronology of infections/clinical problems

since diagnosis

History Health history (any blood transfusions

1978-1985?) History of STDs, infectious diseases Clotting factors, if hemophiliac Assess client’s level of knowledge

Physical AssessmentPossible signs/symptoms:

Cough Fever Night sweats Fatigue

Physical AssessmentPossible signs/symptoms:

N/V Weight loss Lymphodenopathy Diarrhea

Physical AssessmentPossible signs/symptoms:

Visual changes Headache Memory loss Confusion Seizures Personality changes

Physical AssessmentPossible signs/symptoms:

Dry skin Rashes Skin lesions Pain Discomfort

Physical Assessment

Physical Assessment – Opportunistic Infections

Protozoal Infections Pneumocystis carinii pneumonia (PNP) –

fatigue, weight loss; crackles on auscultation

Toxoplasmosis encephalitis – sudden mental, neurological changes

Cryptosporidosis – mild to severe diarrhea with wasting, electrolyte imbalance

Physical Assessment – Opportunistic Infections

Fungal Infections Candida stomatitis/esophagitis –

mouth/retrosternal pain; cottage cheese plaques; (vaginal candidiasis – plaques, pruritis, discharge, perineal irritation)

Cryptococcosis – meningitis (fever, headache, n/v, nuchal rigidity, mental/neurological changes)

Histoplasmosis – respiratory infection (dyspnea, fever, cough, weight loss)

Physical Assessment – Opportunistic Infections

Bacterial Infections MAC syndrome (systemic

mycobacterium infections of respiratory and/or gastrointestinal tracts; tuberculosis) – fever, weight loss, debility; lymphadenopathy, organ disease

Recurrent pneumonia – chest pain, productive cough, fever, dyspnea

Physical Assessment – Opportunistic InfectionsViral Infections

Cytomegalovirus (CMV) – eyes, respiratory/ gastrointestinal tracts, central nervous system

Herpes simplex virus (HSV) – painful lesions/ulcers, fever, pain, bleeding and lymph node enlargement

Varicella zoster (VZ) – shingles (pain, burning along dermatome nerve tracts, headache, low grade fever, large painful vesicles

Physical Assessment – Malignancies

Kaposi’s sarcoma

Malignant lymphomas

Physical Assessment – Other Clinical Manifestations

AIDS Dementia Complex

Wasting Syndrome

Integumentary changes

Laboratory Assessment Lymphocyte counts CD4/CD8 counts Antibody tests – enzyme-linked

immunosorbent assay (ELISA); Western blot test

Viral culture Viral load testing – measures RNA or viral

protein in client’s blood

Psychosocial Assessment Ask about client’s support system –

family, SOs, friends Protect confidentiality Activities of daily living Employment Assess client’s levels of anxiety, self

esteem Assess changes in body image Coping strategies, strengths

NURSING DIAGNOSES

Risk of infection related to immunodeficiency

Impaired gas exchange related to anemia, respiratory infection or malignancy, anemia, fatigue or pain

Acute pain or chronic pain related to neuropathy, myelopathy, malignancy or infection

Imbalanced nutrition: less than body requirements related to high metabolic need, n/v, diarrhea, difficulty chewing/swallowing, or anorexia

Diarrhea related to infection, food intolerance or medications

Impaired skin integrity related to KS, infections, altered nutritional state, incontinence, immobility, hyperthermia or malignancy

Disturbed thought processes related to AIDS dementia complex, central nervous system infection or malignancy

Situational low self-esteem or chronic low self-esteem related to changes in body image, decreased self-esteem, or helplessness

Social isolation related to stigma, virus transmissibility, infection control practices or fear

PLANNING/IMPLEMENTATION

Expected outcome: The client is expected to remain free of opportunistic diseases

Interventions: Drug therapy – antiretrovirals only inhibit viral

replication; they do not kill the virus Immune enhancement – bone marrow

transplant; lymphocyte transfusion; lymphokines

Alternative therapy – vitamins, shark cartilage; botanicals

Health promotion – the nurse teaches client to avoid exposure to infection

See Iggy, Chart 22-8, p. 378

Risk of Infection

Expected outcome: The client is expected to maintain adequate oxygenation and perfusion, and experience minimal dyspnea and discomfort

Interventions: Drug therapy Respiratory support and maintenance Comfort Rest and activity

Impaired Gas Exchange

Expected outcome: The client is expected to maintain optimal weight through adequate nutrition and hydration

Interventions: Drug therapy Diet therapy Mouth care

Imbalance nutrition: less than body requirements

Expected outcome: The client is expected to experience decreased diarrhea; maintain fluid, electrolyte and nutritional status; and minimize incontinence

Interventions: Drug therapy Diet therapy Bedside commode The nurse provides privacy, support and

understanding

Diarrhea

Expected outcome: The client is expected to have healing of any existing lesions and avoid increased skin breakdown or secondary infection

Interventions: Chemotherapy Drug therapy Wound care Make-up, concealers

Impaired Skin Integrity

Expected outcome: The client is expected to demonstrate improved mental status and sustain no injury

Interventions: Orientation Drug therapy Safety measures Support

Disturbed Thought Processes

Expected outcome: The client is expected to identify positive aspects of himself or herself and accept himself or herself

Interventions: The nurse allows for privacy, but does not

avoid, isolate the client Promote self care, independence, control

and decision-making Complementary alternative therapies

Situational Low Self-Esteem

Expected outcome: The client is expected to identify behaviors that cause social isolation and demonstrate behaviors that reduce social isolation

Interventions: Promotion of interaction Education

Social Isolation

EVALUATION

Outcomes: Expected outcomes include that the client will

Not develop opportunistic infections Demonstrate adequate respiratory

function Achieve and acceptable level of

physical comfort Attain adequate weight, nutritional and

fluid status

Maintain skin integrity Remain oriented and/or in a safe

environment Maintain self-esteem Maintain a support system and

involvement with others Comply with the appropriate and

available therapy

Other ImmunodeficienciesTherapy-induced Immunodeficiencies Drug-induced Immunodeficienciesa. Cytotoxic drugsb. Corticosteroidsc. Cyclosporine Radiation-induced Immunodeficiencies –

Collaborative management

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