Acquired immunodeficiency syndrome
A deficient response of the immune system resulting from a missing or damaged immune component is an immunodeficiency. An immunodeficient person’s immune system cannot recognize infectious agents or other antigens and eliminate them. Thus the immunodeficient person cannot defend adequately against potentially harmful substances that an im-munocompetent person can.
A primary or congenital immunodeficiency is one in which the immune malfunction is present from birth. An acquired or secondary immunodeficiency is one that occurs in a person who has a normally functioning immune system at birth but later becomes immunodeficient as a consequence of disease, injury, exposure to toxins, medical therapy, or unknown cause. These people are referred to as immunocompromised because their immune systems have been compromised, resulting in an impaired ability to neutralize, destroy, or eliminate antigens (see Chapter 20).
The immunodeficient client has clinical symptoms that vary in severity and occur in multiple body systems. For many
immunodeficiencies, the cause is unknown or uncontrollable, the pathophysiology is not well understood, and effective treatment may not be available. The complications of immunodeficiencies, not the actual immune defect, can be treated. Most immunodeficiencies are chronic conditions, and periods of wellness are interspersed with clinical problems.
Regardless of the cause, the immunodeficient person constantly faces the possibility that the next infection might be fatal. Normal environmental exposures to people, objects, and microorganisms may pose significant danger. The nurse is instrumental in teaching the immunodeficient person how to avoid infection and the signs and symptoms of infection.
ACQUIRED IMMUNODEFICIENCY SYNDROME
OVERVIEW
Acquired immunodeficiency syndrome (AIDS) is the late stage of a continuum of symptoms that result from infection with the human immunodeficiency virus (HIV). AIDS is not the same as HIV infection, and not everyone infected with 
HIV has AIDS. People with AIDS are profoundly immuno-suppressed and have usually lived with HIV infection for several years before AIDS develops. The nurse provides education, physical care, and psychologic support for the person living with HIV (PLWH).
AIDS is a serious, debilitating, and eventually fatal disease that can occur in any age-group. To date, 86% of those with
|
TABLE 22-1 – AIDS CASES AMONG ADULTS AND ADOLESCENTS |
|
|
IN THE |
і UNITED STATES, JUNE 1981 TO JUNE2000 |
|
Age (years) |
No. Cases |
|
<13 |
8,704 |
|
13-19 |
3,865 |
|
20-24 |
26,518 |
|
25-29 |
99,587 |
|
30-34 |
168,273 |
|
35-39 |
168,778 |
|
40-44 |
124,398 |
|
45-49 |
72,128 |
|
50-54 |
38,118 |
|
55-59 |
20,971 |
|
60-64 |
11,636 |
|
65+ |
10,378 |
|
TOTAL |
753,907 (438,795DEATHS) |
Data from Centers for Disease Control and Prevention. (2000). HIV/AIDS Surveillance Report, /2(1),
IDS have been between the ages of 25 and 49 years (Table 22-1). To be diagnosed as having AIDS, a person must be infected with HIV and have a clinical disease that indicates cellular immunodeficiency, a CD4+ T-lymphocyte (T4) count below 200/mm3, or a CD4+ T-lymphocyte total percentage below 14 (Table 22-2).
Providing care to the person with AIDS can evoke complex personal issues for nurses. Nurses must acknowledge their own fear of acquiring HIV and any negative attitudes regarding possible lifestyles contributing to HIV infection, such as injection drug use or homosexual behaviors. Knowledge and practice of appropriate infection control techniques can reduce nurses’ fears about becoming infected. To provide competent, compassionate nursing care to the person with AIDS, nurses must suspend judgment.
I Pathophysiology
The Centers for Disease Control and Prevention (CDC) classification scheme for HIV infection combines clinical conditions associated with HIV infection and three ranges of CD4+ T-lymphocyte counts (see Table 22-2). The clinical classification begins with acute HIV infection (A) and spans a continuum that ends with AIDS (clinical category C). The clinical classifications are subdivided into 1, 2, and 3 on the basis of the client’s CD4 T-lymphocyte cell count.
Bacterial endocarditis, meningitis, pneumonia, or sepsis
Vulvovaginal candidiasis that is persistent for more than 1 month or poorly responsive to therapy
Oropharyngeal candidiasis (thrush)
Severe cervical dysplasia or carcinoma
Constitutional symptoms, such as fever or diarrhea lasting longer than 1 month
Oral hairy leukoplakia
Herpes zoster (shingles), involving at least two distinct episodes or more than 1 dermatome
Idiopathic thrombocytopenic purpura
Listeriosis
Pulmonary Mycobacterium tuberculosis
Nocardiosis
Pelvic inflammatory disease
Peripheral neuropathy
Bronchial, tracheal, pulmonary, or
esophageal candidiasis Invasive cervical cancer Disseminated or extrapulmonary
coccidioidomycosis Chronic intestinal cryptosporidiosis Cytomegalovirus disease of other than the
liver, spleen, or lymph nodes Cytomegalovirus retinitis with vision loss HIV-related encephalopathy Herpes simplex (chronic, or bronchitis,
pneumonitis, or esophagitis) Disseminated or extrapulmonary
histoplasmosis
Chronic intestinal isosporiasis Kaposi’s sarcoma Lymphoma (Burkitt’s, immunoblastic, or primary brain)
Disseminated or extrapulmonary Mycobacterium avium-intracellulare complex or
M. kansasii
Extrapulmonary Mycobacterium tuberculosis Pneumocystis carinii pneumonia Recurrent infectious pneumonia Progressive multifocal leukoencephalopathy Salmonella septicemia Toxoplasmosis (brain) Wasting syndrome
I CLINICAL CATEGORY A
A person in clinical category A is HIV positive and is either asymptomatic, has persistent lymphadenopathy, or has acute (primary) HIV infection with accompanying illness or a history of acute infection as the only manifestations. Clients with the above criteria have disease classifications of Al, A2, or A3 depending on their CD4+ T-lymphocyte cell count. When the count is equal to or greater than 500/ xL, the disease is classified as Al. When the count is between 200 and 499/ xL, the disease is classified as A2. When the count is less than 200/ xL, the disease is classified as A3.
CLINICAL CATEGORY В
The client with HIV infection is considered to be in clinical category В if one or more of the following conditions are present and are (1) attributed to HIV infection or are indicative of a deficiency in cell-mediated immunity, or (2) are complicated by HIV infection:
• Bacterial endocarditis, meningitis, pneumonia, or sepsis
• Vulvovaginal candidiasis that is persistent for more than
1 month or poorly responsive to therapy
• Oropharyngeal candidiasis (thrush)
• Severe cervical dysplasia or carcinoma
• Constitutional symptoms, such as fever or diarrhea, last
ing longer than 1 month
• Oral hairy leukoplakia
• Herpes zoster (shingles) involving at least two distinct
episodes or more than one dermatome
• Idiopathic thrombocytopenic purpura
• Listeriosis
• Pulmonary Mycobacterium tuberculosis
■ Nocardiosis
• Pelvic inflammatory disease
• Peripheral neuropathy
This list provides examples of category В clinical conditions but is not comprehensive. Clients with the above criteria have disease classifications of Bl, B2, or B3 depending on their CD4+ T-lymphocyte cell count. When the count is equal to or greater than 500/uL, the disease is classified as Bl. When the count is between 200and 499/ oL, the disease is classified as B2. When the count is less than 200/uL, the disease is classified as B3.
CLINICAL CATEGORY
The HIV-positive client in clinical category С is considered to have AIDS if any one of the following conditions that meet the CDC surveillance case definition for AIDS is present:
• Bronchial, tracheal, pulmonary, or esophageal candidiasis
• Invasive cervical cancer
• Disseminated or extrapulmonary coccidioidomycosis
• Chronic intestinal cryptosporidiosis
• Cytomegalovirus disease of other than the liver, spleen,
or lymph nodes
• Cytomegalovirus retinitis with vision loss
• HIV-related encephalopathy
• Herpes simplex (chronic, or bronchitis, pneumonitis, or
esophagitis)
• Disseminated or extrapulmonary histoplasmosis
• Chronic intestinal isosporiasis
• Kaposi’s sarcoma
• Lymphoma (Burkitt’s, immunoblastic, or primary brain)
• Disseminated or extrapulmonary Mycobacterium avium-
intracellulare complex or M. kansasii
s Extrapulmonary Mycobacterium tuberculosis
• Pneumocystis carinii pneumonia
• Recurrent infectious pneumonia
• Progressive multifocal leukoencephalopathy
• Salmonella septicemia
• Toxoplasmosis (brain)
• Wasting syndrome
Clients with the above criteria have disease classifications of Cl, C2, or C3 depending on their CD4+ T-lymphocyte count. When the count is equal to or greater than 500/ xL, the disease is classified as Cl. When the count is between 200 and 499/цЬ, the disease is classified as C2. When the count is less than 2OO/(oL, the disease is classified as C3.
PROGRESSION
The time from initial HIV infection to development of AIDS ranges from months to years. The range depends on how HIV was acquired, a variety of personal factors, and therapeutic intervention. For people who have been transfused with HIV-contaminated blood, for instance, AIDS develops more quickly; for those who become HIV positive as a result of a single sexual encounter, there is a longer latency period before the condition progresses to AIDS. Other personal factors that may influence progression to AIDS include frequency of re-exposure to HIV, presence of other sexually transmitted diseases (STDs), nutritional status, pregnancy, and stress.
Etiology
AIDS is caused by the profound suppression of immune responses resulting from infection with HIV. Two subtypes of the virus have been identified: type 1 (HIV-1) and type 2 (HIV-2). Type 1 is the form most frequently isolated from infected persons in the Western Hemisphere, Europe, and
HIV belongs to a special class of viruses known as retro-viruses, which differ from other viruses in their efficiency of cellular infection. Retroviruses have only ribonucleic acid (RNA) as their genetic material. The most important difference between retroviruses and other viruses is a special complex of enzymes within the retrovirus called reverse tran-scriptase (RT). This enzyme complex increases the efficiency of viral replication once the retrovirus enters a human cell.
Once a retrovirus gains entry into the body and infects a human cell, the RT enzymes force the human cell’s deoxyribonu-cleic acid (DNA) synthesis machinery to use the viral RNA as a pattern and make a piece of human DNA complementary to the viral RNA. This new piece of DNA is then incorporated successfully into the person’s cellular DNA, where it acts as a template for viral production. HIV then spreads quickly throughout the lymphoid system, hiding in macrophages and in he centers of lymph nodes (Sande & Volberding, 1999). Throughout the course of infection, HIV is actively replicated by infected T-lymphocytes, synthesizing up to 2billion viral particles daily (Figure 22-1). After many rounds of replication, these numerous viral particles exhaust the immune system.
The HIV retrovirus attaches to, infects, and finally causes the destruction of those immune system cells with a CD4 surface receptor. These cells include CD4+ lymphocytes and macrophages. The CD4+ lymphocyte (also called the T4-lymphocyte or helper/inducer T-lymphocyte) regulates the activity of all immune system cells (see Chapter 20). When infected by HIV, the CD4 cell does not functioormally, causing general malfunction and suppression of the whole immune system. The results of HIV infection are as follows:
• Lymphocytopenia (decreased numbers of lymphocytes)
with selective CD4 cell depletion
■ Abnormal T-cell function
• Increased production of incomplete and nonfunctional
antibodies
Abnormally functioning macrophages As a result of these immune dysfunctions, the client with HIV infection is susceptible to opportunistic infections and cancer. Macrophages infected by HIV are not destroyed by infection; they act as a reservoir for the virus.
Ш. Incidence/Prevalence
The incidence of AIDS in the
|
Virus DNA |
|
|
AIDS is a disease with high mortality. The overall fatality rate is about 60% for adults (CDC, 1999a) and to date there have beeo reports of a cure. Therefore a major focus for health care in
Currently, there are over 30 persons with HIV infection who have been identified as nonprogressors, individuals infected with HIV for at least 10 years who remain asymptomatic and have maintained CD4+ T-lymphocyte counts within a normal range. Researchers are studying nonprogressors to determine whether they resist disease because of differences in viral factors, such as infection with a weak HIV strain, or because they have an unusually strong immune response (Barnes, 1995;Cohen et al., 1997).
TABLE 22-3 • AIDS CASES AMONG ADULTS AND ADOLESCENTS IN THE UNITED STATES BY EXPOSURE CATEGORY, JUNE 1981 TO JUNE1999
Category No. Cases %
|
Men who have sex with men |
348,657 |
47 |
|
Injecting drug users |
|
|
|
(female and male heterosexual) |
189,242 |
25 |
|
Men who have sex with men |
|
|
|
and inject drugs |
47,820 |
6 |
|
Hemophilia |
5,121 |
1 |
|
Heterosexual contact |
78,210 |
10 |
|
Recipients of blood transfusion, |
|
|
|
blood components, or tissue |
8,666 |
1 |
|
Other and unidentified risk |
67,368 |
9 |
|
TOTAL |
753,907 |
100 |
Data from Centers for Disease Control and Prevention. (2000). HIV/AIDS Surveillance Report, 120),
TABLE 22-4 • DISTRIBUTION OF ADULT/ADOLESCENT AIDS CASES IN THE UNITED STATES BY RACE AND ETHNIC GROUP, JUNE 1981 TO JUNE 1999
Race/Ethnicity No. Cases
|
Caucasian, not Hispanic |
324,822 |
|
African American, not Hispanic |
282,720 |
|
Hispanic |
137,575 |
|
Asian/Pacific Islander |
5,546 |
|
Native American |
2,234 |
|
Unknown |
1,010 |
|
TOTAL |
753,907 |
Data from Centers for Disease Control and Prevention. (2000). HIV/AIDS Surveillance Report, 12 (\),
CONSIDERATIONS
Щ0 More than 56% of HIV/AIDS cases reported in the United States occur in minorities, particularly among African Americans and Hispanics (CDC, 1999a). These two groups show an increasing trend in HIV infection compared with a leveling off among Caucasians. Some of the factors that appear to increase the incidence of HIV infection and progression to AIDS among people of color include the following:
• Limited access to health care
• Cost of highly active antiretroviral therapy
• Insufficient or inadequate culturally sensitive information
about risk and prevention
• Ethnic and cultural differences in health beliefs, values,
sexual practices, roles of women, and reproductive im
portance
WOMEN’S HEALTH CONSIDERATIONS Women make up the fastest-growing group with HIV infection and AIDS (CDC, 1999a). Women with HIV infection appear to have a poorer outcome with shorter survival than men. This outcome may be a result of late diagnosis and social and economic factors that reduce access to medical care rather than any viral pathology.
Gynecologic symptoms, particularly persistent or recurrent vaginal candidiasis, may be the first signs of HIV infection in women. Additional symptoms include genital herpes, pelvic inflammatory disease, and cervical neoplasia (Ungvarski & Flaskerud, 1999).
Most women with HIV infection are of childbearing age. The effect of pregnancy on the course of HIV infection is not known. There is conflicting evidence that it may or may not speed up the progression of disease.
CONSIDERATIONS FOR OLDER ADULTS
BUS Infection with HIV can occur at any age. The nurse or as-sistive nursing personnel should assess the older client for risk behaviors, including a sexual and drug use history. Decline in immune function may increase susceptibility to HIV infection in this population. In the older woman, changes in vaginal tissue as a result of aging may increase susceptibility to sexually transmitted HIV infection.
Ї Prevention
The most important aspect for prevention of HIV transmission is education. All people, regardless of age, gender, ethnicity, or sexual orientation, are susceptible to HIV infection. HIV infection is preventable because of the modes of viral transmission and the fragile nature of the virus.
HIV has been isolated from multiple body secretions and tissues, including blood, semen, vaginal secretions, breast milk, amniotic fluid, urine, feces, saliva, tears, cerebrospinal fluid, lymph nodes, cervical cells, Langerhans’ cells, corneal tissue, and brain tissue. HIV is primarily transmitted in three ways: Sexual: genital, anal, or oral sexual contact with exposure of mucous membranes to infected semen or vaginal secretions
* Parenteral: sharing needles or equipment contaminated with infected blood or receiving contaminated blood productsHEALTHY PEOPLE 2О1О
OBJECTIVES HIV/
Confine annual incidence of diagnosed AIDS cases among adolescents and adults to no more than 12 per 100,000 population
• Include questions regarding sexual activity and use of safer
sex practices whenever obtaining a health history from a
client of any age, gender, occupation, socioeconomic sta
tus, religion, or educational background.
• Assess all clients for current and past exposures to blood-
borne or sexually transmitted diseases.
• Encourage clients to know their own and their partners’ HIV
status.
• Teach clients safer sex practices.
• Direct clients who are IV drug users to drug rehabilitation
programs and support groups.
• Direct clients who abuse alcohol to alcohol rehabilitation
programs and support groups.
• Develop culturally sensitive and age-appropriate education
materials of various literacy levels for HIV prevention.
• Enlist the assistance of educational, religious, and civic
groups and institutions in the dissemination of information
regarding prevention of HIV infection.
• Encourage people who are HIV positive to:
Avoid sharing toothbrushes, razors, or other items that
could become contaminated with blood Not donate sperm, blood, plasma, body organs, or other
body tissues Inform their partner, physician, dentist, and eye doctor
about their HIV status Clean blood or other body fluid spills on household or
other surfaces with freshly diluted household bleach:
1 part bleach to 10 parts water. (Do not use bleach on
wounds.)
Objective 21.11: Increase years of healthy life of an individual infected with HIV by extending the interval of time between an initial diagnosis of HIV infection and AIDS diagnosis and between AIDS diagnosis and death
• Teach HIV-positive persons who have no signs or symptoms of
immunodeficiency to seek regular medical evaluation and
follow-up.
• Encourage HIV-positive persons to adhere to drug regi
men, especially highly active antiretroviral therapy
(HAART).
• Teach HIV-infected persons to begin or maintain behaviors
known to assist in maintaining or improving immune func
tion (e.g., diet appropriate iumber of calories for the
client’s individual metabolic needs that is high in protein
and vitamins and low in fat; regular exercise; adequate rest;
and reduction of physical, emotional, or spiritual stress).
• Encourage HIV-positive persons to use safer sex practices
for their own protection, as well as for partner protection.
• Encourage HIV-positive women to avoid pregnancy.
* Perinatal: from the placenta, from contact with maternal blood and body fluids during birth, or from breast milk from an infected mother to child
HIV is not transmitted by casual contact in the home, school, or workplace. Sharing household utensils, towels and linens, and toilet facilities does not cause HIV transmission. In addition, no evidence supports transmission by insect vectors.
SEXUAL TRANSMISSION
Abstinence and mutually monogamous sex with a noninfected partner are the only absolutely safe methods of preventing HIV infection through sexual contact.These practices not be feasible, however, because of personal, cultural, or economic factors.
Many forms of physical sexual expression can spread HIV infection if one partner is infected. The risk of acquiring the infection with a partner who is HIV positive is always present, although some sexual practices are more risky than others. The virus tends to concentrate most heavily in blood and seminal fluid, although it is also present in vaginal secretions. Thus risk differs by gender, specific sexual act, and the degree of viral load of the infected partner.
GENDER. HIV is most easily transmitted when infected body fluids come into contact with mucous membranes or nonintact skin. The vagina has considerably more mucous membrane than does the penis. Thus HIV, like all other sexually transmitted diseases (STDs), is more easily transmitted from infected male to uninfected female than vice versa.
SPECIFIC SEXUAL ACTS. Sexual acts or practices that permit infected seminal fluid to come into contact with mucous membranes or nonintact skin are the most risky for sexual transmission of HIV. Such practices include oral sex, in which the penis and seminal fluid of an infected individual come into contact with the mucous membranes of the mouth and throat (fellatio), and anal intercourse, in which the penis and seminal fluid of an infected individual come into contact with the mucous membranes of the uninfected partner’s rectum. Anal intercourse wherein the semen depositor is infected is one of the most risky sexual practices regardless of whether the semen receiver is male or female. Anal intercourse not only allows seminal fluid contact with the mucous membranes of the rectum, but also usually causes some degree of tearing or fissunng of the mucous membranes, making infection more likely.
Oral sex in which the uninfected partner’s oral mucous membranes and tongue come into contact with infected vaginal secretions (cunnilingus) also places the uninfected person at risk. This risk is increased if sores or other open areas are present in the mouth.
DEGREE OF VIRAL LOAD. The higher the blood concentration of HIV (viremia), the greater the risk for sexual transmission. Current highly active antiretroviral therapy (HAART) has caused the viral load of some infected individuals to drop below detectable levels. Although it is assumed that such individuals would have far less virus in seminal or vaginal fluids, the risk of disease transmission is presumed to still exist.
Safer sex practices are those that reduce the risk of nonintact skin or mucous membranes coming in contact with potentially infected body fluids and blood. Such practices include using the following:
• A latex condom for genital and anal intercourse (Chart
22-1)
• A condom or latex barrier (dental dam) over the genitals
or anus during oral-genital or oral-anal sexual contact
• Latex gloves for finger or hand contact with the vagina
or rectum
PARENTERAL TRANSMISSION
Preventive practices to reduce parenteral transmission among injection drug users include the use of proper cleaning of “works” (needles, syringes, and other drug paraphernalia).
CLIENT EDUCATION GUIDE
Condom Use to Prevent Sexually Transmitted Diseases
• Use latex condoms rather thaatural membrane
condoms.
• Store condoms in a cool, dry place.
• Do not use condoms that were in damaged packages or
those that show signs of age, such as those that are brit
tle, sticky, or discolored.
• Handle condoms carefully to avoid puncturing them.
• Put a condom on before making any genital contact.
Hold the tip of the condom and unroll it onto the erect
penis, making sure that no air is trapped in the tip. Leave
space at the tip to collect semen.
• Use adequate lubrication. Use water-based lubricants
only. Petroleum or oil-based lubricants such as petro
leum jelly, cooking oil, shortening, and lotions can dam
age the condom.
• Replace a broken condom immediately. If ejaculation oc
curs after the condom breaks, there may be some pro
tection in the immediate use of a spermicide.
• After ejaculation, the condom must remain on until the
penis is withdrawn. While the penis is still erect, hold the
condom against the base of the penis while withdrawing.
s Never reuse condoms.
From Centers for Disease Control. (1988). Condoms for prevention of sexually transmitted diseases. Morbidity and Mortality Weekly Report, 37(9), 133-137.
Clients are instructed to clean a used needle and syringe by first filling and flushing with clear water. Next, the syringe should be filled with ordinary household bleach. The bleach-filled syringe should be shaken for 30 to 60 seconds. Drug users are advised to carry a small container with this solution whenever sharing needles. Some communities have a needle exchange program in which needles and syringes are used only once and exchanged for clean ones.
The risk of AIDS transmission through blood and blood products has been reduced to a national average of 0.02%. Several measures have been implemented to protect the nation’s blood supply. All donated blood in
PERINATAL TRANSMISSION
The risk of perinatal transmission in pregnant clients with AIDS has been reported at 14% to 45% for each pregnancy. Studies have shown that pregnant women who received zi-dovudine had an 8.3% perinatal transmission rate compared with 25.5% in women who received a placebo (National Institute of Allergy and Infectious Disease, 1994). HIV transmission is thought to occur transplacentally in utero, intra-partally during exposure to blood and vaginal secretionsduring birth, or postpartally through breast milk. Women of childbearing age with HIV infection should be fully informed of the risks of perinatal transmission. Consult a maternal-child textbook for more information about reducing perinatal transmission of HIV.I*
RECOMMENDATIONS FOR PREVENTING HUMAN IMMUNODEFICIENCY VIRUS TRANSMISSION BY HEALTH CARE WORKERS
Source client is HiV negative.
and/or
Health care worker had exposure confined to intact
skin.
• No HIV prophylaxis is needed.
Source client is HIV positive, asymptomatic, has a low
viral load, and has a high CD4+ count
and/or
Health care worker had exposure to blood; or the
contaminating substance (small amount) had contact
with mucous membranes or nonintact skin for a short
duration.
• Basic prophylaxis regimen
Zidovudine (Retrovir) 600 mg in divided doses (300 mg twice daily, 200 mg three times daily, or 100 mg every 4 hours)
Lamivudine (Epivir) 150 mg twice daily
Continue both medications for 4 weeks
Source client is HIV positive with any of the following conditions: high or increasing viral load, AIDS, low CD4+ count, primary HIV infection. Health care worker exposure to contaminating substance (large amount) had deeper than superficial skin contact or had prolonged contact.
• Expanded prophylaxis regimen
Zidovudine (Retrovir) 600 mg in divided doses (300 mg twice daily, 200 mg three times daily, or 100 mg every 4 hours)
Lamivudine (Epivir) 150 mg twice daily
Indinavir (Crixivan) 800 mg every 8 hours or nelfinavir (Viracept) 750 mg twice daily
Continue regimen for 4 weeks
HIV status of source client is unknown—consider basic prophylaxis regimen unless health care worker exposure is consistent with the need for the expanded regimen.
• Workers should adhere to standard precautions.
• Workers with exudative lesions or weeping dermatitis
should not perform direct patient care or handle patient
care equipment and devices used in invasive procedures.
• Workers must follow guidelines for disinfection and sterili
zation of reusable equipment used in invasive procedures.
• Workers infected with HIV are not restricted from practice
of non-exposure-prone procedures, provided that they
comply with standard precautions and sterilization/disin
fection recommendations.
• Workers should identify exposure-prone procedures by in
stitutions where they are performed.
• Workers who perform exposure-prone procedures should
know their HIV antibody status.
• Workers who are infected with HIV should seek advice
from an expert review panel before performing exposure-
prone procedures to determine under what circumstances
they may continue to practice these procedures. These
circumstances would include notification of prospective
clients of HIV positivity.
Modified from Centers for Disease Control. (1991). Recommendations for preventing transmission of human immunodeficiency virus and hepatitis В virus to patients during exposure-prone invasive procedures. Morbidity and Mortality Weekly Report, 40(RR-8), 1-9.
not perform direct care activities. The CDC (1991) has issued recommendations for preventing HIV transmission by health care workers during exposure-prone invasive procedures. These include any procedure in which there is a risk of percutaneous injury to the health care worker and the worker’s blood is likely to make contact with the client’s body cavity, subcutaneous tissues, or mucous membranes. These recommendations aim to reduce the risk of HIV transmission to clients (Table 22-5).
1 TRANSMISSION AND HEALTH CARE WORKERS
Needle stick injuries are the primary means of 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. Because there is a time lag between the time of infection with HIV and the production of serum antibodies (seroconversion), infected people can test negative for HIV and still transmit the virus. Therefore the best prevention for health care providers is the scrupulous and consistent application of standard precautions for all clients as recommended by the Centers for Disease Control and Prevention (CDC) (see Chapter 26). Chart 22-2outlines recommended actions for prevention of HIV infection after a needle stick or other occupational exposure.
The public may be alarmed about HIV transmission by health care workers. It is recommended that HIV-infected health care workers wear gloves when in contact with clients’ mucous membranes or nonintact skin. Infected workers with weeping dermatitis or exudative lesions should
В TESTING
Testing plays a role in prevention, because those who test positive can be educated and encouraged to modify their behaviors to prevent transmission to others. The CDC has issued recommendations describing who should be advised to seek HIV antibody testing (Chart 22-3). Pre-test and post-test counseling must be performed by appropriately trained personnel. Counseling helps the client make an informed decision about testing and provides an opportunity to teach risk reduction behaviors. Post-test counseling is needed to interpret the results, discuss risk reduction, and provide psychologic support and health promotion information for the client with a positive test result.
Recommendations for people who have had positive test results for antibody to HIV are presented in the Meeting Healthy People 2010 Objectives box on p. 368.People who test positive should also be counseled on how to inform sexual partners and those with whom they have shared needles.
CLIENT EDUCATION GUIDE
Centers for Disease Control and Prevention Recommendations for HIV Testing
You should be tested for AIDS if you fall within one or more of the following groups:
• People with sexually transmitted disease
• Injection drug abusers
• People who consider themselves at risk
• Women of childbearing age with identifiable risks, includ
ing the following:
Having used injection drugs
Having engaged in prostitution
Having had sexual partners who were infected or at risk
Having had contact with men from countries with high
HIV prevalence Having received a transfusion between 1978 and 1985
• People planning to get married
• People undergoing medical evaluation or treatment for
signs and symptoms that may be HIV related
• People admitted to hospitals
• People in correctional institutions such as jails and prisons
• Prostitutes and their customers
Modified from Centers for Disease Control. (1987). Public Health Service guidelines for counseling and antibody testing to prevent HIV infection and AIDS.Morbidity and Mortality Weekly Report, 36(31), 509-515.
Ш Assessment
The person who has HIV disease should be monitored on a regular basis for changes in immune function or health status that indicate disease progression and warrant prophylaxis or therapeutic intervention. Continuous, careful, comprehensive assessment of the client with AIDS is crucial, because he or she may have signs and symptoms related to disease in multiple organ systems. Subtle changes must be assessed so that infections and other clinical problems can be found early and treated effectively.
■ HISTORY
Information relevant to HIV infection and AIDS from the general history includes age, gender, occupation, and residence. The nurse thoroughly assesses the current complaint or current illness, including its nature, when it started, the severity of symptoms, associated problems, and any interventions to date. The client is asked about when AIDS was diagnosed and what clinical symptoms led to that diagnosis. The client is asked to give a chronology of infections and clinical problems since the diagnosis. The nurse assesses the client’s health history, including whether he or she received a blood transfusion between 1978 and 1985. (Since 1985, donated blood in the United States has been routinely tested for HIV contamination.)
The client is also questioned about sexual practices, any history of sexually transmitted diseases (STDs), and any history of major infectious diseases, including tuberculosis and hepatitis. If the client has hemophilia, the nurse asks about treatment with clotting factors. The client is asked about past or present drug use, including needle exposure and sharing. The nurse assesses the client’s level of knowledge regarding the diagnosis, symptom management, diagnostic tests, treatments, community resources, and modes of transmission of the virus. The client’s understanding and use of safer sex practices is also assessed.
■ PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS
HIV disease and AIDS represent a progression continuum. The client with HIV disease, as defined in Table 22-2, may either have few clinical manifestations or problems or may have problems that are acute in duration rather than chronically present. The client with AIDS, however, usually experiences more problems of longer duration and greater severity. The nurse or as-sistive nursing personnel looks for many possible signs and symptoms. These include shortness of breath or cough, fever, night sweats, fatigue, nausea and vomiting, weight loss, lymph-adenopathy, diarrhea, visual changes, headache, memory loss, confusion, seizures, personality changes, dry skin, rashes, skin lesions, pain, and discomfort (Chart 22-4).
OPPORTUNISTIC INFECTIONS. The client with HIV/AIDS can develop pathogenic infections and opportunistic infections. Pathogenic infections are caused by virulent microorganisms and occur even among people whose immune systems are functioning at an optimal level. Opportunistic infections are those caused by microorganisms that are continually present as part of the normal environment and are kept in check by normal immune function. Only when immune function is depressed or compromised are such organisms capable of causing infection.
Opportunistic infections occur because of the profound immune suppression of the person with AIDS (see Chart 22-4). They may result from primary infection or reactivation of a latent infection. Opportunistic infections account for many of the clinical manifestations observed in AIDS and can be protozoan, fungal, bacterial, or viral. More than one infection may be present in a client with AIDS.
Opportunistic infections do not pose a threat to the im-munocompetent health care worker caring for a client with HIV infection or AIDS. When the client with HIV infection or AIDS has a pathogenic infection, however, such as tuberculosis at a transmissible stage, health care personnel must use appropriate precautions to prevent disease spread.
PROTOZOAL INFECTIONS. Pneumocystis carinii pneumonia (PCP) is the most common opportunistic infection in persons infected with HIV; its incidence ranges from 75% to 80%. The nurse notes dyspnea on exertion, tachypnea, a persistent dry cough, and fever. The client with PCP complains of fatigue and weight loss. On auscultation of the lungs, crackles are present.
Toxoplasmosis encephalitis, caused by Toxoplasma gondii, is acquired through contact with contaminated cat feces or by ingesting infected, undercooked meat. The client may experience subtle changes in mental status, neurologic deficits, headaches, and fever. Other symptoms include difficulties with speech, gait, and vision; seizures; lethargy; and confusion. The nurse performs a comprehensive baseline mental status examination and monitors the client to detect subtle changes.
Cryptosporidiosis is a gastroenteritis caused by Cryp-tosporidium organisms. In AIDS, this illness ranges from a mild diarrhea to a cholera-like syndrome with wasting and electrolyte imbalance. The nurse notes voluminous diarrhea, with a volume loss of up to 15 to 20 L/day.
FUNGAL INFECTIONS. Candida albicans is part of the natural flora of the gastrointestinal tract. In the person with
Concept Map: HIV Infection
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Immunologic Manifestations
• Low white blood cell counts:
CD4+/CD8+ ratio <2 CD4+ count <200/mm3
• Hypergammaglobulinemia
• Opportunistic infections
• Lymphadenopathy
• Fatigue
Integumentary Manifestations
• Dry skin
• Poor wound healing
• Skin lesions
• Night sweats
Respiratory Manifestations
• Cough
• Shortness of breath
Gastrointestinal Manifestations
• Diarrhea
• Weight loss
• Nausea and vomiting
Central Nervous System Manifestations
• Confusion
• Dementia
• Headache
• Fever
• Visual changes
• Memory loss
• Personality changes
• Pain
• Seizures
Opportunistic Infections
• Protozoal infections
Pneumocystis carinii pneumonia
Toxoplasmosis
Cryptosporidiosis
Isosporiasis
Microsporidiosis
Strongyloidiasis
Giardiasis
• Fungal infections
Candidiasis Gryptococcosis Histoplasmosis Coccidioidomycosis
• Bacterial infections
Mycobacterium avium-intracellulare complex infection
Tuberculosis
Nocardiosis
• Viral infections
Cytomegalovirus infection Herpes simplex virus infection Varicella-zoster virus infection
Malignancies
• Kaposi’s sarcoma
• Non-Hodgkin’s lymphoma
• Hodgkin’s lymphoma
• Invasive cervical carcinoma
AIDS, candidiasis occurs because the regulatory mechanisms of the immune system cao longer control fungal overgrowth. Candida stomatitis or esophagitis is a frequent finding in AIDS; clients complain of food tasting “funny,” mouth pain, difficulty in swallowing, and retrosternal pain (pain behind the ribs). On examination of the mouth and the back of the
throat, the nurse sees the characteristic cottage cheese-like, yellow-white plaques and inflammation. Esophagitis is diagnosed by endoscopic biopsy and culture. Women with HIV disease or AIDS may have persistent vaginal candidiasis, characterized by severe pruritus (itching), perineal irritation, and a thick, white vaginal discharge.
Cryptococcosis is a severe, debilitating meningitis and occasionally a disseminated disease in AIDS. It is caused by Cryptococcus neoformans. Clinical manifestations of meningitis include fever, headache, blurred vision, nausea and vomiting, nuchal rigidity (stiff neck), mild confusion, and other mental status changes. Some clients experience seizures and other focal neurologic abnormalities or may have mild symptoms and complain only of malaise and fever with or without headaches.
Histoplasmosis, caused by Histoplasma capsulatum, begins as a respiratory infection and progresses to widespread infection in the person with AIDS. The nurse may note dyspnea, fever, cough, and weight loss. The spleen, liver, and lymph nodes may be enlarged.
BACTERIAL INFECTIONS. Mycobacterium avium-intracellulare complex (MAC) is the most common bacterial infection associated with AIDS. This complex is caused by Mycobacterium intracellulare or Mycobacterium avium, which infects the respiratory or gastrointestinal tract. MAC is a systemic infection. Positive cultures may be obtained from lymph nodes, bone marrow, and blood. Clinical manifestations include fever, debility, weight loss, malaise, and sometimes lymphadenopathy or organ disease.
Tuberculosis, caused by Mycobacterium tuberculosis, occurs in 2% to 10% of persons with AIDS. People with HIV disease are at increased risk for active tuberculosis. More than 50% of all clients who have AIDS and tuberculosis have ex-trapulmonary disease sites, including the central nervous system, bones, liver, spleen, skin, and gastrointestinal tract. Systemic symptoms include fever, chills, night sweats, weight loss, and anorexia. Pulmonary involvement causes cough,dyspnea, and chest pain. Symptoms of extrapulmonary infection vary with the site. The person with tuberculosis and a CD4+ count below 200/mm3 may not have a positive purified protein derivative (PPD) skin test because of an inability to mount an immune response to the antigen, a condition known as anergy. Other diagnostic tests include a chest x-ray film, acid-fast sputum smear, and sputum culture.
The nurse or respiratory therapist giving aerosol treatments, such as pentamidine isethionate prophylaxis, that induce coughing to clients with AIDS should be screened with a PPD skin test every 6 months.
Recurrent pneumonia from bacterial infections occurs frequently among immunocompromised clients. In the current CDC classification system for AIDS, two or more episodes of pneumonia in a 12-month period is an AIDS case definition. Symptoms include chest pain, productive cough, fever, and dyspnea.
VIRAL INFECTIONS. Cytomegalovirus (CMV) can infect multiple sites in persons with AIDS, including the eye (CMV retinitis), respiratory and gastrointestinal tracts, and central nervous system. CMV infection can also result in many nonspecific symptoms associated with AIDS, such as fever, malaise, weight loss, fatigue, and lymphadenopathy.
CMV retinitis causes visual impairment ranging from slight to total bilateral blindness.
CMV infection also causes colitis, with diarrhea, abdominal bloating and discomfort, and weight loss. In addition, CMV can cause encephalitis, pneumonitis, adrenalitis, hepatitis, and disseminated infection.
Herpes simplex virus (HSV) infections in people with HIV disease or AIDS occur in the perirectal, oral, and genital areas. The manifestations tend to be more widespread and of longer duration among clients with HIV/AIDS than among those who are immunocompetent. Clients describe numbness or tingling at the site of infection up to 24 hours before vesicle (blister) formation. Vesicular lesions are painful, with chronic ulcerative lesions after vesicle rupture. The nurse notes fever, pain, bleeding, and lymph node enlargement in the affected area. Systemic symptoms include headache, myalgia, and malaise.
Varicella-zoster virus (VZV) infection is usually not a new infection for people with AIDS. This virus, present in the nerve ganglia of many people, causes chickenpox. When people who have had the chickenpox in childhood are im-munocompromised, VZV leaves the nerve ganglia and enters body fluids and other tissue areas, causing shingles. Symptoms begin with pain and burning along dermatome nerve tracts. Large fluid-filled vesicles form and eventually crust over. Systemic symptoms include headache and low-grade fever.
MALIGNANCIES. The altered immunocompetence of AIDS increases the risk for cancer in this group. Cancers associated with AIDS include Kaposi’s sarcoma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, invasive cervical cancer, seminoma, plasmocytoma, and squamous carcinoma conjunctivitis (CDC, 1999a).
KAPOSI’S SARCOMA. Kaposi’s sarcoma (KS) is the most common malignancy associated with AIDS, occurring in 1% to 21% of clients with AIDS. The risk for KS appears to vary with the way in which HIV was acquired. Clients with hemophilia who have HIV have the lowest incidence of KS, and men infected through homosexual contact have the highest incidence.
KS develops as small, purplish brown, raised lesions that are usually not painful or pruritic. The lesions can occur anywhere on the body. Most clients with KS have mucocuta-neous (skin or mucous membrane) lesions. In some clients, lesions develop in the lymph nodes, gastrointestinal tract, or lungs. The nurse assesses KS lesions for number, size, and location and monitors their progression. KS is diagnosed by biopsy and histologic examination of the lesion.
MALIGNANT LYMPHOMAS. Malignant lymphomas associated with AIDS are primarily non-Hodgkin’s B-cell lymphomas, such as Burkitt’s lymphoma, immunoblastic lymphoma, and primary brain lymphoma. Systemic symptoms include weight loss, fever, and night sweats. (See Chapter 40 on the clinical course and care relevant to malignant lymphomas.)
OTHER CLINICAL MANIFESTATIONS. All body systems are affected to some degree in AIDS; however, manifestations most consistently appear as changes in cognitive function, weight, and the skin.
CHART 22-5
KEY FEATURES of AIDS Dementia Complex
Cognitive Impairment
• Slowed thinking
• Slowed reaction time to external stimuli
• Loss of concentration while thinking or speaking
• Memory loss
• Forgetfulness
• Wandering attention
Motor Impairment
• Loss of coordination
• Loss of balance
• Increased minor accidents such as tripping, bumping
into things, or dropping things
• Slowed motor performance
• Leg weakness
Behavioral Impairment
• Apathy
• Withdrawal
or
• Irritability
• Hyperactivity
AIDS DEMENTIA COMPLEX AND OTHER NEUROLOGIC COMPLICATIONS. HIV-associated dementia complex, or AIDS dementia complex (ADC), refers to the signs and symptoms of central nervous system involvement. ADC occurs in up to 70% of persons with AIDS. It is probably a result of direct infection of cells within the central nervous system by HIV. ADC causes cognitive, motor, and behavioral impairments (Chart 22-5). Symptoms range from barely noticeable to severe dementia.
Other neurologic complications may be due to HIV infection or drug side effects, including peripheral neuropathies and myopathies. Symptoms of peripheral neuropathies include paresthesias and burning sensations, pain, and gait changes. Myopathies are accompanied by leg weakness, ataxia, and muscle pain.
WASTING SYNDROME. AIDS wasting syndrome is not due to any single factor. It may be a result of altered metabolism from malignancy or opportunistic infection. Diarrhea, malabsorption, anorexia, and oral and esophageal lesions can all contribute to persistent and sometimes extreme weight loss, and the client may appear quite emaciated.
INTEGUMENTARY CHANGES. Many clients complain of dry, itchy, irritated skin and many types of skin rashes. Folliculitis, eczema, or psoriasis may also be present. When the platelet count is low, petechiae or bleeding gums may be present.
К PSYCHOSOCIAL ASSESSMENT
Psychosocial data collection for a client with AIDS is extremely important. The nurse asks about the client’s social support system, including family, significant others, and friends. To protect confidentiality, the nurse assesses who in this support system is aware of the client’s diagnosis so that it is not inadvertently mentioned. Some clients, because of real or threatened discrimination, are quite selective about whom they tell. Health care providers must respect the client’s choices as much as possible without compromising care. The nurse can offer resources to help with disclosure to sexual partners or significant others.
The client may be closest to a lover or a friend who is not legally recognized as next of kin. The nurse obtains the name and telephone number of that person and learns whether a health care proxy or durable power-of-attorney document has been executed.
The nurse obtains information about the client’s activities of daily living, as well as any changes that may have occurred since the diagnosis. Employment status and occupation, social activities and hobbies, living arrangements, and financial resources, including health insurance, are assessed.
To plan care and monitor changes, the nurse assesses the client’s anxiety level, mood, and cognitive ability. The client is also asked about any experiences with discrimination and how they were handled. After the nurse assesses the client’s level of self-esteem and changes in body image, together the nurse and client identify strengths and coping strategies. Information is gathered about any suicidal ideation, depression, or other psychologic problems. In addition, information about the client’s involvement with support groups or other community resources is obtained.
К LABORATORY ASSESSMENT
LYMPHOCYTE COUNTS. A lymphocyte count is performed as part of a complete blood count (CBC) with differential (see Chapter 20). The normal white blood cell (WBC) count is between 4500 and 11,000 cells/mm3, with a differential of approximately 30% to 40% lymphocytes (an absolute number of 1500 to 4500).Clients with AIDS are often leukopenic, with a WBC count of less than 3500 cells/mm3, and usually lymphopenic (less than 1500 lymphocytes/mm3).
CD4/CD8 COUNTS. The percentage and number of CD4+ (T4) and CD8+ (T8) cells are an important part of an immune profile. People with HIV disease usually have a lower thaormal number of CD4+ cells. Some clients with AIDS have fewer than 100 cells/mm3 (normal: between 500 and 1600 cells/mm3), whereas the number of CD8+ cells remains normal. The normal ratio of CD4+ to CD8+ cells is approximately 2:1. In HIV disease and AIDS, because of a low number of CD4+ cells, this ratio is low. Low CD4+ cell counts and a low CD4+/CD8+ ratio are associated with increased clinical manifestations of disease.
ANTIBODY TESTS. Antibody tests measure the client’s response to the presence of the virus (the antigen) rather than measuring parts of the virus or the virus itself. HIV antibody can be measured by enzyme-linked immunosorbent assay (ELISA) and Western blot analysis. After infection with the virus, it usually takes from 3weeks to 3 months for a person to test positive for HIV antibodies. In some infected people, however, it can take up to 36 months for antibodies to be detectable (Imagawa et al., 1989). False-negative results (incorrectly indicating the absence of HIV infection) have been reported early in the infection, in people with cancer, and in people receiving long-term immunosuppressive therapy.
ENZYME-LINKED IMMUNOSORBENT ASSAY. The
client’s serum is mixed with HIV grown in culture. If the client has antibodies to HIV, they will bind to the HIV antigens and can be detected (a positive test). False-positive test results (incorrectly indicating HIV infection) occur in approximately 0.1 % of those tested with the enzyme-linked immunosorbent assay (ELISA). False-positive results have been reported in multiparous or pregnant women, injection drug users, people with a history of malaria, clients with lymphomas, and those with reactivity to the HLA-DR4 leukocyte antigen.
WESTERN BLOT. If the results of an ELISA are positive, they are confirmed by Western blot analysis. This test is not as widely available as ELISA because of its cost and complexity. The Western blot analysis is a more specific test to detect serum antibodies to four specific major HIV antigens. A positive Western blot result is based on the presence of antibodies to at least two of the major HIV antigens.
The result is considered indeterminate if two of the major antibodies are not detected but other antibodies to HIV are. The person should then be retested. In people whose tests are positive, conversion from an indeterminate to a positive Western blot usually occurs within 6 months. If a person has a positive test result for HIV antibodies, it does not mean that he or she has AIDS, only that he or she has been infected with the virus.
VIRAL CULTURE. Virus culture techniques also can determine the presence of HIV. One method involves placing the infected client’s blood cells in a culture medium and measuring the amount of reverse transcriptase (RT) activity over a 28-day period. The more RT present, the more actively the virus is thought to be replicating.
VIRAL LOAD TESTING. Viral load testing (also called viral burden testing) measures the presence of HIV viral genetic material (ribonucleic acid [RNA]) or another actual viral protein in the client’s blood rather than the body’s response to the presence of the virus. These test types are quantitative and more directly indicate the level of viral burden or viral load. Such tests are very useful in monitoring disease progression and treatment effectiveness.
QUANTITATIVE RNA ASSAYS. Currently, three quantitative assays are available in some areas for viral load testing: the RT-polymerase chain reaction (RT-PCR), the branched de-oxyribonucleic acid (DNA) method (bDNA), and the nucleic acid sequence-based assay (NASBA). All three assays use gene amplification processes to determine the amount of HIV RNA present in a client’s serum, and all have a specificity of 100%. Even if only a few infected cells are present in a serum sample, tiny amounts of the HIV RNA are amplified by these methods in sufficient quantities to be detected. Such tests are useful in the clinical management of disease and in diagnosing HIV infection in people who have no other indication of infection. These tests are used to determine therapy effectiveness and as indicators of the need to change the drug regimen.
p24 ANTIGEN ASSAY. The p24 antigen assay quantifies the amount of p24 (HIV viral core protein) in the client’s serum. Antibodies to p24 are mixed with the serum and can detect even low levels of viral antigen present in serum. However, the assay is not as sensitive as antibody tests or assays of viral genetic material. This test is
used and has been largely replaced by the more quantitative tests of HIV RNA.
OTHER LABORATORY TESTS. Other laboratory tests monitor the overall condition of the client and detect or diagnose any infections or secondary clinical processes. Standard tests include blood chemistries, a complete blood count (CBC) with differential and platelets, prothrombin time and partial thromboplastin time, a serologic test for syphilis (STS), hepatitis В antigens, and immunoglobulin levels. Tests to further evaluate the immune profile of a client may include bone marrow aspiration with biopsy and cultures.
№ OTHER DIAGNOSTIC ASSESSMENT
On the basis of the clinical symptoms, other diagnostic tests are chosen, including stool for ova and parasites; biopsies of the skin, lymph nodes, lungs, liver, gastrointestinal tract, or brain; a chest x-ray film; gallium scans; bronchoscopy, en-doscopy, or colonoscopy; liver and spleen scans; computed tomography scans; pulmonary function tests; and arterial blood gas analysis.
CRITICAL THINKING CHALLENGE
The client is a 28-year-old Hispanic woman admitted for multiple fractures, lacerations, and abrasions sustained in a car accident. She tells you she has symptoms of a vaginal yeast infection and complains that this is her sixth yeast infection in 7 months, even though she has treated herself each time with an over-the-counter antifungal product.
• What additional assessment data should you obtain?
• What questions should you ask about this client’s sexual
activity?
• What laboratory data already obtained should you examine
more closely?
• How should you approach this client about her HIV status?
For suggested answer guidelines, go to .§MjV- http://www.wbsaunders.com/SIMON/lggy/.
H Analysis
1 COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
The following are the most commoursing diagnoses for clients with AIDS:
1. Risk for Infection related to immunodeficiency
2. Impaired Gas Exchange related to anemia, respiratory
infection or malignancy (Pneumocystis carinii pneumo
nia [PCP], cytomegalovirus [CMV] pneumonitis, pul
monary Kaposi’s sarcoma [KS], and/or Mycobacterium
infection), anemia, fatigue, or pain
3. Acute Pain or Chronic Pain related to neuropathy, my-
elopathy, malignancy, or infection
4. Imbalanced Nutrition: Less Than Body Requirements
related to high metabolic need, nausea and vomiting, di
arrhea, difficulty chewing or swallowing, or anorexia
5. Diarrhea related to infection, food intolerance, or
medications
6. Impaired Skin Integrity related to KS, infection, altered
nutritional state, incontinence, immobility, hyperther-
mia, or malignancy
7. Disturbed Thought Processes related to AIDS dementia
complex (ADC), central nervous system infection, or
malignancy
8. Situational Low Self-Esteem or Chronic Low Self-
Esteem related to changes in body image, decreased
self-esteem, or helplessness
9. Social Isolation related to stigma, virus transmissibility,
infection control practices, or fear
The primary collaborative problem is Potential for Infection (processed under Risk for Infection, below).
m. ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS
In addition to the common nursing diagnoses and collaborative problems, clients with AIDS may have one or more of the following:
• Activity Intolerance related to fatigue, discomfort, cen
tral nervous system defect, weakness, or anemia
• Risk for Injury related to central nervous system defect,
mental status changes, depression, or thrombocytopenia
• Disturbed Sensory Perception (Visual) related to CMV
retinitis or blindness
• Disturbed Sleep Pattern related to pain, discomfort, anx
iety, or depression
• Ineffective Coping related to the diagnosis of AIDS
• Disabled Family Coping related to the diagnosis of AIDS
• Anticipatory Grieving related to potential loss of role
and function or impending death
P» Planning and Implementation
і RISK FOR INFECTION
The client with AIDS is susceptible to opportunistic infections because of immunodeficiency secondary to HIV infection.
PLANNING: EXPECTED OUTCOMES. The client is expected to remain free of opportunistic diseases.
INTERVENTIONS. NIC interventions that can help the client minimize the chances of acquiring an infection are provided in Chart 22-6. Chart 22-7 outlines best practices for prevention of infection in a hospitalized immunocompromised client. Some strategies are investigational, including drug therapy and immune function enhancement.
DRUG THERAPY. Chart 22-8 lists treatments for opportunistic infections. Some medications have demonstrated antiretroviral effects; however, it is important to remember that antiretroviral therapy only inhibits viral replication and does not kill the virus (Chart 22-9). Treatment with only one antiretroviral agent, known asmonotherapy, does not significantly improve the duration or quality of life for the client with HIV/AIDS. Instead, multiple drugs are used together in regimens called “cocktails.” These regimens consist of combinations of different types of antiretroviral agents. Such a therapeutic approach is termed highly active antiretroviraltherapy (HAART) and is showing good results as measured by reduced viral load and improved CD4+ lymphocyte counts. Major drawbacks to HIV/AIDS drug therapy include the expense of the drugs (see the Cost of Care box on p. 381),
Infection Protection: Prevention and early detection of infection in a client at risk
• Monitor for systemic and localized signs and symptoms
of infection.
• Monitor vulnerability to infection.
• Monitor absolute granulocyte count, WBC, and differen
tial results.
• Follow neutropenic precautions, as appropriate.
• Screen all visitors for communicable disease.
• Maintain asepsis for client at risk.
• Inspect skin and mucous membranes for redness, ex
treme warmth, or drainage.
• Obtain cultures, as needed.
• Promote sufficient nutritional intake.
• Monitor for change in energy level/malaise.
• Instruct client to take medications as prescribed.
• Teach client and family members how to avoid infections.
NIC intervention activities selected from McCloskey, J.C., & Bulechek, G.M. (Eds.). (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis: Mosby. No part of this work is to be altered without prior written permission from the Publisher. WBC, white blood cell.
the numerous side effects, and the sheer volume of daily medications. The main actions of each drag category are explained below. The specific drags, dosages, and nursing implications are presented in Chart 22-9.
NUCLEOSIDE ANALOG REVERSE TRANSCRIPTASE INHIBITORS. Nucleoside analogs are structurally similar to various nucleotides (nucleosides) that are important in making DNA. These drags are converted in the virally infected cell into a “counterfeit” form of a nucleoside and compete with the actual nucleoside for incorporation into reverse transcriptase-de-pendent DNA chains. Thus they suppress production of reverse transcriptase and inhibit viral DNA synthesis and genetic replication. This class of antiretroviral agents includes zidovudine (Retrovir), didanosine (ddl, Videx), zalcitabine (ddC, HIVID), lamivudine (Epivir, 3TC*), stavudine (d4T, Zerit), and aba-cavir (Ziagen).
NON-NUCLEOSIDE ANALOG REVERSE TRANSCRIPTASE INHIBITORS. Non-nucleoside analog reverse transcriptase inhibitors, through an unknown mechanism, inhibit synthesis of the enzyme reverse transcriptase. Like nucleoside analogs, these drags protect uninfected cells and suppress viral replication but do not kill the virus. These drags include nevirapine (Viramune), delavirdine (Rescriptor), and efavirenz (Sustiva) (see Chart 22-9).
PROTEASE INHIBITORS. Protease inhibitors block the HIV protease enzyme, preventing viral replication and release of viral particles. The HIV initially produces all of its proteins, including the ones necessary to move viral particles out of a cell, in one long strand. For the proteins to be active, the large initial protein must be broken down into individual smaller proteins through the action of the viral enzyme protease. The protease inhibitor drags, when taken into an HIV-infected cell, make the protease work on the drug rather than on the initial large protein. As a result, active proteins are not
Place the client in a private room whenever possible. Use good handwashing technique before touching the client or any of his or her belongings.
Ensure that the client’s room and bathroom are cleaned at least once each day.
Do not use supplies from common areas for immunosup-pressed clients. For example, keep a sleeve or box of paper cups in the client’s room, and do not share this box with any other client. Other articles include drinking straws, plastic knives and forks, dressing materials, gloves, and bandages. Limit the number of health care personnel entering the client’s room.
Monitor vital signs every 4 hours; note minor temperature elevation, which may suggest early sepsis. Inspect the client’s mouth at least every 8 hours. Inspect the client’s skin and mucous membranes (especially the anal area) for the presence of fissures and abscesses at least every 8 hours.
Inspect open areas, such as IV sites, every 4 hours for manifestations of infection. Change wound dressings daily. Obtain specimens of all suspicious areas for culture, and promptly notify physician.
Assist the client in performing coughing and deep-breathing exercises.
Encourage activity at appropriate level for the client’s current health status. Change IV tubing daily.
Keep frequently used equipment in the room for use by the client only (e.g., blood pressure cuff, stethoscope, thermometer).
Limit visitors to healthy adults.
Use strict aseptic technique for all invasive procedures. Monitor the white blood cell count, especially the absolute neutrophil count (ANC), daily. Avoid the use of indwelling urinary catheters. Keep fresh flowers and potted plants out of the client’s room.
produced and the newly made viral particles cannot leave the cell to infect other cells. Drags in this class include ritonavir (Norvir), indinavir (Crixivan), saquinavir (Invirase), nelfi-navir (Viracept), amprenavir (Agenerase), and lopinavir (ABT-378r, Kaletra). All protease inhibitors have fewer side effects than the nucleoside analogs but have shown rapid resistance (see Chart 22-9).
RIBONUCLEOTIDE REDUCTASE INHIBITORS. Ri-
bonucleotide reductase inhibitors actually represent a new use for other cytotoxic therapies. The drug hydroxyurea (Hydrea) has been successfully used for cancer chemotherapy as an antimetabolite. The drug is structurally similar to the DNA base thymidine. When it is taken up by the cell, this drug interferes with DNA synthesis, stopping viral replication.
IMMUNE ENHANCEMENT. Research is also being conducted to evaluate treatments that may enhance or reconstitute the immune system of clients who are made immuno-deficient by HIV infection. Some of these methods include bone marrow transplantation, lymphocyte transfusion, and administration of lymphokines, particularly interleukin-2, and other biologic response modifiers (Ungvarski, 1997).
|
NUCLEOSIDE ANALOG REVERSE TRANSCRIPTASE INHIBITORS |
|
Zidovudine (Retrovir) |
300 mg q12h |
|
Didanosine (ddl, Videx) |
125-300mgq12h |
|
Zalcitabine (ddC, HMD) |
0.75 mg q8h |
|
Lamivudine (Epivir, 3TC*) |
150 mg q8h |
|
Stavudine (d4T, Zerit) |
40 mg q12h |
|
Abacavir (Ziagen) |
300 mg q12h |
|
NON-NUCLEOSIDE ANALOG REVERSE TRA Nevirapine 200 mg q12h (Viramune) |
|
|
Efavirenz (Sustiva) |
600 mg once per day |
|
Delavirdine (Rescriptor) |
200 mg tid x14 days 400mg tid |
|
PROTEASE INHIBITORS Saquinavir 600 mg q8h (Invirase) |
|
|
Indinavir (Crixivan) |
800 mg q8h |
|
Ritonavir (Norvir) |
600 mg q12h |
|
Nelfinavir (Viracept) |
750 mg q8h |
|
Amprenavir (Agenerase) Lopinavir (Kaletra; ABT-378/r) |
200 mg q12h400 mg q12h |
Monitor CBC, hepatic and renal function.
Administer on an empty stomach. Assess vision, hearing, touch, and
balance. Monitor CBC.
Assess vision, hearing, touch, and
balance. Tell client to avoid alcoholic
beverages.
Teach client to avoid fatty foods. Assess vision, hearing, touch, and balance.
Assess vision, hearing, touch, and
balance. Assess for generalized pain.
Assess for flu-like symptoms.
If flu-like symptoms are present, stop drug permanently.
Give 1 hr before or after antacids. Assess for headache.
Assess for generalized pain.
Assess for headaches, dysphoria, and nightmares.
Avoid contact with medication during pregnancy. Store at room temperature.
Assess for headache or rash.
Tell client to take with or just after a
high-fat, high-calorie meal. Instruct client to wear sunscreen.
Administer on an empty stomach.
Assess for jaundice.
Assess for flank pain or hematuria.
Administer on an empty stomach. Monitor triglyceride levels.
Administer with food.
Monitor blood glucose levels. Monitor blood glucose levels.
Administer with food. Administer with 100 mg ritonavir. Avoid giving to clients with known sulfonamide allergy.
Drug crosses the blood-brain barrier, causing dizziness.
Zidovudine induces bone marrow suppression, hepatotoxicities, and nephrotoxicities.
Food decreases drug absorption. Drug induces peripheral neuropathy.
Drug induces bone marrow
suppression. Drug induces peripheral neuropathy.
Drug elevates liver enzymes.
Drug can cause severe pancreatitis. Drug induces peripheral neuropathy.
Drug induces peripheral neuropathy.
Drug induces arthralgias.
Drug can cause manifestations of a hypersensitivity reaction.
Hypersensitivity can progress to life-threatening emergency.
Absorption is inhibited by antacids. Headache is most common side
effect. Drug induces arthralgias.
Drug crosses blood-brain barrier and induces headaches, dysphoria, and nightmares.
Drug is mutagenic and can induce birth defects.
Room temperature is recommended
storage. Headache and rash are common
side effects.
Drug is best absorbed with a fatty
meal. Drug increases photosensitivity.
An empty stomach enhances drug
absorption.
Drug induces hyperbilirubinemia. Drug induces nephrolithiasis.
An empty stomach enhances drug
absorption. Drug can elevate triglyceride
synthesis.
Drug causes diarrhea, which is lessened when drug is taken with food. Drug can induce hyperglycemia.
Drug can induce hyperglycemia.
Food enhances drug absorption. Ritonavir synergizes drug activity. Cross-reactivity is possible.RIBONUCLEOTIDE REDUCTASE INHIBITORS
Hydroxyurea 500-1000 mg daily
(Hydrea)
Monitor CBC.
Drug induces bone marrow suppression.ANTIRETROVIRAL DISEASE
Cost of Care
• The most useful agents in suppressing retroviral replication
are combinations of nucleoside analog reverse transcrip-
tase inhibitors, non-nucleoside analog reverse transcriptase
inhibitors, and protease inhibitors.
• The cost of maintaining therapeutic levels of these drug
combinations ranges between $1100 and $2000 per month.
• These drug combinations cause many unpleasant and se
vere side effects.
• Without these drugs, clients progress in HIV disease and
opportunistic infections.
• Inpatient care costs are high in terms of length of stay and
intensive therapies.
• Compliance with drug regimens is difficult, and most drugs
are ineffective unless taken regularly as prescribed.
Implications for Nursing
Because of the high cost of antiretrovirals and adherence issues, nurses need to develop individualized plans in conjunction with clients to increase adherence with the drug regimen. Helping clients to take medications as prescribed can reduce hospitalizations for opportunistic infections and contribute to health maintenance.
Data from Bechtel-Boenning, С (1996). State of the art: Antiviral treatment of HIV infection. Nursing Clinics of North America, 3/(1), 1-13; Williams, A. (1999). Adherence to highly active antiretroviral therapy. Nursing Clinics of North America, 34(1), 113-129; United States Pharmacopeia Dispensing Information USP Dl: Vol. I. Drug information for the health care professional (20th ed.). (2000). Englewood, CO: Micromedex; and CVS Pharmacies. (March 2000). Personal communication.
COMPLEMENTARY AND ALTERNATIVE THERAPIES FOR HIV/AIDS
|
IMMUNE-ENHANCING AGENTS • Astragalus • Echinacea • Ascorbic acid |
AGENTS WITH ANTIVIRAL EFFECTS
• Shark cartilage
• Curcumin
• Hypercin
• Compound Q
• SPV-30
• Aloe vera
COMPLEMENTARY AND ALTERNATIVE THERAPIES.
Complementary therapies to increase immune function are frequently used by people with HIV/AIDS. Such therapies include vitamins, shark cartilage, and botanical products available at health food stores. The clinical usefulness of these products has yet to be established through well-controlled clinical trials. In addition, some botanicals alter the effects of prescription drugs. The nurse asks the client which botanicals are being used and checks with the pharmacist to determine known drug interactions. Table 22-6 lists the botanical agents used to enhance immune function or slow viral replication.
HEALTH PROMOTION. HIV can remain latent inside a cell for long periods and cause active infection when the cell is stimulated. The specific signals for the cell to become activated are not known, but concurrent viral or parasitic infections are suspected. The nurse teaches the client to avoid exposure to infection (Chart 22-10).
CLIENT EDUCATION GUIDE
Prevention of Infection
Avoid crowds and other large gatherings of people who might be ill.
Do not share personal toilet articles, such as toothbrushes, toothpaste, washcloths, or deodorant sticks, with others. If possible, bathe daily.
Wash the armpits, groin, genitals, and anal area at least twice a day with an antimicrobial soap. Clean your toothbrush daily by either running it through the dishwasher or rinsing it in liquid laundry bleach. Wash your hands thoroughly with an antimicrobial soap before you eat or drink, after touching a pet, after shaking hands with anyone, as soon as you come home from any outing, and after using the toilet. Eat a low-bacteria diet, and avoid salads, raw fruit and vegetables, undercooked meat, pepper, and paprika. Wash dishes between use with hot, sudsy water or use a dishwasher.
Do not drink water that has been standing for longer than 15 minutes.
Do not reuse cups and glasses without washing. Avoid changing pet litter boxes. If unavoidable, use gloves or wash hands immediately. Avoid turtles and reptiles as pets. Do not feed pets raw or undercooked meat. Take your temperature at least once a day. Report any of the following signs or symptoms of infection to your physician immediately: Temperature greater than 100° F (38° C) Persistent cough (with or without sputum) Pus or foul-smelling drainage from any open skin area
or normal body opening Presence of a boil or abscess Urine that is cloudy or foul smelling or that causes
burning on urination
Take all prescribed medications as ordered. Do not dig in the garden or work with houseplants. Avoid travel to areas of the world with poor sanitation or less-than-adequate health care facilities.
К IMPAIRED GAS EXCHANGE
PLANNING: EXPECTED OUTCOMES. The client is expected to maintain adequate oxygenation and perfusion, and experience minimal dyspnea and discomfort.
INTERVENTIONS. The nurse, respiratory therapist, or assistive nursing personnel provides interventions, including drug therapy, respiratory support and maintenance, comfort, and rest.
DRUG THERAPY. Appropriate drag therapy is initiated after identification of an infectious or neoplastic cause for respiratory difficulty (see Chart 22-8). A common respiratory infection among people with HIV disease or AIDS is Pneumo-cystis carinii pneumonia (PCP). The treatment of choice for PCP is trimethoprim/sulfamethoxazole (Apo-Sulfatrim^, Bactrim, Cotrim, Septra), given intravenously or orally, depending on the severity of infection. A high percentage ofclients with AIDS experience adverse reactions to this medication, including nausea, vomiting, hyponatremia, rashes, fever, leukopenia, tnrombocytopenia, and hepatitis.
Pentamidine isethionate (Pentacarinat4*1, Pentam), usually given intravenously or intramuscularly, is also used to treat
PCP. Aerosolized pentamidine isethionate is used prophylac-tically in those with CD4+ counts below 200 and in those who have already had PCP.
Other drug therapies include dapsone (Avlosulfon) and ato-vaquone (Mepron), which can be used as therapy for existing PCP or as prophylaxis. For moderate to severe PCP, steroids may be added to the regimen to reduce the inflammation.
RESPIRATORY SUPPORT AND MAINTENANCE.
The client also needs appropriate care to maintain respiratory function and avoid complications. The nurse, respiratory therapist, or assistive nursing personnel assesses the respiratory rate, rhythm, and depth; breath sounds; and vital signs and monitors for cyanosis at least every 8 hours. Oxygen therapy and room humidification are applied as ordered. In addition, the nurse monitors mechanical ventilation, performs suction-ing and chest physical therapy as needed, and evaluates blood gas results.
COMFORT. The nurse or assistive nursing personnel assesses the client’s comfort. The client with respiratory difficulties often is more comfortable with the head of the bed elevated. Activities are paced to minimize shortness of breath and exhaustion. The nurse provides psychologic support during periods of respiratory distress.
REST AND ACTIVITY. Most clients with HIV/AIDS experience some degree of fatigue, especially when respiratory problems also are present. Fatigue can be made worse by certain therapies (see the Evidence-Based Practice for Nursing box at right). The nurse consults with the client to pace activities to conserve energy. The client is guided in active and passive range-of-motion (ROM) exercises. Non-time-critical activities, such as bathing, are scheduled so that the client is notfatigued at mealtime.
■ PAIN
The client with more severe HIV disease or AIDS frequently has pain from a variety of causes. Pain can result from enlarged organs stretching the viscera or compressing nerves. Tumor invasion of bone and other tissues can cause pain. Many clients with AIDS experience peripheral neuropathy-induced pain from the disease or drug therapies. Many suffer from generalized joint and muscle pain.
PLANNING: EXPECTED OUTCOMES. The client is expected to achieve an acceptable level of comfort and pain reduction from appropriate interventions.
INTERVENTIONS. Pharmacologic and nonpharmaco-logic approaches are used to manage pain in the client with HIV/AIDS, depending on the cause of the pain.
COMFORT MEASURES. The use of pressure-relieving mattress pads, warm baths, or other forms of hydrotherapy, massage, and the application of heat or cold to painful areas may reduce pain levels, with or without drag therapy. Care is taken when moving or otherwise physically assisting the client in order to avoid pulling or grasping the client with joint pain. Lift sheets are used whenever possible. The client may be thin and have poor circulation, contributing to pain
EVIDENCE-BASED PRACTICE
This purpose of this prospective, descriptive study was to quantify and characterize fatigue experienced by men living with HIV/AIDS. The study was an adjunct to a randomized clinical trial of the biologic response modifier (BRM) interleukin-2 (IL-2). Fifty subjects diagnosed with HIV/AIDS were randomized to an IL-2 treatment group (28 subjects) or a control group (22 subjects). In addition, 20 control subjects who later crossed over to IL-2 treatment also were studied. Data regarding fatigue were collected for all subjects using self-reports of fatigue and subscales of the Piper Fatigue Scale ([PFS], an established measure of fatigue with strong internal consistency, content validity, and concurrent criterion validity), as well as the Global Fatigue Index (GFI). All subjects completed fatigue measures at baseline and at designated intervals for 6 months.
All subjects experienced fatigue as indicated by fatigue scores and self-reports. Subjects in the IL-2 treatment and crossover groups experienced significantly higher scores than did controls within the week following IL-2 treatment, although these scores returned to baseline and were comparable with those of the control group 1month after initiation of IL-2 therapy.
Critique. This clinical study was well designed and implemented. The number of subjects was appropriate for the measurements used. Results are generalizable within the population studied.
Implications for Nursing. Nurses can validate the fatigue experience in clients with HIV/AIDS. Together, the client and nurse can adjust health care, work-related, and social schedules to allow the client to maintain as near normal an activity level as possible during periods of fatigue. and discomfort. The nurse helps him or her to change positions frequently.
DRUG THERAPY. The type of drags used depends on what is thought to be causing the pain. For general arthralgia and myalgia, nonsteroidal anti-inflammatory drags (NSAIDs) may be helpful in reducing inflammation and increasing comfort without inducing drowsiness.
The neuropathic pain associated with peripheral neuropathy may respond best to tricyclic antidepressants such as amitriptyline (Elavil) or to anticonvulsant medication such as phenytoin (Dilantin) or carbamazepine (Tegretol). Drugs for neuropathic pain may take from several days to weeks before a full effect is seen. During this time, opioids may be needed to temporarily control pain.
When opioids are needed to control pain, the client is evaluated for pain intensity. Mild to moderate pain is treated with weak opioids such as oxycodone or codeine. More intense pain is treated with stronger opioids such as morphine, hy-dromorphone (Dilaudid), or fentanyl transdermal (Dura-gesic). Individualized combinations of weak and strong opioids along with nonopioid medications may be used to provide the best sustained pain relief and allow the client to participate in activities to the extent that he or she wishes.
COMPLEMENTARY AND ALTERNATIVE THERAPY.
Many clients with pain from HIV/AIDS use therapies such as guided imagery, distraction, progressive relaxation, and biofeedback to help control pain. Such therapies can be used with more traditional and pharmacologic measures to promote maximal comfort.
I UNBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS
Many clients with AIDS have difficulty maintaining their weight and nutritional status. This problem may be associated with fatigue, anorexia, nausea and vomiting, difficult or painful swallowing, diarrhea, or wasting syndrome.
PLANNING: EXPECTED OUTCOMES. The client is expected to maintain optimal weight through adequate nutrition and hydration.
INTERVENTIONS. Because there are multiple factors for alterations iutrition in AIDS, diagnostic procedures are undertaken to determine the cause. Once the cause is determined, appropriate therapy is initiated. For example, in the client who has candidal esophagitis, nutrition is affected because of swallowing difficulties.
DRUG THERAPY. Therapy can include ketoconazole (Ni-zoral) or fluconazole (Diflucan) orally, or intravenous (IV) amphotericin В (Fungizone). The nurse administers the medication as ordered and monitors for side effects such as nausea and vomiting, which further compromise nutritional status. The nurse provides mouth care and ice chips and keeps unpleasant odors out of the client’s environment. Antiemetics are used as ordered.
DIET THERAPY. The client’s weight, intake and output, and calorie count are monitored. The nurse assesses food preferences and any dietary cultural or religious practices. The client is instructed about a high-calorie, high-protein, low-microbial, nutritionally sound diet. In most cases, he or she is encouraged to avoid dietary fat, since fat intolerance often occurs as a result of the disease and as a side effect of some an-tiretroviral medications. In collaboration with the dietitian, thenurse provides an appropriate diet, including small, frequent meals (better tolerated than large meals). Supplemental vitamins and fluids are indicated in some cases. For the client who cannot achieve adequate nutrition through food, tube feedings or total parenteral nutrition may be needed.
MOUTH CARE. For clients susceptible to oral ulceration or infection, the nurse or nursing staff member provides meticulous mouth care. Rinses of sodium bicarbonate with normal saline every 2 hours or several times a day are helpful. The client is given a soft toothbrush and advised to drink plenty of fluids. For oral pain that interferes with eating ability, analgesics or viscous lidocaine may be necessary.
К DIARRHEA
Clients with AIDS frequently suffer from diarrhea. Sometimes an infectious cause (e.g., Giardia or Amoeba) can be determined and treated, or the cause is determined but no effective therapy is available, as in cryptosporidiosis or cy-tomegalovirus (CMV) colitis. Many clients, especially non-Caucasians, are lactose intolerant, and HIV disease may
aggravate this pre-existing condition. Diarrhea may occur as a side effect of therapy with protease inhibitors. In some cases, clients with AIDS have diarrhea and no cause can be identified.
PLANNING: EXPECTED OUTCOMES. The client is expected to experience decreased diarrhea; maintain fluid, electrolyte, and nutritional status; and minimize incontinence.
INTERVENTIONS. For most clients with AIDS and diarrhea, symptomatic management is all that is available. An-tidiarrheals, such as diphenoxylate hydrochloride (Diarsed^, Lomotil), given on a regular schedule, provide some degree of relief. In collaboration with the dietitian, the nurse offers dietary counseling and appropriate foods. Recommended dietary changes include less roughage; less fatty, spicy, and sweet food; and no alcohol or caffeine. Some clients experience symptomatic relief if they eliminate dairy products from the diet or eat smaller amounts of food more often and drink plenty of fluids, especially between meals.
The nurse or assistive nursing personnel provides the client a bedside commode or a bedpan if needed. Some clients cannot reach the bathroom in time because of immobility or anal sphincter weakness, others because of the urgency to defecate. The nurse provides privacy, support, and understanding.
I IMPAIRED SKIN INTEGRITY
The most common skin lesion in AIDS is Kaposi’s sarcoma (KS). Skin involvement may be localized or widespread. Large lesions can cause pain and restrict movement or ambu-lation. They can impede circulation, causing open, weeping, painful lesions. Another cause of impaired skin integrity is herpes simplex virus (HSV) infection.
PLANNING: EXPECTED OUTCOMES. The client is expected to have healing of any existing lesions and avoid increased skin breakdown or secondary infection.
INTERVENTIONS. KS can be treated locally with radiotherapy, intralesional chemotherapy, or cryotherapy. KS responds to local radiation therapy but only transiently.
Systemic therapy is used in clients with rapidly progressive disease or with significant involvement of the gastrointestinal tract, lungs, or other organs. These therapies include chemotherapy (single agent or combination), interferon-alpha, and interferon-alpha plus zidovudine.
Treatment of painful KS lesions includes the use of analgesics and comfort measures. Open, weeping KS lesions must be kept clean and dressed to minimize the risk of secondary infection. Many clients with cutaneous KS are concerned about their appearance and the risk of being identified as HIV positive. Makeup (if open lesions are not present), long-sleeved shirts, and hats may help in maintaining a normal appearance.
For the client with an HSV abscess, the nurse provides meticulous skin care. Abscesses are cleaned regularly with a diluted solution of povidone-iodine (Betadine) and left to air-dry or dry with a heat lamp. This infection can be painful and requires analgesics, assistance with position, and other comfort measures. Modified Burow’s solution (Domeboro) soaks help to promote healing for some clients. HSV infection is
treated with acyclovir (Zovirax) given intravenously, orally, or in some cases, topically, depending on the severity of the infection.
Ж DISTURBED THOUGHT PROCESSES
Neurologic changes and alterations in thought processes are major areas of concern for clients with HIV disease or AIDS. These changes may be due to psychologic stressors accompanying the disease or to organic disorders caused by opportunistic infections, cancer, or HIV encephalitis.
PLANNING: EXPECTED OUTCOMES. The client is expected to demonstrate improved mental status and sustain no injury.
INTERVENTIONS. Clients with AIDS suffer from enormous loss and psychologic stress, which complicates the assessment of any changes in behavior or affect. The nurse or assistive nursing personnel establishes baseline neurologic and mental status by using neurologic assessment tools (see Chapter 41) to compare any changes. Subtle changes in memory, ability to concentrate, affect, and behavior are evaluated. Differential diagnosis is important to determine whether the cause of the neurologic changes is treatable.
ORIENTATION. The nurse reorients the confused client to person, time, and place as needed, reminding the client of the nurse’s identity and explaining what is to be done at any given time. Using calendars, clocks, and radios and putting the bed close to a window also may help keep the client oriented. The nurse gives simple directions; uses short, uncomplicated sentences; explains activities in simple language; and involves the client in planning the daily schedule. Relatives or significant others are asked to bring in familiar items from home, and all items in the client’s environment are arranged in the same location as at home.
DRUG THERAPY. Charts 22-8 and 22-9 list agents appropriate for different conditions contributing to altered thought processes in the person with AIDS. In addition, psy-chotropic medications can be used to treat ongoing behavioral problems or emotional disorders. Antidepressants and anxi-olytics are commonly used to help this population.
SAFETY MEASURES. Attention to safety is crucial to the well-being of the neurologically impaired client with AIDS. He or she may not be aware of activities or surroundings and may need assistance with bathing, dressing, eating, ambulating, and other activities of daily living. The environment, whether a hospital room, long-term care facility, or home, is made safe and comfortable. Some clients are prone to seizures. The nurse or assistive nursing personnel institutes seizure precautions, including using padded siderails and having an artificial oral airway available. Anticonvulsants may be added to the medications.
The nurse assesses the client with neurologic disease for signs and symptoms of increased intracranial pressure. Any changes in level of consciousness, vital signs, pupil size or reactivity, or limb strength are reported immediately to the physician for appropriate intervention. Some clients are given corticosteroids to reduce intracranial pressure.
SUPPORT. The nurse and assistive nursing personnel work closely with the family and significant others of the neurologically impaired client. There is great trauma in seeing a loved one unable to care for himself or herself or demonstrating unusual or childlike behavior. The nurse answers questions honestly and sensitively and teaches the family and significant others how to reorient the client. They are encouraged to continue to provide the client with news of family happenings or current events. The nurse, in collaboration with the social worker, identifies community resources for the client and family.
Ш SITUATIONAL LOW SELF-ESTEEM
The client with AIDS is susceptible to changes in self-esteem and self-concept. Contributing to this are real and often dramatic changes in appearance that alter the person’s body image. Many clients also experience abrupt, significant changes in their relationships with others and in day-to-day activities, including a job or other productive activities. All changes can disrupt the self-concept.
HOC PLANNING: EXPECTED OUTCOMES. The client is expected to identify positive aspects of himself or herself and accept himself or herself.
INTERVENTIONS. The entire health care team provides a climate of acceptance for clients with AIDS by promoting a trusting relationship and helping clients express feelings and identify positive aspects of themselves. The nurse allows for privacy but does not avoid or isolate the client. Self-care, independence, control, and decision making are encouraged by helping the client formulate short-term, attainable goals and offering encouragement and praise when these are achieved.
COMPLEMENTARY AND ALTERNATIVE THERAPIES.
Complementary therapy in the form of guided imagery is used by many clients to increase their sense of control and enhance self-esteem. Imagery can focus on helping clients cope with distressing side effects or painful procedures. Other uses of imagery include picturing battle scenes in which the virus is killed by immune system cells.
і SOCIAL ISOLATION
Many clients with AIDS face discrimination, rejection, and isolation. Friends or health care workers sometimes avoid or refuse to have anything to do with them. Misunderstanding and fear lead to misuse of proper infection control procedures, and clients are inappropriately isolated.
PLANNING: EXPECTED OUTCOMES. The client is expected to identify behaviors that cause social isolation and demonstrate behaviors that reduce social isolation.
INTERVENTIONS. Interventions for social isolation focus on promoting interactions and on education to reduce fear of AIDS transmission.
PROMOTION OF INTERACTION. The nurse does not isolate the client but establishes a therapeutic nurse-client reationship. Showing understanding and concern while helping the client find ways to minimize feelings of rejection and isolation is important. The nurse reduces barriers to social contact. Social support resources are assessed. Family and significant others are taught about HIV transmission and the use of standard precautions to reduce anxiety and increase contact with the client (see Chapter 26).
The client is encouraged to verbalize feelings about self, coping skills, and a sense of ability to control the situation. The nurse helps in identifying support systems, including those already in place and those that need to be arranged.
EDUCATION. The most important aspect for prevention of HIV transmission is education. All people, regardless of age, gender, ethnicity, or sexual orientation, are susceptible to HIV infection. HIV infection is preventable because of the mode of viral transmission and the fragile nature of the virus. (See earlier discussion under Prevention, pp. 368-370).
CRITICAL THINKING CHALLENGE
Your client, a 28-year-old sexually active woman, has been diagnosed with HIV/AIDS at CDC classification B2. In addition, she tells you she is about 11 weeks pregnant and does not want to take medications that might harm the baby. She does not want her husband to know she has AIDS, because she is certain that she acquired the disease from another sexual contact in the past.
• How will your care of this client be different to protect your
self and others from exposure to HIV?
• What should you tell her about antiretroviral medications?
• How should you handle her request not to tell her husband
about her HIV status?
For suggested answer guidelines, go to £h_HV – http://www.wbsaunderB.com/SIMON/lggy/.
• Community-Based Care
The usual course of illness is one of intermittent acute infections interspersed with periods of relative wellness over months or years and, ultimately, a chronic, progressive debilitation. Because of the fluctuating nature of HIV infection, the client often spends long periods at home between hospital admissions or clinic visits. In some instances, especially as the illness becomes more severe, he or she may need referral to a long-term care facility, home care agency, or hospice.
The nurse, in collaboration with the social worker, dietitian, and other available resources, works with clients to plan what will be needed and how they will manage at home with self-care and activities of daily living.
IS HEALTH TEACHING
Educating the client, family, and significant others is a high priority, especially when preparing the client for discharge. The nurse instructs about modes of transmission and preventive behaviors (guidelines for safer sex; not sharing toothbrushes, razors, and other potentially blood-contaminated articles). Caregivers also need instruction about best practices for infection control precautions to prevent transmission while caring for the client in the home (Chart 22-11), nursing techniques to use in the home, and coping and support strategies. The nurse teaches the client, family, and significant others how to protect the client from infection, how to identify signs
BEST PRACTICE/or
Infection Control for Home Care of the Person with AIDS
Direct Care
• Follow standard precautions and good handwashing
techniques.
• Do not share razors or toothbrushes.
Housekeeping
• Wipe up feces, vomitus, 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 household bleach (1 part bleach to 10 parts
water). Wear gloves during cleaning.
• Soak rags, mops, and sponges used for cleaning in a 1:10
bleach solution for 5 minutes to disinfect them.
• Wash dishes and eating utensils in hot water and dishwash
ing soap or detergent.
• Clean bathroom surfaces with regular household cleaners,
then disinfect them with a 1:10 solution of household bleach.
Laundry
• Rinse clothes, towels, or bedclothes if they become soiled
with feces, vomitus, sputum, urine, or blood. Then 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.
Waste Disposal
• Dispose of needles and other “sharps” in a labeled punc
ture-proof container such as a coffee can with a lid, using
standard precautions to avoid needle stick injuries. Deconta
minate full containers by adding a 1:10 bleach solution. Then
seal the container with tape and place it in a paper bag. Dis
pose of the container in the regular trash.
• Remove solid waste from contaminated trash such as paper
towels or tissues, dressings, disposable incontinence pads,
and disposable gloves, then flush the waste down the toilet.
Place these items in tied plastic bags and dispose of them in
the regular trash.
and symptoms of potential infections, and what to do if these appear. The nurse instructs about the importance of self-care strategies, such as good hygiene, balanced rest and exercise, skin care, mouth care, and safe administration of any ordered medications (including potential side effects). Dietary teaching stresses the following:
• Good nutrition
• Avoidance of raw or rare fish, fowl, or meat
• Thorough washing of fruits and vegetables
• Proper food handling
• Refrigeration practices
The nurse also teaches the client about preventing infections by avoiding large crowds, especially in enclosed areas, not traveling to countries with poor sanitation, and not cleaning pet litter boxes.
Ш. HOME CARE MANAGEMENT
When the client is discharged to home, the nurse carefully assesses the client’s status, ability to function, and actual or potential needs for care. Some clients do not need home care but do need to maintain a link with the physician or primary care providers. Home care can range from assistance with activities of daily living for clients with weakness, debility, or limited function to around-the-clock nursing care, medications, and nutritional support for severely or terminally ill clients. The nurse assesses available resources, including family members and significant others willing and able to be care-givers. The nurse helps to make arrangements for outside caregivers or respite care, if needed. Clients may need referrals or help in planning housing, finances, insurance, legal services, funeral arrangements, and spiritual counseling.
Home care aides may be involved in daily or weekly care of the client with AIDS in the home. Usually a home care nurse makes routine visits for assessment purposes, especially as he or she becomes increasingly debilitated. Chart 22-12 lists focused assessment areas for the client with AIDS at home.
Ш PSYCHOSOCIAL PREPARATION
Clients with AIDS are often concerned about the possible social stigma and rejection that they may experience. The nurse is aware that this fear is realistic and helps identify ways to avoid problems, as well as coping strategies for difficult situations. Family and significant others are supported in efforts to help the client and provide protection from discrimination. The nurse encourages clients to continue as many usual activities as possible. Except when too ill or too weak, they can continue to work and participate in most social activities. Because of potential stigma and discrimination, clients are supported in their selection of friends and relatives with whom to discuss the diagnosis. Sexual partners and care providers should be informed; beyond that, it is up to the client. Some clients experience severe depression or anxiety about the future. Almost all feel the burden of having a fatal disease widely considered unacceptable and feel compelled to maintain some secrecy about the illness. Referrals to community resources, mental health professionals, and support groups can help the client verbalize fears and frustrations and cope with the illness.
CHART 22-12
FOCUSED ASSESSMENT of The Home Care Client with AIDS
Assess cardiovascular and respiratory status.
• Vital signs
• Presence of acute chest pain or dyspnea
• Presence of cough
• Presence of fever
• Activity tolerance
Assess nutritional status.
• Food intake
• Weight loss or gain
• General condition of skin
• Financial resources
Assess neurologic status.
• Cognitive changes
• Motor changes
• Sensory disturbances
Assess gastrointestinal status.
• Mouth and oropharynx
• Presence of dysphagia
• Presence of abdominal pain
• Presence of nausea, vomiting, diarrhea
Assess psychologic status.
• Presence of anxiety
• Presence of depression
Assess activity and rest.
• Activities of daily living
• Mobility and ambulation
• Fatigue
• Sleep pattern
• Presence of pain
Assess home environment.
• Safety hazards
• Structural barriers affecting functional ability
Assess client’s and caregiver’s adherence and understand
ing of illness and treatment, including the following:
• Signs and symptoms to report to nurse
• Medication schedule and side or toxic effects
Assess client’s and caregiver’s coping skills.
