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Practice nursing care for Clients with HIV/AIDS and other Immunodeficiencies

June 11, 2024

Practice nursing care for Clients with HIV/AIDS and other Immunodeficiencies

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.

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 (SECONDARY) IMMUNODEFICIENCIES

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	UNITED STATES, JUNE 1981 TO JUNE 2000
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 (438,795 deaths)

Data from Centers for Disease Control and Prevention. (2000). HIV/AIDS Surveillance Report, /2(1), Atlanta: Author.

AIDS 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.

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.

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.

TABLE 22-2 CENTERS FOR DISEASE CONTROL AND PREVENTION CLASSIFICATION SYSTEM FOR HIV INFECTION AND AIDS CASE DEFINITION

CD4 Cell Categories

clinical category A

HIV positive, asymptomatic

Persistent generalized lymphadenopathy

Acute (primary) HIV infection with accompanying illness or history of acute infection as the only manifestations

1 >500/(xL A1

2 200-499/p.L A21

3 <200/(JLL* A3

clinical category B

Bacterial endocarditis, meningitis, pneumonia, or sepsis

Vulvovaginal candidiasis that is persistent for more than 1 month or poorly responsive to herapy

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

1 >500/(xL B1

2 200-499/p.L B2

3 <200/(JLL* B3

clinical category C

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

1 >500/(xL C1

2 200-499/p.L C2

3 <200/(JLL* C3

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, lasting 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 200 and 499/ oL, the disease is classified as B2. When the count is less than 200/uL, the disease is classified as B3.

CLINICAL CATEGORY С

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

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 Asia.

Type 2 is endemic to West Africa. Although they differ in viral markers, both subtypes can cause AIDS. More recently, variants within each subtype have been identified.

Although these variations are thought to be related to differences in virulence or efficiency of infection, the exact significance of the variants has yet to be determined.

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 transcriptase (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 the centers of lymph nodes (Sande & Volberding, 1999). Throughout the course of infection, HIV is actively replicated by infected T-lymphocytes, synthesizing up to 2 billion viral particles daily. 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 function normally, 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

o 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.

Incidence/Prevalence

The incidence of AIDS in the United States has grown exponentially from the early 1980s. In 1981, 291 new cases of AIDS were reported; in 1995, 74,180 new cases were reported. From June 1981 through June 2000, there have been 753,907 reported cases and 458,795 AIDS-related deaths in the United States (Centers for Disease Control and Prevention [CDC], 2000). The CDC estimates that 1 million persons in the United States are infected with HIV. This includes those living with AIDS, those who have tested positive for HIV, and those who are HIV positive but have not been tested.

Epidemiologic and demographic data have shown that most people with AIDS in the United States are (1) men who have had sex with other men (MSM) (47%) or (2) persons of either gender who have used injection drugs (22%). The fastest-growing infected groups are women and minorities, with a disproportionate number of cases reported in racial and ethnic minority groups. Approximately 52% of all AIDS cases in North America have occurred in African Americans and Hispanics, who constitute only 18.5% of the population. Between 1985 and 1995, the demographics of the disease changed dramatically. The rates for women increased 8.2%, and the incidence of AIDS in minority groups increased 41.7%

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 North America and worldwide is prevention of HIV infection. The United States has highlighted several goals related to HIV and AIDS prevention, as shown in the Meeting Healthy People 2010 Objectives box on p. 368.

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).

CULTURAL CONSIDERATIONS

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 importance

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.

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 products

· 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.

HEALTHY PEOPLE 2010

HIV/AIDS

OBJECTIVES

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 status, 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 ousehold 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.

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

• 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).

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 North America is screened for the HIV antibody, and blood that reacts positively is discarded. However, current tests detect the antibody, not the virus itself. Because of the time lag in antibody production (sero-conversion) after exposure to HIV, infected blood can test negative for HIV antibodies. False-negative results also can occur. The small but real possibility of HIV transmission through blood and blood products has resulted in more stringent indications for transfusion and an increase in autologous transfusion.

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 brittle, 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 damage the condom.

• Replace a broken condom immediately. If ejaculation occurs 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.

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.

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 secretions during 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.

RECOMMENDATIONS FOR PREVENTING HUMAN IMMUNODEFICIENCY VIRUS TRANSMISSION BY HEALTH CARE WORKERS

Data from Centers for Disease Control and Prevention. (1998). Public Health Service guidelines for the management of health-care worker exposure to HIV and recommendations for postexposure prophylaxis. Morbidity and Mortality Weekly Report, 47(RR-7), 1-32.

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).

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 shouldnot 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.

TESTING

This is the contents of the CAPILLUS™ HIV-1/HIV-2 Rapid Test
Kit that tests whole blood, serum, or plasma.

Image Source: CDC/ Cheryl Tryon; Stacy Howard

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 . 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, including 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.

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

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.

KEY FEATURES of AIDS

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

FUNGAL INFECTIONS.

Candida albicans is part of the natural flora of the gastrointestinal tract. In the person with 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.

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

• 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. 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.

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.

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 3 weeks 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?

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 pneumonia [PCP], cytomegalovirus [CMV] pneumonitis, pulmonary Kaposi’s sarcoma [KS], and/or Mycobacterium infection), anemia, fatigue, or pain

3. Acute Pain or Chronic Pain related to neuropathy, myelopathy, malignancy, or infection

4. Imbalanced Nutrition: Less Than Body Requirements related to high metabolic need, nausea and vomiting, diarrhea, 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, hyperthermia, 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).

ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the commoursing 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

Planning and Implementation

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. Some strategies are investigational, including drug therapy and immune function enhancement.

DRUG THERAPY.

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 as monotherapy, 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 antiretroviral therapy (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), the numerous side effects, and the sheer volume of daily medications. The main actions of each drag category are explained below.

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 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.

BEST PRACTICE for

Prevention of Infection in an Immunocompromised Client

§ 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.

RIBONUCLEOTIDE REDUCTASE INHIBITORS.

Ribonucleotide 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).

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.

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 of clients with AIDS experience adverse reactions to this medication, including nausea, vomiting, hyponatremia, rashes, fever, leukopenia, tnrombocytopenia, and hepatitis.

Pentamidine isethionate (Pentacarinat, 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 not fatigued 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.