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HIV Ati/understanding medsurg4thed
Terms in this set (30)
Where is HIV found?
feces, urine, tears, saliva, cerebrospinal fluid, cervical cells, lymph nodes, corneal
tissue, and brain tissue
What are the three stages of HIV infection?
Progression of HIV infection
Manifestations occur within 2 to 4 weeks of infection.
similar to those of influenza and can include a rash and a sore throat.
This stage is marked by a rapid rise in the HIV viral load, decreased CD4+ cells, and increased
The resolution of clinical manifestations coincides with the decline in viral HIV copies.
■ Lymphadenopathy persists throughout the disease process.
Chronic asymptomatic infection
■ This stage may be prolonged and clinically silent (asymptomatic).
■ The client may remain asymptomatic for 10 years or more.
■ Anti-HIV antibodies are produced (HIV positive).
■ Over time, the virus begins active replication using the host's genetic machinery.
☐ CD4+ cells are destroyed.
☐ The viral load increases.
☐ Dramatic loss of immunity begins.
This stage is characterized by life-threatening opportunistic infections.
■ This is the end stage of HIV infection. Without treatment, death occurs within 5 years.
■ All people with AIDS have HIV, but not all people with HIV have AIDS.
Ways to Promote Health and Prevent Diease?
Teach the client how the virus is transmitted and ways to prevent infection, such as the use of
condoms, abstinence, and avoiding sharing needles.
● Encourage the client to maintain up-to-date immunizations, including yearly seasonal influenza and
pneumococcal polysaccharide vaccine (PPSV).
● Health care providers should use standard precautions when caring for the client
Risk factors r/t HIV(assessments)
◯ Unprotected sex (vaginal, anal, oral)
◯ Multiple sex partners
◯ Occupational exposure (health care workers)
◯ Perinatal exposure
◯ Blood transfusions (not a significant source of infection in the U.S.)
◯ Intravenous drug use with a contaminated needle
◯ HIV infection may go undiagnosed in older adult clients due to the similarity of its manifestations
to other illnesses that are common in this age group.
◯ Older adults are more susceptible to fluid and electrolyte imbalances, malnutrition, skin
alterations, and wasting syndrome than younger adults.
◯ Older women experience vaginal dryness and thinning of the vaginal wall, increasing their
susceptibility to HIV infection.
Subjective Patient Data r/t HIV?
◯ Anorexia, nausea, weight loss
◯ Weakness and fatigue
◯ Headache and sore throat
◯ Night sweats
Stages of HIV R/t labs and defining conditions.Stage 1
DEFINING CONDITIONS= None
COUNT=500 cells/mm3,or more
TOTAL LYMPHOCYTES= › 29 or more
Objective Data r/t Hiv( Physical assessment /Labs
■ CBC and differential - Abnormal (anemia, thrombocytopenia, leukopenia)
■ Platelet count - Decreased less than 150,000/mm3CHAPTER 87 Hiv/AidS
956 RN Adult MedicAl SuRgicAl NuRSiNg
◯ Diagnostic Procedures
■ HIV determination
☐ Positive result from an HIV antibody screening test (enzyme-linked immunosorbent
assay [ELISA]) confirmed by a positive result from a supplemental HIV antibody test
(Western blot or indirect immunofluorescence assay test)
☐ Positive result or report of a detectable quantity from any of the following HIV
virologic (viral load) testing:
X HIV nucleic acid (DNA or RNA) detection test (reverse transcriptase [RT-PCR])
X Branched DNA (bDNA) method
X Nucleic acid sequenced-based assay (NASBA)
■ Liver profile, biopsies, and testing of stool for parasites
☐ Nursing Actions
X Prepare the client for the test.
☐ Client Education
X Inform the client about the details of the test, such as length and what to expect.
■ Brain or lung MRI or CT scan
☐ Detailed image of the brain or lung to detect abnormalities
☐ Nursing Actions
X Prepare the client for the procedure.
☐ Client Education
X Inform the client about the length of time the test takes (sometimes up to 1 hr).
What are Nursing Care r/t HIV
Assess risk factors (sexual practices, IV drug use).
◯ Monitor fluid intake/urinary output.
◯ Obtain daily weights to monitor weight loss.
◯ Monitor nutritional intake.
◯ Monitor electrolytes.
◯ Assess skin integrity (rashes, open areas, bruising).
◯ Assess the client's pain status.
◯ Monitor vital signs (especially temperature).
◯ Assess lung sounds/respiratory status (diminished lung sounds).
◯ Assess neurological status (confusion, dementia, visual changes).
◯ Encourage activity alternated with rest periods.
◯ Administer supplemental oxygen as needed.
◯ Provide analgesia as needed.
◯ Provide skin care as needed
Medications R/T Hiv Patients?
Highly active antiretroviral therapy (HAART) involves using three to four HIV medications in
combination with other antiretroviral medications to reduce medication resistance, adverse effects,
■ Infusion inhibitors - enfuvirtide (Fuzeon)
=Blocks the fusion of HIV with the host cell
■ Entry inhibitors - maraviroc (Selzentry)
■ Nucleoside reverse transcriptase inhibitors (NRTIs) - zidovudine (Retrovir)
=Interfere with the virus's ability to convert RNA into DNA
■ Non-nucleoside reverse transcriptase inhibitors (NNRTIs) - delavirdine (Rescriptor) and
=Inhibit viral replication in cells
■ Protease inhibitors - atazanavir (Reyataz), nelfinavir (Viracept), saquinavir (Invirase), and
indinavir (Crixivan)=Inhibit an enzyme needed for the virus to replicate
■ Integrase inhibitors - raltegravir (Isentress)
■ Antineoplastic medication - interleukin (Interferon)= Immunostimulant that enhances the immune response and reduces the production of
cancer cells (used commonly with Kaposi's sarcoma)
Nursing Consideration r/t HIV medications
Monitor laboratory results (CBC, WBC, liver function tests). Antiretroviral medications
may increase alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin,
mean corpuscular volume (MCV), high-density lipoproteins (HDLs), total cholesterol,
Patient education R/T Hiv medications
■ Educate the client about the side effects of the medications and ways to decrease the severity of
the side effects.
■ Educate the client about the need to take medications on a regular schedule and to not miss
doses. Missed medication doses can cause drug resistance.
Teamwork and Collaboration r/t Hiv
Infectious disease services may be consulted to manage HIV.
◯ Respiratory services may be consulted to improve respiratory status.
◯ Nutritional services may be consulted for dietary supplementation.
◯ Rehabilitation services may be consulted for strengthening and improving the client's level
Alternative Therapy r/t HIV
Vitamins, herbal products, and shark cartilage may help alleviate the symptoms of HIV.
■ Ask the client if she is taking herbal products. These can alter the effects of the
Discharge After care r/t HIV
Refer the client to local AIDS support groups as appropriate.
◯ Home health service may be indicated for clients who need help with strengthening and assistance
◯ Home health services may also provide assistance with IVs, dressing changes, and total parenteral
◯ Respiratory services may be consulted for providing portable oxygen.
◯ Long-term care facilities may be indicated for clients with chronic HIV.
◯ Hospice services may be indicated for clients who have a late stage of HIV.
◯ Food services may be indicated for clients who are homebound and need meals prepared.
discharge after care teachings r/t HIV patient
Instruct the client to practice good hygiene and frequent hand hygiene to reduce the risk
■ Instruct the client to avoid crowded areas or traveling to countries with poor sanitation.
■ Encourage the client to avoid raw foods, such as vegetables and meats.
■ Instruct the client to avoid cleaning pet litter boxes to reduce the risk of toxoplasmosis.
■ Encourage the client to keep the home environment clean and to avoid being exposed to
family and friends who have colds or flu viruses.
■ Provide client teaching.
☐ Transmission, infection control measures, and safe sex practices
☐ The importance of maintaining a well-balanced diet
☐ Self-administration of prescribed medications and potential side effects
☐ Signs/symptoms that need to be reported immediately (infection)
■ Instruct the client to adhere to the antiretroviral dosing schedules.
■ Instruct the client about the need for frequent follow-up monitoring of CD4+ and viral
■ Encourage the use of constructive coping mechanisms.
■ Assist the client with identifying primary support systems.
■ Teach the client to report signs of infection immediately to the health care provider.
● Opportunistic Infections
◯ Bacterial diseases, such as tuberculosis, bacterial pneumonia, and septicemia (blood poisoning)
◯ HIV-associated malignancies, such as Kaposi's sarcoma, lymphoma, and squamous cell carcinoma
◯ Viral diseases, such as those caused by cytomegalovirus, herpes simplex, and herpes zoster virus
◯ Fungal diseases, such as PCP, candidiasis, cryptococcosis, and penicilliosis
◯ Protozoal diseases, such as pneumocystis jiroveci pneumonia (PCP), toxoplasmosis,
microsporidiosis, cryptosporidiosis, isosporiasis, and leishmaniasis
Nursing Interventions r/t Opportunistic infections in patients With HIV
■ Implement and maintain antiretroviral medication therapy as prescribed.
■ Administer antineoplastics, antibiotics, analgesics, antifungals, and antidiarrheals as prescribed.
■ Administer appetite stimulants (to enhance nutrition).
■ Monitor for skin breakdown.
■ Maintain fluid intake.
■ Maintain nutrition.
◯ Client Education
■ Teach the client to report signs of infection immediately to the health care provider
Nursing Interventions r/t Wasting syndrome?
Maintain nutrition orally or by TPN if indicated.
■ Provide between-meal supplements/snacks.
■ Serve at least six small feedings with high protein value
Nursing Interventions r/t Fluid/Electrolyte Imbalance in patients With HIV
■ Monitor fluid/electrolyte status.
■ Report abnormal laboratory data promptly.
■ Maintain IV fluid replacement.
■ Make dietary adjustments to reduce diarrhea.
Seizures (HIV encephalopathy) R/T Hiv Patients?
Maintain client safety.
■ Implement seizure precautions.
A nurse working in an outpatient clinic is assessing a client who reports night sweats and fatigue. He states
he has had a cough along with nausea and diarrhea. His temperature is 38.1° C (100.6° F) orally. The client is
afraid he has HIV. Which of the following actions should the nurse take? (Select all that apply.)
A. Perform a physical assessment.
B. Determine when current symptoms began.
C. Teach the client about HIV transmission.
D. Draw blood for HIV testing.
E. Obtain a sexual history.
A nurse is caring for a client who is suspected of having HIV. Which of the following diagnostic tests
and laboratory values are used to confirm HIV infection? (Select all that apply.)
A. Western blot
B. Indirect immunofluorescence assay
C. CD4+ T-lymphocyte count
D. CD4+ T-lymphocyte percentage of total lymphocytes
E. Cerebrospinal fluid (CSF) analysis
A nurse is assessing a client for HIV. Which of the following are risk factors associated with this virus?
(Select all that apply.)
C. Monogamous sex partner
D. Older adult woman
E. Occupational exposure
. A nurse is completing discharge instructions with a client who has AIDS. Which of the following
statements by the client indicates an understanding of the teaching
"I will wear gloves while changing the pet litter box."
B. "I will rinse raw fruits with water before eating them."
C. "I will wear a mask when around family members who are ill."
D. "I will cook vegetables before eating them."
. A nurse is caring for a client who has HIV and has been newly diagnosed with Burkitt's lymphoma.
Which of the following HIV infection stages is the client in?
B. Stage 2
C. Stage 3
D. Stage 4
Stages of HIV R/t labs and defining conditions.Stage 2
DEFINING CONDITIONS= › None
COUNT=200 to 499 cells/mm3
TOTAL LYMPHOCYTES=14 to 28
Stages of HIV R/t labs and defining conditions Stage 3 (AidS)*
› One or more of the following:
» Candidiasis of the esophagus,
bronchi, trachea, or lungs
» Herpes simplex - Chronic ulcers
(of more than 1 month duration)
» HIV-related encephalopathy
» Disseminated or extrapulmonary
» Kaposi's sarcoma
» Burkitt's lymphoma
» Mycobacterium tuberculosis of
» Pneumocystis jirovecii pneumonia
» Recurrent pneumonia
» Progressive multifocal
» Recurrent Salmonella septicemia
» Wasting syndrome attributed to HIV
COUNT=Less than 200 cells/mm3 Less than 14
TOTAL LYMPHOCYTES=Less than 14
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