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HIV/AIDS

N3 TEST 9
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1,000,000 people in North America are living with HIV/AIDS - many are????
Unaware of their status
10% of those living with aids in the US are ages?
50 and over
40,000 people are diagnosed with......?
HIV/ AIDS every year in the US
What countries are effected at much higher rates?
Africa
Remains a disease of?
Marginalized individuals (those who are disenfranchised by virtue of gender, race, sexual orientation, poverty, drug use, or lack of access to health care)
AIDS has killed....... people throughout the world and ..........are infected
>20 million/>60 million
Who are being infected at increasing rates?
Women and Children
Someone in the US is being infected with HIV every?
9 1/2 minutes
It's projected that the number of deaths caused by AIDS in the next 10 years will?
Be greater that the combines fatalities in all wars of the 20th century
HIV is a fragile virus that can only be transmitted under specific conditions that allow contact with infected body fluids, including???
Blood, Semen, Vaginal fluids, Brest Milk
Infection occur after an exposure depends on ?
1. Duration and frequency of contact, 2. Volume of fluid in exposure, 3. Virulence (The ability of any agent of infection to produce diseas) and the concentration of the organism, 4. Host immune defense capability.
Once the person is infected, they have a LIFELONG ability to?
Transmit HIV to others (Few days post infection to death: HIV infected individuals can transmit HIV to others)
When is it most infections?
When large amounts of HIV virus are in the blood
When are the large amounts in the blood?
2-6 days (most initial infection), and During late stages of the disease...........VIRAL LOAD IS HIGH DURING THESE TIMES
LEWIS
Look at Viral Load in the blood and CD4+. There is a diagram thing.
HIV cannot be spread through?
Tears, Saliva, Urine, emesis, sputum, feces, sweat, hugging, DRY KISSING, shaking hands, sharing eating utensils, attending school, working with HIV infected people, insects or formites(non-living material - necktie, stethoscope)
Toothbrush?
Dont Share!
What is Viral load?
The number of HIV particles in the blood
HIV is a ?
Human immunodeficiency virus
What is Aids?
Acquired immunodeficiency syndrome - END STAGE OF CHRONIC HIV infection.
HIV sexual transmission?
Must be positive for HIV to infect another
Why is unprotected anal sex the most risky?
Its more traumatic to the tissues and likelihood of bleeding (ouch!)
Risk is greater for the?
Receptive partner (prolonged contact with infected material - anal, vaginal, or oral sex)
Presence of blood increases the risk? When?
during menstruation, trauma to the tissues, genital lesions present from STD's
MSM
Men who have sex with men
Sharing in?
Injection equipment (street drugs and prescribed meds)
Get HIV from blood transfusions?
Unlikely!
Puncture wounds?
Greatest risk for occupational transmission of HIV
Splash..........
exposure
Risk of HIV infection after a?
Needle Stick. (exposure is higher with high viral load, puncture wound is deep, needle is hallow bore with visible blood, venous or arterial access with the device, or if the PT dies within 60 days.
Perinatal Transmission possible when?
During preggo, during delivery, or during breast feeding
25% of infants born to untreated HIV- infected women will be born with
HIV
U.S children with AIDS under 13:
90% were infected at birth (others through blood products and abuse)
What has significantly reduced transmission?
Zidovudine Therapy
What are potential influences on HIV transmission in infants?
Limit time membranes rupture before birth, mode of birth, duration of labor, exposure to cervical and vaginal secretions
Medication use?
ART prohylaxis AZT(zidovudine) to pregnant woman ...?....weeks of pregnancy until labor
New born will receive?
Oral AZT for 6 weeks after birth
Occupational Exposure?
What is recommended practice after an exposure? Mercy Policy, Iowa City for Questions, Contact Employee Health to determine risk and where to go from there. Concerns exist also about Hepatitis B and Hepatitis C exposure as well
Factors that increase risk for HIV transmission (lecture)
Prev hx of a child with HIV infection, AIDS, Preterm Birth, Low maternal CD4 count, 1st born twin, elevated maternal viral load, intrapartum blood exposure, Chorioamnionitis, failure to tx mom and fetus with AZT during prenatal period
HIV is a retrovirus discovered in 1983 (obligate parasite) it......???
must be in a living cell to replicate
HIV replicates in a backward manner - from.....?
RNA to DNA
HIV carries its genetic formation in?
RNA (ribonucleic acid; found in nucleus and cytoplasm of cells. Transmit genetic instructions from nucleus to cytoplasm)
HIV infects cells which have?
CD4+ (primarily lymphocytes, monocytes/macrophages)
These CD4+ cells include.................primarily
T Cells
So how does the HIV virus invade cells?
This is important to understand because of pharmacologic interventions!!!
HIV enters the cells after?
Binding to cell surface, then genetic material enters the cell, then Viral RNA is transcribed into Viral DNA through the assistance of TRANSCRIPTASE which is made why HIV?
Transcriptase
Assist transcription of Viral RNA to Viral DNA
HIV more specifically enters the cell when?
The gp 120 "knobs" on the virus binds of fit to specific CD4+ and chemokine receptor sites on the surface of the CD4+ T Cells (FUSION)-or knobs on
This is usually a lymphocyte
(a leukocyte or white blood cell that develops in the bone marrow - 2 forms are T-cell and B-cell)
Once bound, the......?
HIV genetic material enters the CD4+ cell (oh no!)
HIV Cell
Look for a picture; find GP120, p24, Viral Dna, and Reverse trascriptase enzyme
HIV then sheds its protein coat and converts?
RNA to DNA with the assistance of REVERSE TRANSCRIPTASE (an enzyme that is made by HIV)
The Viral DNA can now enter the poor CD4+ cell's nucleus and?
With the use of INTEGRASE it becomes a permanent part of the CD4+ cell's genetic structure
What are the consequences of this action?
There are two!
First consequences
Since all genetic material is replicated during cellular division, all daughter cells from the infected cells will also be infected
Second consequences
Because the genome (gene in the chromosome of each cell) now has a viral DNA, the cell's genetic codes CAN DIRECT CELL TO MAKE NEW HIV - small virus --> can mutate!
Production of HIV within the cell is a complicated and involved process that......?
Results in long strands of HIV RNA that must be CUT INTO appropriate lenghts
What enzyme helps cleaving or splitting these genetic strands?
Protease (one of the 1st drugs came out, worked on this enzyme)
All steps are required to?
Produce new virions (virus particle)
Initial infection results in?
VIREMIA (large amounts of virus in the blood) or high viral load, very infectious time)
This is followed by a prolonged period during which?
HIV levels in the blood remains low even without treatment (happens after a few weeks and may last for 10-12 years) and few clinical symptoms are present. HIV REPLICATION IS STILL CONTINUING THOUGH! Still continuing w/o symptoms
Look for Timeline for the spectrum of untreated HIV infection
LEWIS Page 250
But even without symptoms, HIV replication continues at a?
Rapid Constant rate in blood and lymph tissues early in the infection
Thus, there is a steady state of?
VIRAL LOAD (the number of copies of HIV detectable in a blood sample) that is achieved and maintained in the body of those infected for years!
In order for the body to maintain this...the body makes?
1,000,000,000 to 10,000,000,000 new viruses A DAY! Wow!
Rapid replication can cause problems....
During the copying process
This can lead to?
Mutations - contributing to DIFFICULTIES in tx and vaccine development
What is HIV1?
Immune suppression and AIDS milder
What is HIV2?
West, West Africa (?)
REVIEW
REVIEW
Acute illness develops?
Shortly after the virus is contracted - as the rapid rise in viral levels are present
Antibodies are formed and remain present?
Through course if infection
Late in the disease?
Viral activation and an increase in the virus circulating.
CD4+ (T cells) decrease as they?
Destroyed with viral replication
Antibody levels?
Decrease as immune function is impaired.
Although HIV may remain inactive in infected cells for years, antibodies are?
Produced to its proteins - a process knows as SEROCONVERSION (detectable in blood or cells)
When are Seroconversion detectable?
6 weeks to 6 months after the initial infection
There antibodies have?
Little effect on the virus.
LEWIS
Look at Viral Load in the blood and CD4+ diagram again.
What are the 2 major classes of lymphocytes?
B & T Cells
In the normal immune response, foreign antigens interact with B cells, which start the process of?
Antibody Development
Antigens also interact with T cells which initiate?
A cellular immune response
So, in initial stages of HIV infection....?
B and T cells function NORMALLY.
B cells
Make HIV specific antibodies that are effective in reducing blood viral loads
T cells
respond to the site when viruses are trapped in the lymph vessels
REMEMBER which cells the HIV(virus) infects and destroys?
T cells
Lymphocytes
Lymph nodes swollen
HIV
primarily destroys CD4+ T cells (these are also known as T helper Cells or CD4+ lymphocytes)
Why the destroy that?
Because T cells have more CD4+ RECEPTOR on their surface than other CD4+ cells, SO HIV PREFERS THESE!
Adults have?
800-1200 CD4+ T cells per microliter (uL) of blood
Normal life span of CD4+ cell is?
100 days
But in HIV CD4+ cells die after?
2 days
Viral activity destroys?
1 billion CD4+ cells everyday!
Fortunately, bone marrow and thymus produce enough CD4+ cells to last for?
Years!
But eventually?
The ability if HIV to destroy T cells (CD4+ cells) exceed the body's ability to replace cells
Decease in the T cell count equals
Decrease in the immune capability of the body
Immune system remains healthy?
500 T cells/uL
Immune problems start?
200-499 T cells/uL
Severe problems develop?
<200 T cells/uL
Severe immune suppression leads to?
Development of infections and cancers that cause mortality and morbidity
HIV destroys CD4+ cell in?
3 ways
1
Viral replication with the process of BUDDING
2
Infected cells fuse with other cells and can combine into a mass (syncytium) that destroys all cell involved
3
Initiation of destruction through the infected persons immune system and the antibodies that decrease immunity BIND AND DESTROY INFECTED CELL
Budding Process
LEWIS Page 252
2. HIV spreads throughout the body
Lymphoid tissue becomes an early reservoir for HIV/ HIV causes significant degenerative change in the lymph system/ Allows the viral particles to spill over into the blood --> leads to DECREASED IN IMMUNITY
3. HIV Spreads throughout the body
infects the monocytes/ infected monocytes move into tissues and become macrophages (phagocytic cells)/ These cells become "HIV factories" and can rupture, spreading newly formed HIV into the surrounding tissue: SKIN, CNS, LYMPH NODES, BONE MARROW, and LUNG.
Look at TIMELINE FOR THE SPECTRUM OF UNTREATED SPECTRUM OF HIV INFECTION
LEWIS PAGE 267
Stages of HIV Infection Acute Infection
Symptoms usually occur 1-3 weeks after an initial infection and last 1-2 weeks but can persist for months./ CD4+ T cell counts temporarily fall (that dip the chart) but quickly RETURN TO BASELINE/ Most symptoms are mild - may may mistaken for a COLD or FLU/ In a few people, neurologic complications may develop(meningitis, peripheral neuropathy, facial palsy, Guillain-Barre syndrome
Stages of HIV infection Acute Infection
Seroconverting (development of HIV specific antibodies) - fever, rash, sore throat, HA, joint pain, malaise, muscle pain, Nausea, Diarrhea, and Swollen Lymph nodes.
Early Chronic Infection?
HIV infection to the diagnosis of AIDS
Medial interval of the process is?
11 years
CD4+ T lymphocyte count remain above?
500 cell/uL (normal or drop slightly)
Viral load is?
Low (during early chronic infection)
Referred to as asymptomatic but......?
May feel......fatigue, HA, low-grade fevers, night sweats, persistant generalized lymphdenopathy (PGL) and other vague symptoms. they dont understand that they are infected
No lifestyle changes if.....?
Not aware of diagnosis/ No medical help may be sought/ Can create public health concern as they are still able to transmit HIV to others even when unaware of Dx or..........(i missed this).....
Intermediate Chronic Infection
AKA Early symptomatic disease
Lymphocyte T cell count drops to?
200-499 cells/uL / Viral load increase/ HIV advance to a more ACTIVE STAGE
Symptoms seen earlier get worse....
Persistent fever, frequent drenching night sweats, chronic diarrhea, recurrent HA's, fatigue severe enough to interrupt normal routines.
Localized infections
in Intermediate chronic infection.
Most common is?
Oropharyngeal candidiasis
More localized infections
Shingles(varicella roster), Persistant vaginal....?....., Outbreaks of oral or genital herpes, and Bacterial infections
More...
Lypmphadenopathy & Kaposi sarcoma (KS) [ cancerous tumor of the connective tissue, and is often associated with AIDS], Neurological manifestations, and Oral hairy leukoplakia.
Oropharyngeal candidiasis or Trush
Will occur in most (90%) of HIV-infected people at some time/ Whitish yellow patches IN MOUTH, ESOPHAGUS, OR GI TRACT/ Diagnosed with microscopic exam of scraping from lesion and culture
Oropharyngeal candidiasis is treated with?
Fluconazole (or other antifungal)
GREEN MEDS?
Know it! (in lewis text)
Oral Hairy Leukoplakia (look like trush, painless)
Epstein- Barr virus infection/ Painless, white, raised lesions on lateral aspects of tongue/ May be THE EARLIEST signs of HIV INFECTION/ Also an INDICATION OF DISEASE PROGRESSION
Late Chronic Infection - AIDS
Diagnosed of acquired immunodeficiency syndrome (AIDS) cannot be made until the HIV infected person meets the CDC guidelines for the case definition criteria.
Must have AT LEAST one of the criteria by CDC:
1. CD4+ T cell count drops below 200 cells/ml
2. Development of one of the opportunistic infections (Fungal, Viral....) 3. Development of one of the opportunistic cancers (KS, Burkitt's..), 4. Wasting syndrome, 5. DIMENTIA DEVELOPS
DIAGNOSTIC CRITERIA FOR AIDS
Look at Table 15-10 LEWIS
LATE CHRONIC INFECTION
These criteria are more likely to occur when the immune system becomes severely compromised/ These opportunistic conditions generally do not occur in people with FUNCTIONING IMMUNE SYSTEM/ These infections can be severe, debilitating, and life-threatening
LATE CHRONIC INFECTION
Immune system is SEVERELY COMPRIMISED/ Increased amount of HIV in the blood/ Decrease in the lymphocyte/ Advance in tx have led to significant decreases in the rates of opportunistic diseases- successful tx of HIV helps to maintain the immune system and prevent infections and cancers.
What is Koposi's Sarcoma? (opportunistic diseases)
Often the presenting SYMPTOM of AIDS/ Most common CANCER FROM AIDS/ Manifest as firm, flat, raised or nodular hyperpigmented, multicentric lesions/ Diagnosed with BIOPSY OF LESIONS/ Treated with cancer chemotherapy, radiation of lesions, alpha-interferon or local radiation or cryotherapy (risk for bleeding) for skin lesions.
Koposi Sarcoma (KS) is a?
A common neoplasm caused by herpes virus 8/ Common neoplasm in HIV-infected patients/ Associated with SEXUALLY TRANSMITTED HERPES VIRUS/ Can effect many organ systems
KS can frequently be seen on?
Skin and mouth, but can cause bleeding and respiratory distress with lesions in those areas
Nursing focus?
Provide information about treatment options, provide CARING SUPPORT AS DISEASE PROGRESSES
What is Pneumocystis Carinii Pneumonia?
Caused by a FUNGUS/ Most common opportunistic infection - many clients will develop PCP at some point/ Recurrent problem - PROPHYLAXIS NEEDED
Clinical manifestations are?
nonproductive cough that may progress to productive, SOB, fever, night sweats, and fatigue
PCP diagnosed with?
CXR, and sputum for culture
Treated when?
CD4+ T cells <200 u/L with TMP/SMX (recommended) (trimethoprim-sulfamethoxazole (Bactrim), dapsone as PROPHYLAXIS AND ALSO IF DISEASE PRESENT
Nursing Implementation?
Acute exacerbations/ Pneumocystic carinii pneumonia (PCP): cause by a common fungus/ Most people exposed by age 3/ Does not cause disease unless immunocompromised - major SOURCE OF MORTALITITY
Nursing resp
Monitor resp status, fever, give meds and O2, position to FACILITATE BREATHING, FLUID REPLACEMENT (NIGHT SWEAT-FLUID MONITORING LOSS)
Tuberculosis (TB) or Mycobacterium tuberculosis
Can affect the respiratory system or any site
TB clinical manifestations.
productive cough/ FEVER/ NIGHT SWEATS/ WEIGHT LOSS
TB diagnosed by?
CXR, sputum culture, and AFB stain
TB treatment?
isonaizid (INH), ethambutol (Myambutol), rifampin (Rifadin)
Cytomegalovirus (CMV) clinical manifestation?
stomatitis, esophagitis, gastritis, colitis, diarrhea (can be bloody), pain, weight loss, and RETINITIS
CMV diagnosed with?
stool exam, small bowel BIOPSY or COLON BIOPSY
CMV treatment?
Ganciclovir (Cytovene), foscarnet (Foscavir) ---> both are antivirals
Ask yourself?
Is it a bacteria? is it a virus? Is it a fungus? Will determine what to treat!
CMV nursing implementation?
Acute exacerbation/ CMV : eye floaters that can progress to BLINDESS/ Can cause colitis, pneumonia and neurologic problems also with eye problems
Goals of nursing care for CMV?
to encourage periodic eye exams for early IDENTIFICATION AND TX TO PREVENT VISION LOSS
Mycobacterium Avium Complex (MAC) clinical manifestations?
Watery diarrhea, weight loss, and gastroenteritis
MAC diagnostic tests?
small bowel biopsy with AFB STRAIN AND CULTURE
MAC TX?
clarithromycin (Biaxin), rifampin (RIfadin), ciprofloxacin (Cipro), azithromycin (Zithromax) ---> Bacterias...
MAC Nursing Implementation?
GI problems-chronic DIARRHEA - SO MUCH, CANT FUNCTION/ Also can cause widely disseminated infection in blood, spleen, lymph nodes, bone marrow and liver
Signs of MAC?
chronic diarrhea, abdominal pain, fever, fluid loss, dehydration, and dyperrash (monitor skin)
MAC nursing focus?
Teaching about drug therapy and problems related to DIARREA
Cryptococcal Meningitis clinical manifestations?
Cognitive impairment, motor dysfunction, FEVER, SEIZURES, HA
Cryptococcal Dx with?
CT Scan, serum antigen test, and CSF analysis (spinal test)
Cryptococcal Tx?
amphotericin B (Fungizone), fluconazole (Diflucan) ----> Fungi.........prevent relapse(from notes)
Cryptococcal meningitis nursing implimentation?
Acute exacerbations/ Caused by a yeast - PREVENT RELAPSE
Cryp Symptoms?
Can be vague
Cryp Nursing Care?
Giving medications, teaching to encourage patient to continue with maintenance therapy to prevent relapse - 50-75% WILL RELAPSE WITHIN 1 YEAR.
Other Opportunistic Diseases?
Lymphomas: 2 are common with AIDS (non-Hodgkin's lymphoma and CNS lymphoma or Primary Lymphoma of the brain)
Hodgkin's Disease is?
5 times more common in the HIV clients.
Cervical cancer
40% of women with HIV have cervical dysplasia and cervical cancer, its FREQUENT and AGRESSIVE, and women with HIV should have PAP Q 6 MONTHS!
Herpes Virus?
Can affect the Integumentary system, the EYE, or the GI system. Lesions on mouth, genial area or perianal mucosa, cornea or retinal lesions or pharyngeal or perioral esophageal mucosa.
Herpes Virus Dx with?
VIRAL CULTURES and EYE EXAMS
Herpes Tx?
acyclovir (Zovirax), famciclovir (Famvir), valacyclovir (Valtrex), foscarnet (Foscavir)
Look at Table
16-11 and 15-11 in LEWIS
Summary of HIV pathogenesis
1. HIV enters the body through sexual, parenteral, or vertical route (born with it) 2. The virus preferentially infects CD4+ T-lymphocytes, or CD4+ T cells which play a critical role in immune function 3. Viral load progressively increase as more virus is produced 4. The number of CD4+ cells progressively Decrease to a point that immune function is compromised 5. When immunosuppression becomes profound (CD4 count <200) risk of opportunistic infections and malignancies increase dramatically
Can give live vaccine?
NO!
Look at
LeFever page 499 Figure 34-1
Cerro Gordo Public Health
Testing: Disease Prevention Specialist
Counseling session of about 30-45 minutes
Discuss why at risk and how to stay safe in the future/ Discuss the 3 month window where HIV wont be detected/ Free of charge
Confidential but name based
Under 18 years of age can have tests w/o parental notification, but if positive, parents will be notified
Screening Procedures
See page 109 on P/W
What will they test?
Test for antibody's CD4+ for immune status only
Who will get it free?
IV drug abusers, 6 or more partners, African Americans, and Homosexuals
Diagnostic studies with HIV infection
Most usefull tests are those that detect antibodies specific to HIV
Window period?
up to a 2 month time frame from infection before antibodies can be detected/ Now can be done with oral fluid and urine/ Newer tests are rapid -20 minute blood tests in the office setting- CDC recommends these
why are Infants are more difficult to tests?
Maternal antibodies across the placenta
Screening for HIV - specific detection
ORASURE/ Episcreen
Blood tests for serum antibodies or directly to gene proteins - effective 99% for those infected 12 weeks or more
EIA (Enzyme immunoassay), abd ELISA (enzyme linked immunosorbent assay)
Confirmation test?
Western Blot and IFA (immunoflurescence assay) --- ONLY THEN CONFIRM HIV+
HIV ANTIBODY TEST-SCREENING TEST
SEE LEWIS 15-12 PAGE 256
Diagnostic studies with HIV infection
screening tests available from the internet/ free of charge or fee associated/ OTC screening test available
Dx studies with HIV infection in the newborn
Complicated because of maternal IgG antibodies that cross the placenta after 32 WEEKS GESTATION
What are the most accurate test for THOSE UNDER 18 MONTHS?
HIV DNA PCR assay on neonatal blood/ Follow up tests at INTERVALS
1st and 3rd trimester/ Risk Vs benefit
P/W 109 (can opt out)
CD4+ T cell count
to measure progression of HIV infection/ Decrease as the disease progresses/ Marker for decreased immune function
Viral load
to assess viral activity, clinical status and disease progression/ Counts the number of viral particles in a sample of blood/ Help to determine: when to initiate therapy. efficacy of therapy and if the CLINICAL GOALS ARE BEING MET, EVEN IF THE VIRAL LOADS ARE LOW, ITS STILL ABLE TO TRANSMIT
Lab Studies
wbc counts LOW, Platelets counts LOW, RBC counts LOW/ L
Liver function tests?
altered, common and important for drug therapy (coinfection of hepatitis b & c.
Testing for resistance to antiretroviral drugs done by?
Assay tests.
Genotype assay?
detects drug-resistant viral mutations that are present in reverse transcriptase and protease genes.
Phenotype assay?
measure the growth of the virus in various conditions of the antiretroviral drugs
Therapeutic Management Collaborative Care Focus
Monitor the disease PROGRESSION AND IMMUNE FUNCTION/ Initiate and monitor antiretroviral therapy/ Prevent the dev of Oppurtunistic disease/ Manage SYMPTOMS/ Prevent and treat the complications of tx/ Prevent TRANSMISSION OF THE DISEASE TO OTHERS
What to do in initial visit?
Gather data and establish rapport/ Psychosocial Hx and Medical Hx/ Patient education
What are some pt education?
Spectrum of THE DISEASE/ TRANSMISSION/ Improving health/ Diet review/ Family planning/contraception/ May be in state of shock, denial-process could take several months
HAART and ART Therapy?
Highly active antiretroviral therapy and Antiretroviral therapy
Goals of HAART and ART?
1. Decrease the VIRAL LOAD 2. Maintain or raise CD4+ CELL count 3. Delay the development of HIV related symptoms and OPPORTUNISTIC DISEASE
cd4+
NORMAL 800-1200/ DANGER <200, PROPHYLACTIC THERAPY
Drug Therapy
Changing constantly/ The national institutes of Health (NIH) guidelines on the principles of drug therapy/ Other guidelines on the use of antiretroviral therapy also published
Goals or ART?
prevent development of VIRAL RESISTANCE TO DRUGS
Resistance can happen?
rapidly if patient misses or delays dose of meds - STRICT ADHERANCE TO TX IS EXTREAMLY IMPORTANT!
Table
15-13 lewis page 257
Why would they use combinations of drugs from different drug groups?
Various combination attack viral replication in several different ways to : Makes is MORE DIFFICULT FOR THE VIRUS TO RECOVER and IT DECREASED LIKELIHOOD OF DRUG RESISTANCE. And also virus mutates, may have different combination, more cost effective.
Drugs used to tx HIV are?
Antiretroviral drugs (ART)/ Drugs work at various point in the HIV replication cycle
None Cure HIV but?
Can 1. Decrease VIRAL REPLICATION 2. Delay PROGRESSION OF THE DISEASE
ART drug therapy can be devided into groups by action?
Nucleoside reverse transcriptase inhibitors (NRTI's), Nonnucleoside reverse transcriptase inhibitors (NNRTI's), NucleoTIDE reverse transcriptase inhibitors (NtRTI's), Protease Inhibitators (PI's) and Fusion Inhibitors (Entry Inhibitors)
Also medications given to tx the opportunistic infections
Anti- inflammatory medications, Anti-infective medications, Anti-fungal medications, and Anti-viral Medications
Number of opportunistic diseases associated with HIV can be prevented through?
Use of ART, vaccines, and disease specific measures
Prevention, diagnosis and treatment of opportunistic diseases have?
Increased life expectancy
TABLE
Review table 15-11 in Lewis page 254 -255 and Chapter 34 in LeFever
What are the major problems with ART?
Resistance develops rapidly when they are USED ALONE OR INADEQUATE DOSES/ Need to use combination of 3 or more ART at FULL STRENGTH/ Dangerous interactions with PI's, NNRTI's and come commonly used meds, OTC meds and herbal therapy (ST JOHNS WORT INTERFERES WITH ART)
What are other issues?
Treatment protocol can reduce viral load by 90-99% in many cases, there are problems/ Some people with HIV will not experience dramatic response with ART and will cause feelings OF DESPAIR and FAULTY (why are we even trying this!)/ Many patients will not be able to use combination therapy because of? - expense, side effect, inability to adhere to REQUIRED SCHEDULES AND DIETARY CHANGES
Nucleoside reverse transcriptase inhibitators (NRTI's)
SE of all: lactic acidosis with HEPATIC STEATOSIS (fatty liver-cant metabolize them), lipododystrophy (distribution of fats)
NRTI's Drugs
1. zivovudine (AZT, ZDV, Retrovir) - can cause nausea, vomiting, anemia, leukopenia, fatigue, pacreatitis and HEADACHE 2. didanosine (ddI, Videx) - can cause Nausea, Diarrhea, Peripheral neuropathy and pacreatitis 3. stavudine (d4t, Zerit) - can cause peripheral neuropathy and pancreatitis
Nonnucleoside reverse transcriptase inhibitors (NNRTI's)
SE of all: rash, erythema multiforme, increased LFT (liver function), and HEPATOTOXICITY
NNRTI's Drugs
1. nevirapine (Viramune) - can cause rash, Stevens - Johnson syndrome (skin disease), hepatitis, and increased transaminase LEVELS (LIVER FUNCTION TEST) 2. efavirenz (Sustiva) - can cause rash, dizziness, confusion, difficulty concentrating, dreams and encephalopathy - taken at bedtime to decrease side effects
NucleoTIDE Reverse transcriptase inhibitors (NtRTI's)
1. tenofovir DF (Viread) - can cause nausea, vomitting, and diarrhea.
Protase Inhibitors (PI's)
SE of all: hyperglycemia, hyperlipidemia, LIPODYSTROPHY, DIARRHEA, NAUSEA, AND HA
PI's drugs
1. saquinavir (Fortovase) - can cause nausea, diarrhea, and headache (REFRIGERATE CAPSULES) 2. RITONAVIR (NORVIR) - can cause nausea, vomitting, diarrhea, altered taste sensations, circumoral paresthesia (MOUTH), hepatitis and increased triglyceride levels
Fusion Inhibitors (entry inhibitors)
enfuvirtide (Fuzeon)
Fuzeon
use for advanced HIV disease with evidence of resistance to other therapy/ can cause skin irritation at injection site, fatigue, nausea, insomnia, pneumonia, and peripheral neuropathy/ SUBCUTANEOUS INJECTION WITH ROTATION OF SITE/ Monitor for reactions at injection site, signs and symptoms of pneumonia, and changes in HIV lab studies (CD4+ counts, viral load)
Anti-inflammatory Medications
sulfasalazine (Azulfidine)
Azulfidine
used to treat toxoplasmosis (local disease) or nocardiosis/ Administered orally, can cause renal toxicity, suppresses bone marrow function, increases photosensitivity/ Monitor urine output and CBC, monitor for sore throat, pallor, purpura, jaundice, and weakness/ Encourage fluid INTAKE AND AVOID SUN EXPOSURE
Anti-infective medication
1. pentamidine isethionate (Pentam 300, Nubupent 2. azithromycin (Zithromax)
Pentam 300/ Nubupent
Used to tx PNEUMOCYSTIS CARINII PNEUMONIA/ Administer IM and IV/ Can cause Nephrotoxicity, is immunosupressive and hepatotoxic/ Monitor hypoglycemia, BP, HR, LFT's, and CBC's
Zithromax
Used to tx MAC (Mycobacterium Avium Complex), Toxoplasma gondii, and cryptosporidium muris/ Administered ORALLY OR IM/ Used for infections in multiple system/ Can cause hepatotoxicity, HA, DIZZ, Nausea, Vomiting, diarrhea, or abdominal pain/ Monitor for loose STOOLS, DIARRHEA, AND AVOID DIRECT SUNLIGHT
Anti - fungal medications
1. fluconazole (Diflucan) 2. ketoconazole (Nizoral), 3. amphotericin B (Fungizone)
Diflucan
Used to tx CANDIDIASIS/ Given orally or IV/ Can cause nausea, vomitting, diarrhea, increase in AST(Aspartate Aminotransferase)(and other LFT's) and rash
Nizoral
used to tx candidiasis, coccidioidmycosis, or histoplasmosis/ Given PO with food or milk/ Can cause hapatotoxicity and SENSITIVITY TO SKIN
Fungizone
Used to tx candidiasis and other fungal infections/ generally admministered IV, can cause nephrotoxicity and bone marrow suppression/ Monitor renal function, IV site, and CBC
Anti-Viral medications
1. acyclovir (Zovirax) 2. ganciclovir (Cytovene), and 3. foscarnet (Foscavir)
Zovirax
used to tx herpes simplex, HERPES ZOSTER, VARICELLA ZOZTER/ Given IV or PO (some topical)/ Can be nephrotoxic, and irritating to IV site
Cytovene
Used to tx CMV RETINITIS/ Given IV or PO/ Can cause bone marrow suppression
Foscavir
Used to tx CMV retinitis/ Given IV/ Can cause nephotoxicity
PT and FAM teachings with ART meds
Resistance to antiretroviral drugs is a major problem in tx HIV infection.
Ways to decrease risk for resistance?
Take at least 3 different ART drugs at a time/ Know what and how to take meds prescribed/ Take full dose on SCHEDULE/ If unable to take d/t side effects, call PCP/ understand the interactions with other meds/ understand "viral" load/ Low viral load does not mean ABSENCE OF DISEASE OF VIRUS -> STILL CAN SPREAD IT [refer page 15-23 on page 265]
Problems in developing vaccine?
HIV lives away from CIRCULATING IMMUNE FACTORS/ HIV mutates RAPIDLY/ 2 Strains of HIV (HIV 1&2) that causes AIDS and at least 9 families of HIV around the world/ Can only be tested in humans - ETHICAL ISSUES/ Vaccine will not replace current prevention methods-now need to decrease risk behaviors as no vaccine is likely to be found 100% effective/ Cultural CONSIDERATION IN OTHER COUNTRIES-FEMALE DOMINANT? LEWIS 259
Nursing Assessment
Risk assessment for unknown HIV infection: 4 questions to ask?
4 questions to ask?
1. Have you ever had a blood transfusion or used clotting factors? 2. Have you ever shared needles, syringes, or other injecting equipment with another person? 3. Have you ever had a sexual experience in which your penis, vagina, rectum, or mouth came into contact with another persons penis, vagina, rectum or mouth? 4. Have you ever had STD's? --LEWIS 15-23 TEACHING
Important points?
Complete hx and systems review - specific questions r/t anticipated problems (lungs, eyes, oral mucosa, sexuality-reproductive, coping-stress tolerance, elimination) --- REVIEW 15-16 LEWIS 259 NURSING ASSESSMENT HIV INFECTED PT
Nursing Dx?
Understand some possible ND for HIV pt!
Some nursing dx
acute pain/ anticipatory grieving/ disturbed sleep patterns/ powerlessness/ ineffective coping/denial/ social isolation/ impaired oral mucous membranes/ imbalanced nutritoin/ anxiety/ fear/ diarrhea, and fatique
Nursing planning/ Goals
Encourage patient to learn safer and healthier and less risky behaviours/ Adherance to medication regimes/ adequate nutrition status/ Prevention of opportunistic disease (reduced or eliminated )/ Prevention transmission of HIV to others/ Healthy and SUPPORTIVE RELATIONSHIPS/ Cope with the consequences of HIV/AIDS/ Maintain the best quality of life possible/ Come to terms with issues r/t disease, death and spirituality
Nursing planning/ goals?
Main goals once HIV infection is established ---- 1. Keep viral load AS LOW AS POSSIBLE/ 2. Maintain a functioning IMMUNE SYSTEM!
Nursing Implementation
Prevention of HIV infection: HIV infection is 100% preventable
Safe Activities or Risk-reducing activities assess your comfort level
Decreasing risk r/t sexual intercourse - outercourse vs. abstaining/ Barrier use: proper use of male and female condoms (lewis teaching)/ Nurses must be familiar with terms OF CULTUBE, NEED TO BE AGE SPECIFIC
Decreasing risks r/t drug use
Basic rules: dont do drugs; if use drugs-do not share equipment; do not have sex under THE INFLUENCE OF DRUGS OR ALCOHOL
Decreasing risks of perinatal transmission
Ask women about reproductive DESIRES IF ALREADY INFECTED WITH HIV/ Use ART and council about options
Decreasing risk at work
Risk is small but REAL/ Know institutional guidelines/ Postexposure prophylaxis- combination ART based on type AND VOLUME OF EXPOSURE AND THE STATUS OF THE PATIENT
HIV testing and counseling
Encourage at the risk to GET TESTED/ Use of pre-test and post-test counseling
Acute intervention with early dx?
Initial response to THE DX OF HIV/ Antiretroviral drug therapy/ When to begin antiretroviral therapy/ Adherence TO REGIMEN
Acute intervention with early diagnosis- Health promotion issues
nutritional changes to promote healthy immune system=maintain lean body mass, vitamins/ Smoking cessation and restrict drug use/ Limit ALCOHOL/ Exercise/ Avoid exposure to NEW INFECTIOUS AGENTS/ Mental health counseling/support groups (reactions to HIV tests=same as any life threatening, debilitating illness-anxiety, fear, depression, denial, anger, guilt, suicidal ideation, hopelessness, powerlessness) --PAGE 266 TABLE
Nursing implementation
Wasting syndrome/ Take on characteristics if TRAIL, OLDER ADULT/ Loss of 10% ideal body mass/ Hair thins and grays, posture slumps, gait unsteady/ May need enteral supplements (oral or gastric tube), IV therapy -
AIDS
IS A CHRONIC DISEASE, NOT A DEATH SENTENCE
Nursing Implementation
Ambulatory and home care/ Ongoing care/ Terminal Care
Physical problems that may persist even in healthy periods - Ongoing care
Diarrhea, Fatigue, New metabolic disorders emerging with ART
Diarrhea
affects 60% of HIV patients - caused by pathogens, side effect of meds/ Leads to weight loss, dehydration, electrolyte imbalance, skin breakdown/ Nursing interventions as WOULD OTHERS WITH DIARRHEA
Fatigue
Teach pt to assess fatigue patterns, determine contributing factors, set activity priorities, conserve energy, schedules rest periods, exercise, avoid substances like caffeine, nicotine, ALCOHOL AND OTHER DRUGS THAT MAY DISTURB SLEEP.----> "today, just do dishes"
New metabolic disorders emerging from ART
Include changes in body shape, hyperlipidemia, insulin resistance, hyperglycemia, bone disease, lactic acidosis, and cardiovascular diseases/ Nursing should focus on helping pt make tx decisions and DEALING WITH NEGATIVE BODY IMAGE
Terminal Care
AIDS related Dementia Complex (ACD)
ACD
also called HIV-associated cognitive motor complex/ Caused by HIV infection to the brain and other HIV related CNS problems. Symptoms sometimes reversible if TREATABLE CAUSE IS DIAGNOSED
ACD Symptoms?
decreased concentration, apathy, depression, inatention, forgetfulness, social withdrawal, personality changes, confusion, hallucinations, ataxia, clumsiness
Nursing interventions for ACD?
Safety, assistive devices, encourage self care, reorientation, reduce stress, family and significant other support.