Caring for individuals with human immunodeficiency virus

72 Caring for individuals with human immunodeficiency virus




Overview/pathophysiology


Acquired immunodeficiency syndrome (AIDS) is a life-threatening illness caused by the human immunodeficiency virus (HIV). AIDS is characterized by disruption of cell-mediated immunity. This breakdown of the immune system is manifested by opportunistic infections such as Pneumocystis jirovecii pneumonia ([PCP] previously Pneumocystis carinii pneumonia) or tumors such as Kaposi’s sarcoma (KS). According to the Centers for Disease Control and Prevention (CDC), the HIV epidemic in the United States continues to grow with an estimated 56,300 new HIV infection cases in 2006 (Hall, 2008).


Confirmed routes of transmission of HIV infection include the following:


• Blood: Exposure to HIV-infected blood by sharing of unsterile needles or other drug paraphernalia, unsterile invasive instruments, exposure to needlesticks or sharps, transfusion with contaminated blood, mucocutaneous exposure to blood or other infected body fluids.

• Semen: Exposure to HIV-infected semen during male to male or male to female sexual activity. Anal receptive sex with an HIV-infected person is the greatest sexual risk for exposure to HIV.

• Vaginal fluid: Exposure to HIV-infected vaginal fluids.

• Breast milk: Infant exposure to HIV-infected breast milk from an HIV-infected woman.

• Perinatal: Fetal exposure to HIV during all stages of pregnancy with the highest rates of transmission during labor and delivery.

HIV infection has transcended all racial, social, sexual, and economic barriers, and all persons who engage in high-risk behaviors are at risk of transmission.


It is estimated that the average time span between infection with HIV and seroconversion (development of a positive HIV antibody test) is 10 d-12 wk, although antibody response may be absent for 6 mo. Therefore a negative test does not guarantee absence of infection. Individuals with a recent history of high-risk behavior and a negative HIV antibody test should be retested at 3-mo intervals for 6 mo, then annually, and follow the guidelines for safer sex practices (Bartlett, 2007). Anyone with a positive HIV antibody test must be considered infectious and capable of transmitting the virus.


To a minimal extent, health care workers who come into contact with body substances of patients are also at risk. Understanding and practicing stringent infection prevention is essential for all health care workers. Review Appendix A, p. 721, for a discussion of the handling of blood and body fluids for all patients. Postexposure prophylaxis is available for prevention of HIV transmission in case an occupational or high-risk nonoccupational exposure occurs, but is most effective when initiated soon after exposure.


HIV targets CD4+ T cells, weakening the immune system. When the immune system has been significantly depleted of CD4+ T cells, the body becomes increasingly vulnerable to various infections. This phase of HIV infection is called AIDS. Thus, HIV is a chronic viral disease that covers a wide spectrum of illnesses and symptoms for a variable course of time. Although not all individuals will follow the classic disease progression, the stages of illness, when therapy is not initiated, are described under “Assessment.”


Since the introduction of antiretroviral therapy (ART) there has been a dramatic reduction in HIV-related morbidity and mortality. Strict adherence to a combination of antiretroviral agents slows viral replication at different points in the life cycle of HIV. Use of antiretroviral agents reduces the amount of circulating virus (viral load). This viral load reduction has been shown to enable immune system recovery and slow progression of the disease, resulting in reduction in symptoms and opportunistic diseases; reducing risk of cardiovascular, renal, or hepatic disease; prolonging survival time; and improving quality of life.


Maintenance of a positive attitude by the patient and caregivers is an essential element in the therapeutic plan, but an honest approach to this life-threatening illness is also important. This plan must include discussion of adherence to medication, ongoing follow-up, and prevention of HIV transmission to others through safe sex and risk reduction.



Health care setting


Primary care, hospice, and home care with possible acute care hospitalization resulting from complications or occurrence of opportunistic infections



Assessment




HIV risk assessment:


Because of continued transmission of HIV infection and incidence of new infections regardless of race, gender, sexual preference, or age, continuous HIV risk assessment and prevention education within all clinical settings is essential. Health care providers have a responsibility to assess each patient’s risk for HIV infection and be sensitive to issues of sexual orientation and practices, as well as cultural values, norms, and traditions. A risk assessment should be used not only for the purpose of recommending testing, but also for development of a “patient-centered” risk reduction plan.



Key components of conducting a sexual history:



• Focus on sexual “behaviors” rather than on categories or labels.

• Avoid making assumptions about individuals.

• Ask about specific sexual behavior rather than ask general questions.


• For example, “How many sexual partners have you had?” “In the last 5 years?” “In the last month?”

• “Do you have sex with men, women, or both?”

• “When is the last time you had sex while under the influence of drugs or alcohol?”

• Ask nonjudgmentally about traditional and nontraditional sexual practices.


• “What type of sexual intercourse (vaginal, anal, oral) do you have with your partner(s)?”

• “When you have anal or oral intercourse, are you the insertive or receptive partner?”

• It is essential that clinicians provide patients with risk reduction information in a consistent and continuous process within the clinical care relationship. This intervention should include development of specific skills and ongoing monitoring of patient successes and continued challenges.


Key components of conducting a drug history:



• Focus on specific drug-using behaviors. For example:


• “Do you use alcohol or tobacco?” If so, ask how much and how often.

• “What drugs do you use?” “What drugs do you inject?”

• “When did you last inject drugs?” “When did you last share needles?”

• “Do you clean your works?” “How do you do this?”

• Avoid making assumptions about individuals because drug use occurs in all socioeconomic groups.

• Convey a nonjudgmental attitude.


Stages of HIV disease (for untreated individuals):


The four stages of HIV infection can be categorized as acute infection, asymptomatic, symptomatic, and AIDS.



Acute or primary infection:

Period of rapid viral replication during which the person may experience flu-like symptoms at the time of seroconversion.



Asymptomatic stage:

Immune system continues to mount a massive response to HIV, causing a drop in viral load but viral replication continues. It may last 10 yr or more and the person may remain free of symptoms or opportunistic infections.



Early symptomatic stage:

Rate of viral replication remains relatively constant; however, gradual failure of the immune system results in inability to control the virus, causing increased viral load.



Advanced stage, AIDS:

The immune mechanism for virus control fails, resulting in large amounts of circulating virus and significant destruction of CD4+ T cells. Clinical manifestations include wasting and opportunistic diseases such as neoplasms and viral, bacterial, and fungal infections. Dementia also can occur, characterized by cognitive impairment and mood changes.



Physical assessment:


The following indicators are commonly seen with HIV infection.



General:

Fever, night sweats, weight loss.



Cutaneous:

Herpes zoster or simplex lesions, seborrheic or other dermatitis, fungal infections of the skin (moniliasis, candidiasis) or nail beds (onychomycosis), KS lesions, petechiae, warts.



Head/neck:

“Cotton-wool” spots visualized on funduscopic examination; oral KS; candidiasis (thrush); hairy leukoplakia; aphthous ulcers; enlarged, hard, and occasionally tender lymph nodes.



Respiratory:

Tachypnea, dyspnea, diminished or adventitious breath sounds (crackles [rales], rhonchi, wheezing).



Cardiac:

Tachycardia, friction rub, gallops, murmurs.



Gastrointestinal:

Enlargement of liver or spleen, nausea, vomiting, diarrhea, constipation, hyperactive bowel sounds, abdominal distention.



Genital/rectal:

KS lesions, herpetic lesions, candidiasis, balanitis, warts, syphilitic chancres, warts, rectal or cervical dysplasia, fistulas.



Neuromuscular:

Flattened affect, apathy, withdrawal, memory deficits, headache, muscle atrophy, speech deficits, gait disorders, generalized weakness, incontinence, neuropathy.



Diagnostic tests


A variety of diagnostic tests are used for specific reasons in the course of HIV disease. The following tests are used to determine HIV infection. Because it can take up to 6 mo to develop enough antibodies to test positive, the person may be infected but test negative. This is often referred to as the “window period” for HIV infection. Individuals who test negative should be retested in 3-6 mo to confirm seronegativity. The CDC currently recommends routine HIV screening for all individuals 13-64 yr old, regardless of risk factors.




Enzyme-linked immunosorbent assay (ELISA):


The standard test for HIV. ELISA tests for presence of HIV antibody. An initially reactive ELISA should be repeated on the same specimen. If reactive, a confirmatory Western blot (WB) is performed. A positive ELISA with a confirmatory WB signals infection with HIV.



Western blot:


A confirmatory test used to detect immune response to the specific viral proteins of HIV. A reactive WB is defined by a specific pattern of protein bands separated by electrophoresis on a strip of nitrocellulose paper; three of the following bands must be present for reactivity: p24 (see the following), gp41, and gp210 or gp160.



p24 antigen test:


Detects HIV p24 antigen in serum, plasma, and cerebrospinal fluid (CSF) of infected individuals. Its advantage is that it may detect viral antigen (HIV p24) early in the course of infection before seroconversion.



Immunofluorescence assay:


Tests for HIV antibody and is equivalent to the WB.



Rapid tests:


Several relatively new Food and Drug Administration (FDA)-approved rapid antibody tests indicate presence of HIV antibodies in oral fluid, serum, and/or whole blood within approximately 20-40 min. Confirmation of positive results with a WB is imperative. This method of testing is ideal when a rapid result is critical and assists in increasing the number of persons obtaining results.



Monitoring tests


With use of ART in the clinical management of HIV disease, monitoring tests have become increasingly essential in making appropriate clinical treatment decisions. These clinical decisions are based not only on clinical symptoms but also on the person’s CD4+ T-cell count and viral load. Based on the current Department of Health and Human Services (DHHS) HIV treatment guidelines, asymptomatic persons, depending on these measurements, are appropriate candidates for initiation of ART.




CD4+ T-cell count:

A measure of the amount of CD4+ T cells per milliliter in the blood. It is a marker for the impact of HIV infection on the immune system and the individual’s susceptibility to infections. With increased viral load there is a reduction in CD4+ T-cell counts because of destruction of these lymphocytes by HIV. A CD4+ T-cell count of less than 200 is diagnostic of AIDS.



Viral load testing:

Only 3%-4% of the virus is located in the plasma. The remaining 90+% is located in lymphoid tissues and other blood cells. The viral load test measures the free virus in the plasma but not in these other areas. It is used to determine response of antiretroviral treatment, monitor development of drug resistance, and determine need to change antiretroviral treatment. When a patient is on ART, the viral load should be undetectable.



Viral resistance testing:

Testing for viral resistance to specific antiretroviral drugs. Before initiating treatment, this test is used to determine if the virus is already resistant to a specific agent. It is also used to assess treatment failure and assist in determining appropriate changes in the introduction of new or alternative antiretroviral agents. The different types of resistance testing include genotypic assays, phenotypic assays, and virtual phenotype.





Nursing diagnosis:


Impaired gas exchange


related to altered oxygen supply occurring with pulmonary infiltrates, hyperventilation, and sepsis


Desired Outcomes: After treatment/intervention, patient has adequate gas exchange as evidenced by respiratory rate (RR) 12-20 breaths/min with normal depth and pattern (eupnea) and absence of adventitious sounds, nasal flaring, and other clinical indicators of respiratory dysfunction. By hospital discharge, patient’s oximetry demonstrates O2 saturation greater than 92% or arterial blood gas (ABG) results as follows: PaO2 80 mm Hg or higher; PaCO2 35-45 mm Hg; pH 7.35-7.45.











































ASSESSMENT/INTERVENTIONS RATIONALES
Assess respiratory status as often as indicated by patient’s condition. Assess rate, rhythm, quality, cough, and sputum production. Use of accessory muscles, flaring of nares, presence of adventitious sounds, cough, changes in color or character of sputum, or cyanosis occur with respiratory dysfunction. See discussion in next nursing diagnosis about adventitious sounds that can occur with opportunistic infections that have pulmonary signs and symptoms.
Maintain continuous or frequent monitoring of O2 saturation via pulse oximetry. Report findings of less than 92%. O2 saturation 92% or less may signal need for supplementary oxygen and should be reported to health care provider.
Assess ABG results for changes and report abnormal findings. Decreased PaCO2 (less than 35 mm Hg) and increased pH (greater than 7.40) can occur with hyperventilation.
As prescribed, initiate or adjust oxygen therapy.
Administer oxygen with humidity.		 This measure helps ensure optimal oxygenation as determined by ABG values.
Humidity alleviates convective losses of moisture and relieves mucous membrane irritation, which can predispose patient to coughing spells.
Instruct patient to report changes in cough, as well as dyspnea that increases with exertion. These indicators may be seen with opportunistic respiratory disease.
Provide chest physiotherapy as prescribed. Encourage use of incentive spirometry at frequent intervals. These measures help loosen secretions, prevent atelectasis, and improve expectoration of secretions.
Reposition patient q2h, and assist with ambulation and sitting up as tolerated. Repositioning and walking help prevent stasis of lung fluids.
Assess for changes in color or character of sputum; obtain sputum for culture and sensitivity as indicated. Changes in color and character of patient’s sputum may signal infection; a culture confirms infection type.
Group nursing activities to provide patient with uninterrupted periods of rest, optimally 90-120 min at a time. Rest promotes optimal chest excursion.
When administering Trimethoprim + Sulfamethoxazole (TMP-SMX) for PCP, monitor closely for rash, fever, or bone marrow suppression (leukopenia, neutropenia). These are side effects of TMP-SMX.
If administering pentamidine for PCP, be alert to hypotension, hypoglycemia, hyperglycemia, or nephrotoxicity. These side effects necessitate frequent blood pressure (BP) checks and fingersticks for blood sugar levels.
If administering corticosteroids, be alert for additional infections or other potential side effects. Side effects of corticosteroids include masking of and increased susceptibility to infection. Corticosteroids may be given for PCP when PaO2 is less than 70 mm Hg or arterial alveolar O2 gradient is more than 35 mm Hg.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Caring for individuals with human immunodeficiency virus

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