Syndrome (AIDS) • Ina, a nurse phlebotomist, is assigned to an HIV- positive patient. She was tasked to withdraw blood from the said patient to be sent to the laboratory. While Ina is withdrawing blood from the patient, he suddenly went berserk, and Ina’s needle plunged deep into her arm. Afraid of being reprimanded, Ina kept the incident from her colleagues. A month after, Ina reported fever and skin rash to her physician. She confessed about the incident of the needle prick with her physician, so he ordered a series of tests to confirm Ina’s diagnosis. The laboratory results showed that Ina is in the primary infection stage of HIV infection. Description • HIV or human immunodeficiency virus and acquired immunodeficiency syndrome is a chronic condition that requires daily medication. • HIV- 1 is a retrovirus isolated and recognized as the etiologic agent of AIDS. • HIV-2 is a retrovirus identified in 1986 in AIDS patients in West Statistics and Epidemiology • In 2008, the CDC reported that approximately 56, 300 new HIV infections occurred in the United States in 2006. • The figure was roughly 40% higher than their former estimate of 40, 000 HIV infections per year. • Almost 7000 people still contract HIV infection every day. • An estimated 33 million people are living with HIV/AIDS; however, the number of new infections declined from 3 million in 2001 to 2.7 million in 2007. • The global percentage of women among people with HIV/AIDS remains at 50%. • Sub-Saharan Africa continues to be most heavily affected by HIV/AIDS, with 67% of all people living with the disease. • In 2007, 72% of deaths from HIV/AIDS occurred in the same region. Classification The stages of HIV disease is based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies. • Primary infection (Acute/Recent HIV Infection). The period from infection with HIV to the development of HIV-specific antibodies is known as primary infection. • HIV asymptomatic (CDC Category A). After the viral set point is reached, HIV-positive people enter into a chronic stage in which the immune system cannot eliminate the virus despite its best efforts. • HIV symptomatic (CDC Category B). Category B consists of symptomatic conditions in HIV- infected patients that are not included in the conditions listed in category C. • AIDS (CDC Category C). When the CD4+ T-cell level drops below 200 cells/mm3 of blood, the person is said to have AIDS. Causes • Sharing infected drug use equipment such as needles. • Having sexual relations with infected individuals (both male and female). • Blood transmission : Receiving HIV-infected blood or blood products especially before blood screening. • Maternal HIV : Infants born to mothers with HIV infection. Pathophysiology The virus is present in lymphoid cells ,semen , blood,vaginal secrections , saliva ,breast milk ,tears , urine ,serum ,CSF etc. of the patient Infections occurs by : Sexual contact with infected person Transfusion of blood and blood products From mother to child before birth via placenta after birth through breast milk Needle stick injuries and blood splash on open wound Sharing of needles in drug addicts Virus after entry
Infects CD4 cells ( T helpers cells )
Death of CD4 cells
Reduced number of CD4 cells
Immunity reduced (cell mediated immunity in particular)
Loss of protection
Results
Opportunistic infections Kaposi’s sarcoma
Clinical Manifestations AIDS is characterized by : • Fever • Malaise • Weight loss • Chronic Diarrhea • Night Sweats • Cervical Lymphadenopathy • Persistent cough • Enlarged lymph nodes in the neck, armpits, and groin • White Patches on tongue • Shortness of Breath • Kaposi’s Sarcoma – a dermal malignancy • Opportunistic infections caused by bacteria ,fungi ,virus ,parasites etc Prevention and Control • Health education through television,radio,news paper, etc. regarding the basic concepts of HIV transmission • Avoidance of sexual contact with unknown person / multiple sex partners • Use of physical barriers such as condoms • Use of same needle and syringe should be avoided • Screening of blood and blood products • Change of lifestyle • Isolation and Treatment of AIDS patient • Vaccine - no effective vaccine is available – a number of vaccine preparations are under trial Complications • Opportunistic infections : Patients who are immunosuppressed are at risk for opportunistic infections such as pneumocystis pneumonia which can affect 80% of all people infected with HIV. • Respiratory failure: Impaired breathing is a major complication that increases the patient’s discomfort and anxiety and may lead to respiratory and cardiac failure. • Cachexia and wasting : Wasting syndrome occurs when there is profound involuntary weight loss exceeding 10% of the baseline body weight and it is a common complication of HIV infection and AIDS. Assessment and Diagnostic Findings • History Collection • Physical Examination • Confirming Diagnosis (patient’s CD4+ T-cell count falls below 200 cells/mm3 ) • CBC • PPD • Serologic • Western blot test • Viral load test • STD screening tests • Cultures • Neurological studies : (EEG), (MRI), (CT) (EMG) • Chest x-ray • Pulmonary function tests • Biopsies • Bronchoscopy/tracheobronchial washings • Barium swallow, endoscopy, colonoscopy Medical Management Medical management focuses on elimination of opportunistic infections.
• Treatment of opportunistic infections. For Pneumocystis pneumonia, TMP-SMZis
the treatment of choice; for mycobacterium avian complex, azithromycin or clarithromycin are preferred prophylactic agents; for cryptococcal meningitis, the current primary treatment is IV amphotericin B. • Prevention of opportunistic infections. TMP-SMZ is an antibacterial agent used to treat various organisms causing infection. • Antidiarrheal therapy. Therapy with octreotide acetate (Sandostatin), a synthetic analog of somatostatin, has been shown to be effective in managing severe chronic diarrhea. • Antidepressant therapy. Treatment for depression in patients with HIV infection involves psychotherapy integrated with imipramine, desipramine or fluoxetine. • Nutrition therapy. For all AIDS patients who experience unexplained weight loss, calorie counts should be obtained, and appetite stimulants and oral supplements are also appropriate. Nursing Management Nursing Assessment Nursing assessment includes identification of potential risk factors, including a history of risky sexual practices or IV/injection drug use. • Nutritional status: Nutritional status is assessed by obtaining a diet history and identifying factors that may affect the oral intake. • Skin integrity : The skin and mucous membranes are inspected daily for evidence of breakdown, ulceration, or infection. • Respiratory status : Respiratory status is assessed by monitoring the patient for cough, sputum production, shortness of breath, orthopnea, tachypnea, and chest pain. • Neurologic status: Neurologic status is determined by assessing the level of consciousness; orientation to person, pace, and time; and memory lapses. • Fluid and electrolyte balance : F&E status is assessed by examining the skin and mucous membranes for turgor and dryness. • Knowledge level : The patient’s level of knowledge about the disease and the modes of disease transmission is evaluated. Diagnosis • Impaired skin integrity related to cutaneous manifestations of HIV infection, excoriation, and diarrhea. • Diarrhea related to enteric pathogens of HIV infection. • Risk for infection related to immunodeficiency. • Activity intolerance related weakness, fatigue, malnutrition, impaired F&E balance, and hypoxia associated with pulmonary infections. • Disturbed thought processes related to shortened attention span, impaired memory, confusion, and disorientation associated with HIV encephalopathy. • Ineffective airway clearance related to PCP, increased bronchial secretions, and decreased ability to cough related to weakness and fatigue. • Pain related to impaired perianal skin integrity secondary to diarrhea, KS, and peripheral neuropathy. • Imbalanced nutrition, less than body requirements related to decreased oral intake. Planning & Goals • Achievement and maintenance of skin integrity. • Resumption of usual bowel pattern. • Absence of infection. • Improve activity intolerance. • Improve thought processes. • Improve airway clearance. • Increase comfort. • Improve nutritional status. • Increase socialization. • Absence of complications. • Prevent/minimize development of new infections. • Maintain homeostasis. • Promote comfort. • Support psychosocial adjustment. • Provide information about disease process/prognosis and treatment needs Nursing Interventions • Promote skin integrity • Promote usual bowel patterns • Prevent infection • Improve activity intolerance • Maintain thought processes • Improve airway clearance • Relieve pain and discomfort • Improve nutritional status Discharge and Home Care Guidelines • Patients and their families or caregivers should receive instructions about how to prevent disease transmission, including hand-washing techniques and methods for safely handling and disposing of items soiled with body fluids. • Patients are advised to avoid exposure to others who are sick or who have been recently vaccinated. • Medication administration : Caregivers in the home are taught how to administer medications, including IV preparations. • The patient’s adherence to the therapeutic regimen is assessed and strategies are suggested to assist with adherence. • Infection prevented/resolved. • Complications prevented/minimized. • Pain/discomfort alleviated or controlled. • Patient dealing with current situation realistically. • Diagnosis, prognosis, and therapeutic regimen understood. • Plan in place to meet needs after discharge. Bibliography • Brunner and Suddarth’s ,”Text Book Of Medical Surgical Nursing”,7th edition, Page no: • B.S.Nagoba, “Microbiology For Nurses ‘’ 2nd edition, BI Publication , New Delhi , Page no: 183 to 186 • NURSESLAB : https://nurseslabs.com/hiv-aids/