Presented by: Concepcion, John Angelo Lubrin, Christian Paglinawan, Rosalinda

An immune system is a system of

biological structures and processes within an organism that protects against disease. To function properly, an immune system must detect a wide variety of agents, from viruses to parasitic worms, and distinguish them from the organism's own healthy tissue.

 a lentivirus (a member of

the retrovirus family) that causes acquired immunodeficiency syndrome (AIDS), a condition in humans in which progressive failure of the immune system allows lifethreatening opportunistic infections and cancers to thrive.

Unsafe sex
Contaminated needles Breast milk

Perinatal transmission

Stages Primary Infection (Acute HIV Infection)

Definition Intense viral replication and widespread throughout the body.

HIV Asymptomatic

A chronic, asymptomatic state begins.

HIV Symptomatic

Decrease in CD4 T cells count.

AIDS

When CD4 T-cell levels drop below 200 cells/mm3

Systems

Findings

Integumentary

Disheveled appearance Deficits in many or all personal care, selfcare activities Poor skin turgor Generalized pruritic dermatitis Slow healing (if anemic); bleeding longer with injury Tachycardia, postural BP changes Decreased peripheral pulse volume Pallor or cyanosis; delayed capillary refill
Frequent, persistent upper respiratory infections (URIs) Respiratory distress Congestion or tightness in chest Changes in breath sounds/adventitious breath sounds Sputum yellow (in sputum-producing pneumonia) Persistent Cough for one month

Circulatory

Respiration

System

Findings
Hyperactive bowel sounds Abdominal distension (hepatosplenomegaly) Weight loss; thin frame; decreased subcutaneous fat/muscle mass Lesions of the oral cavity, white patches, discoloration; poor dental/gum health, loss of teeth Anorexia, changes in taste of foods/food intolerance, nausea/vomiting Dysphagia

Digestion

System

Findings Mental status changes ranging from confusion to dementia, forgetfulness, poor concentration, decreased alertness, psychomotor retardation/slowed responses; paranoid ideation, unrealistic expectations Fine/gross motor tremors, focal motor deficits; hemiparesis, seizures Fainting spells/dizziness; headache; stiff neck Impaired sensation or sense of position and vibration Loose-formed to watery stools with or without mucus or blood; Abdominal tenderness Rectal, perianal lesions or abscesses Changes in urinary output, color, character Urinary, bowel incontinence Difficult and painful elimination; rectal pain, itching

Neurosensory

Elimination

System Sexual

Findings Pregnancy or risk for pregnancy (sexually active); pregnancy resulting in HIVpositive infant Genitalia: Skin manifestations (e.g., herpes, warts); discharge Loss of libido, being too sick for sex; being afraid to engage in any sexual activities

Muskuloskeletal

Abnormal reflexes, decreased muscle strength, ataxic gait Muscle weakness, tremors, changes in visual acuity Numbness, tingling in extremities (feet seem to display earliest changes) Changes in visual acuity; light flashes/floaters; photophobia

System

Findings

Immune System

Prolonged fever for one month Chronic Disseminated herpes simplex Generalized Lymphadenopathy

Laboratory Exams

Indications
To detect antibodies

ELISA

Serologic Also detects antibodies to HIV; used to confirm EIA/ELISA

Western Blot Test

Viral Load Test

Measures HIV RNA in the plasma

Laboratory Exams

Indications

STD screening Test

For confirmation of presence of sexual infection

Cultures

To determine the causative agent

Medication Zidovudine (Retrovir), d4t (Zerit), abacavir (Ziagen)

Classification Nucleoside analog reverse transcriptase inhibitors (NRTIs) Non-nucleoside analog reverse transcriptase inhibitors (NNRTIs)

MOA Act by becoming a part of HIVs DNA and derail its building process. Act by attaching to the reverse transcriptase enzyme, which prevents it from converting HIV RNA into HIV DNA . Works at a later stage in the HIV replication process by preventing the protease enzyme from cutting HIV viral proteins into the viral particles that infect new CD4 T4 cells

Nevirapine (Viramune), delavirdine (Rescriptor), efavirenz (Sustive)

Ritronavir (Norvir), indinavir ( Crixivan)

Protease Inhibitor

 High risk for infection, related to presence of HIV. Nutrition: imbalanced, less than body requirements R/T

decreased oral intake

Altered thought process, related to AIDS dementia, as evidenced by

confusion, memory problems and disorientation.

Diarrhea R/T enteric pathogens Social Isolation R/T stigma of the disease, withdrawal of support

systems, isolation procedures, and fear of infecting others

 WASH HANDS BEFORE AND AFTER ALL CARE

CONTACTS. INSTRUCT PATIENT/SO TO WASH HANDS AS INDICATED. Monitor vital signs, including temperature. Examine skin/oral mucous membranes for white patches or lesions. (Refer to ND: Skin Integrity, impaired, actual and/or risk for, and ND: Oral Mucous Membrane, impaired.) Clean patients nails frequently. File, rather than cut, and avoid trimming cuticles. Inspect wounds/site of invasive devices, noting signs of local inflammation/infection.

 Wear gloves and gowns during direct contact with

secretions/excretions or any time there is a break in skin of caregivers hands. Wear mask and protective eyewear to protect nose, mouth, and eyes from secretions during procedures (e.g., suctioning) or when splattering of blood may occur. Dispose of needles/sharps in rigid, puncture-resistant containers. Label blood bags, body fluid containers, soiled dressings/ linens, and package appropriately for disposal per isolation protocol. Monitor laboratory studies, e.g.: CBC/differential; Culture/sensitivity studies of lesions, blood, urine, and sputum.

 Administer medications as indicated:

Antiretrovirals, e.g.: Provide frequent mouth care, observing secretion precautions. Avoid alcohol-containing mouthwashes. Provide rest period before meals. Avoid stressful procedures close to mealtime. Review laboratory studies, e.g., BUN, glucose, liver function studies, electrolytes, protein, and albumin. ASSESS MENTAL AND NEUROLOGICAL STATUS USING APPROPRIATE TOOLS.