Med-Surg: Chapter 22: Coordinating Care for Patients with HIV

Question 1

What is Human Immunodeficiency Virus (HIV) Disease?

Answer 1

caused by the human immunodeficiency virus (HIV)

• several stages, ranging from acute infection to death
• HIV infected individual who does not receive treatment, their time from infection until death is 12 years
• malnutrition, TB, and malaria are comorbidities that shorten survival time in the untreated
• highly communicable
• lethal if untreated

Question 2

How do you contract the disease?

Answer 2

• Most commonly a sexually transmitted disease
• Sexually through: Blood, Semen, Preseminal fluids, Rectal fluids, and Vaginal fluids
• IV drug use; blood containing the HIV virus is injected into the bloodstream of an uninfected individual when needles or syringes are shared
• Pregnant women or breastfeeding women infected with HIV can transmit the disease to their child by pregnancy, delivery, or breastfeeding

Question 3

Pathophysiology of HIV

Answer 3

when an individual becomes infected with HIV, immune system functions are compromised, and the individual becomes more susceptible to a variety of infections
-there is a chronic, persistent destruction of infection-fighting cells (CD-4) by the replication of HIV; HIV targets the CD-4 cell (T-helper cell)
(CD4 cell is a type of T lymphocyte, normally when stimulated by a recognized antigen from a virus-infected cell, the CD4 release cytokines. This activates B lymphocytes and killer T lymphocytes in an effort to destroy the invading organism)

• the infected individual manifests various stages of HIV disease over the course of time
• if untreated, can eventually die, usually from opportunistic infection (OI)

Question 4

Viral Transmission, Acute Viral Infection, and Seroconversion

Answer 4

when a person is first infected with HIV, the virus causes an inflammatory reaction, bringing WBCs and macrophages to the site of the inoculation with the virus

• a virus particle attaches to the specific receptors on the CD4 cell (T-helper cell) and enters the cell
• on the inside of the cell, viral RNA is changed to viral DNA using enzyme reverse transcriptase
• the viral DNA is then integrated with the CD4 lymphocyte cellular DNA in the nucleus of the lymphocyte
• the HIV DNA is now in charge of cell reproduction and produces new viral proteins
• viral proteins are assembled, and new HIV viruses are released, able to infect other CD4 lymphocytes; the CD4 lymphocyte is destroyed as a result of new viruses being produced

> the result:

• rapid decrease in CD4 lymphocyte count
• rapid increase in viral load (amount of HIV virus in blood)

> During this acute infection:
-flu like viral symptoms: low-grade fever, generalized aches and pains, swollen lymph nodes, generally feeling ill

> After several weeks:

• immune system develops antibodies to HIV
• seroconversion occurs (interval when HIV antibodies are first produced and rise to detectable levels) and person tests positive for HIV
• until seroconversion occurs, HIV test will be negative

Question 5

Asymptomatic Chronic Infection

Answer 5

the immune system begins to exert control but is not able to eliminate viral replication

• CD4 count increases to near normal
• Viral load drops to a set-point level

> the viral set point occurs when viral replication is still taking place but the immune system is able to destroy the virus in equal amounts as is being produced

> over the years:

• CD4 count slowly falls losing 50 to 100 CD4 cells per year
• viral load slowly increases
• progresses to symptomatic chronic infection

Question 6

Symptomatic Chronic Infection

Answer 6

as the HIV-infected individuals CD4 count continues to fall, control over viral replication is slowly lost
-immune system less able to fight infections

> Develop nonspecific symptoms:

• frequent respiratory tract infections
• skin problems
• lymphadenopathy (enlarged lymph nodes)
• weight loss
• CD4 count fall more rapidly
• rapid increase in viral replication
• once a person becomes symptomatic, the average time to develop AIDS is 2 years

Question 7

Acquired Immune Deficiency Syndrome (AIDS)

Answer 7

as the CD4 count continues to fall, the immune system is les and less able to fight off infections

• infections can use the “opportunity” of a nonfunctioning immune system to infect the body, or the immune system loses the ability to control infections that are in the dormant phase, allowing the infection to come reactivated
• An HIV-infected individual has AIDS when the CD4 count is less than 200 cells/uL or when he/she is diagnosed with one or more AIDS defining illnesses

Question 8

When does an individual have AIDS

Answer 8

• when a HIV-infected individuals CD4 count is less than 200 cells/uL
• he/she is diagnosed with one or more AIDS defining illness

Question 9

Commonly occurring AIDS-defining illnesses

Answer 9

• Pneumocystis (carinii) jiroveci pneumonia
• Mycobacterium avium complex
• Toxoplasmosis
• Esophageal candidiasis
• Recurrent bacterial pneumonia

Question 10

Target Organs Secondary to HIV

Answer 10

• kidneys
• peripheral and central nervous system
• cardiovascular system

Question 11

HIV Replication

Answer 11

1. Fusion of HIV to the host cell surface
2. HIV RNA, reverse transcriptase, integrase and other viral proteins enter the host cell
3. Viral DNA is formed by reverse transcription
4. Viral DNA is transported across the nucleus and integrates into the host DNA
5. New viral RNA is used as genomic RNA and to make viral proteins
6. New viral RNA and proteins move to the cell surface and a new, immature HIV forms
7. The virus matures by protease releasing individual HIV proteins

Question 12

Progression through HIV/AIDS Stages

Answer 12

• Viral Transmission
• Acute Viral Infection, 1 to 2 weeks
• Seroconversion
• Asymptomatic Chronic Infection, average 3 to 10 years
• Symptomatic/AIDS, average 2 years
• Death

Question 13

Common Signs and Symptoms

Answer 13

• fever
• cough
• weakness
• nausea/vomiting
• diarrhea
• dysphagia, or difficulty swallowing
• forgetfulness
• skin lesions
• SOB, or dyspnea on exertion
• headache
• vision changes
• pain
• night sweats
• lymphadenopathy

Question 14

Clinical Manifestations indicating deterioration in status requiring immediate attention by a health care provider

Answer 14

• new cough
• increased fatigue
• fever less than 97 degrees F or higher than 102 Degrees F
• night sweats
• new onset of headache
• new onset of visual blurring
• recent changes in mental status
• new skin lesions
• new onset of diarrhea
• weight loss greater than 10% of previously recorded weight

Question 15

Clinical Manifestations of HIV and Probable Cause

Answer 15

HIV weakens immune system, killing immune system, infection fighting cells
>Weight loss
-worsening disease

> Fever
-infection

> Night sweats
-mycobacterial infection

> Cough
-pneumonia, TB

> Dyspnea on exertion but not at rest
-Pneumocystis carinii pneumonia

> Unable to do usual activities
-neurological infections, anemia

> Severe headache
-meningitis

> Pain when Swallowing
-oral or esophageal candidiasis, aphthous ulcers

> Mental Status changes
-CNS infection/tumor

> Fatigue
-anemia, infection

Question 16

Diagnostic Testing

Answer 16

diagnostic or screening tests assess for antibodies to the HIV virus
-Rapid Tests or point-of-care tests

Question 17

Diagnostic Testing: Rapid Test

Answer 17

utilizing blood or oral fluids

• used in settings where a quick answer for the presence or absence of HIV antibodies is required (health screening, occupational exposure, or labor and delivery)
• do not require a laboratory to perform the test
• results available in 5 to 30 minutes

Question 18

Diagnostic Testing: ELISA (enzyme-linked immunosorbent assay)

Answer 18

screening test

• requires blood sample
• specimen must be sent to the lab for testing
• results available in 24 to 48 hours

Question 19

Screening In HIV

Answer 19

• a negative screening test does not require confirmation but should be repeated in 3 to 6 months, allowing time for antibodies to develop and be detected if they are present
• ELISA screening test
• screened for common comorbidities

Question 20

HIV Western Blot Test

Answer 20

a positive screening requires confirmation by a HIV western blot test

• confirmation of HIV
• confirms the presence of proteins unique to the HIV virus
• if the proteins are absent, the person is not infected with HIV
• A positive screening test followed by a confirmatory western blot test is used to diagnose HIV in all individuals over the age of 12 months

Question 21

Medications: Prophylaxis

Answer 21

if an HIV (+) individual has a CD4 count of 200 cells/L or less, prophylaxis to reduce the risk of opportunistic infections (OIs) such as toxoplasmosis and PCP, is initiated prior to starting antiretrovirals
-prevention

Question 22

Medications: Antiretroviral Therapy (ART)

Answer 22

• recommended to all HIV (+) individuals

- antiretrovirals interfere with the ability of HIV to reproduce itself

Question 23

Prior to the Initiation of ART

Answer 23

hepatic and renal function are evaluated
-significant abnormalities influence the medication choice b/c medication metabolism takes place in the liver and kidneys

Question 24

What happens when ART is begun

Answer 24

• CD4 count will increase
• HUV viral load will decrease to nondetectable levels
• occurs in 6 to 8 weeks

Question 25

Prevention of HIV

Answer 25

Testing for HIV
-all providers should offer routine opt-out screening for all individuals between ages 15 and 65
in HIV-negative individuals, yearly testing is recommended for those at high-risk (being in a community with a HIV prevalence of greater than 1 %; sexual transmitted infection clinic attendees and incarcerated individuals)

Question 26

Complications of HIV

Answer 26

related to decrease in immune function and consist of opportunistic infections and malignancies

• CD4 count greater than 500 cell/L: no s/s r/t HIV infection but women may have an increased incidence of vaginal candidiasis unrelated to antibiotic use or diabetes
• CD4 count between 500 and 350 cells/L: increased respiratory illness or dermatological manifestations like herpes zoster
• CD4 count between 350 and 200 cells/L: increase in infections mediated by the adaptive immune system and develop symptoms of fever, fatigue, or severe bacterial infections
• CD4 falls below 200 cell/L: have AIDS
• immune reconstruction inflammatory syndrome (IRIS)

Question 27

Assessment and Analysis: Clinical Manifestations

Answer 27

reflection of the opportunistic illnesses associated with HIV (frequent respiratory illness, pneumonia, meningitis, or Candida esophagitis)

• fever
• cough
• weakness
• nausea/vomiting
• diarrhea
• dysphagia, or difficulty swallowing
• forgetfulness
• skin lesions
• SOB, or dyspnea on exertion
• headache
• vision changes
• pain
• night sweats
• lymphadenopathy

Question 28

Nursing Assessments

Answer 28

• Temperature, pulse, respirations, oxygen saturation
• Weight trends
• CD4 Count
• Viral loud
• Adherence to ART
• TB status
• Immunization status
• Depression

Question 29

Nursing Assessments: Temperature, pulse, respirations, oxygen saturation

Answer 29

• fever often first indicator of infection
• in individuals with low CD4 lymphocytes, there is an inability to release pyrogens, resulting in low-grade fever even in the face of a significant infection
• a drop in body temperature in the presence of infection is a sign of compensatory failure
• increased HR is an effort to reduce the core body temperature
• hypoxemia, or decreased oxygen carrying capacity, may occur as a result of decreased number of functioning alveoli secondary to a respiratory infection such as PCP or from anemia secondary to a side effect of medication or pancytopenia from the invasion of the bone marrow by HIV

Question 30

Nursing Assessment: Weight Trends

Answer 30

• weight loss results from caloric expenditure exceeding caloric intake and can affect cellular metabolism
• weight loss of 10% or more can indicate worsening disease, treatment failure if on ART, or depression
• can lead to decreased albumin levels, impairing medication transport and utilization

Question 31

Nursing Assessments: CD4 levels

Answer 31

-the lower the CD4 count, the more suppressed the individuals immune system is

Question 32

Nursing Assessments: Viral Load

Answer 32

reflects the amount of viral replication

• indicator of disease progression
• the higher the viral load, the more quickly the disease progresses from HIV to AIDS

Question 33

Assessments: Immunization Status

Answer 33

• immunocompromised individuals should maintain up-to-date immunization status
• not receive live-virus vaccines b/c of the risk of developing the disease
• immunizations in the individuals with a CD4 count less than 200 cell/L may not be as effective b/c of the compromised ability to produce antibodies in response to the immunization

Question 34

Nursing Actions

Answer 34

> Utilize universal precautions consistently

• hand hygiene (15 to 30 seconds)
• PPE such as gloves, goggles, and gown

> Administer ART as prescribed and on time

• maintaining medication level is critical to preventing medication resistance
• administering doses more than 1 or 2 hours after the usual time can increase the risk of development of viral resistance

> Provide nutritionally dense foods and small, frequent meals

• anorexia, nausea, and vomiting commonly seen in HIV/AIDS; persistent can lead to dehydration, weight loss, and electrolyte imbalances
• small, frequent meals/snacks, foods such as nuts or nutritional supplements, will increase caloric intake and provide protein and essential micronutrients

> Provide emotional support
Refer to Social Services evaluation

Question 35

Teaching

Answer 35

> Avoid high-risk behaviors that increase risk of transmission

• use of condoms
• avoid use of street drugs or alcohol

> Adherence to treatment regimen
-take as ordered and at the same time each day

> Implementing infection-control precautions at home

• blood spills cleaned with bleach solution
• avoid raw or undercooked eggs, meat, poultry, or fish to reduce risk of diarrheal illness
• animal excrement taken care of by a non-HIV-infected, non-pregnant individual to avoid exposure to toxoplasmosis and other animal-borne illness

> S/S to report to healthcare provider
Health maintenance needs

Question 36

Evaluating Care Outcomes

Answer 36

can live a normal life span when adherent to therapy

• strict compliance with the medical regimen is necessary to achieve viral suppression and prevent development of resistance
• practicing infection control practices at home and eliminating risky behaviors
• response to ART is determined by measuring the CD4 count and viral load
• within 6 to 8 weeks of therapy initiation, there is an increase in CD4 count and a decrease in viral load
• Over several months, viral load should reach nondetectable levels

Question 37

Medications given for HIV

Answer 37

• acyclovir
• enfuvirtide
• ritonavir

Question 38

Medication given for HIV: Enfuvirtide

Answer 38

fusion inhibitor

• only subcutaneous injection
• decreases and limits the spread of HIV by blocking HIV from attaching to and entering CD4 T cell
• prevents the HIV virus from entering target cells

> may cause an injection-site reaction

• rotate injection sites
• monitor for swelling and redness

> may cause bacterial pneumonia

• assess breath sounds prior to start of therapy
• monitor for pneumonia (fever, cough, or SOB)

> may cause fever, chills, rash, hypotension

• monitor for medication reaction
• d/c and notify provider

> contraindicated in clients who have medication hypersensitivity and who are breastfeeding
rotate injection sites and avoid previous skin reaction areas
bring solution to room temperature before injection
monitor for bacterial pneumonia
monitor for systemic hypersensitivity reaction
notify provider is pregnancy suspected

Question 39

Medication Given for HIV: Acyclovir

Answer 39

antiviral

• prevent the reproduction of viral DNA and interrupts cell replication
• oral, topical, IV
• used to treat HIV

> Can cause phlebitis and inflammation at the site of infusion

• rotate IV injection sites
• monitor IV sites for swelling and redness

> Can Cause Nephrotoxicity

• administer acyclovir slowly over 1 hour
• ensure adequate hydration during infusion and 2 hour after to minimize nephrotoxicity by administering IV fluids and increasing oral fluid intake as prescribed
• use caution in clients who have renal impairment or are dehydrated

> Can cause mild discomfort associated with oral therapy

• nausea, headache, diarrhea
• observe for manifestations and notify provider

> use cautiously with renal impairment and dehydration, and clients taking nephrotoxic medications
pregnancy risk category B and C
use barrier contraception
administer IV infusion slowly over 1 hour or longer
continue to use condoms even when have healed herpetic lesions
expect relief of manifestations but not a cure
for topical administration put on rubber gloves to avoid transfer of virus to other areas of body

Question 40

Medication for HIV: Ritonavir

Answer 40

antiretroviral; protease inhibitor

• oral
• act against HIV-1 and HIV-2 to alter and inactivate the virus by inhibiting enzymes needed for HIV replication
• used to treat HIV infection
• given with other PIs to increase effect

> may cause bone loss/osteoporosis

• severe bone loss is treated with medications (raloxifene and alendronate)
• diet high in calcium and vitamin D

> may cause diabetes mellitus/ hyperglycemia

• monitor blood glucose
• adjust diet and administer antidiabetic medications

> hypersensitivity reaction
-monitor for rash; notify provider

> nausea and vomiting
-take medication with food to reduce GI effects and increase absorption

> Elevated blood lipids
-monitor for hyperlipidemia; adjust diet

> Altered fat distribution
-warn clients of effects

> contraindicated in liver disease, pancreatitis, DM, Av block, and hypercholesteremia
pregnancy risk B or C
avoid grapefruit juice
use alternative forms of birth control
take with food
administer with another antiretroviral to reduce risk of medication resistance

Question 41

Classification of HIV: The Stages

Answer 41

> Stage 1 HIV Infection
-at least 500 CD4 cells/uL

> Stage 2 HIV Infection
-200-499 CD4 cells/uL

> Stage 3 HIV Infection (AIDS)
-less than 200 CD4 cells/uL

Question 42

HIV Safety Alert: Occupational Exposure

Answer 42

Occupational exposure to blood or bodily fluids should be REPORTED immediately
-if patients HIV status is unknown, permission may be requested to do the appropriate screening
-if there is visible blood or fluids, wash the area under running water
-do not squeeze the injured area b/c that increases possibility of infection
-a HIV test to ascertain seropositivity is offered:
>if positive: a referral for acre is initiated
>if negative: antiretrovirals prescribed
-two or three medications are prescribed to be taken for 28 days; HIV testing at 6 weeks, 12 weeks, and 4 to 6 months after exposure; nursing mothers encouraged not to breastfeed

Question 43

HIV Cannot Be Spread Through?

Answer 43

• water
• saliva
• sweat
• tears
• kissing
• insects
• pets
• sharing toilets, food, or drinks

Question 44

What Happens if HIV is left Untreated?

Answer 44

can progress into several stages before developing AIDS

• no infection–>acute asymptomatic chronic HIV—>Symptomatic chronic HIV—> AIDS
• process takes 12 years in developed areas vs 5 in underdeveloped countries

Question 45

What does HIV Affect?

Answer 45

The immune system

• more difficult for the body to fight infections
• virus attacks immune cells (CD4 cells)
• viral RNA converts to DNA (seroconversion); this DNA integrates with the nucleus of the CD4 cell which produces new proteins and affects other immune cells

Question 46

What happens when a person becomes infected with HIV?

Answer 46

• immune system functions are compromised and are more susceptible to infections b/c of the chronic persistent destruction of immune fighting cells
• these infections lead to death associated with HIV complications

Question 47

When Caring for a Patient with HIV

Answer 47

-monitor for s/s of infection
-monitor: weight loss (more than 10%), fever, night sweats, cough, diarrhea, dyspnea on exertion, severe headache. pain with swallowing, mental status changes, and fatigue
>Immediate medical attention of new onset or worsening of these symptoms

Question 48

Key to a prolonged life

Answer 48

• early identification
• consistent maintenance
• aggressive treatment of secondary infections
• anti-retroviral therapy; interferes with the viruses ability to reproduce