Nursing Continuing Education

HIV/AIDS

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This is Your Course on HIV/AIDS

Syllabus

Introduction

Human immunodeficiency virus (HIV) is a condition that nurses may come across in a variety of fields of health care practice. HIV targets CD4+ lymphocytes, also known as T‑cells or T‑lymphocytes. T‑cells work in concert with B‑lymphocytes. Both are part of specific acquired (adaptive) immunity. HIV integrates its RNA into host cell DNA through reverse transcriptase, reshaping the host’s immune system.

It is a retrovirus that is transmitted through blood and body fluids, such as semen, blood, saliva, vaginal secretions, and breast milk. Working with clients, nurses are often exposed to contact with bodily fluids and therefore need to be aware of the pathophysiology of the virus, the impact that it has on health care, and protective precautions that need to be employed. While it is found in feces, urine, tears, saliva, cerebrospinal fluid, cervical cells, lymph nodes, corneal tissue, and brain tissue, these are not the most common methods of transmission. However, epidemiologic studies indicate that the latter are unlikely sources of infection. Since pregnancy exposes health care providers and the fetus with the possibility of contagion, it is recommended that all clients who are pregnant be screened for HIV.

The Disease Process

The progression of the disease occurs due to HIV attaching itself to CD4+ cells. It replicates and destroys these, leading to a decrease in the number of CD4+ cells available. The host produces extra CD8 cells to compensate for this loss. HIV continues to take over more cells and replicate itself, taking over progressively more of the host’s immune response.

HIV infection is known to be a single, continuous disease process of four stages. These progress from initial infection to the development of acquired immunity disease syndrome (AIDS) (CDC, 2017). Therefore, a client who has HIV does not necessarily have AIDS, but any client who has AIDS has it because of an HIV infection. Clients in stage 3 are severely immunocompromised and require complex care.  Stages 1, 2, and 3 are determined using the CD4+ count; however, the CD4+ percentage is used when the count is unavailable. If neither of these findings are available, the client is considered “stage unknown”. Laboratory findings listed in the following text for CD4+ counts and percentage are based on a client six years-old or older (CDC, 2014).

Stage 0

This stage is used to represent early HIV infection. During this time frame, the client has a negative HIV test, but within a 6-month time frame tests positive. It is therefore assumed the prior negative test was unable to detect the presence of HIV. 

Stage 1

The first manifestations of the disease process will occur within four weeks following an infection. These manifestations may be mistaken for influenza and can include weakness, fatigue, headache, rash, night sweats, and a sore throat. This stage is marked by a rapid rise in the HIV viral load, decreased CD4+ cells, and increased CD8 cells. According to the CDC this stage has the following characteristics:

·             Absence of an opportunistic, AIDS-defining condition.

·             CD4+ T-Lymphocyte count – 500 cells/mm3 or more

·             CD4+ T-Lymphocyte percentage of total lymphocytes – 26% or more

The resolution of manifestations of the infection is coincidental with the decline in viral HIV copies. However, lymphadenopathy persists throughout the disease process. 

Stage 2

This stage is known as the latency stage, noted for being asymptomatic, given the decline in viral HIV copies. This decline results from the body’s immune system attacking HIV, and being able to minimize it, although it is unable to totally eliminate the virus. This can be a prolonged stage with the client remaining asymptomatic for ten years or more without taking medication. For this reason, this stage is also referred to as “chronic HIV”.  During this time, anti-HIV antibodies are produced and the client should test as being HIV positive. The amount of virus in the body after the body’s efforts to eliminate it is known as the viral set point, and this amount relates directly to the client prognosis. A high viral set point equates to probable poorer outcomes for the client. 

Over a period of time the virus will use the host’s genetic machinery to begin active replication of itself. The viral load increases and CD4+ cells are destroyed. This results in a dramatic loss of immunity that can have life-threatening consequences for the client, and are a major concern in relation to health care delivery. 

According to the CDC this stage has the following characteristics:

·             Absence of an opportunistic, AIDS-defining condition.

·             CD4+ T-Lymphocyte count – 200 to 499 cells/mm3 or more

·             CD4+ T-Lymphocyte percentage of total lymphocytes – 14% to 25%

As can be seen in the decrease in the CD4+ T-Lymphocyte count and CD4+ T-Lymphocyte percentage from stage 1, the client is experiencing a significant loss of immunity at a time when the virus is becoming more active. This places the client in a more vulnerable position as they move into the third stage of the disease process. 

Stage 3

In stage 3 of the disease process the client develops AIDS and is at grave risk for opportunistic infections. It should be noted that, although all people who have AIDS have developed this condition through HIV infection, not all people who have HIV will necessarily progress to stage 3 of the disease process and develop AIDS.

According to the CDC this stage has the following characteristics:

·             Presence of an opportunistic, AIDS-defining condition.

·             CD4+ T-Lymphocyte count – less than 200 cells/mm3

·             CD4+ T-Lymphocyte percentage of total lymphocytes – less than 14%

A client is considered to be in stage 3 of the disease process if an AIDS-defining condition is present, even if the CD4+ count or percentage is outside the expected for that stage. The third stage is the final stage of the HIV infection, and if the client does not receive treatment, death is likely to occur about three years after developing AIDS. Unlike stage 1 and stage 2, which had no defining conditions, stage 3 is associated with a range of conditions.

As can be seen from the description of the stage, stage 3 is associated with serious health challenges for the client. This condition brings the nurse into contact with a client who is extremely ill and for whom personal protective measures need to be instituted. The nurse should be aware of the pathophysiology of the defining conditions associated with stage 3 to plan care for the client who has these conditions. Since the client has the potential to develop more than one of the defining conditions, this does present a challenge for the health care team when planning and delivering care. The following is a brief list of defining conditions associated with the AIDS (stage 3 of the HIV infection) as outlined by the Centers for Disease Control (CDC, 2017). 

a)         Candidiasis of the esophagus, bronchi, trachea, or lungs

b)         Herpes simples – chronic ulcers (more than one-month duration)

c)         HIV-related encephalopathy

d)         Disseminated or extra-pulmonary histoplasmosis

e)         Kaposi’s sarcoma

f)            Various types of lymphoma

g)         Mycobacterium tuberculosis of any site

h)         Pneumocystis jiroveci pneumonia (PCP; formerly known as Pneumocystis carinii pneumonia)

i)             Recurrent pneumonia

j)             Progressive multi-focal leukoencephalopathy

k)         Recurrent salmonella septicemia

l)             Wasting syndrome attributed to HIV

Summary Table of HIV Progression of Infection*

Concepts of HIV Management

i)             Disease Prevention

Dealing with an infection associated with blood and body fluids leads the nurse into the assessment of risk factors for the infection. The nurse should use this knowledge of risk factors to educate clients regarding prevention of HIV, or to help with disease screening and diagnosis.  Risk factors for HIV exposure include the following: 

·             Exposure through sexual acts. The virus is transmitted through infected seminal or vaginal secretions, and exposure of the secretions during vaginal, anal or oral sexual acts increases the risk of infection. The risk of infection is increased if the client has multiple sexual partners. Prevention measures for sexual activity include the following:

o   Abstinence, or having a single sexual partner who is committed to monogamy.

o   Avoiding anal intercourse, which greatly increases the risk of infection due to potential trauma to the mucous membranes of the rectum.

o   Use of latex or polyurethane barriers during sexual acts. This includes the use of male and female condoms for the genitals, use of dental dams for oral sexual contact, and finger or hand gloves for hand contact with the rectum or vagina. 

o   Avoiding sharing toys or articles used in sexual acts that could be contaminated with body secretions.

·             Exposure through contaminated, shared equipment, which includes intravenous drug use with needle sharing and exposure to medical equipment used in treatments and procedures. Prevention strategies to prevent exposure through needles and other equipment include:

o   Discuss needle exchange programs to prevent the reuse of or sharing of needles. 

o   Reinforce methods to clean needles, syringes, and associated paraphernalia prior to reuse if exchange is not available. 

o   Assist in the referral of clients to programs to treat substance use disorder. 

o   Follow medical facility protocols and standards for decontamination and sterilization of reusable sharps and other equipment to prevent cross-contamination. 

·             Perinatal transmission. Neonates born to a mother who has an HIV infection are at risk for contracting HIV through exposure to blood from the placenta, exposure to vaginal secretions during the birth process, or consumption of contaminated breast milk. Caesarean birth can be required to prevent transmission, depending on the mother’s viral load. Other prevention measures follow:

o   Offer universal screening for HIV for all clients who are pregnant. Retest high risk clients in the third trimester; rapid testing can be used during labor if the client’s HIV status is unknown. 

o   Encourage women who are pregnant to continue antiviral HIV therapy, or begin as soon as possible. 

o   Inform the parents about use of alternate forms of infant nutrition (e.g. formula, screened donor milk) to prevent exposure to contaminated breast milk. Breastfeeding might still be encouraged in underdeveloped nations. 

o   Provide counseling and referral on family planning. Inform individuals who express a desire to have children of the potential risk to the fetus through conceptive, provide information about alternative, or discuss contraceptive methods if the client desires to prevent contraception. 

·             Blood transfusions. The risk for this exposure type depends on the blood product screening methods required by the government of that nation. Even if blood products are screened for HIV, there is a chance that they were tested at a time when the amount of anti-HIV antibodies is not detectable. Reducing the need for transfusion of blood products is the only intervention to prevent this type of transmission (reducing the risk of bleeding, early detection of bleeding, use of growth factors).

·             Occupational groups (e.g., health care workers) who regularly handle blood and body fluids. The nurse can recommend the following prevention measures:

o   Provide ongoing education about the maintenance of standard precautions in these occupational settings. 

o   Review protocols for post-exposure prophylaxis and treatment. 

Reproductive anatomy can affect HIV risk. The vaginal canal has a larger amount of mucous membrane than the penis, increasing the risk for exposure. Age is also a factor. While many HIV prevention and screening programs target adolescence and young adulthood, clients who are 50 years or older are a target population of concern. This age group represents about one fourth of HIV cases. The number of individuals in this age group who are HIV positive has been increasing and is expected to continue. This increase is attributed to a combination of a several factors: an increase in the number of adults who acquire HIV at a young age and live longer lives with treatment and decreased knowledge about HIV risk and prevention. HIV infection may be misdiagnosed or under-diagnosed because of the similarity of the manifestations of HIV infection to other illnesses that are common to this age group (Devi and Malhotra, 2014). In addition, physiological changes associated with aging, such as vaginal dryness and the thinning of the vaginal wall, increase the risk for infection transmission. 

ii)           Testing for HIV 

HIV screening is recommended for any client who self-identifies as at-risk for the condition. Specifically, the nurse should recommend screening for any client who is being screened or treated for another sexually transmitted infection, clients who use intravenous drugs, residents of correctional institutions, and individuals who have sexual partners who are infected or are at high risk for exposure. The CDC recommends screening at least once for every individual aged 13 to 64 years old. The CDC also recommends that facilities do not require specialized consent prior to HIV testing.

Diagnosis of HIV infection can involve several steps. Previously, the enzyme‑linked immunosorbent assay (ELISA) was given first, and if results were positive, a second test was given to confirm diagnosis (Western blot or indirect immunofluorescence assay [IFA]). Research and revision to testing strategies has led to more accurate immunoassay tests that are more specific and that can accurately confirm diagnosis sooner.  CDC testing recommendations from 2014 include initial screening for HIV using an antibody test or antigen/antibody test. This test is designed to detect HIV-1 antibodies, HIV-2 antibodies, and HIV-1 p24 antigen. 

·             If the initial test is nonreactive for these antigens and antibodies (negative result), no further testing is required at the time.

·             If the initial test is reactive (positive result), then the specimen should be tested using an FDA-approved immunoassay test to determine the type of HIV infection (HIV-1, HIV-2, both, or undifferentiated).

·             If results are unclear following the first two tests, the specimen should be tested using a nucleic acid test (NAT) to detect the actual virus. The NAT is only used when necessary due to its expense.

False negative testing can occur, if the client is testing during what is referred to as the “window period”. This is the time following infection that extends until a substance is produced in enough quantity to be identified by a particular laboratory test. Refer to the table below to determine the time frame for accuracy, which indicates the window period for specific test types. Due to limits of the test in relation to the window period, clients with known exposure or symptoms who have initial negative results might need to be retested in 45 to 90 days. 

Following diagnosis of HIV, the client requires further testing to determine the stage, such as HIV-1 RNA viral load, antiretroviral resistance assay, and CD4+ determination. These also assist the provider in determining a treatment plan for the client. 

Summary of Laboratory Tests

The following table summarizes information on laboratory testing related to the initial diagnosis of HIV for clients:


The client might require additional testing to monitor other aspects of health, including CBC, electrolyte profiles, lipid profiles, and kidney and liver function. These can assist with monitoring the effects of medications on the body or to detect the presence of infection or complications.  Tests to detect secondary conditions can include tuberculin (TB) skin testing, culture of urine, stool, sputum or drainage to identify infectious agents, and screening for viral hepatitis as well as other sexually transmitted infections (STI). Secondary or opportunistic conditions can worsen the outcome of HIV infection. Diagnostic imaging such as MRI and CT can help determine changes in the brain or lungs such as HIV/AIDS-related dementia, pneumonia, or neoplasm. 

Nursing Actions with Testing

1.           Prepare the client for testing.  

2.           Inform the client about the details of each test (preparation, what to expect). 

3.           Allow the client time to ask questions or express emotions.

Client Education for Test Results 

Clients should receive counseling about HIV testing and diagnosis from individuals with specific training regarding the condition. However, the nurse should inform the client of general information regarding results in the interim before specialized counseling is available. The nurse should uphold ethical principles regarding client care and avoid allowing personal values to interfere in the care and counseling of a client who has HIV if the client’s diagnosis is associated with lifestyle choices that are socially stigmatized. 

iii)         Safety and Infection Control

Nurses work within the health care team and therefore should be vigilant to ensure protection of themselves and other health care providers when dealing with a client who has an infectious disease such as HIV. Because HIV is transmitted through blood and body fluids, the nurse should follow standard precaution requirements. 

iv)       Reporting and Disclosure

The nurse who suspects a client has HIV has a duty to discuss the information with the provider, as with any other condition or finding for which the nurse is concerned. When caring for a client who is HIV positive, the nurse can communicate the client’s condition to others involved in the client’s care. If a client is newly diagnosed as HIV positive, the clinic or agency should report the results to the health department in the state in which the test has been carried out. This is to ensure that the public health department can monitor the HIV prevalence rate in that state. The information is recorded because federal and state funding is often targeted to support areas with high HIV need. The health department will then remove all personal client information and send the test results to the CDC to track national trends. 

The nurse should encourage the client to disclose a positive HIV status any partners, which includes individuals the client may engage in sexual activity with or share needles with. The notification can come from a provider, keeping the client anonymous, if the client is concerned about a partner who might become violent. Some states have partner notification laws, meaning that if a person has tested positive for HIV they are legally obliged to tell a potential sexual partner that they have HIV prior to sexual intercourse. If the partner is not informed, this can be considered a crime in some states. The client should also provide notification before sharing needles with another person. Some state health departments require providers to report the name of the client’s partners, if that information can be ascertained.. Some states have a “duty to warn” mandate. This requires clinic staff to notify a “third” party if they know that a person has a significant risk to exposure to HIV from a client that the staff member knows the client is infected with HIV. Some states require, follow up and screenings for the client’s intimate contacts who may have unwittingly become exposed to HIV. 

The nurse should inform the client that an employer might need to know about the client’s positive HIV status if the client works in an occupation where it could be a risk to others, such as working in the surgical setting where sharp instruments are commonly held which could cause bleeding. HIV is a condition covered under the Americans with Disabilities Act, so lawfully, an employer cannot discriminate against the client simply due to a positive HIV status.  

The negative outcomes of HIV self-disclosure center around the stigma and stereotyping that can be associated with HIV infection. This can lead to the marginalization of these clients within society and even from people that they have had close or intimate contact with. There is often misunderstanding and fear relating to HIV infection and AIDS. Common misconceptions are that the client diagnosed with HIV infection has a very poor prognosis and short life span, and that contagion can occur through casual contact with the client, or through items that the client has touched. The nurse should assist the client to maintain desired employment and social activities by clarifying misconceptions and assisting clients, family, and friends with education and counseling referrals.  The nurse should teach the client about issues related to contagion and safety that could be shared with individuals with whom the client interacts.

v)         Medications

Efforts to develop a vaccine to prevent HIV or minimize its effects are underway. Although no vaccine is available to the public, it is important for the nurse to note that clients who have received an HIV vaccine as part of clinical trials might test positive to HIV antibodies. HIV is not curable; however, medications for HIV management help to slow virus replication and therefore reduce the viral load.  Highly active antiretroviral therapy (ART) involves using three to four HIV medications in combination with other antiretroviral medications to reduce medication resistance, adverse effects, and dosages. Some clients at high risk might take antiviral medications as pre-exposure prophylaxis (PrEP), but effectiveness depends on the ability of the client to adhere strictly to the prescribed regime. Additionally, clients might be able to take post-expose prophylaxis (PEP) to prevent infection following actual or suspected exposure. PEP must be initiated within 72 hours of the exposure event. Detailed information about specific treatment guidelines are available at https://aidsinfo.nih.gov/guidelines.

 

Initiation of ART is usually based on CD4+ counts. Various other factors such as client ability to adhere to the treatment regimen can also affect individualized treatment plans. Goals of treatment include providing a long life with high quality of life, promoting optimal immune function, minimizing the HIV viral load, and lowering the risk of transmission of the virus to others. Specific medications work at various stages of HIV virus replication; therefore, many clients take more than one medication. This also helps to prevent medication resistance.

 

Combination products are also available that contain more than one of the antiviral medications. Additionally, the client might require medications to treat secondary or opportunistic conditions, such as antineoplastic medications, antivirals, or antifungals, or to combat adverse effects, such as antidiarrheal medications. If the client has depression, antidepressants might be prescribed which have secondary beneficial effects that reduce fatigue and lethargy, such as imipramine and fluoxetine. Methylphenidate can improve neuropsychiatric impairment. 

In the few months following initiation of ART, some clients develop immune reconstitution inflammatory syndrome (IRIS) as a result of the sudden boost in the body’s immune capabilities. This results in an exaggeration of symptoms associated with opportunistic pathogens that might be present in the client’s body (tuberculosis, fungi, hepatitis, cytomegalovirus). Treatment with corticosteroids helps to reduce the inflammation and resolve this condition. 

Nursing Actions with Medications

  • Review laboratory findings to monitor for adverse medication effects (e.g., alanine aminotransferase, aspartate aminotransferase, bilirubin, mean corpuscular volume, high‑density lipoproteins, total cholesterol, and triglycerides). 
  • Monitor total CD4+ T-lymphocyte count, CD4 percentage, and ratio of CD4 to CD8 cells to monitor disease progression and effectiveness of the medication regimen.
  • Reinforce teaching to the client about the adverse effects of the medications and explore ways to decrease the severity of adverse effects. This promotes adherence to the prescribed treatment regime.
  • Obtain a list of prescribed, over-the-counter, or herbal medications the client takes to monitor for possible interactions.

Client Education for Medication Issues

·             Take medications on a regular schedule and do not miss doses. Missed medication doses can cause medication resistance. The goal is on-time dosing 90% of the time to maintain effectiveness. 

·             Obtain information from the provider regarding protocols for missed doses specific to the respective medications. 

·             Understand medication administration timing and restrictions, and potential interactions with food or other substances.

vi)       Alternative Therapies

Clients may choose to use alternative and complementary therapies to supplement prescribed therapies in an attempt to alleviate manifestations of HIV. Common treatments used may include the following:

·             Supplements such as vitamin D to promote bone health.

·             Herbal products such as echinacea and ginseng for their effects of improving immunity.

·             Shark cartilage used in the treatment of Kaposi’s sarcoma.

·             Physical therapies such as yoga, massage and acupuncture

·             Relaxation techniques to alleviate stress and fatigue, such as meditation, visualization, guided imagery, and hypnosis.

·             Selenium supplements to slow the progression of HIV..

Ask if the client is taking herbal products. Botanicals can alter the effects of prescribed medications. For example, some clients may use St. John’s Wort to treat depression. This herbal medicine is processed via the liver and can alter the efficacy of some anti-HIV drugs such as protease inhibitors and NNRTIs. Question the client about use of therapies that might not be approved or have evidence to demonstrate effectiveness, because some treatments might cause harm to the client. Encourage the client to discuss preferences about alternative therapies with the provider.            

 

vii)     Acute nursing care

 

Nursing care in an acute setting for a client who has HIV should be prioritized according to need. Almost every body system is affected by either the pathophysiology of HIV or secondary/opportunistic conditions.  The client’s respiratory status might be affected due to fatigue or secondary infection. Confusion is possible if the brain has been affected. Pain is often a problem, so the nurse should implement both pharmacological and non-pharmacological measures to promote comfort.   Changes to the endocrine system can affect nutrition, gonads, and hormone production. Nutrition is another area of concern for a client who has HIV. The nurse should intervene to ensure the client maintains or gains weight, drinks adequate fluid, and demonstrates laboratory evidence of adequate nutrition.  Diarrhea is a common problem; the nurse should promote normal bowel movements and prevent complications from fluid or electrolyte imbalances.  Skin integrity can be compromised easily, so skin care and prevention of breakdown are important nursing strategies. 

Nursing Interventions for HIV

  • Provide a private room, if possible, if the client is immunocompromised. 
  • Provide 2 to 3 L of fluid input daily.
  • Monitor fluid intake/urinary output as well as nutritional intake. 
  • Obtain daily weights to monitor weight loss. 
  • Monitor electrolytes. 
  • Monitor skin integrity for rashes, open areas, or bruising. 
  • Monitor pain status, and implement interventions to promote comfort. 
  • Monitor vital signs (especially temperature as an indicator of infection). 
  • Auscultate lung sounds and check respiratory rate. 
  • Check neurological status to monitor for confusion, dementia, or visual changes. 
  • Monitor bowel sounds, and administer antidiarrheal medications as indicated. 
  • Encourage activity alternated with rest periods. 
  • Administer supplemental oxygen as needed. 
  • Reinforce client teaching. 
  • Assist the client with identifying primary support systems.
  • Employ the principles of asepsis when performing venipunctures or other invasive procedures.
  • If immunity is low, keep fresh plants, fruits and vegetables out of the client’s room. 

viii)    Psychological Concerns

There can be several psychological concerns for a client who has HIV. Clients can face depression due to loss of friends and acquaintances as well as physical changes to the body. Clients can experience a loss of initiative at the thought of a life-altering condition.  The client might verbalize feelings of worthlessness or helplessness.  The client can face social isolation or anticipatory grieving at expected changes in the future. Later, with AIDS, body image changes can occur such as wasting or the presence of sores or rashes. These changes can affect the client’s self-perception. Disclosing HIV positive status to family and friends can be a particular topic of concern for the client. However, clients have identified that there are positive as well as negative consequences for revealing their HIV status to others such as lowering of stigma and promotion of safe sex practices.

The nurse should demonstrate sensitivity in addressing these psychological issues with the client. Using therapeutic communication techniques, the nurse can encourage the client to express concerns and identify positive self-characteristics. Other strategies include the following:

  • Promote client independence and self-care. 
  • Advocate for client decision-making.
  • Assist the client in setting goals. 
  • Determine a baseline for the client’s typical social patterns and monitor for changes.

ix)       Interprofessional Care

Because HIV changes the course of the client’s life, the client faces many challenges in learning to manage the disease and maintain his or her preferred lifestyle. This chronic condition affects the entire body as well as affecting the client financially and psychologically. The client can require intermittent hospitalizations when immune function wanes and illness occurs. The nurse should assist with care coordination by connecting the client with members of the interprofessional team that can help with various needs related to HIV diagnosis and disease progression:

  • Infectious disease services can manage HIV therapy. 
  • Respiratory services can improve respiratory status and provide portable oxygen. 
  • Nutritional services can be consulted for dietary supplementation following recommendations from a registered dietician. Food services are indicated for clients who are homebound and need meals prepared. 
  • Rehabilitation services can be consulted for strengthening and improving the client’s level of energy. 
  • Support groups for HIV/AIDS for clients, family members, and support persons can assist with psychological coping and grieving related to the condition. 
  • Home health services are indicated for clients who need help with strengthening and assistance regarding ADLs. Home health services can also provide assistance with IVs, dressing changes, and total parenteral nutrition (TPN). 
  • Long‑term care facilities can be indicated for clients who have chronic HIV. 
  • Hospice services are usually indicated for clients who have stage 3 HIV.
  • Respite care can assist loved ones with care of the client who needs significant assistance for ADLs.
  • Community programs might be able to provide the client assistance with housekeeping, shopping, and transportation. 
  • A social worker can assist the client with financial support resources. 
  • A case manager can coordinate services for the client across the continuum of care. 

x)         Client Self-Management

The nurse plays and important role in assisting the client with self-management by discussing topics related to prevention of transmission of HIV to others, and protecting the client from acquiring infection. A major role of the nurse regarding HIV is client education for management of the disease. Education should be targeted around prolonging a functional life and prevention of complications. Clients may or may not be aware of the potential risk of contamination from blood, but this more recently this has become a generally known fact.  Therefore, protecting close contacts from exposure to contaminated blood or other body secretion is important.  Another important role for the nurse in relation to health promotion and disease prevention relates to ensuring the client is up-to-date with immunizations. The timing of this is crucial and needs to be before the client is exposed to the opportunistic infections that will develop in the third stage of the disease process. Older adult clients may be at increased risk for complications due to age-related changes and conditions, such as resistance to infection, fluid and electrolyte imbalances, malnutrition, skin alterations, and loss of muscle tissue. In addition, the nurse needs to emphasize for the client to take medications on a regular schedule, and not to miss any doses. Missed medications can cause medication resistance. Most clients should obtain the seasonal influenza vaccine and pneumococcal polysaccharide vaccine. Many immunizations are appropriate, even with a CD4+ count below 200 cells/mm3.

Client Education for Self-Management

  • Self-care
    • Report manifestations of infection immediately to the provider (cough with or without sputum, shortness of breath, pain in the mouth or with swallowing, swollen lymph nodes, gastrointestinal upset, difficulty urinating, mental changes, edema or drainage).
    • Practice good hygiene, including frequent hand hygiene. 
    • Bathe daily using an antimicrobial soap. If a full bath isn’t possible, at least clean the armpits, genitals, groin, and anus. 

o   Avoid raw foods (fruits, vegetables, paprika, black pepper) and undercooked foods (meat, fish, eggs). 

o   Do not drink liquids that have been sitting for over 1 hour, and rewash cups before use.

o   Sanitize your toothbrush weekly in the dishwasher, or by pouring bleach solution over it and rinsing with hot, running water.

o   Avoid crowds, and do not travel to countries with poor sanitation.

o   Identify positive coping mechanisms, and seek support to manage feelings of grief or loss. 

o   Return to the provider as scheduled for monitoring of CD4+ levels and percentages, and viral load. This is an important part of ensuring medications are working and preventing secondary conditions. 

o   Adhere strictly to medication schedules, and talk to your provider about helping to manage adverse medication effects. Do not begin any new prescription, over-the-counter, or botanical supplements without discussing it with the provider who manages your ART therapy.

o   Maintain a well-balanced diet; monitor for and report weight loss. 

  • Avoid sharing items that contain body secretions or blood, such as eating utensils, razors, or toothbrushes.

o   Talk to the provider about obtaining immunizations to protect from infectious diseases.

    • Avoid exposure to individuals who have colds or flu viruses.
  • Home Environment interventions
    • For household items contaminated with body secretions, clean the area with soapy water, then disinfect the surface. 
    • Store clothes or linens soiled with excreta in plastic until able to launder. Rinse, discarding the water in the toilet. Wash the fabrics in hot water, adding 1 cup of bleach.
    • Keep the home environment clean by using a disinfectant.
    • Wash dishes in hot sudsy water, using a dishwasher, if available. Do not handle pet urine or feces; avoid cleaning birdcages, litter boxes, or aquariums.
    • Discard solid waste or cleaning solutions in the toilet. 
    • Discard contaminated, disposable items in a plastic bag (paper towel, dressings, perineal pads). Tie the bag securely, and dispose in the regular garbage. 
    • Designate a sharps container for disposal of needles to prevent stick injuries. Use a metal coffee can or hard plastic bleach bottle. Add bleach to full containers, seal with tape, and place in a plastic bag in the regular trash. 

Caring for a Client who has AIDS 

As the course of HIV progresses and the immune system becomes depleted, the client moves into the AIDS phase of the disease process (stage 3 HIV). AIDS syndrome is evidenced clinically by the development of complications such as opportunistic infections. In general, the nurse should implement many of the care strategies previously mentioned for a client who has HIV; however, the AIDS client has a more complicated disease status, so the nurse may need to be more aggressive regarding symptom management and coordinate with a larger team of health care professionals to provide comprehensive management of the client’s condition. A client who is diagnosed with AIDS is eligible for some government benefits including housing and disability assistance that were not available with initial HIV diagnosis. 

i)             Client Care Needs

When planning for the care priorities of clients who have AIDS, it is important to address the potential problems and comfort measures to support these clients. While treating existing conditions, the nurse must also be proactive in preventing the development of new infection. The major need categories are addressed as life preserving needs, physical needs,  and psychological needs. 

Life Threatening Care Needs

The nurse can use the prioritization principle of airway, breathing, circulation to address client physical needs. Some clients experience problems with airway clearance and could develop respiratory distress. If this is anticipated, the nurse should have suction equipment and oxygen available. Rigorous monitoring of vital signs, including breath sounds, are imperative. Bronchodilators and antibiotics should be given as prescribed and the client should be monitored for the symptoms of secondary infections. Electrolyte disturbances could lead to arrhythmias or alterations in blood pressure, and neurological changes place the client at increased risk for injury. 

Physical Care Needs

Clients who are immunocompromised due to conditions, such as AIDS, are susceptible to developing a range of diseases because of their compromised immune status. Therefore, the standard infection control precautions should reinforced with the client and family, and everyone who enters or leaves the room should be reminded to wash their hands. The client should be monitored for a range of opportunistic oral infections, as well as meningitis. They should be regularly assessed for hydration and their weight monitored. Nutritional supplements should be encouraged as required. As the disease process progresses the client may experience fatigue and require assistance with their activities of daily living. They should be encouraged to relax and rest, and they may have to restrict visitations from family and friends until they feel strong enough to engage in these activities. The clients should be regularly assessed for pain and given prescribed medication that will be effective for the client.

Emotional Care Needs 

 

The client may be embarrassed about their situation and should be encouraged to express their feelings and discuss their problems. The responsibilities and the expectations of the client should be discussed. A discussion on life style choices should be handled in a non-judgmental manner. In addition to using therapeutic communication techniques, the nurse can offer referrals to counselors or spiritual advisors if the client expresses a desire to talk.

ii)           Common Complications

The nurse should be knowledgeable about common complications that can affect the client who has AIDS. While an in-depth discussion of each is beyond the scope of this module, key information and nursing strategies are presented. Four major issues relating to the care of these clients revolve around dealing with complications that can be summarized under four main themes: 

(1)      Opportunistic infections

(2)      Wasting syndrome

(3)      Fluid and electrolyte imbalance

(4)      Seizures (HIV encephalopathy)

 

 (1) Opportunistic infections

a.     Bacterial diseases

·             Tuberculosis (TB)– pulmonary or extrapulmonary (may be lymphatic). Negative skin testing does not necessarily rule out TB; a false-negative can occur if the client’s immune system is not strong enough to elicit a response to the injected purified protein derivative solution.

·             Bacterial pneumonia – may impact the airway. Client complains of pain, chills and shivering. Client may exhibit wheezing.

b.     Septicemia (blood poisoning) – can be caused by infectious organisms

c.     HIV-associated malignancies

·             Kaposi’s sarcoma – purple-blue lesions on the skin that usually occur on the arms and legs. There may be an invasion of the GI system, lymphatic system, lungs and brain. Diagnosis is confirmed with a biopsy. Antineoplastic medications are used for treatment.

·             Lymphoma – may cause psychomotor slowing and changes in mental status, resulting in seizures and apathy. Standard lymphoma treatment is usually ineffective for clients who have AIDS.

·             Squamous Cell Carcinoma – aggressive forms are a complication associated with HIV infection.

d.     Viral Diseases 

·             Cytomegalovirus - Major cause of morbidity and mortality. Usually affects the retina and commonly causes blindness for clients who have AIDS. The client reports visual impairment if the eyes are affected, along with weight loss, fatigue and fever.

·             Herpes simplex – can affect the oral, perirectal or genital areas. Course of illness is more severe than for the standard population.

·             Varicella-zoster virus – this condition is associated with HIV infection. Lesions may be painful or necrotic. e

e.     Fungal Diseases

·             Pneumocystis jirovecii pneumonia (PCP) – initial manifestations are mild (dry cough, fever chills) but can progress to respiratory failure within several days.

·             Candidiasis (Candida albicans) – due to overgrowth of normal intestinal flora. Common in the oral cavity and esophagus, producing thick white exudate in the mouth with possible ulcerations. The client reports altered taste and might experience retrosternal burning.

f. Protozoal Diseases

·             Toxoplasmosis (Toxoplasmosis gondii) – can result in toxic encephalitis. It is accompanied by headache, altered mental status and fever.

·             Microsporidiosis – caused by one of many parasites. Findings depend on the organism, but diarrhea is most common.

·             Cryptosporidiosis – this is a parasite in the small bowel mucosa. It can cause chronic, watery diarrhea in AIDS clients. For clients who are not immunocompromised, the infection is usually only 1 to 2 weeks. 

·             Isosporiasis – a parasite that is found in feces. Symptoms for the AIDS client include stomach cramps, watery diarrhea, weakness and weight loss. 

·             Leishmaniasis – this has been correlated with poor environmental resources and a weakened immune system, and is transmitted by sandflies. More often found in underdeveloped areas. Clinical manifestations are associated with cutaneous, mucocutaneous, and visceral forms of lesions.

 

Nursing Interventions for Opportunistic Infections

  • Implement and maintain antiretroviral medication therapy. 
  • Administer antineoplastic, antibiotic, analgesic, antifungal, and antidiarrheal medications. 
  • Administer appetite stimulants (to enhance nutrition). 
  • Monitor for skin breakdown. 
  • Maintain fluid intake and electrolyte status. 
  • Maintain adequate nutrition, consulting a dietician if needed and providing supplementation.
  • Protect the client from acquiring other infectious conditions during treatment.
  • Caution the client to report indications of infection immediately to the provider, since recovery is often much longer and the risk of complications is greater.

(2) Wasting syndrome

In 1987 the CDC recognized “wasting” as an AIDS defining condition. Current guidelines define the condition as unintended weight loss of over 10% in a year, over 5% in 6 months, or a BMI <20 (Dudek, 2018). Disease progression and mortality are related to weight loss in AIDS clients and is characterized by depletion of both fat and lean tissue due to multiple factors such as malignancy, malabsorption of nutrients, decreased appetite and intake, and diarrhea. The nurse should address these conditions to promote adequate weight and intake and monitor the client for weight loss. Adequate food intake is essential and measures must be put in place to encourage stimulation of the appetite. 

 

Nursing Interventions for Wasting Syndrome

  • Maintain nutrition orally or by TPN. 
  • Monitor weight, calorie counts, and I&O. 
  • Provide between‑meal supplements/snacks. 
  • Decrease fat content of foods to prevent complications of fat intolerance. 
  • Provide mouth care several times daily to reduce pain and increase appetite. 
  • Serve at least six small feedings with high protein value per day.
  • Administer mediation to control diarrhea, increase appetite, and combat infections infecting the gastrointestinal tract.

Client Education for Wasting Syndrome

 

·             Report indications of weight loss immediately to the provider.

·             Consume more calories and protein to prevent loss of muscle mass.

·             Add the following foods to boost calories and protein: instant breakfast drinks, eggs, cheese, milkshakes, dried beans and peas, peanut butter, and sauces.

·             Engage in strength building exercises such as resistance exercises and modified weight training as tolerated.

(3) Fluid/electrolyte Imbalance

Clients with HIV infection who go on to develop AIDS can develop a wide variety of fluid and electrolyte disturbances. The cause can be secondary to the condition, or adverse medication effects. The client might experience an imbalance of calcium, magnesium, phosphorus, potassium, or sodium. The nurse should use knowledge of findings associated with electrolyte levels above or below the expected reference range when monitoring the client for these conditions.

 

Nursing Interventions for Fluid/electrolyte Imbalance

  • Monitor fluid status, particularly for indicators of dehydration. 
  • Monitor kidney function and electrolyte levels. Report abnormal laboratory data promptly. 
  • Observe the client for physiological manifestations of electrolyte imbalance (changes in neuromuscular ability, alterations to vital signs or deep tendon reflexes).
  • Encourage the client to drink 2 to 3 L fluid daily. 
  • Make dietary adjustments to reduce diarrhea.
  • Inform the client that electrolyte monitoring might be required every 3 to 6 months. 
  • Ensure client is aware of potential electrolyte disturbances associated with HIV stage and treatment, and to monitor for and report abnormalities.

(4) HIV Encephalopathy

As AIDS develops, the client may experience neurocognitive disorders, and these are collectively known as HIV-Associated Neurocognitive Disorders (HAND). When HIV cells infect the brain they secrete neurotoxins and the client may begin to experience cognitive impairment with motor dysfunction, speech problems and behavioral change. Cognitive impairment may be marked by mental slowness, memory problems, lack of concentration, apathy and diminished spontaneity. These cognitive and behavioral symptoms may be accompanied by a similar reduction in motor abilities such as loss of fine motor control with associated clumsiness or lack of balance. The condition can progress to absence of verbal response (mutism), spastic paraparesis, hallucinations, psychosis, seizure, and death. Although the specific symptoms of HIV dementia may vary from person to person. The client can deteriorate to the point where they are unable to support their own activities of daily living and need full-time care.  

 

The major symptoms of HIV Encephalopathy include:

·             Psychomotor slowing

·             Depression and apathy

·             Memory loss

·             Impaired concentration

·             Incontinence


Nursing Interventions for HIV Encephalopathy

As is the case in dealing with all clients who are in the process of moving to a state of dementia, it is important for the nurse to recognize that this may be a prolonged and potentially graduate process with varying levels of impairment coming into play as the disease process continues. It is important to try to encourage the client to maintain self-care and participate in activities of daily living for as long as possible. The nurse should and to engage them in skills and exercises that will help to maintain and promote their cognitive and physical functioning. The level of nursing care required will increase as the level of neurocognitive disorder increases. Nursing interventions include the following:

  • Maintain client safety
  • Implement seizure precautions
  • Promote self-care
  • Encourage cognitive exercises
  • Promote psychomotor skills

·              Inform the provider of worsening manifestations, especially if ability for self-care is a concern.

·              Discuss the effects of HIV on the brain leading to impairment with thinking, emotions and movement. 

  • Assure the client that feelings of frustration can results from muscle weakness and clumsiness. Provide reassurance for client efforts with self-care.

Recent Developments

In recent years the life expectancy of HIV infected clients has increased. This is due to a number of factors related to the development of antiretroviral therapies. This has resulted in a decline in the incidence of malignancies associated with AIDS. A greater percentage of these clients are now being diagnosed with non-AIDS defining malignancies and this aspect of caring for AIDS clients requires further research.

Case Study #1

Please answer the following questions related to the case study. Use the material in the previous continuing education article to construct your answers. This CNE activity is not graded and will not impact the score you receive for correctly answered items.

Following a prenatal visit, a client who is at 8 weeks of gestation is informed of a positive result on an HIV antibody/antigen test. 

1.         What information should the nurse provide about the purpose of the test? What further testing is needed? 

2.         The client asks the nurse about how she might have been exposed to HIV. What information should the nurse include about modes of HIV transmission?

3.         The client reports that she is not aware of having any illness manifestations other than pregnancy-related fatigue. How would the nurse respond to this statement?

4.         After a positive HIV diagnosis is confirmed for this client, what initial counseling can the nurse provide about the progression of HIV?   

5.         The client asks if there is a risk for her developing fetus to contract HIV. How should the nurse respond, and what information can the nurse provide about protecting the fetus before, during, and after birth?

6.         The client asks the nurse whether she should reveal her positive HIV status to other people. How would the nurse respond?

7.         What are the responsibilities of the health care team in reporting the client’s conditions? What restrictions exist for who has the right to know about the client’s status? 

Case Study #2

Please answer the following questions related to the case study. Use the material in the CE to construct your answers. This CNE activity is not graded and will not impact the score you receive for correctly answered items.

A client is admitted to hospital for possible Pneumocystis jiroveci pneumonia. He reports having lived in another country for several years and having a surgical procedure in that country.

1.         What information should the nurse identify as cue that the client could have HIV or AIDS? What are the common findings that might be looked for?

2.         It is confirmed that the client is HIV positive. What additional test related to staging the client’s condition should the nurse expect to be prescribed?

3.         What interventions should the nurse plan to provide to the client related to the client’s pneumonia?

4.         The client tells the nurse that he knows HIV is transmitted sexually, and asks how people with HIV usually tell their partners about HIV. What information should the nurse provide, given ethical considerations and professional responsibilities?

5.         What information would the nurse give to the client regarding opportunistic infections in AIDS? What manifestations or findings should the client be aware of?

6.         Discuss precautions the nurse can review with the client, that will assist the client to protect himself from future opportunistic infections?

7.         The client asks the ICU nurse about his prognosis, and specifically if they are going to die and how long they have to live. How should the nurse address the client’s concerns?

 8.         In helping the client develop a plan for treatment, what interprofessional team members might be appropriate to recommend for the client?

Case Study #3 

Please answer the following questions related to the case study. Use the material in the CE to construct your answers. This CNE activity is not graded and will not impact the score you receive for correctly answered items.

A nurse at a community health department is assisting with preparing a presentation about HIV. The focus of the presentation is prevention and screening. 

1.         What information should the nurse include about risk factors for HIV?

2.         Name two prevention measures the nurse can include to minimize the risk of sexual transmission, blood transmission, and occupational transmission?

3.         What information should the nurse provide to differentiate between PrEP and PEP?

4.         Sheila’s fiancé is confirmed to be HIV positive and she asks the nurse about the possibility of having children. What information would the nurse give to Sheila about her risk of HIV infection and the potential exposure risk for any children?

5.         What information can the nurse include for individuals who have HIV in regards to methods to prevent transmission of the condition to other household members? 

6.         What information should the nurse provide about viral load? Can a client who has an undetectable viral load still transmit HIV to others?

References 

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Lowdermilk, D. L.  (2016). Sexually transmitted and other infections. In D. L Lowdermilk, S. E. Perry, M. C. Cashion, & K. R. Aldean (Eds.)  Maternity & women’s health care (11th ed., pp 145-170). St. Louis, MO: Elsevier.

National Center for Complementary and Integrative Health (2017). Health topics A to Z. Retrieved November 28, 2017 from here.

Pagana, K. D. & Pagana, T. J. (2018). Mosby’s manual of diagnostic and laboratory tests (6th ed.). St. Louis, MO: Elsevier.

Sampson, J., & Workman, M. L. (2016). Care of clients with HIV disease and other immune deficiencies. In D. D. Ignatavicius & M.L. Workman (Eds.), Medical-surgical nursing (8th ed., pp. 326-370). St. Louis, MO: Elsevier. 

Solodokin, L. J. (2016)  Concerns regarding administration of antineoplastic therapy in HIV-positive patients. U. S. Pharmacist (Specialty & Oncology supplement),  41(7), 13-18

Toskaa, E., Cluverab, L.D., Hodesc, R & Khameer, K. (2015) Sex and secrecy: How HIV-status disclosure affects safe sex among HIV-positive adolescents. AIDS Care, 27(sup1), 47–58. from here.

Touhy, T.A. (2016). Intimacy and Sexuality. In Touhy, T.A., & Jett, K.F. (Eds.) Ebersole & Hess’ toward healthy aging: Human needs and nursing response (9th ed., pp. 445-462). St. Louis, MO: Elsevier.

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