HIV and AIDS Nursing Care Management and Study Guide

HIV destroys CD4+ T cells, so the threat you manage on the floor is immunosuppression. Your priorities are protecting an immunocompromised patient from infection, keeping the airway clear, guarding skin and perianal integrity, supporting nutrition against wasting, and knowing where the patient sits on the CD4 count. AIDS is the endpoint: CD4+ below 200 cells/mm3 or a defining opportunistic illness.

What are HIV and AIDS?

HIV (human immunodeficiency virus) is a chronic, retroviral infection that requires daily medication for life. HIV-1 is the retrovirus recognized as the etiologic agent of AIDS. HIV-2 is a related retrovirus identified in 1986 in AIDS patients in West Africa.

Classification

Staging rests on clinical history, exam, lab evidence of immune dysfunction, and the infections and malignancies present.

Primary (acute) infection runs from the moment of infection to the development of HIV-specific antibodies. Once the viral set point is reached, the patient enters the asymptomatic chronic stage (CDC Category A), in which the immune system cannot clear the virus. Category B covers symptomatic conditions not listed in Category C. AIDS (Category C) is diagnosed when CD4+ T-cell count drops below 200 cells/mm3 or a Category C condition appears.

Pathophysiology

HIV integrates itself directly into the immune system, which is why the infection is lifelong. GP120 and GP41 glycoproteins bind the host CD4+ receptor and a chemokine coreceptor (usually CCR5), fusing the virus to the CD4+ T-cell membrane and emptying the viral core into the cell. Reverse transcriptase converts viral RNA into double-stranded DNA, and integrase splices that viral DNA into the host genome, producing permanent infection. When the CD4+ T cell activates, the integrated DNA generates messenger RNA that builds new viral proteins and enzymes. HIV protease cleaves the polyprotein chain into individual proteins, the new virions migrate to the cell membrane, exit, and repeat the cycle.

Statistics and Epidemiology

In the fall of 1982, after the first 100 cases were reported, the CDC issued a case definition for AIDS. In 2008 the CDC estimated roughly 56,300 new HIV infections occurred in the United States in 2006, about 40% higher than the former estimate of 40,000 per year. Almost 7000 people still contract HIV every day. An estimated 33 million people live with HIV/AIDS, though new infections fell from 3 million in 2001 to 2.7 million in 2007. Women remain 50% of people living with HIV/AIDS. Sub-Saharan Africa carries the heaviest burden, with 67% of all people living with the disease and 72% of HIV/AIDS deaths in 2007.

Causes

HIV transmits through body fluids carrying free virions and infected CD4+ T cells: sharing contaminated needles or drug equipment, sexual contact with an infected partner, transfusion of infected blood or blood products (especially before screening), and perinatal transmission from an infected mother to her infant.

Clinical Manifestations

Manifestations track the four stages. Early infection produces an acute retroviral syndrome. Category B reflects the chronic symptomatic stage. Constitutional symptoms, fever above 38.5°C or diarrhea lasting more than 1 month, point to active HIV disease. Category C patients develop wasting syndrome with severe muscle loss.

Prevention

Until an effective vaccine exists, prevention is teaching. Other than abstinence, consistent and correct condom use is the only effective way to cut sexual transmission. In March 2007, based on three clinical trials, the WHO and UNAIDS recognized male circumcision as an effective strategy to reduce HIV acquisition in men. Patients should avoid sexual contact with multiple partners, known HIV-positive partners, or injection drug users, and HIV-positive or injection-drug-using patients must not donate blood or share drug equipment.

Complications

Watch for opportunistic infection, the defining danger in an immunosuppressed patient. Pneumocystis pneumonia (PCP) can affect 80% of all people infected with HIV. Impaired breathing can progress to respiratory and cardiac failure. Wasting syndrome, involuntary weight loss exceeding 10% of baseline body weight, is a common complication of HIV and AIDS.

Assessment and Diagnostic Findings

AIDS is not officially diagnosed until CD4+ T-cell count falls below 200 cells/mcl or an associated clinical condition appears. CBC shows anemia (in up to 85% of AIDS patients, sometimes profound) and idiopathic thrombocytopenia; leukopenia may be present, with a left shift suggesting an infectious process such as PCP. PPD determines TB exposure or active disease; 100% of AIDS patients exposed to active Mycobacterium tuberculosis will develop the disease. ELISA screens serum antibody; a positive result indicates exposure but is not diagnostic because of false positives. Western blot confirms HIV in blood and urine.

Viral load testing drives therapy decisions. RT-PCR detects viral RNA as low as 50 copies/mL of plasma up to an upper limit of 75,000 copies/mL; the bDNA 3.0 assay covers a wider range of 50 to 500,000 copies/mL and is the leading indicator of treatment effectiveness. Total T-lymphocyte count is reduced. CD4+ count below 200 indicates severe immune deficiency and a diagnosis of AIDS. A reversed T8+ to T4+ ratio (2:1 or higher) indicates immune suppression. PCR for HIV-DNA is most helpful in newborns of HIV-infected mothers, who carry maternal antibodies and test positive by ELISA and Western blot even when uninfected.

STD screening (hepatitis B envelope and core antibodies, syphilis, and other common STDs) may be positive. Cultures of urine, blood, stool, spinal fluid, lesions, sputum, and secretions identify opportunistic organisms: protozoal and helminthic (PCP, cryptosporidiosis, toxoplasmosis); fungal (Candida albicans, Cryptococcus neoformans, Histoplasma capsulatum); bacterial (Mycobacterium avium-intracellulare and CMV both occur with CD4 counts less than 50, plus miliary mycobacterial TB, Shigella, Salmonella); and viral (CMV, herpes simplex, herpes zoster). Neurologic studies (EEG, MRI, CT of the brain, EMG/nerve conduction) evaluate altered mentation, fever of undetermined origin, or sensory and motor changes. Chest x-ray may be normal early or show progressive interstitial infiltrates from advancing PCP or TB. Pulmonary function tests detect early interstitial pneumonia, and a gallium scan shows diffuse pulmonary uptake in PCP. Biopsy differentiates Kaposi's sarcoma and other neoplastic lesions. Bronchoscopy with tracheobronchial washings and biopsy confirms PCP or lung malignancy. Barium swallow, endoscopy, and colonoscopy identify GI opportunistic infection or stage Kaposi's sarcoma.

Medical Management

Management targets opportunistic infections. For Pneumocystis pneumonia, TMP-SMZ is the treatment of choice; for Mycobacterium avium complex, azithromycin or clarithromycin are the preferred prophylactic agents; for cryptococcal meningitis, IV amphotericin B is the primary treatment. TMP-SMZ also serves as prophylaxis. Octreotide acetate (Sandostatin), a synthetic somatostatin analog, controls severe chronic diarrhea. Depression is treated with psychotherapy plus imipramine, desipramine, or fluoxetine. For unexplained weight loss, obtain calorie counts and add appetite stimulants and oral supplements.

Nursing Management

Any organ system can become the target of infection or cancer, which makes this nursing challenging.

Nursing Assessment

Identify risk factors including risky sexual practices and injection drug use. Assess nutritional status with a diet history and the factors limiting oral intake. Inspect skin and mucous membranes daily for breakdown, ulceration, or infection. Monitor respiratory status for cough, sputum, dyspnea, orthopnea, tachypnea, and chest pain. Check neurologic status (level of consciousness; orientation to person, place, and time; memory). Assess fluid and electrolyte balance through skin and mucous membrane turgor and dryness, and gauge the patient's knowledge of the disease and its transmission.

Diagnosis

Common diagnoses include impaired skin integrity related to cutaneous HIV manifestations, excoriation, and diarrhea; diarrhea related to enteric pathogens; risk for infection related to immunodeficiency; activity intolerance related to weakness, fatigue, malnutrition, impaired fluid and electrolyte balance, and hypoxia; disturbed thought processes related to HIV encephalopathy; ineffective airway clearance related to PCP, increased secretions, and weak cough; pain related to perianal breakdown, Kaposi's sarcoma, and peripheral neuropathy; and imbalanced nutrition, less than body requirements, related to decreased oral intake.

Planning & Goals

Goals include intact skin, a usual bowel pattern, absence of infection and complications, improved activity tolerance and thought processes, clear airway, comfort, improved nutrition, increased socialization, prevention of new infections, maintained homeostasis, psychosocial support, and patient understanding of the disease and treatment.

Nursing Interventions

Protect skin integrity: discourage scratching, use nonabrasive, nondrying soaps and nonperfumed moisturizers, give regular oral care, and clean the perianal area after each bowel movement. Monitor stool frequency and consistency and any abdominal pain. Watch for signs of infection and abnormal labs. Plan daily routines that balance activity and rest. Have the family speak in simple, clear language and allow time to respond. For airway clearance, provide coughing, deep breathing, postural drainage, percussion, and vibration as often as every 2 hours to prevent stasis of secretions. Relieve pain with soft cushions, foam pads, and prescribed NSAIDs and opioids. Encourage foods that are easy to swallow and avoid rough, spicy, and sticky items.

Evaluation

Expected outcomes: maintained skin integrity, usual bowel pattern, absence of infection and complications, improved activity tolerance and thought processes, clear airway, increased comfort, improved nutrition, and increased socialization.

Discharge and Home Care Guidelines

Teach the patient and family to prevent transmission, including handwashing and safe handling and disposal of items soiled with body fluids. Advise avoiding exposure to others who are sick or recently vaccinated. Teach caregivers to administer medications, including IV preparations. Assess adherence to the regimen and suggest strategies to support it. Confirm that infection is prevented or resolved, complications minimized, pain controlled, the patient is coping realistically, the diagnosis and regimen are understood, and a plan is in place for needs after discharge.

Documentation Guidelines

Document lesion or condition characteristics; the impact on self-image and lifestyle; assessment findings including elimination pattern; risk factors including current antibiotic therapy; signs of infection; breath sounds, secretions, and use of accessory muscles; caloric intake; cultural or religious restrictions and preferences; the plan and teaching plan; response to interventions; progress toward outcomes; modifications to the plan; and long-term needs.