Chapter 25 

  Interventions for Clients with HIV/AIDS and Other Immunodeficiencies

Disease of T-lymphocyte; virus attaches to t-cell; lining of t-lymph cell and get into t-lymph and
grow within it (attaching in nucleus) using material and grows and replicates, moving out of t-
lymph and spread; Specific CD4 lymph (Helper);
▪ HIV classifications include:
-            A person in clinical category A is HIV positive.
-            A person in clinical category B is infected with HIV.
-            A person in clinical category C has AIDS. (meaning they are HIV+ as well)
-         Normal healthy 800-1000 CD4 T lymphocytes; (can find virus, etc.) but if the CD4 T-
lymph is in normal range your fine (still have HIV but ok)… but if it falls to 200 or less pt has
moved into category of AIDS; no cure for HIV/AIDS
Measure viral load, CD4 counts as the virus grows and replicates the CD4 falls;
Virus spreads through different routes, cold – droplet; HIV – higher incident in semen, blood, etc
(breast milk, sex, etc) contact w/ infected body fluids;
 
 Health Promotion and Illness Prevention    
1. Education is the best hope for prevention.
2. HIV is transmitted most often in three ways:
ü  Sexual
1. ABC’s - Abstinence, BE CAREFUL, BE Monogamous, Wear Condoms; 
More likely for male to infect female than vice versa; 
Anal intercourse has high probability of spread no matter who has it;
Latex condoms helps prevent spread of disease if one is engaging outside monogamous
relationship;
May never convert from HIV to AIDS
ü  Parenteral
▪ Blood, needles and syringes  (needle exchange program, to decrease spread of disease) 
WATER & HOUSE HOLD BLEACH (teach drug user to clean equipment)
▪ (Individual could have sex with unknown HIV person and then gets check but there is no
evidence, LAG TIME – not enough time since exposure, just don’t have positive
antibody yet)  sooo.. we may be giving blood and when they checked it was negative… in
6wks it may be fine;
▪ Faster HIV progressing to AIDS compared to sexual;
ü  Perinatal – 25% chance that infected mom will transmit it to unborn fetus
▪ Can lower chance by giving meds
▪ Shouldn’t breast feed baby
 
Question:  Which group has highest percentage of AIDS cases in North America?
▪  Men or women who use injection drugs
▪  Newborn of mothers who are HIV positive
▪  Men with other men
▪  Women with women
Answer: A
Transmission and Health Care Workers
▪ Standard  Precautions (sufficient) Gloves into contact with mucous membranes, blood, vag or
semen secretions; 
▪ All clients with or w/out HIV; we assume all pt are HIV+ because we do not know
their status; 
▪ Prevention of Needle stick or ‘sharps’ injuries. – needless system, etc.
▪ Prevention of exposure through nonintact skin or mucous membranes
▪ If stuck, wash wash wash, report to supervisor and employee health (surveillance)
 
Collaborative Management 
▪ History – risky behaviors; known HIV status;  
If they have virus they are immunosuppressed;
Physical assessment and clinical manifestations
Infections: opportunistic = won’t effect person with good immune function: 
specific type of pneumonia with Pneumocystis carinii  & Toxoplasma
gondii, (protozoal) fungal, bacterial, viral (SEVERE diarrhea, losing
liters/day)
These are worse than normal pneumonia or other infections;
Candiditis, etc
Malignancies: Kaposi’s  sarcoma,  malignant lymphomas (higher risk
for these)
Kaposi sarcoma:  Nodules in skin, mouth looks like blood
blisters;
Endocrine complications  (gonadal, adrenal, & pancreatic)
Gonadal suppression – decrease in normal hormones,
decrease sperm count, irregular period, etc
Adrenal, excess (Cushing) or def. (Addisons)
Pancreatic- diabetes/pancreatitis
Question: Reviewing chart of pt with AIDS< nurse recalls most opportunistic infection with HIV
1.  TB caused by mycobacterium tuberculosis
2.  PJP Pneumocystis jirovencipneumonia
3.  CMV – Cytomegalovirus, causing CMV retinitis
4.  Toxoplasmosis encephalitis, caused by Toxoplasma gondii
Answer B
Other Clinical Manifestations
1. AIDS dementia complex
Neurologic diminishing;
 Wasting syndrome
Severe malnutrition with AIDS; Loss of fat and muscle mass;
No energy, bed ridden
Skin changes
No WBC to heal broken area
Question: Pt fearful that he been infected with HIV.  Nurse recognizes that 1st manifestation of
HIV infection is
▪  Opportunistic infection
▪ Fever, night sweat, and muscle ache
▪  Lymphocytopenia (decrease lymphocyte count)
▪  Reduced numbers of CD4+ TCells
Answer B, flu like
Laboratory Assessment
▪ Lymphocyte counts (low)
▪ CD4/CD8 counts (low)
Lymphocyte count low is a clue to look further and then look at the CD values;
Antibody tests
Enzyme-linked immunosorbent assay (ELISA)
RAPID blood test; Not real accurate; cheap
Western blot, viral culture, viral load
Western blot expensive; takes time but more accurate
Viral load so its not even detectable
 
Drug Therapy
Meds with antiretroviral effects -- only inhibit viral replication but do not kill the virus.
▪ Nucleoside analog reverse transcriptase inhibitors (‘look’  like the virus, but prevent it from
replicating itself) – Retrovir®, Videx®
▪ Non-nucleoside analog reverse transcriptase inhibitors
▪ Protease inhibitors – Norvir®, Crixivan®, Invirase®, Kaletra®, Pentam (pg 379)
▪ Fusion inhibitors
▪ Immune enhancement
Question:  When teaching pt about AIDS & drug therapy, nurse emphasizes that drug must be
taken exactly as prescribes w/out missing doses.  The reason for is
▪  Missed doses can promote drug resistance, lowering effectiveness of drugs
▪ Missed doses allow dev of opp. Infection
▪  An increased chance of allergic rx the drug may occur
▪  Viral replication decreases when doses are missed
Answer A
 
Nutrition-Related Deficiencies
▪ Good nutrition needed for proper immune function
▪ Malnutrition, a major cause of global immunodeficiency
▪ Protein-calorie malnutrition
▪ Increased incidence and  severity of infectious disease in obesity
Nutrition support; emotional support; etc
 
Immunodeficiencies
▪ Primary (congenital)
▪ Therapy-induced (secondary) immunodeficiencies
▪ Drug-induced immunodeficiencies
ü  Cytotoxic drugs
ü  Corticosteroids
ü  Cyclosporine
▪ Radiation-induced  immunodeficiencies
Chapter 22 : Interventions for Clients with Immune Function Excess: Hypersensitivity
(Allergy) and Autoimmunity
Hypersensitivities/Allergies
▪ Increased or excessive response to the presence of an antigen to which the client has been
exposed
▪ Reaction: uncomfortable → life threatening
▪ Hypersensitivity  =  allergy
Type I: Rapid Hypersensitivity Reactions
1. Atopic allergy, most common.
2. Occurs within minutes to hours of antigen exposure
3. Development of IgE antibodies in response to the typical harmless environment antigens.
4. Release of vasoactive amines (histamines) and other inflammatory mediators this causes
vasodilation and increase vascular permeability resulting in edema & smooth muscle
contraction in arterial and arteriole walls (vasoconstriction)
Contacted by
-         Inhaled
-         Ingested
▪ Localized reactions
-         E.g. Asthma
-         Food or ingested allergens primarily affect the gastrointestinal tract
▪ Systemic reactions
Anaphylaxis – with skin testing allergies
 
Collaborative Management
▪ History
▪ Physical assessment/clinical manifestations
▪ Laboratory assessment
▪ Allergy testing:  intradermal testing, oral food challenge
▪ Avoidance therapy, symptomatic therapy, drug therapy
▪ Drug therapy :  Decongestant, Antihistamines, Corticosteroids
▪ Desensitization therapy
 
Anaphylaxis
▪ First:  uneasiness, apprehension, weakness, and impending doom
▪ Pruritus and urticaria
▪ Erythema and sometimes angioedema of the eyes, lips, or tongue
▪ Histamine causes capillary leak, bronchoconstriction, mucosal edema, and excess mucus
secretion.
Stridor; wheezing;
Congestion, rhinorrhea, dyspnea, and increasing respiratory distress with audible
wheezing result.
Anaphylaxis can be fatal.
Question: Chem responsible for cap leak: HISTAMINE
 Interventions:  A - B - C
▪ First assess respiratory function; an airway must be established.
▪ CPR may be needed.
▪ Epinephrine is given as soon as symptoms appear; Epi Pen if has severe allergy; Need med
alert bracelet;
▪ Solution is 1:1000, dose is 0.3 ml-0.5ml = 0.3 mg-0.5mL SQ.
▪ Antihistamines treat angioedema and urticaria. IV
▪ Oxygen reduces hypoxemia.
Type IV: Delayed Hypersensitivity Reactions
▪ In a type IV reaction, the reactive cell is the T-lymphocyte (T-cell).
▪ Antibodies and complement are not involved.
▪ Local collection of lymphocytes and macrophages causes edema, induration, ischemia, and
tissue damage at the site.
▪ Examples include positive purified protein derivative (antigen) (+PPD), contact dermatitis,
poison ivy skin rashes, insect stings, tissue transplant rejection, and sarcoidosis
-         Someone who is immunosuppressive may not have enough neutrophils to stimulate
reaction, etc;
-         Sarcoid causes scar tissue (Scar tissue in lungs, pulmonary, no tx)
Question: Type of transfusion rx would pt who received multiple transfusion during cancer tx
most likely experience? Febrile most often in pt with anti-WBC antibody, situation that dev after
multiple transfusion.  Bacterial rx occur as result of infusin contaminated blood products. 
Allergic rx are most often seen in pt with hx of allergy.  Hemolytic rx are cause Rh incompat
 
Bacterial
Allergic
Hemolytic
 
Question: Women of which ethical group are most freq affected by autoimmune disease?
AA
Asian
White
Hispanics
 
Autoimmunity
▪ An inappropriate immune response with failure to recognize certain body cells or tissues as self
and triggers immune reactions.
▪ Antibodies and/or lymphocytes are directed against healthy normal cells and tissues.
▪ Treatment:
▪ Examples of Autoimmune Disorders
▪ Systemic Lupus Erythematous (SLE) -
▪ Rheumatoid Arthritis
▪ Hashimoto’s thyroiditis –women in women, inflame of thyroid resulting in hypothyroidism;
Synthroid (thyroid hormone) Pt wont gain wt, blood pressure and heart rate normal, body
temp fine; Greater risk for lymphomas etc (RECALL THYROID PROBLEMS)
▪ Sjőgren’s – Extreme dryness of mucous membranes; Mouth (no saliva), tears, vaginal, Enzyme
(amylase) break down carbs, at risk for decay, difficulty swallowing; difficulty talking;
corneal dryness or irritation; scratches (PAIN) Visual;
Eye drops (liquid tears); drugs restatsis (cyclosporine) – chemo drug;