y Acquired immunodeficiency syndrome (AIDS) is defined

as the most severe form of a continuum of illnesses associated with human immunodeficiency virus (HIV) infection. If untreated, it causes slow degeneration of the immune system with the development of opportunistic infections and malignancies. HIV disease implies the entire course of HIV infection, from asymptomatic infection and early symptoms to AIDS. Since 1996, HIV disease has been viewed as a chronic condition, controllable with medications and strict adherence to treatment recommendations.
y

y The causative agent is a retrovirus that infects and depletes

the CD4+ T-helper lymphocytes, one of the protector cells of the immune system. B lymphocytes secrete antibodies into the body fluids, or humors; this is known as humoral immunity. T lymphocytes can penetrate living cells, a process called cell-mediated immunity. y Monocytes and macrophages, whose role is to present antigen to T cells, thereby initiating the body's immune response, are also infected by HIV. y Once HIV has entered the body, it attaches most efficiently to CD4+ molecules, which are predominantly located on the cell membrane of T4 helper lymphocytes. After penetrating the cell membrane, the HIV genome and enzymes are released in the cell and integrated into the lymphocyte's genome. The result of this reproductive process is the production of many new HIV virions and cell death for the T4 helper lymphocyte.

y With progressive invasion of HIV, cellular and

humoral immunity declines and opportunistic infections that characterize this disease begin to emerge. y Body fluids known to transmit HIV are blood, vaginal secretions, semen, and breast milk. y HIV is transmitted by injection of blood or blood components, by sexual contact (vaginal or anal intercourse, oral sex), and perinatally from an infected mother to the child.

y Homosexual or bisexual men y I.V. drug users y Transfusion and blood product recipients (before 1985) y Heterosexual contacts of HIV-positive individuals y Newborn babies of mothers who are HIV-positive

y Approximately 50% to 90% of persons will experience

a brief flulike illness about 2 to 4 weeks following exposure to HIV referred to as primary HIV infection (also called acute HIV infection). Typical symptoms include fever, adenopathy, pharyngitis, and rash. Although most patients seek clinical care, few are diagnosed because the symptoms mimic a common flu. During this phase the immune system is compromised by a sudden decrease in T4 helper cells and an increase in viral load for a brief period before returning to baseline.

y Seroconversion occurs when the person has developed

enough antibodies to HIV that the serologic test is positive. This usually occurs 4 to 6 weeks after acute HIV infection. y The Centers for Disease Control and Prevention (CDC) provides a mechanism to stage HIV disease and to define AIDS using clinical findings and the CD4+ count (see Table 29-1). A normal CD4+ count is 800 to 1,000/mm3. Because HIV destroys a CD4+ molecule as it enters the T4 lymphocyte, the number of CD4+ cells diminishes over time.

CD4+ CELL CATEGORIES

1. 500/ mm3 ( <29%)

Asymptomatic, or Symptomatic (n PGL or Acute HIV ot A or C) / B Infection/ A A1 B1

AIDS Indicator Condition (1987) C C1

A2
2. 200- 499/mm3 (14-28%)

B2

C2

A3
1. <200mm3 (<14%)

B3

C3

y Pulmonary manifestations
y Persistent cough with and without sputum production,

shortness of breath, chest pain, fever y From Pneumocystis carinii pneumonia (PCP) (most common), bacterial pneumonia (community-acquired pneumonia), Mycobacterium tuberculosis, disseminated Mycobacterium avium complex, cytomegalovirus (CMV), Histoplasma, Kaposi's sarcoma, Cryptococcus, Legionella, and other pathogens

y GI manifestations
y Diarrhea, weight loss, anorexia, abdominal cramping,

rectal urgency (tenesmus) y From enteric pathogens including Salmonella, Shigella, Campylobacter, Entamoeba histolytica, C. difficile, CMV, M. avium complex, herpes simplex, Strongyloides, Giardia, Cryptosporidium, Isospora belli, Chlamydia, and others

y Oral manifestations
y Appearance of oral lesions, white plaques on oral

y y y y y

mucosa, particularly in the posterior pharynx and angular cheilitis from Candida albicans of mouth and esophagus Vesicles with ulceration from herpes simplex virus White, thickened lesions on lateral margins of tongue from hairy leukoplakia Oral warts due to human papillomavirus and associated gingivitis Periodontitis progressing to gingival necrosis Aphthous ulcers of unclear etiology painful, solitary lesions with raised margins

y Central nervous system (CNS) manifestations

y Cognitive, motor, and behavioral symptoms (AIDS

dementia complex/HIV encephalopathy) y Demonstrated by mental slowing, impaired memory and concentration, loss of balance, lower extremity weakness, ataxia, apathy, and social withdrawal y May be caused by CNS toxoplasmosis, cryptococcal meningitis, herpesvirus infections, CMV encephalitis, progressive multifocal leukoencephalopathy, and CNS lymphoma. y May also have sensory symptoms (distal symmetric polyneuropathy) demonstrated by numbness, tingling, and neuropathic pain.

y Ocular manifestations
y Retinopathy due to CMV retinitis y Visual impairment that progresses to blindness, if

untreated
y Malignancies
y Kaposi's sarcoma (aggressive tumor involving skin,

lymph nodes, GI tract, and lungs) y Non-Hodgkin's lymphoma and lymphomas y Cervical carcinoma

y History of risk factors/high-risk behaviors y Positive blood test for HIV

y Enzyme-linked immunosorbent assay (ELISA) serologic

test for detecting antibody to HIV y Western blot test used to confirm a positive result on ELISA y When infected with HIV, it usually takes the body up to 12 weeks to develop enough antibody to HIV for the test result to be positive, resulting in a false-negative test if evaluated early.

y Occasionally, a sample that tests reactivity by ELISA may give

an indeterminate result by Western blot. The cause of an indeterminate result may be early HIV seroconversion, HIV vaccine, infection with O strain or HIV-2 or a false-positive in a low-risk individual. The test should be repeated every 2 to 3 months until Western blot becomes positive or there is no longer suspicion of HIV disease. y Two Food and Drug Administration (FDA) approved rapid HIV tests are available. They are blood tests that can show a result in about 20 minutes. These tests are frequently used in health care settings where urgent diagnostic determination is needed for decision-making. A negative result is definitely negative, but a positive result must be confirmed positive by the ELISA.
y OraSure is an FDA-approved HIV test that uses saliva rather than

blood. The results are available in about 3 days. y Calypte HIV-1 Urine EIA is an FDA-approved HIV test that uses urine. A positive result must be confirmed positive by the ELISA.

y Lymphocyte panel shows decreased CD4+ count. y A complete blood count may show anemia and a low

white blood cell count. y Presence of indicator disease (eg, candidiasis of esophagus, Kaposi's sarcoma). y Diagnostic procedures (biopsies, imaging procedures) of the organ system involved to confirm opportunistic infection, malignancy, or other causes. y Neuropsychological testing to identify cognitive deficits associated with AIDS dementia complex.

y Viral load (quantitative HIV ribonucleic acid [RNA]

via either branched deoxyribonucleic acid [DNA] or PCR testing) is a measure of the amount of HIV in the blood. A higher number (greater than 750,000 copies/mL) indicates greater viremia. High viral loads are usually found in acute seroconversion and late disease, but also occur when patients have another infectious process in the body. A viral load test result can be undetectable, meaning the amount of virus is less than 50 copies/mL; therefore, the virus could not be found. (This does not indicate that the body is free of HIV. Latent reservoirs exist in the lymphoid tissues indefinitely.)

y Development of HIV virus resistant to antiretroviral

treatment. y Repeated overwhelming opportunistic infections

NAME

CLINICAL MANIFESTATIO NS
Cough: dry or scant white sputum production Shortness of breath Low-grade fever

DIAGNOSTIC TESTS
Chest X-ray Sputum culture for silver stain Bronchoscopy

MEDICATIONS

Pneumocystis carinii pneumonia

Co-trimoxazole (Bactrim) Dapsone (Dapsone) Atovaquone (Mepron) Pentamidine (Pentam) (I.V. only) Nystatin (Mycostatin) Clotrimazole (Mycelex) Itraconazole (Sporanox) Fluconazole (Diflucan) Amphotericin B (Fungizone)

Candida esophagitis

White coating in mouth White coating down throat Sensation of food getting caught in throat while swallowing

Gross observation Microscopy for hyphae Endoscopy

Mycobacterium avium complex

o o o o

Weakness Weight loss Diarrhea Fever, chills

Blood culture for acid-fast bacilli

Mycobutin (Rifabutin) Ethambutol (Myambutol) Azithromycin (Zithromax) Clarithromycin (Biaxin)

NAME

CLINICAL MANIFESTATIONS
o

DIAGNOSTIC TESTS

MEDICATIONS

Kaposi's sarcoma

Pink, purple, or brown spots Pain, edema of affected area Fever Headache

o o

Gross observation Biopsy

Highly active antiretroviral therapy (HAART)

Toxoplasmosis

o o o

Computed tomography (CT) Magnetic resonance imaging (MRI) Serum Toxoplasma antibodies
Positive purified protein derivative ( 5 mm induration) Chest X-ray Sputum culture for acid-fast bacilli

Pyrimethamine (Daraprim) Sulfadiazine (Microsulfon) Folinic acid

Change in mental status Confusion

o

o o o o

Lethargy Frank psychosis

Cough: dry or scant frothy white/pink sputum Shortness of breath Fever Lymphadenopathy
o

Tuberculosis

o o o o

Isoniazid (INH) Rifampin (Rifadin) Pyrazinamide (PZA) Ethambutol (Myambutol)

o o o

o o

NAME

CLINICAL MANIFESTATIONS
o o

DIAGNOSTIC TESTS

MEDICATIONS

Cryptosporidium

Severe diarrhea Severe abdominal cramping

Stool culture for Cryptosporidium

Octreotide (Somatostatin) Paromomycin (Humatin)

Cryptococcal meningitis

o o

Headache Confusion, memory loss Nausea

Cerebrospinal fluid (CSF) culture for cryptococcosis

Amphotericin B (Fungizone) Flucytosine (Ancobon) Fluconazole (Diflucan)

o o o

Seizures Change in mental status Fever Photophobia

o o

NAME

CLINICAL MANIFESTATIONS
o

DIAGNOSTIC TESTS

MEDICATIONS

Cytomegalovirus (CMV)

Visual changes; floaters/blindness Difficulty swallowing Nausea, vomiting Abdominal cramping

Ophthalmologic examination Blood, urine, tissue culture for CMV

Valganciclovir (Valcyte) Ganciclovir (Cytogene) Foscarnet (Foscavir) Cidofovir (Vistide) Intraocular ganciclovir release device
Antiretroviral therapies that penetrate the central nervous system (zidovudine, stavudine hydroxyurea, abacavir, nevirapine, efavirenz, indinavir)

o o

HIV encephalopathy/AIDS dementia complex

Early Inattention Reduced concentration Forgetfulness Slowed movements Clumsiness Ataxia, Apathy,Agitation Late Paraplegia Mutism Vegetative state

o o o

CT MRI CSF evaluation

y Respiratory failure. y Wasting. y Medication-related conditions, lipodystrophy,

hyperlipidemia, insulin-resistance, and lactic acidosis.

y Treatments are available for the underlying

immunodeficiency and are usually successful when patients receive at least 90% of doses. Patient education that stresses adherence to treatment and monitoring adherence are essential elements of treatment success. y HIV vaccine studies for preventive and therapeutic (to promote immune response in HIV-infected individuals) are ongoing. HIV is characterized by constant mutation, making successful vaccine development complicated and challenging.

y Treatment is available for some opportunistic

infections and other diseases associated with AIDS. Although individual response to treatment can be variable, treatment of opportunistic infections may suppress the disease for months or for the life of the patient. When patients sustain immune reconstitution, prophylaxis may be discontinued. (For example, PCP prophylaxis can be discontinued when patients have a sustained CD4+ count greater than 200/mm3.) y Management requires the expertise of many specialties: infectious disease, pulmonary medicine, gastroenterology, neurology, obstetrics and gynecology, dentistry, surgery, psychiatry, nursing, nutrition, and social work.

y Highly active antiretroviral therapy (HAART) consists

of medications that belong to four different classifications because they act to prevent HIV replication at four different points along the replication process. The standard for HAART is to take a minimum of three different drugs from at least two different drug classifications. y HAART refers to any medication regimen that interferes with HIV viral activity and ideally can suppress viral activity. y Classes of antiretroviral drugs

DRUG

ADVERSE REACTIONS

Nucleoside Reverse Transcriptase Inhibitors

Zidovudine (AZT, Retrovir) bone marrow suppression: anemia, neutropenia; GI intolerance, fatigue, headaches, insomia Peripheral neuropathy, pancreatitis, diarrhea, nausea, oral ulcaers Hypersensitivity reaction (in 5% of patients)

Didanosine (ddl, Videx)

Abacavir (Ziagen)

Stavudine (d4T, Zerit)

Peripheral neuropathy, pancreatitis, facial wasting, fungal infx, nausea minimal toxicity, anemia, fatigue, hair loss, haedache, nausea, peripheral neuropathy Adverse reactions are rare

Lamivudine (3TC, Epivir)

Tenofovir (Viread)*

Emtricitabine (Emtriva)

Adverse reactions are rare

Nonnucleoside Reverse Transcriptase Inhibitors drugs Nevirapine (Viramune)

Adverse reaction Hepatotoxicity, skin rash, hepatitis, fever, headache, nausea, stomach upset, increased transaminase levels Strange dreams and vertigo in first 2 weeks, poor concentration, anxiety, CNS symptoms skin rash, headache, diarrhea, fatigue, stomach upset, ITL Generally well tolerated Mild to moderate GI side effects

Efavirenz (Sustiva)

Delavirdine (Rescriptor)

Tenofovir (Viread)

Drugs Indinavir (Crixivan) Saquinavir (Fortovase; also as Invirase, hard capsules)

Adverse reaction All PI medications have potential longterm adverse effects in varying degrees, including: drug-induced hepatitis, hyperlipidemia, insulin resistance leading to diabetes mellitus and lipodystrophy. Initial adverse reactions includes nausea, diarrhea and, perhaps, vomiting.

Nelfinavir (Viracept)

Ritonavir (Norvir) Lopinavir with ritonavir (Kaletra) Amprenavir (Agenerase) Fosamprenavir (Lexiva) Atazanavir (Reyataz)

Drug Enfuvirtide (T-20, Fuzeon)

Adverse reaction Inflammation at injection site

* Use with caution in patients with renal compromise **Monitoring for all types of HAART includes: complete blood count (CBC), chemistries, and human immunodeficiency virus ribonucleic acid (RNA) viral load during the first month; CD4+, HIV RNA viral load, ultrasensitive, CBC, and chemistries in the second month and every 3 months thereafter once the patient is stable and has undetectable HIV RNA viral load.

y Nucleoside/nucleotide reverse transcriptase inhibitors

(NRTI); historically, the first class of medications used in the treatment of HIV. y Nonnucleoside reverse transcriptase inhibitors (NNRTI). y Protease inhibitors (PI), the second class of HIV medications, which made of three-drug cocktails possible and transformed HIV from a terminal illness to a chronic illness for many patients. These generally became available in 1996. y Entry inhibitors, the newest class of HIV treatment.

y Prolong life and improve quality of life. y Reduce viral load to as low as possible for as long as

possible. y Increase the CD4+ count to allow immune reconstitution. y Maintain options for future treatment by preventing the development of treatment-resistant virus. y Avoid drug toxicities.

CRITERIA

TREATMENT CONSIDERATIONS

Symptomatic with AIDS-defining condition or severe symptoms

Asymptomatic, CD4+ count < 200

Human immunodeficiency virus (HIV) treatment regardless of HIV viral load

Asymptomatic, CD4+ count 200-350, viral load > 55,000

Asymptomatic, CD4+ count 200-350, viral load < 55,000

May offer, may defer HIV treatment

Asymptomatic, CD4+ count > 350, viral load < 55,000

Defer HIV treatment until above criteria are met

y Acute retroviral syndrome or less than 6 months since

seroconversion. y HIV symptoms, such as oral thrush, unexplained fevers, Kaposi's sarcoma, and opportunistic infections. y No HIV symptoms but has a CD4+ count between 200 and 350/mm3 and a viral load greater than 55,000 copies/mL. y Patient Readiness
for HAART, including knowledge regarding stringent medication adherence requirement, adverse effect management, and how to access resources for management of treatment complications.

y Lactic acidosis/steatohepatitis occurs with some NRTI

y y y

medications; presents with nausea, vomiting, fatigue, and abdominal pain. Hyperlipidemia, associated with some PI-containing regimens and some NNRTI-containing regimens. Insulin resistance leading to hyperglycemia, associated with some PI containing regimens. Lipodystrophy with fat accumulation in specific areas such as the abdomen and fat depletion in face and extremities, noted with some PI-containing regimens; lipoatrophy (depletion of fat), particularly with some NRTI medications. Hepatotoxicities can occur with any class, noted especially with nevirapine and PI medications as a class.

y Opportunistic infections
y PCP prophylaxis is started when the CD4+ count is less

than 200/mm3and the most effective medication is trimethoprim/sulfamethoxazole (Bactrim); others are dapsone, atovaquone (Mepron), and aerosolized pentamidine. y M. avium complex prophylaxis is started when the CD4+ count is less than 50/mm3; medications used are azithromycin (Zithromax) and clarithromycin (Biaxin). y Toxoplasmosis prophylaxis is appropriate when CD4+ count is less than 100/mm3; co-trimoxazole (Bactrim) is most commonly used. y CMV retinitis monitoring with dilated ophthalmological exam is indicated every 6 months when the CD4+ count is less than 50/mm3.

y Vaccinations

all patients should be screened every year with a purified protein derivative; 5 mm induration is considered positive. y Pneumococcal pneumonia all patients should receive Pneumovax and it should be repeated every 5 to 6 years. y Influenza patients with a CD4+ greater than 100 should receive a flu vaccine each fall. y Tetanus booster patients with a CD4+ count greater than 200/mm3 should receive routine booster every 10 years.
y Tuberculosis

y If a patient decides to stop taking antiviral therapy, he

must stop all antiviral medications at the same time. Taking only some of the antiviral therapies will create resistance to HIV; could lead to loss of effective treatment options for this patient in the future. Resistance can develop within a few days to a few weeks of incorrect dosing.

y Treatment of reversible illnesses y Nutritional support y Palliation of pain y Evaluation and management of psychological and

social aspects of HIV/AIDS infection y Treatment to relieve symptoms (cough, diarrhea) y Antidepressant drugs; psychiatric interventions

Nursing Assessment y Obtain history of risk factors, constitutional signs and symptoms, recent infections, positive blood test for HIV antibodies, most recent CD4+ count, and HIV RNA viral load. y Review patient's present complaints, such as cough, shortness of breath, diarrhea. y Evaluate nutritional status by assessing for weight loss, body mass depletion, hypoalbuminemia, decreased iron-binding capacity, anemia or complications of drug toxicities, including hyperlipidemia, hyperglycemia, lipodystrophy. y Assess respiratory rate and depth and auscultate lungs for breath sounds; assess for skin color and temperature, palpable lymph nodes, and evidence of fever, night sweats. y Inspect mouth for lesions, especially candida in the posterior pharynx; examine skin for rash, sores, Kaposi's sarcoma lesions. Record number, size, and locations.

Nursing Assessment
y Ask about bowel patterns, changes in habits, constipation,

y y

y y

abdominal cramping, number and volume of stools, presence of perianal pain and ulceration. Is patient oriented to time, place, and person? Affect? Any problem with memory and concentration? Headaches? Seizures? How much does the patient know about HIV/AIDS? Etiology? Signs and symptoms? Mode of transmission? Methods for limiting exposure? Disease progression and importance of CD4+ count and HIV RNA viral load monitoring? Find out as much as possible about patient's premorbid personality, experience and skills, social support system. Assess the patient's adherence to medications by reviewing all prescribed drugs, the dose, and how often the patient is taking the medication. Ask the patient how many times over the last day/week he or she may have missed a dose.

When caring for patients with HIV disease and AIDS, make sure that you: y Utilize universal precautions. y Protect confidentiality. y Educate the patient about methods for the prevention of HIV transmission. y Perform a psychosocial assessment. y Develop adherence strategies for patients taking antiviral therapy. y Provide education and interventions for HIV symptom management.

y Fear of disease progression, treatment effects, isolation, and y y y y y y y y

death related to having AIDS Risk for Infection related to immunodeficiency Imbalanced Nutrition: Less Than Body Requirements related to disease/treatment effects Impaired Oral Mucous Membranes related to opportunistic infection Diarrhea related to disease/treatment effects Disturbed Thought Processes (Impaired Cognition and Dementia) related to disease effects Hyperthermia related to HIV infection, opportunistic infection Ineffective Breathing Pattern related to opportunistic infections Ineffective Therapeutic Regimen Management: Individual related to complicated regimen of medications, treatment plans, clinical appointments, lack of social support, impaired cognitive functioning, substance use, and psychiatric illness

y Fatigue related to underlying HIV infection and reactive y

y y y

depression Disturbed Body Image related to rapid body changes from debilitating disease or body changes related to medication toxicities Hopelessness related to inexperience with illness, sense of loss of control, depression, and vulnerability associated with HIV/AIDS Acute and Chronic Pain related to infection, peripheral neuropathies, diarrhea Anticipatory Grieving related to awareness of implications of HIV/AIDS, changes in lifestyle, dying and death Disabled Family Coping related to crisis created by HIV/AIDS, guilt, fear, overwhelming caretaking responsibilities

y Never assume the family or loved ones know that the

patient is HIV-positive. Always ask the patient who knows of the HIV status. Confidentiality regarding HIV infection must be maintained. However, encourage the patient to share the diagnosis to decrease isolation. Offer to be with the patient when the diagnosis is shared with the family; role playing before you meet with family or loved ones can be helpful.

Reducing Fear y Maintain nonjudgmental attitude and nonprejudicial approach. y Anticipate that the patient may pass through a series of stages: initial crisis, transitional stage, acceptance state and, possibly, preparation for death if treatment options have been exhausted. y Allow patient to use denial as a protective mechanism gives some control over when and how patient will confront the diagnosis and his prognosis.
y Expect some displaced anger; avoid being personally affronted by patient's

anger. y Allow patient to acknowledge reality of the situation without false reassurance.
y Explain that symptoms of anxiety and depression are common initially but y y y y

generally improve with time and support. Anticipate that patients with substance use issues may exhibit antisocial behaviors and feelings of alienation and isolation. Provide careful discussion and clarification of treatment options. Help patient set realistic goals and expectations. Offer counseling services, especially when HIV/AIDS is initially diagnosed and as patient enters terminal phase of illness and treatment options have been exhausted. Obtain social service referral for available resources such as community-based case management

Reducing Fear y Help patient identify and strengthen personal resources, such as positive coping skills, relaxation techniques, strong support network, and optimistic outlook. y Encourage patient to join a support group helpful in defusing stressful issues and in developing strategies to cope with the disease. y Observe for emerging psychiatric problems, especially in persons who are socially isolated, those with guilt about sexuality and lifestyle, and those with poor accommodation. y If the patient has advanced disease and further treatment options, provide information on advance directives and encourage patient to arrange personal business because cognitive deterioration may make it impossible for patient to act on own behalf at a later date. y If indicated allow discussion of nature and management of death
y Assure patient of palliative care, pain control, and help with anxiety

and depression. y Respect the right of the patient to participate in treatment decisions

Preventing Infection y Have a high index of suspicion for infection even when clinical manifestations are subtle or absent opportunistic infections may be reactivated at any time during the course of the disease. y Follow universal precautions for all patients. y Administer prescribed pharmacologic agents promptly and avoid medication administration delays. y Administer and teach patient and family good skin care, a break in the skin is a source of secondary infection; use position changes, emollient lotions, special pads and beds, and attend to hydration and nutrition. y Maintain cleanliness of environment. y Use aseptic techniques when performing invasive procedures.

Preventing Infection y Teach patient to make the most of what remains of the immune system by minimizing the risk of disease.
y Avoid exposure to persons with infections y y y

these can

y y y

increase HIV viremia. Turn, cough, and do breathing exercises, when confined to bed. Discontinue injection drug use. Avoid unprotected sex even with an HIV-positive partner to prevent superinfection
with treatment-resistant HIV virus. Instruct visitors about hand washing before entering and leaving the room. Advise patient not to eat raw or undercooked foods. Tell the patient to have someone else clean a cat box or bird cage; if that is not possible, use rubber gloves.

Improving Nutritional Status y Monitor nutritional status by weighing, recording dietary intake and calorie count y Monitor for sore throat that progresses to dysphagia or odynophagia (pain on swallowing) or persistent heartburn suggestive of esophageal candidiasis. y Consult with dietitian to develop strategies for nutrition care y Include patient in decision making regarding nutrition care. y Review times of drug administration to improve absorption, either taking on empty stomach or with food. y Administer or teach patient to administer prescribed antiemetic 30 minutes before meals if nausea is a problem and to use antidiarrheal medication as needed. y For patient with oral/esophageal pain from Candida esophagitis, herpetic esophagitis, endotracheal Kaposi's sarcoma:
y Administer prescribed antifungal therapy. y Avoid highly seasoned or acidic foods. y Offer fluids and blenderized foods to minimize chewing and ease swallowing.

y Discourage excessive alcohol intake has immunosuppressive effect. y Make appropriate community referral if patient is unable to shop or prepare

meals.

y Protease inhibitor levels can be affected by grapefruit

juice, as can other common medications. Therefore, patients taking any of the antiviral therapies within the protease inhibitor class should be discouraged from consuming grapefruit juice.

Relieving Oral Discomfort y Ask about persistent sore throat, dysphagia, and heartburn these symptoms are suggestive of oral/esophageal candidiasis. y Examine mouth for oral candidiasis and other lesions. y Administer or teach patient to administer prescribed antifungal mouth rinses or lozenges for oral candidiasis

Minimizing the Effects of Diarrhea y Keep in mind that GI infections and diarrhea decrease absorptive efficiency. y Tell patient to monitor stools for blood and try to determine if bleeding is before, with, or after bowel movement to help determine source of bleeding. y Monitor intake and output; assess skin and mucous membranes for poor turgor and dryness, indicating dehydration. y Administer fluids and electrolytes as prescribed. y Advise patient to rest to achieve bowel rest. y Use enteric precautions. y Plan regimen of skin care, including cleaning/blotting/drying of the anal area, application of ointment or skin barrier cream. y Advise patient to eliminate caffeine, alcohol, dairy products, foods high in fats, fresh juices, and acidic juices if diarrhea persists. Drink liquids at room temperature. y Advise patient to avoid foods that increase motility and distention such as gasforming fruits and vegetables. y Advise patient to report symptoms and signs of increased weakness, dizziness, and continuing weight loss.

Managing Disturbed Thought Processes y Remember that the brain is a critical target organ for HIV infection in end-stage AIDS. y Provide daily assessment of mental status; monitor for changes in behavior, memory, concentration ability, and motor system dysfunction, patient may become vegetative and unable to ambulate.
y Onset of dementia is usually insidious but may be abrupt, precipitated

by acute infection.

y y y y y

Reorient patient frequently; use calendar, clock, family/friends' pictures, lists, and structured care plan. Provide for patient safety: bed rails up, call signal available, articles within patient's reach. Give repeated reassurance. Assess for depressive or suicidal symptoms end-stage AIDS represents a risk for suicide. Anticipate necessity of guardianship, durable power of attorney for health care, and informed consent if patient has AIDS dementia complex because patient may have poor insight and become indifferent to illness.

Reducing Fever y Assess for chills, fever, tachycardia, and tachypnea. y Encourage high fluid intake to replace insensible water losses incurred by fever/diaphoresis. y Administer or teach patient to administer antipyretics as prescribed. y Teach patient or caregiver to report a change in fever pattern or significant change in condition.

Improving Breathing Pattern y Provide supplemental oxygen as ordered. y Watch for sudden change in respiratory function, patient may be developing a secondary infection. y Administer or teach patient to administer prescribed opioid for post infectious cough, a complication of PCP and viral pneumonia. y Encourage smoking cessation to enhance pulmonary ciliary defense. y Administer saline nebulization to induce sputum collection for culture and sensitivity.
Wear mask and gloves during sputum collection. Instruct patient to brush tongue, buccal surfaces, teeth, and palate with water before sputum induction to remove superficial squamous epithelial cells and their adherent bacteria and foreign material. y Instruct patient to gargle and rinse mouth with water.
y y

y Answer questions and support end-stage patient's decision for or

against resuscitation and mechanical ventilation.

Improving Patient's Management of HAART y Assess patient's adherence to medications and clinical appointments in the past; if there has been poor adherence in the past, have patient explore what contributed to it. y Provide education about prescribed medications before the therapy is started and periodically thereafter; provide education materials that can remain in the home as a resource. y Develop a medication schedule for the patient that incorporates his or her usual day's activities; place pills in a medication box according to the schedule. y Encourage the involvement of a household member in the education and administration of the patient's medications. y Continue to monitor for medication adherence after patient has achieved an undetectable viral load.

Community and Home Care Considerations y If patient is homebound, suggest contacting an agency that offers help specifically for HIV patients, and provide home visits for services, such as hospice care and food services. y Assist patient/family/significant other to locate assistance agencies in the community. y Assess the home for patient safety and provide durable medical goods that can enhance safety and comfort. y Provide latex gloves for the home for handling body fluids of the HIV-positive household member.

y Community and Home Care Considerations y Explain that routine household cleaning of the bathroom,

dishes, and laundry is sufficient to prevent HIV transmission. y Explain that the HIV-positive household member should never share toothbrushes or razors because they can provoke bleeding and, therefore, are a potential source of HIV transmission. y Establish whether there are persons in the home who will participate in the HIV-positive household member's care; engage these caregivers while attending to the patient. Assess the needs of the caregiver; acknowledge that it is important to have a break from the caregiver role. Provide information about respite services in which the patient can be cared for during the day or for days or weeks at a longterm care facility.

Community and Home Care Considerations y Emphasize to injection drug users that continued use may expose them to additional infection and such infections may accelerate disease progression. y Encourage patient to modify sexual behaviors for safer sex.
y Use latex male condoms. y If a man will not use a condom, the woman can use a female

condom. y Refrain from anal sex. y Encourage patient to read literature from various AIDS action groups on safer sex techniques.
y If the patient abuses substances (drugs, alcohol):
y Encourage enrollment in a treatment program. y Caution patient not to share needles and to join needle

exchange program, if available. y If unused needles are not available, advise cleaning needles before using with a bleach/water solution.

Community and Home Care Considerations y Teach patient to optimize immune system function by sound dietary practices, exercise, and regular sleep; promote changes in the direction of more healthful living. y Some patients may use complementary or alternative therapies, such as vitamins, herbs, and teas. Caution the patient to share these additional therapies with the primary provider.

y speaks openly about HIV disease with health care y y y y y y y y

providers, significant others No signs of opportunistic infections Eats three to four meals per day Oral mucosa without lesions Reports formed stools one to three times per day Responds appropriately to questions of self, time, and place; verbalizes accurate account of activities Afebrile with a normal heart rate Respirations unlabored, rate 20/minute; no cough or sputum production Reports medication adherence greater than 90% of doses; HIV viral load remains non detectable

The end
By: Leo T. Ocariza RN,MN