UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC

RSPONSE AND PERCEPTION AND COORDINATION

AIDS INFORMATICS! HIV TRANSMISSION HIV is transmitted in body fluids containing HIV or infected CD4+ T lymphocytes. These fluids include BLOOD, SEMINAL FLUIDS, VAGINAL SECRETIONS, AMNIOTIC FLUIDS and BREAST MILK. Mother to child transfer may occur in the utero at the time of delivery or during breast feeding but most perinatal infections occur during delivery. Inflammation and breaks in the skin or mucosa result in the increased probability of exposure to HIV. HIV is not transmitted through casual contact. Blood and blood products can transmit HIV to recipients. The risk for HIV transmission in blood transfusions has been eliminated as a result of voluntary self deferral, completion of a detailed health history, extensive testing, heat treatment of clotting factor concentrates, and more effective virus inactivation methods. Donated blood is tested for antibodies to HIV-1, HIV-2 and P24 antigens. However blood donated during the window period after infection is infectious even though it tests negative for HIV. (HIV window period is the time between the contraction of the disease and production of the antibodies. It can be named as the first or the initial stage of HIV infection. HIV test, conducted during the window period cannot detect any traces of HIV antibodies and the result of such antibody tests, like ELISA, Rapid Test or the Western Blot, would be fallaciously negative. On an average, the window period lasts for 2 to 12 weeks. A HIV test proves positive only after the termination of the HIV window period when enough anti bodies have been produced within our system.) PREVENTIVE EDUCATION Abstinence Consistent and correct use of condoms (the only method proven to decrease the risk but does not protect against HIV) A condom should also be used even during oral contact with the penis SAFER SEX BEHAVIORS Abstain from sharing sexual fluids. Reduce number of sexual partners to one. Advise patients to use latex condoms Advise patients to avoid using cervical caps or diaphragms without using a condom as well Avoid reusing condoms Avoid anal intercourse damages tissues Advise to avoid manual anal intercourse fisting Advise patient not to ingest urine or semen Educate patients regarding non penetrative sexual activities such as body massage, social kissing, mutual masturbation, fantasy and sex films Avoid sharing needles, razors, toothbrushes, sex toys or blood contaminated articles. Advise HIV seropositive patients to avoid having unprotected sex with another seropositive patient. Cross infection can increase the severity of the infection. Advise HIV seropositive patients to avoid donating blood, plasma, body organs or sperms. HOW TO USE A CONDOM

NCM 009 INSTRUCTORS1

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

Buy a package of lubricated latex condoms, in the appropriate size at your local pharmacy. Make note of the expiration date. As soon as the penis is hard, open the package and squeeze the tip of the condom to remove the excess air inside. Look for damage and use another condom if damage is detected or the condom is dry. Put the open end of the condom on the head of the penis. Roll the condom down the shaft of the penis until it fits comfortably. The condom should extend almost to the base of penis and have a smooth fit. Leave space at the tip of the condom for semen. After ejaculation, the man should hold the condom secure while withdrawing his penis from the vagina to help prevent the condom from coming off or spilling. Never use the same condom twice. Once out of the vagina the condom can be removed and disposed of. The penis should be washed to prevent any semen from inadvertently making its way back into the vagina. Tips: Use only water based lubricants on latex condoms. Oil based lubricants such as petroleum jelly can damage the condom. The lubricant can be placed on the outside of the condom prior to intercourse. PATHOPHYSIOLOGY Viruses are intracellular parasites, HIV belongs to a group of viruses called RETROVIRUSES. These viruses carry their genetic material in the form of RNA rather than in DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins. For HIV to enter the target cell, the membrane of the viral envelope must be fused with the plasma membrane of the cell, a process mediated by the envelope glycoproteins of the cell. HIV life cycle The HIV GP120 and GP41 attach to the uninfected CD4 cell surface (receptor) and fuse with the cell membrane. The viral core contents are emptied into the host cell, a process called uncoating. HIV enzyme REVERSE TRANSCRIPTASE copies the viral genetic material from RNA into double stranded DNA. Double stranded DNA is spliced into the cellular DNA by the action of integrase, another HIV enzyme. Using the integrated DNA or provirus as a blueprint, the cell makes new viral proteins and viral RNA. HIV protease cleaves the new proteins. The new proteins join the viral RNA into new viral particles New viral particles bud from the cell and start the process all over again.

STAGES OF HIV DISEASE The stages of HIV are based on clinical history, physical examination, laboratory evidence of immune dysfunction, signs and symptoms, and infections and malignancies. PRIMARY INFECTION (ACUTE HIV INFECTION ACUTE HIV SYNDROME) The period from infection with HIV to the development of antibodies to HIV is known as primary infection. During the primary infection, a window period occurs, during which a person with HIV infection tests negative. NCM 009 INSTRUCTORS2

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

After someone is infected with HIV, blood tests can detect antibodies to the virus, even if they never had any symptoms of their infection. This is called HIV seroconversion (converting from HIV negative to HIV positive by blood testing), and usually occurs within 3 months of exposure, but on rare occasions can by delayed up to a year after infection. Following the initial infection, there may be no further evidence of illness for the next 10 years. This stage is called asymptomatic HIV infection. Acute HIV infection can, but does not always, progress to early symptomatic HIV infection and to advanced HIV disease (AIDS). However, the vast majority of patients do ultimately progress to AIDS. To date there are a small number of people who have tested positive for HIV, but later no longer test positive and have no signs of disease. Although this is relatively rare, it provides evidence that the human body may be capable of removing the disease. These people are being carefully watched and studied. HIV has spread throughout the world. Higher numbers of people with the disease are found in large metropolitan centers, inner cities, and among certain populations with high-risk behaviors. Symptoms Note: At the time of diagnosis with HIV, many people have not experienced any symptoms. Acute HIV infection can appear like infectious mononucleosis, flu, or other viral illnesses. If symptoms occur, they are usually seen 1 - 4 weeks after becoming infected. Any of the following symptoms can occur: Decreased appetite Fatigue Fever Headache Malaise Muscle stiffness or aching Rash Sore throat Swollen lymph glands Ulcers of the mouth and esophagus These symptoms can last from a few days to 4 weeks, and then subside. HIV ASYMPTOMATIC (CDC CATEGORY A: MORE THAN 500 CD4+ LYMPHOCYTES) Asymptomatic HIV infection is a phase of chronic infection with human immunodeficiency virus (HIV) during which there are no symptoms of HIV infection. Causes Asymptomatic HIV infection is a period of time, which varies in length from person to person, in which the immune system slowly deteriorates but there are no symptoms. The length of this phase varies depending on how quickly the HIV virus is copying itself and the individual's genetic differences that affect the way his or her immune system handles the virus. Some people can go 10 years or longer without symptoms, while others may have symptoms and worsening immune function within a few years after the original infection. Symptoms

NCM 009 INSTRUCTORS3

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

Asymptomatic HIV infection, by definition, does NOT have symptoms typically associated with HIV, such as: Fever Opportunistic infections (opportunistic means they occur because the weakened immune system provides the "opportunity" for infections to take hold. Serious opportunistic infections includePneumocystis jirovecii pneumonia, cytomegalovirus, and Mycobacterium avium). Oral thrush (also an opportunistic infection, but not life-threatening and does not require a seriously weakened immune system to occur) Weight loss HIV SYMPTOMATIC (CDC CATEGORY B; 200 TO 499 CD4+ T LYMPHOCYTES) Early symptomatic HIV infection is a stage of infection with the human immunodeficiency virus when symptoms are present but AIDS has not yet developed. Causes Early symptomatic HIV infection has signs and symptoms typical of HIV infection but not full-blown AIDS. The onset of symptoms signals the transition from asymptomatic HIV infection to HIV disease. At this early stage of HIV infection, the person does not have signs or symptoms of AIDS such as opportunistic infections, certain cancers, or a CD4 count of less than 200. Risk factors for HIV infection are: Being born to an HIV-positive mother Receiving a blood transfusion or blood components Injection drug use Sexual contact with an infected partner in which there is an exchange of semen or vaginal fluids Symptoms Diarrhea that persists Excessive sweating or night sweats Fatigue that persists Fever that persists General feeling of discomfort, illness, or lack of well-being Herpes zoster infections (shingles) that keep coming back Joint pain Mouth disorders o Gingivitis o Oral hairy leukoplakia of the tongue, caused by a viral infection o Oral thrush ("yeast infection") Pain, loss of sensation, and inability to control muscles (peripheral neuropathy) Skin disorders o Fungal infection of the skin or nails o Molluscum contagiosum o Seborrheic dermatitis Swollen lymph glands Weight loss AIDS (CDC CATEGORY C; FEWER THAN 200 CD4+ T LYMPHOCYTES) NCM 009 INSTRUCTORS4

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

when CD4+ T cells drop bellow 200cells/mm3

DIAGNOSTIC FINDINGS Before an HIV antibody test is performed, the meaning of the test and possible test results are explained and an informed consent from the patient is obtained HIV ANTIBODY TEST ELISA/ EIA Enzyme linked immunosorbent assay Now just enzyme immune assay Determines antibodies directly specifically against HIV The western blot is used to confirm seropositivity when the EIA is postitive ORAQUICK RAPID HIV-1 ANTIBODY TEST Uses less than a drop of blood and has results within 20 minutes with 99.6 reliability and accuracy. Becoming the standard method of settings where there is usually a delay VIRAL LOAD TEST Quantifies the amount HIV RNA or DNA in the plasma. Reverse transcriptase polymerase chain reaction (RTPCR ) and nucleic acid sequence based amplification. These tests track viral load or viral set point and also the response to treatment. HIV TEST RESULT INTERPRETATION o Positive result Antibodies to HIV are present in the blood HIV is active in the body Despite HIV infection, the patient does not have AIDS yet The patient is not immune to HIV and the antibodies does not indicate immunity o Negative result Antibodies to HIV are not present If infected the body has not produced antibodies yet The window period is usually 3 weeks to 6 months to a year The patient should continue taking precautions The test result means does not mean that the patient is immune to the virus TREATMENT Treatment decisions are individualized depending on a number of factors including CD4+ cell count, viral load, severe symptoms of HIV disease or AIDS and willingness of the patient to adhere to a lifelong treatment regimen. In general, antiretroviral medications should be offered to individuals with a T cell count of less than 350cells/mm3 or plasma HIV RNA levels exceeding 100,000 copies/ml. There are potential complications of antiretroviral regimens and pose difficulties regarding adherence: these includes resistance due to non adherence or suboptimal levels of antiretroviral agents. The goals of treatment include maximal and sustained suppression of the viral load, restoration or preservation of immunologic function, improved quality of life and reduction of HIV related morbidity and mortality. NCM 009 INSTRUCTORS5

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

Results of therapy is evaluated through viral load testing. Viral load levels should be measured prior to therapy and again after 2 to 8 weeks because in most patients adherence to the regimen of potent antiretroviral drugs should result in a large decrease in the viral load. The CD4+ count should increase by 100 to 150 cells/mm3 per year with an accelerated response within the first three months. There are 4 classes of antiretroviral drugs: NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIS) NON NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS) PROTEASE INHIBITORS AND FUSION AND ENTRY INHIBITORS o Acts by targeting the GP120 during the attachment stage of the HIV cycle and T20 is administered subcutaneously. REFERENCE PAGE 1827 DRUG RESISTANCE o Can be broadly defined as the ability of pathogens to withstand the effects of the medication that are intended to be toxic to them. Resistance develops as a result of spontaneous genetic mutation of the pathogens or in response to exposure to medication.

CLINICAL MANIFESTATIONS Treatment of the manifestations of HIV depends on the management of specific symptoms. RESPIRATORY MANIFESTATIONS PNEUMOCYSTIS PNEUMONIA (PCP) o The most common infection seen with AIDS o Causative organism: P. Jiroveci and no longer P. Carinii o Signs and symptoms: Non productive cough Fever and chills SOB Dyspnea and occasionally chest pain 02 saturation may be slightly decreased indicating mild hypoxemia If untreated PCP causes impaired respiratory function and ultimately failure. Dramatic onset may result to severe hypoxemia, cyanosis, tachypnea, and altered mental status. MYCOBACTERIUM AVIUM COMPLEX o A common opportunistic infection from the a group of acid fast bacillis (mycobacterium) o Causes respiratory tract infections but is also commonly found in the GI tract, lymph nodes and bone marrow. TUBERCULOSIS GASTROINTESTINAL MANIFESTATIONS ORAL CANDIDIASIS o A fungal infection NCM 009 INSTRUCTORS6

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

o o o

Occurs in most patients with AIDS Characterized by creamy white patches in the oral cavity If untreated can affect the esophagus and stomach

WASTING SYNDROME o Part of the category C case definition of AIDS o Diagnostic criteria includes profound weight loss exceeding 10% of baseline body weight o Chronic diarrhea for 30 days o This protein energy malnutrition is multifactorial o Patients experience a hypermetabolic state in which excessive calories are burned and lean body mass is lost.

ONCOLOGICAL MANIFESTATIONS o Higher than usual incidence of cancer o Possibly related to HIV stimulation of developing cancer cells or the immune deficiency that allows cancer cells to proliferate. o KAPOSIS SARCOMA o Kaposi's sarcoma is a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs. The patches are usually red or purple and are made of cancer cells and blood cells. The red and purple patches often cause no symptoms, though they may be painful. If the cancer spreads to the digestive tract or lungs, bleeding can result. Lung tumors can make breathing hard. B CELL LYMPHOMAS o These are types of lymphoma affecting B cells. Lymphomas are "blood cancers" in the lymph glands. They develop more frequently in older adults and in immunocompromised individuals (such as those with AIDS). DEPRESIVE MANIFESTATIONS o The prevalence of depression among people with HIV infection is unknown o The cases are multifactorial and may include an existing history of mental illness. o Depression may also occur as a response to the physical symptoms, including the pain and weight loss and lack of someone to talk to with about their concerns. o They may experience irrational guilt and shame, loss of self esteem, feelings of helplessness and worthlessness and suicidal ideation. NURSING DIAGNOSIS IMPAIRED SKIN INTEGRITY RELATED TO CUTANEOUS MANIFESTATIONS OF HIV INFECTION, EXCORIATION AND DIARRHEA DIARRHEA RELATED TO ENTERIC PATHOGENS OR HIV INFECTION RISK FOR INFECTION RELATED TO IMMUNODEFICIENCY ACTIVITY INTOLERANCE RELATED TO WEAKNESS, FATIGUE, MALNUTRITION, HYPOXIA ASSOCIATED WITH PULMONARY INFECTIONS PAIN RELATED TO IMPAIRED PERIANAL SKIN INTEGRITY SECONDARY TO DIARRHEA, KS AND PERIPHERAL NEUROPATHY INEFFECTIVE AIRWAY CLEARANCE RELATED TO PCP, INCREASED BRONCHIAL SECRETIONS AND DECREASED ABILITY TO COUGH (DUE TO FATIGUE AND WEAKNESS) IMBALANCED NUTRITION LESS THAN BODY REQUIREMENTS RELATED TO DECREASED ORAL INTAKE NCM 009 INSTRUCTORS7

UNIVERSITY OF LASALETTE COLLEGE OF NURSING NURSING CARE MANAGEMENT- 009 CARE OF CLIENTS WITH PROBLEMS IN INFLAMMATORY AND IMMUNOLOGIC RSPONSE AND PERCEPTION AND COORDINATION

SOCIAL ISOLATION RELATED TO STIGMA OF THE DISEASE, WITHDRAWAL OF SUPPORT SYSTEM, ISOLATION PROCEDURES AND FEAR OF INFECTING OTHERS. ANTICIPATORY GRIEVING RELATED TO CHANGES IN THE LIFESTYLE AND ROLES AND UNFAVORABLE PROGNOSIS DEFICIENT KNOWLEDGE RELATED TO HIV INFECTION, MEANS OF PREVENTING HIV TRANSMISSION AND SELF CARE.

NCM 009 INSTRUCTORS8