Slide 1 ___________________________________

Human Immunodeficiency ___________________________________

Virus
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 2 ___________________________________
Transmission of HIV
___________________________________
 Exchange of blood or other body fluids containing HIV
(blood, semen, vaginal & cervical secretions & breast milk,
and cerebrospinal fluid (CSF) ) i.e. unprotected sex or by


sharing needles
HIV-infected individuals can transmit HIV within a few
days after becoming infected; transmit ability lifelong
___________________________________
 Sexual contact (anal, vaginal, oral) with an HIV-
infected partner – 75% cases (most common mode of


transmission)
Accidental needle sticks, needle sharing among IV drug
users
___________________________________
 Perinatal Transmission (most common route for
infecting children) – HIV-infected mother to her infant
occur during pregnancy in utero or at time of delivery or
after birth through breastfeeding ___________________________________
___________________________________
___________________________________

Slide 3 ___________________________________
Pathophysiology (Natural Hx of HIV)
___________________________________
 HIV is a ribonucleic acid (RNA) virus
(retroviruses – replicate in a
“backward” manner going from RNA
___________________________________
to deoxyribonucleic acid (DNA);


reverse flow of genetics)
Must have living cell to replicate; T
___________________________________
lymphocytes (T4 or CD4 cells)
(invade living host cell) ___________________________________
___________________________________
___________________________________
Slide 4 ___________________________________
Clinical Manifestations
___________________________________
 typical course of untreated HIV
Early Stage -First phase of HIV infection; As virus
___________________________________

begins to replicate person develops an acute
retroviral syndrome/primary HIV infection (PHI)
 Period of time between initial exposure to virus &
appearance of HIV antibodies
 No test can detect antibodies in early stage

 Body starts to produce antibodies

___________________________________
 Flu like symptoms

___________________________________
___________________________________
___________________________________

Slide 5 ___________________________________
Clinical Manifestations (cont.)
___________________________________
 Second Phase of HIV infection
 SSx of PHI resolve


Viral load decreases
Seroconversion occurs ( converting from HIV negative to
HIV positive)
___________________________________
 Seroconversion
The process by which a newly infected person
develops antibodies to HIV. These antibodies
are then detectable by an HIV test.
Seroconversion may occur anywhere from days
___________________________________
to weeks or months following HIV infection.
(CDC definition)

___________________________________
___________________________________
___________________________________

Slide 6 ___________________________________
Clinical Manifestations (cont.)
___________________________________
 Chronic infection
 Patient seems well ( no clinical
apparent disease)
___________________________________
 Virus is busy replicating itself and
spreading to uninfected cells
 If no treatment – loose T cells – HIV
___________________________________
associated infections

___________________________________
___________________________________
___________________________________
Slide 7 ___________________________________
Clinical Manifestations (cont.)
___________________________________
 Symptomatic HIV infection
T-cell count continues to decline
___________________________________

 Patient develops a symptomatic infection
(pneumocystis pneumonia (PCP) or candidiasis)
 HIV infection Dx at this stage
 HIV-associated illnesses appear
 Acquired immunodeficiency syndrome
(AIDS) ___________________________________
 Meets definition of AIDS established by US center
for disease control and prevention (CDC)



HIV+ & have CD4 cell ct below 200/mm or less than
14% of all lymphocytes
HIV+ & have AIDS defining illness
___________________________________
___________________________________
___________________________________

Slide 8 ___________________________________
Diagnostic Studies
___________________________________
 Most useful screening tests are those that detect
HIV-specific antibodies



Problem – median delay of 2 months after
infection before antibodies can be detected
Health care providers alerted to do HIV screening
___________________________________
based on sexual practices, IV drug use, receipt of
blood transfusions, exposure to body fluid


(needlestick)
HIV antibody testing
___________________________________
 Requires education & counseling – meaning of test
& possible results



Informed consent
Privacy
Test results kept confidential
___________________________________
___________________________________
___________________________________

Slide 9 ___________________________________
Diagnostic Studies
___________________________________
 OralQuick Rapid HIV-1 – (2002)



Antibody test allow rapid notification of
individuals
Accurate results in 20 minutes
___________________________________
Uni-Gold Recombigen (Dec 2003)
___________________________________

 Results in 10 minutes
 Oral Quick Rapid HIV – ½ Antibody test
(March 2004)
 99% accurate; results in 20 mins; saliva
specimen
___________________________________
___________________________________
___________________________________
Slide 10 ___________________________________
Diagnostic Studies
___________________________________
 EIA (enzyme immunoassay) formerly ELISA
(enzyme linked immunosorbent assay)




Detect serum antibodies that bind to HIV antigen
Serum & saliva
Western Blot or immunofluorescence Assay (IFA)
___________________________________
 More specifically confirms HIV
Viral Load test
___________________________________

 Measure plasma HIV RNA level
 Used to track viral load & response to tx for HIV
infection
 CD4 T-cell count to monitor progression of the

___________________________________
infection
 WBC count, RBC count, and platelets decrease with
progression of HIV

___________________________________
___________________________________

Slide 11 ___________________________________
Collaborative Care (Rapidly Changing)
___________________________________
 Protocols change often
Treat for life
___________________________________

 Highly Active Antiretroviral Therapy (HAART)
/Antiretroviral (ARV) regimen
 Treatment based on
 HIV RNA (viral load)


CD4T cell count
Clinical condition of patient ___________________________________
 Antiretroviral regimens are complex, major side
effects, adherence difficult, carry serious
potential consequences from viral resistance r/t
lack of adherence or suboptimal levels of
antiretroviral agents
___________________________________
___________________________________
___________________________________

Slide 12 ___________________________________
Drug Therapy
___________________________________
 Nonnucleoside reverse transcriptase inhibitors
(NNRTIs) – attach to the reverse transcriptase

___________________________________
enzyme, preventing the enzyme from converting HIV
RNA to DNA
 Nucleoside reverse transcriptase inhibitors
(NRTIs) become part of HIV’s DNA and derail its
building process. (damaged DNA can’t take control of
the cell’s DNA)
 Protease inhibitors work at later stage in replication
process, preventing the protease enzyme from cutting
HIV viral proteins into the virions that infect new CD4+
___________________________________
cells (new copies of HIV will be defective and unable to
infect other CD4+ cells.
 Fusion Inhibitors – interferes with HIV’s ability to
fuse with and enter the host cell ___________________________________
___________________________________
___________________________________
Slide 13 ___________________________________
HAART Therapy
___________________________________
 Combining drugs from above categories allows them to
block HIV at several points in the replication, slowing its
spread in the body



Strategy known as highly active (or highly aggressive)
antiretroviral therapy (HARRT)
Death rate has dropped because of HARRT
___________________________________
 Initiated during acute HIV infection

___________________________________
 Pregnancy
 Post exposure health care worker, rape victims
 Offered to all patients that are symptomatic
 <350 CD4 or VL > 55,000 (low positives 10,000)
 Barrier – failure to adhere to treatment
 If patient doesn’t take medication as prescribed,
virus will mutate and become resistant to it ___________________________________
___________________________________
___________________________________

Slide 14 ___________________________________
Common Opportunistic Infections (OIs)
___________________________________
 Pneumocystis carinii pneumonia
 Cytomegalovirus
 Mycobacterium tuberculosis
___________________________________
 Toxoplasmosis
 Candidiasis
___________________________________
___________________________________
___________________________________
___________________________________

Slide 15
Clinical Manifestations
 Widespread and effect
any organ system
___________________________________
___________________________________
 Nonproductive (dry)
cough, fever, chills,

 Pneumocystis carinii
pneumonia (PCP)
 Most common OI
resulting in an AIDS
diagnosis
Fungus – P carinii
___________________________________
shortness of breath,
dyspnea, occ. chest
pain, tachypnea,
tachycardia, breath
sounds may initially be
normal, sputum may be

___________________________________

causes disease only in present
immunocompromised  Treatment
hosts, invading and  TMP-SMZ drug of choice
proliferating within  Pentamidine(Pentam 300,
pulmonary alveoli with Nebu-Pent) nebulizer tx.
resultant consolidation

___________________________________
 Dupsone – anti-infective, anti
of the pulmonary leprosy
parenchyma  Mepron – anti-infective, anti-
protozal, antipneumocystic
activity

___________________________________
___________________________________
Slide 16 Mycobacterium avium complex
(MAC)
 Group of acid-fast bacilli  Treatment
 Occurs late in course of
disease CD4 count less
then 50
 Major cause of “wasting
syndrome”
Frequently causes GI tract

problems for HIV-infected
patients
 SSx – chronic diarrhea,
abdominal pain, chills
fever, malaise, weight
loss, anemia,
neutropenia,
malabsorption syndrome,
& obstructive jaundice
Slide 17
Tuberculosis
 Mycobacterium Management
tuberculosis occur in
IV drug users &
groups with high
preexisting high
prevalence to TB

infection
Productive cough,
purulent sputum,
fever, fatigue, night
sweats, weight loss,
lymphadenopathy Rifampin
Rifabutin
INH, ethambutol
Slide 18
GI Manifestations
Loss of appetite  Manage
Nausea & vomiting
Oral & esophageal
candidiasis
Chronic diarrhea
Salmonella
 Candidiasis -
Clostridium difficile
___________________________________
___________________________________
clarithromycin
___________________________________

(Biaxin)
 azithromycin
(Zithromax)
 Rifabutin
(Mycobutin)
___________________________________
combined with
azithromycin more
effective but costly
 Nursing – teach
about complicated
drug therapy; help
deal with diarrhea ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
complex -
taking ___________________________________
numerous meds
which may
interact with
antituberculosis
___________________________________
meds - expert
___________________________________
consulted
___________________________________
___________________________________
___________________________________
___________________________________
chronic
diarrhea -
octreotide ___________________________________
acetate
(Sandostatin)
clotrimazole
___________________________________
(Mycelex) oral
troches or
nystatin
___________________________________
suspension
___________________________________
___________________________________
Slide 19 ___________________________________
Kaposi’s Sarcoma (KS)
___________________________________
 Most common HIV-  Surgical excision
related malignancy - of lesions
disease involving
endothelial layer of  application of ___________________________________
blood and lymphatic nitrogen
vessels -
 Localized cutaneous
lesions; disseminated
 Radiation therapy
- palliative to ___________________________________
disease involving
relieve pain
Alpha-interferon
___________________________________
multiple organ 
systems
 Brownish, pink to
deep purple cutaneous
lesions
___________________________________
___________________________________

Slide 20 ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 21 ___________________________________
HIV Encephalopathy
___________________________________
 Clinical syndrome - progressive decline in
cognitive, behavioral, and motor functions
 SSx - (early) memory deficits, headache,
difficulty concentrating, progressive
___________________________________
confusion, psychomotor slowing, apathy
and ataxia
 Later stages - global cognitive
impairments, delay in verbal responses, a
___________________________________
vacant state, spastic paraparesis,
hyperreflexia,psychosis, hallucination,
tremors, incontinence, seizures, mutism &
death
___________________________________
___________________________________
___________________________________
Slide 22 AIDS – dementia complex (ADC) &
___________________________________
Neurologic Effect
___________________________________
 Dementia that accompanies final stage of AIDS
 Caused by HIV infection in brain, or HIV related CNS
problems caused by lymphoma, toxoplasmosis, CMV,
herpes virus, Cryptococcus, PML, dehydration or drug
SE ___________________________________
 SSx – decreased ability to concentrate, apathy,
depression, inattention, forgetfulness, social

___________________________________
withdrawal, personality changes, insomnia, confusion,
hallucinations, slowed response rates, clumsiness and
ataxia
 Progresses – global dementia, paraplegia, incontinence
and coma

___________________________________
 Sensory neuropathies – numbness, tingling and pain in
lower extremities; progress to weakness and paralysis
 Nursing intervention – focus on safety; issues r/t
assistance devices, home environment, and smoking;
encourage self-care as long as possible & help
caregiver
___________________________________
___________________________________

Slide 23 ___________________________________
Cryptocococcal meningitis
___________________________________
 Fungal infection  IV amphotericin B
Fever, headache, flucytosine or
___________________________________


malaise, stiff neck,
nausea & vomiting,
Diflucan
mental status
changes, seizures
___________________________________
___________________________________
___________________________________
___________________________________

Slide 24 ___________________________________
Cytomegalovirus Retinitis (CMV)
___________________________________
 Leading cause of blindness - retinal


lesions
Blurred or loss of vision, floaters
___________________________________
 Oral ganciclovir - prophylaxis with
T-cell counts less than 50 ___________________________________
 foscarnet (Foscavir) -
 Does not kill the virus but control
growth - requires lifelong tx
___________________________________
___________________________________
___________________________________
Slide 25 ___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 26 ___________________________________
Depressive Manifestation
___________________________________
 Multifactorial  Psychotherapy
causes
 May experience
 Antidepressants
 imipramine ___________________________________
irrational guilt and (Tofranil
shame, loss of fluoxetine (Prozac)
___________________________________


self-esteem,  desipramine
feeling of (Norpramin)
helplessness and  Relieve fatigue &
worthlessness,
and suicidal
lethargy
___________________________________
ideation

___________________________________
___________________________________

Slide 27 ___________________________________
Skin Manifestations
___________________________________
 OIs - herpes zoster & herpes
simplex - painful vesicles disrupt
skin integrity
___________________________________
 Seborrheic dermatitis - indurated,
diffuse, scaly rash involving scalp &
face
___________________________________
Generalized folliculitis - dry,flaking
___________________________________

skin or atopic dermatitis (eczema or
psoriasis)

___________________________________
___________________________________
Slide 28 ___________________________________
Skin Manifestations
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________
___________________________________

Slide 29 ___________________________________
Gynecologic Manifestations
___________________________________
 Persistent, recurrent vaginal
candidiasis - first sign in HIV
infection in women
___________________________________
 Ulcerative STDs - chancroid syphilis,
herpes more severe in women ___________________________________
 PID
Cervical Cancer

___________________________________
___________________________________
___________________________________

Slide 30 ___________________________________
Older Adults & HIV
___________________________________
 Seniors are a growing segment pf the HIV +
population and AIDS diagnoses among seniors are


on the rise
Between 11 and 15% of U.S. AIDS cases occur in
people over age 50
___________________________________
 Referred to as an “overlooked epidemic” and
“forgotten population”
 Older adults do not use condom; view as means
of unneeded birth control & do not consider
___________________________________
themselves at risk
 Modes of transmission identical as for other age


groups
Teach safe sex practices to prevent sexually
transmitted diseases
___________________________________
___________________________________
___________________________________
Slide 31 ___________________________________
Nursing Care
___________________________________
 Very challenging – organ system


target for infection & Cancer
Complicated by emotional, social &
___________________________________
ethical issues
___________________________________
___________________________________
___________________________________
___________________________________

Slide 32 ___________________________________
Prevention of HIV Infection
___________________________________
 Effective educational program to eliminate &
reduce risk behaviors
 Safer sexual practices – use of latex or non-latex
condoms during vaginal & anal intercourse, and ___________________________________
oral contact with penis
 Dental Dams used for oral contact with vagina &


rectum
Avoid sexual practices that might cut, tear, lining ___________________________________
of rectum, penis or vagina
Avoid contact with multiple partners or people
___________________________________

know HIV infection and use injection drugs
 Avoid donating blood & sharing drug equipment

___________________________________
___________________________________

Slide 33 ___________________________________
Prevention of HIV Infection
___________________________________
 Family planning issues need to be
addressed
 Estrogen in oral contraceptives increase risk of
HIV infection
___________________________________
 Use estrogen in HIV + women increase


shedding in vagina & cervical secretion
IUD string serves as means to transmit HIV &
___________________________________
causes penile abrasion
 Female condom- 1st
barrier method that
can be controlled by women ___________________________________
___________________________________
___________________________________
Slide 34 Transmission to Health Care
___________________________________
Providers
___________________________________
 Standard Precautions
Applies to all patients receiving care in hospital
___________________________________

regardless of Dx or presumed infection status
 Goal – prevent transmission of nosocominal
infection
Transmission Base Precautions

 Used for pt with documented or suspected
infections
___________________________________
 Airborne precautions


Droplet precautions
Contact precautions ___________________________________
___________________________________
___________________________________

Slide 35 ___________________________________
Nursing Interventions
___________________________________
 Promoting skin integrity
Assess
___________________________________

 Balance rest and mobility
 Immobile – turn Q 2 hrs
 Pressure relieving devices; low air loss beds
(Clinitron)


Avoid scratching & nonabrasive soaps
Medicated lotions, ointments & dressings ___________________________________
 Avoid adhesive tape
 Regular oral care



Perianal area – clean after each BM; soft cloth or
sponge less irritating; Sitz bath or gentle irrigation
Wounds cultured for infection
___________________________________
___________________________________
___________________________________

Slide 36 ___________________________________
Promoting bowel habits
___________________________________
 Assess for diarrhea
 Monitor frequency & consistency of stools & report



abdominal pain & cramping
Measure quantity & volume of liquid stools
Obtain stool cultures
___________________________________
 Oral fluid restriction (NPO) acute inflammation
Avoid foods that act as irritants, i.e. raw fruits &
___________________________________

vegetables, popcorn, carbonated beverages, spicy
foods, and foods extreme temperature
 Small frequent meals – prevent abdominal distention
 Administer anticholinergic antispasmodics or opioids
which decrease diarrhea by decreasing intestinal


spasms & motility
Antibiotics & antifungal Rx to combat pathogens (stool
cultures)
___________________________________
___________________________________
___________________________________
Slide 37 ___________________________________
Preventing Infection
___________________________________
 Monitor for SSx infection; fever,
chills, night sweats, cough with or
without sputum production; SOB; ___________________________________
difficulty breathing, oral pain or
difficulty swallowing…
 Monitor labs, CBC with differential ___________________________________
 Obtain culture specimens as
ordered
 Avoid others with active infections ___________________________________
i.e. upper respiratory infection
___________________________________
___________________________________

Slide 38 ___________________________________
Maintaining thought process
___________________________________
 Assess alteration in mental status
 Speak to patient in simple, clear language & give


pt time to respond to questions
Orient to daily routines ___________________________________
 Provide regular daily schedule for med
administration, grooming meal times, bedtimes,

___________________________________
and awakening
 Provide nightlights
 Remain calm, not to argue with the patient while
protecting patient from injury
Sitter – around the clock supervision
___________________________________


___________________________________
___________________________________

Slide 39 ___________________________________
Activity intolerance
___________________________________
 Monitor ability to ambulate and perform
ADLs
 Balance activity & rest ___________________________________
 Personal items kept within pt’s reach
 Relaxation and guided imagery beneficial
to decrease anxiety which contributes to ___________________________________
weakness and fatigue
 Collaborate with Health care team
 Fatigue R/T anemia – administer Epogen as ___________________________________
ordered

___________________________________
___________________________________
Slide 40 ___________________________________
Relieving pain and discomfort
___________________________________
 Assess pain quality and severity associated with
impaired perianal skin integrity, KS lesions, peripheral

___________________________________
neuropathy
 Keeping perianal area clean – promote comfort
 Soft cushions or foam pads
 Pain from KS – described as sharp, throbbing pressure
& heaviness if lymphedema present



Pain management – NSAIDS and opioids +
nonpharmacological approach (relaxation techniques)
NSAIDS + zidovudine – monitor hepatic & hematologic
___________________________________
status
Pain R/T peripheral neuropathy – burning, numbness,

___________________________________

& “pins & needles”
 Opioids, tricyclic antidepressants, gabapentin (Neurontin),
elastic compression stockings

___________________________________
___________________________________

Slide 41 ___________________________________
Nutritional Status
___________________________________
 Monitor weight, dietary intake; anthropometric
measurements, serum albumin, BUN, protein, and transferrin
levels


Control nausea & vomiting – adm antiemetic
Inadequate intake from pain caused by mouth sores or sore
throat administer Opioids; Viscous lidocaine – rinse and
___________________________________
swallow
 Eat foods easy to swallow



Provide oral care before and after eating
Encourage rest before eating
Avoid fiber rich foods or lactose if lactose intolerant
___________________________________
 Add eggs, butter, margarine, and fortified milk to gravies,
soups or milkshakes to provide additional calories & protein


Supplement – puddings, powders, milkshakes
Advera – nutritional supplement designed for people with HIV
infection or AIDS
___________________________________
 May require enteral or parenteral nutrition

___________________________________
___________________________________

Slide 42 ___________________________________
Decreasing sense of Isolation
___________________________________
 AIDS patients at risk for double stigmatization – “dread
disease” & lifestyle considered unacceptable



Overwhelmed with emotions like anxiety, guilt, shame
and fear
Multiple losses
___________________________________
 Guilt R/T lifestyle & having infected someone else
Anger toward sexual partner who transmitted virus

___________________________________

 Infection control measures used further contribute to
emotional isolation
 Nurse provide atmosphere of acceptance and
understanding
Nonjudegmental, establish trusting relationship
___________________________________

 Allow verbalization of feelings of isolation and
loneliness
 Assure that feelings are not unique or abnormal
 Therapeutic touch
 Spirituality – assess spiritual needs; provide spiritual
support; resources – Chaplin, Minister ___________________________________
___________________________________
Slide 43 ___________________________________
Coping with Grief
___________________________________
 Anticipatory grief
Help patients verbalize feelings and

explore and identify resources for support
and ways of coping
___________________________________
 Encourage contact with family and


friends, coworkers
Use local and national AIDS support
___________________________________
groups and hotlines, chatline


Continue activities whenever possible
Mental health consult ___________________________________
___________________________________
___________________________________

Slide 44 ___________________________________
Monitor for Complications
___________________________________
 Immunosuppressed – at risk for OIs
Impaired breathing major complication

 Wasting syndrome and fluid & electrolyte ___________________________________
imbalance & dehydration common
complication
 Cachexia – state of ill health,
malnutrition, wasting
___________________________________
 Antiretroviral drugs can cause severe
toxic effects & concurrent use with many
other meds ___________________________________
___________________________________
___________________________________

Slide 45 ___________________________________
Terminal Care
___________________________________
 Nursing Care should focus on
 Keeping patient comfortable
 Facilitateemotional and spiritual
___________________________________
acceptance of death
 Help pt & pt significant other deal with
grief and loss
___________________________________
 Choose terminal care at home (Hospice
Care)
___________________________________
___________________________________
___________________________________