1
Q
IMMUNODEFICIENCY DISORDERS
A
PRIMARY
- GENETIC
- MAY AFFECT PHAGOCYTIC FUNCTION, B CELLS OR T CELLS, OR THE COMPLEMENT SYSTEM
SECONDARY MORE COMMON THAN PRIMARY
- ACQUIRED
- HIV/AIDS
- RELATED TO UNDERLYING DISORDERS, DISEASES, TOXIC SUBSTANCES, OR MEDICATIONS
2
Q
ACQUIRED IMMUNEDEFICIENCY SYNDROME (AIDS)
A
- HUMAN IMMUNE DEFICIENCY VIRUS (HIV) CAN PROGRESS TO AIDS
- MOST COMMON IMMUNE DEFICIENCY DISEASE IN THE WORLD
- SERIOUS WORLDWIDE EPIDEMIC
3
Q
HEALTH PROMOTION AND MAINTENANCE
A
HIV USUALLY TRANSMITTED VIA:
- SEXUAL CONTACT
- PARENTERALLY
- PERINATALLY
HIV IS NOT TRANSMITTED:
- CASUALLY
- BY SHARING HOUSEHOLD UTENSILS, TOWELS, LINENS, TOILETS
- VIA MOSQUITOES OR INSECTS
4
Q
TRANSMISSION OF HIV
A
Transmitted in body fluids of:
- BLOOD SEMINAL FLUID
- VAGINAL SECRETIONS
- AMNIOTIC FLUID
- BREAST MILK THAT CONTAIN INFECTED CELLS
5
Q
risk associated with HIV infection
A
- Sharing infected injection drug use equipment
- Having sexual relations with infected individuals
- Infants born to mothers with HIV infection and/or who are breast-fed by HIV infected mothers
- People who received organ transplants, HIV infected blood, or blood products
6
Q
Sexual transmission
A
- Gender transmission
- Sexual acts
- Viral load
7
Q
CDC DESCRIBES ABCS OF SAFER SEX:
A
- A – ABSTINENCE
- B – BE FAITHFUL
- C – CONDOM USE
- TEACH SAFE SEX
8
Q
PARENTERAL TRANSMISSION
A
- PROPER CLEANING OF “WORKS”
— NEEDLES AND SYRINGES (clean with bleach/ water)
— OTHER DRUG PARAPHERNALIA - NEEDLE EXCHANGE PROGRAMS
9
Q
BLOOD TRANSFUSION TRANSMISSION
A
- RISK FOR TRANSMISSION BY BLOOD TRANSFUSION REDUCED TO A NATIONAL AVERAGE OF 0.02%.
- ALL DONATED BLOOD SCREENED
- TIME LAG BETWEEN ANTIBODY PRODUCTION POST EXPOSURE CAN CAUSE FALSE NEGATIVE.
10
Q
PERINATAL TRANSMISSION
A
- ACROSS THE PLACENTA DURING PREGNANCY
- INFANT EXPOSURE AT BIRTH TO BLOOD AND VAGINAL SECRETIONS
- EXPOSURE AFTER BIRTH THROUGH BREAST MILK
11
Q
WOMEN AND HIV
A
- 25% OF NEW CASES
- CAUSE IS SEXUAL EXPOSURE
- POORER OUTCOMES THAN MEN
— more apt to get opportunistic diseases and late DX - GYNECOLOGIC PROBLEMS ARE USUALLY FIRST SIGN
12
Q
GENETIC CONSIDERATIONS
A
- NON PROGRESSORS
- 1% OF THOSE WITH HIV
- ASYMPTOMATIC
- SOME MAY NOT NEED MEDS
13
Q
HIV AND THE ELDERLY
A
- 50 YEAR OR GREATER
- EARLY MORTALITY AND MORBIDITY
- MOST PROGRAMS FOCUS ON YOUNGER AGE GROUPS
- ASSESS FOR RISKY BEHAVIORS
- DECREASED IMMUNITY
- less likely to get tested
14
Q
HEALTH PROMOTION AND MAINTENANCE
A
- Teach everyone about transmission routes, and ways to reduce exposure.
- Teach all people regardless age, gender, ethnicity, or sexual orientation
15
Q
Protecting Against HIV Infection All patients should be advised to:
A
- Abstain from exchanging sexual fluids (semen and vaginal fluid)
- Reduce the number of sexual partners to one
- Always use latex condoms. *If the patient is allergic to latex, nonlatex condoms should be used; however, they will not protect against HIV infection.
- Not reuse condoms
- Avoid using cervical caps or diaphragms without using a condom as well
- Always use dental dams for oral–genital or anal stimulation.
- Avoid anal intercourse, because this practice may injure tissues; if not possible, use lubricant—there are water and silicone-based products designed for anal sex.
- Avoid manual–anal intercourse (“fisting”).
- Avoid sharing needles, razors, toothbrushes, sex toys, or blood- contaminated articles.
- Consider PrEP if regularly engage in high-risk behaviors.
16
Q
Protecting Against HIV Infection (Continued)
A
Patients who are HIV seropositive should also be advised to:
- *Take ART regularly to achieve viral suppression. antiretroviral therapy
- PrEP, pre-exposure prophylaxis.
- Inform previous, present, and prospective sexual and drug-using partners of their HIV-positive status.
- If the patient is concerned for their safety, advise the patient that many states have established mechanisms through the public health department in which professionals are available to notify exposed contacts.
- Avoid having unprotected sex with another HIV-seropositive person. Cross-infection with that person’s HIV can increase the severity of infection.
- Do Not donate blood, plasma, body organs, or sperm.
17
Q
PRE EXPOSURE PROPHYLAXIS (PrEP)
A
- NEW RESEARCH
- COMBO DRUG TRUVADA
— (EMTRICITABINE AND TENOFOVIR) - DOES NOT REPLACE SAFER SEX BUT IS USED
- TO TREAT AND PREVENT TRANSMISSION
18
Q
TRANSMISSION AND HEALTH CARE WORKERS
A
- NEEDLE STICK (“SHARPS”) INJURIES
- EXPOSURE OF NONINTACT SKIN/MUCOUS MEMBRANES TO BLOOD AND BODY FLUIDS
- STANDARD PRECAUTIONS IS BEST PREVENTION
- POST-EXPOSURE PROPHYLAXIS (PEP)
- SEE CHART 19-1 RECOMMENDATIONS FOR PREVENTING HIV TRANSMISSION BY HCW
19
Q
Outside
- Shell has special docking features that assist in finding a host.
Inside
- Genetic material and enzymes.
A
20
Q
LIFE CYCLE OF HIV
A
STEP 1-8
- ATTACHMENT/BINDING
- UNCOATING/FUSION
- DNA SYNTHESIS
- INTEGRATION
- TRANSCRIPTION
- TRANSLATION
- CLEAVAGE BUDDING
21
Q
HIV CLASSIFICATION
A
22
Q
COLLABORATIVE MANAGEMENT
A
- ASSESSMENT; ask pt if ok to speak in front oft of family
- HISTORY
- PHYSICAL ASSESSMENT/CLINICAL
- MANIFESTATIONS:
— INFECTIONS – OPPORTUNISTIC, PROTOZOAL, FUNGAL, BACTERIAL, VIRAL
— MALIGNANCIES — KAPOSI’S SARCOMA (KS), MALIGNANT LYMPHOMAS, INVASIVE CANCERS, HPV
— ENDOCRINE COMPLICATIONS - PSYCHOSOCIAL ASSESSMENT – SUPPORT SYSTEMS, CONFIDENTIALITY
23
Q
LABORATORY ASSESSMENT
A
- LYMPHOCYTE COUNTS – PART OF CBC - NORMAL WBC’S 5,000 - 10,000
- CD4+ T-CELL AND CD8+ T-CELL COUNT
- ANTIBODY TESTS
- ELISA
- WESTERN BLOT – USED WHEN ELISA IS POSITIVE
- HOME TESTS (E.G., ORAQUICK IN-HOME HIV TEST)
- VIRAL LOAD TESTING
- BLOOD CHEMISTRIES, CBC, STOOL TESTING, BIOPSIES
24
Q
TESTING
A
- COMPLEX PROCEDURE REQUIRING INTERPRETATION, COUNSELING AND CONFIDENTIALITY
- CDC RECOMMENDATIONS FOR HIV TESTING
— PEOPLE WITH STD’S
— IV DRUG USERS
— PEOPLE WHO CONSIDER THEMSELVES AT RISK
— WOMEN OF CHILDBEARING AGE. - PRETEST AND POST TEST COUNSELING MUST BE PERFORMED BY TRAINED PROFESSIONALS
25
TEST RESULTS CHART 36 -7
HIV TEST RESULTS: IMPLICATIONS FOR PATIENTS
- INTERPRETATION OF POSITIVE TEST RESULTS
- ANTIBODIES TO HIV ARE PRESENT IN THE BLOOD (THE PATIENT HAS BEEN INFECTED WITH THE VIRUS, AND THE BODY HAS PRODUCED ANTIBODIES).
- HIV IS ACTIVE IN THE BODY, AND THE PATIENT CAN TRANSMIT THE VIRUS TO OTHERS.
- DESPITE HIV INFECTION, THE PATIENT DOES NOT NECESSARILY HAVE AIDS.
- THE PATIENT IS NOT IMMUNE TO HIV (THE ANTIBODIES DO NOT INDICATE IMMUNITY).
26
INTERPRETATION OF NEGATIVE TEST RESULTS
- ANTIBODIES TO HIV ARE NOT PRESENT IN THE BLOOD AT THIS TIME, WHICH CAN MEAN THAT THE PATIENT HAS NOT BEEN INFECTED WITH HIV OR, IF INFECTED, THE BODY HAS NOT YET PRODUCED ANTIBODIES (STAGE 0).
- THE PATIENT SHOULD CONTINUE TAKING PRECAUTIONS. THE TEST RESULT DOES NOT MEAN THAT THE PATIENT IS IMMUNE TO THE VIRUS, NOR DOES IT MEAN THE PATIENT IS NOT INFECTED; IT JUST MEANS THAT THE BODY MAY NOT HAVE PRODUCED ANTIBODIES YET. IF VIRAL TEST USED, A NEGATIVE RESULT IS MORE CONSISTENT WITH THE CONCLUSION THAT THE PATIENT IS UNINFECTED.
-
- HIV, HUMAN IMMUNE DEFICIENCY VIRUS; AIDS, ACQUIRED IMMUNE DEFICIENCY SYNDROME.
27
MEDICATIONS TABLE 36-4
- DEVELOPED BY EXPERTS FROM THE US DEPT OF HEALTH AND HUMAN SERVICES
- ANTIRETROVIRAL DRUGS – MULTIPLE DRUGS USED TOGETHER IN COMBO (HAART) HIGHLY ACTIVE ANTIRETROVIRAL THERAPY SHOULD NOT BE MISSED , DELAYED OR TAKEN IN LOWER DOSE IN KEEP EFFECTIVE
- NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTIS) – “FOOLS THE VIRUS” NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTIS)- BINDS TO PREVENT REPLICATION
28
MEDICATIONS CHART 36-4
- PROTEASE INHIBITORS (PIS) – BLOCKS HIV
- INTEGRASE INHIBITORS – VIRUS NEEDS INTEGRASE TO REPLICATE
- FUSION INHIBITORS – BLOCKS FUSION OF HIV IN HOST CELL
- ENTRY INHIBITORS – BLOCKS RECEPTOR SITES COMBO PRODUCTS
29
PROMOTING ADHERENCE TO ART
- CDC ESTIMATES 36% OF PEOPLE WITH HIV IN THE US ARE PRESCRIBED ART
- ONLY 76% HAVE SUPPRESSED VIRAL LOADS
- POOR ADHERENCE TO TREATMENT PLAN.
— BARRIERS INCLUDE
—- DEPRESSION
—- MENTAL ILLNESSES
—- NEUROCOGNITIVE IMPAIRMENT
—- LOW HEALTH LITERACY
—- LOW LEVELS OF SOCIAL SUPPORT
—- STRESSFUL LIFE EVENTS
—- DRUGS AND ALCOHOL
—- HOMELESSNESS/POVERTY
—- NONDISCLOSURE OF HIV STATUS
—- DENIAL
- NEED TO SIMPLIFY TREATMENT REGIMENS AND DECREASING NUMBER OF MEDICATIONS
- your hiv status is confidential
30
DURING A HEALTH ASSESSMENT, A 22-YEAR-OLD COLLEGE STUDENT TELLS THE NURSE THAT SHE IS SEXUALLY ACTIVE AND PROTECTS HERSELF FROM HIV AND OTHER SEXUALLY TRANSMITTED DISEASES (STDS) BY USING ORAL CONTRACEPTIVES. WHAT IS THE NURSE'S BEST ACTION?
- A REMIND THE STUDENT THAT ONLY ABSTINENCE PREVENTS STDS.
- B ASK THE HEALTH CARE PROVIDER TO ORDER AN HIV TEST FOR THIS STUDENT.
- C INFORM THE STUDENT THAT ORAL CONTRACEPTIVES PROTECT AGAINST PREGNANCY BUT NOT AGAINST ANY STD.
- D REINFORCE THE STUDENT'S PREFERRED USE OF ORAL CONTRACEPTIVES, AND REFRAIN FROM COMMENTING ON HER SEXUAL ACTIVITY.
C?
31
KEY FEATURES OF AIDS
- LOW WBC’S FATIGUE
- OPPORTUNISTIC INFECTIONS VS. PATHOGENIC INFECTION
- DRY SKIN
- POOR WOUND HEALING
- COUGH
- SOB
- DIARRHEA, WEIGHT LOSS, NV
- CONFUSION, DEMENTIA
- UNCOMMON INFECTIONS
- CANCERS
32
INFECTIONS
OPPORTUNISTIC INFECTIONS
— No threat to HCW
— (PCP)
— Toxoplasmosis encephalitis
*
Pathogenic infection
— Positive threat to HCW
— TB 2–10% of persons with aids
33
KEY FEATURES OF AIDS
- RESPIRATORY – PNEUMOCYSTIS PNA (PCP), MYCOBACTERIUM AVIUM, TB
- TX - TRIMETHOPRIM–SULFAMETHOXAZOLE (TMP–SMX), PREDNISONE, CLARITHROMYCIN (BIAXIN),
- GASTROINTESTINAL – N,V, ANOREXIA, CANDIDIASIS, CRYPTOSPORIDIUM MURIS, HIV WASTING SYNDROME
- FOR DIARRHEA, OCTREOTIDE ACETATE (SANDOSTATIN)
- APPETITE SIMULANTS MEGESTROL ACETATE (MEGACE)
34
KEY FEATURES OF AIDS 2
- ONCOLOGIC – KAPOSI’S SARCOMA, AIDS RELATED LYMPHOMA - CHEMOTHERAPY
- NEUROLOGIC – DECREASED COGNITION, MOTOR FUNCTION, MEMORY, ENCEPHALOPATHY, PERIPHERAL NEUROPATHY FROM HIV OR SIDE EFFECT OF ART
- DEPRESSION – 30-40% TX ANTIDEPRESSANTS IMIPRAMINE (TOFRANIL), DESIPRAMINE (NORPRAMIN), AND FLUOXETINE (PROZAC), ELECTROCONVULSIVE THERAPY
- INTEGUMENTARY – HERPES ZOSTER, DERMATITIS, RASH, DRY FLAKING SKIN- APPLY MEDICATED LOTIONS, AVOID ADHESIVE TAPE,
- GYNECOLOGIC – VAGINAL CANDIDIASIS, GENITAL ULCERS, HPV, PID MENSTRUAL ABNORMALITIES
35
AIDS S/S: opportunistic infections
Central:
- Encephalitis
- Meningitis
Eyes: retinitis
Lungs:
- Pneumocystis pneumonia
- Tuberculosis (multiple organs)
- Tumors
Skin: tumors
Gastrointestinal:
- Esophagitis
- Chronic diarrhea
- Tumors
Karposis
36
HIV PROGRESSION
- CAN TAKE MONTHS TO YEARS
- PERSONAL LIFE FACTORS CAN AFFECT TIMING PROGRESSION
- FREQUENCY OF RE-EXPOSURE TO HIV
- PRESENCE OF OTHER STDS
- NUTRITION STATUS
- STRESS
37
EFFECTS OF HIV INFECTION
- CD4+ T-CELLS BECOME “HIV FACTORY” TO MAKE NEW VIRAL PARTICLES DAILY
- GRADUALLY, CD4+ T-CELL COUNT FALLS, VIRAL LOAD RISES
IMMUNE SYSTEMS WEAKENS
- EVERYONE WITH AIDS HAS HIV; HOWEVER NOT EVERYONE WITH HIV HAS AIDS
- A HEALTHY ADULT USUALLY HAS AT LEAST 800 TO 1000 CD4+ T-CELLS PER CUBIC MILLIMETER (MM3) OF BLOOD.
DX = CD4 COUNT LESS THAN 200 WITH A POSITIVE HIV TEST
38
PRIORITY PATIENT PROBLEMS
- POTENTIAL FOR INFECTION
- INADEQUATE OXYGENATION
- PAIN
- INADEQUATE NUTRITION
- DIARRHEA
- REDUCED SKIN INTEGRITY
- CONFUSION
- REDUCED SELF-ESTEEM
- POTENTIAL LOSS OF SOCIAL CONTACT
39
NURSING INTERVENTIONS
- PREVENTING INFECTION
- CARE OF THE HOSPITALIZED IMMUNOSUPPRESSED PATIENT
- INFECTION CONTROL FOR HOME CARE OF THE PERSON WITH AIDS
40
ENHANCING OXYGENATION
- DRUG THERAPY
- RESPIRATORY SUPPORT AND MAINTENANCE
- COMFORT
- REST AND ACTIVITY CHANGES
41
ENHANCING NUTRITION
- DRUG THERAPY
- NUTRITION THERAPY
- MOUTH CARE
- COMPLEMENTARY AND ALTERNATIVE THERAPIES
42
MANAGING PAIN
COMFORT MEASURES
DRUG THERAPY
COMPLEMENTARY AND ALTERNATIVE THERAPIES
43
TISSUE INTEGRITY
MINIMIZE DIARRHEA
- ANTIDIARRHEALS – DIPHENOXYLATE HYDROCHLORIDE (LOMOTIL, IMMODIUM)
- KEEP PERINEAL AREA CLEAN AND DRY
RESTORE SKIN INTEGRITY – ASSESS EVERY 8-12 HOURS
- ANTIRETROVIRAL DRUG THERAPY (FOR KS)
- ANALGESICS AND COMFORT MEASURES
- APPROPRIATE SKIN CARE
44
MINIMIZING CONFUSION
- REORIENTATION
- DRUG THERAPY
- SAFETY MEASURES
- SUPPORT
- ANY CHANGE IN LOC NEEDS TO BE REPORTED AND DOCUMENTED.
45
SUPPORTING SELF- ESTEEM
- Provide climate of acceptance
- Promote trusting relationship
- Encourage expression of feelings
- Identify positive aspects of self
- Allow for privacy; avoid isolation
- Encourage self-care, independence, control
- Guided imagery
46
What is the most important question the nurse asks the client prescribed to begin highly active antiretroviral therapy (HAART)?
- A. Do you have any symptoms now of active infection?
- B. Is there any possibility that you are pregnant?
- C. Are you currently sexually active?
- D. What other medications do you take?
D
Drug interaction
47
Which dietary change does the nurse suggest for the client who has diarrhea associated with HIV disease?
- A “Avoid fatty foods.”
- B “Increase your intake of fiber.”
- C “Take an antacid 30 minutes before each meal.”
- D “Restrict your intake of fluids to 1 liter per day.”
A?
48
COMMUNITY-BASED CARE
- HOME CARE MANAGEMENT
- TEACHING FOR SELF- MANAGEMENT
- PSYCHOSOCIAL PREPARATION
- HEALTH CARE RESOURCES
- INFECTION CONTROL AT HOME (CANVAS)
49
A 30-YEAR-OLD MAN WITH HIV IS ADMITTED TO THE ACUTE CARE UNIT. WHICH ASSESSMENT FINDINGS DOES THE NURSE RECOGNIZE THAT MAY INDICATE THAT THE PATIENT CURRENTLY HAS AIDS? (SELECT ALL THAT APPLY.)
- A. KAPOSI’S SARCOMA
- B. HIV-POSITIVE STATUS
- C. WASTING SYNDROME
- D. ESOPHAGEAL CANDIDIASIS
- E. PERSISTENT GENERALIZED LYMPHADENOPATHY
A,B,C,D?
50
(CONT.)
- THE PATIENT IS VERY WEAK. DURING THIS ADMISSION HE HAS EXPERIENCED ANOREXIA, PAINFUL SWALLOWING, SEVERE DIARRHEA, AND OCCASIONAL VOMITING. FREQUENT MOUTH CARE IS TO BE DELEGATED TO THE UNLICENSED ASSISTIVE PERSONNEL (UAP).
- WHAT INSTRUCTIONS SHOULD THE NURSE GIVE THE UAP?
51
(CONT.) 2
- AFTER 8 DAYS, THE PATIENT IS BEING DISCHARGED HOME, WHERE HE LIVES WITH HIS MOTHER AND FATHER. THE NURSE IS COMPLETING DISCHARGE INSTRUCTIONS FOR HIM AND HIS FAMILY.
- WHAT INFECTION CONTROL TEACHING SHOULD THE NURSE PROVIDE TO THE PATIENT AND FAMILY?
52
- AS THE NURSE IS TALKING TO THE PATIENT, THE PATIENT COMMENTS THAT HE DOESN’T KNOW WHY HE MUST LIVE WITH SUCH A HORRIBLE DISEASE, AND STATES THAT HE KNOWS HE WILL DIE SOON.
- WHAT IS THE APPROPRIATE NURSING RESPONSE?
53
TRUE OR FALSE: GENETIC TESTING HAS NO BENEFIT IN THE TREATMENT PLAN OF A PATIENT WITH HIV.
- A. TRUE
- B. FALSE
54
A PATIENT TELLS THE NURSE THAT SHE HAS RECENTLY ENGAGED IN UNPROTECTED SEXUAL INTERCOURSE. THE NURSE RECOGNIZES THAT WHICH SYMPTOM(S) MAY BE CONSISTENT WITH AN ACUTE INFECTION, FOLLOWING INFECTION WITH HIV? (SELECT ALL THAT APPLY)
- A. FEVER
- B. CHILLS
- C. HEADACHE
- D. NIGHT SWEATS
- E. MUSCULAR ACHES
55
A PATIENT IS FEARFUL THAT HE HAS BEEN INFECTED WITH HIV. THE NURSE RECOGNIZES WHICH AS THE FIRST SYMPTOM ASSOCIATED WITH POSSIBLE HIV INFECTION?
- A. LYMPHOCYTOPENIA
- B. OPPORTUNISTIC INFECTION
- C. FEVER, NIGHT SWEATS, MUSCLE ACHES
- D. REDUCED NUMBERS OF CD4+ T-CELLS
C?
56
Should there be mandatory testing programs for
AIDS?
Should the names of people who test positive for HIV
infection be reported to public health authorities?
Should health care workers, such as doctors, nurses,
and paramedics, be permitted to refuse to treat
patients with AIDS?
57
- Because some dentists, doctors, nurses, and health care workers are also afraid of catching AIDS, they have refused to treat people known to be infected with HIV.
- In these instances, what are the rights of the patient?
- What are the rights of the doctors, nurses, and health care workers?
- Whose rights should the law protect? In what way?
Test 2 🏁🏁
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