Nursing diagnosis

Diagnosis: Risk for infection related to immune deficiency as evidenced by fever.

Goals: Rule out infection, identify both new infections and possible causes of infection.

Nurses should:

• Identify and participate in behaviors to reduce risk of infection.
• Assess patient knowledge adhere to medication regimen
• Implement isolation precautions to prevent nosocomial infections
• Administer both prophylactic and suppressive therapy.

Diagnosis: Impaired gas exchange related to pneumocystis carinii pneumonia (PCP) as evidenced by restlessness, confusion and/or dyspnea.

Goal: the patient will experience adequate O2/CO2 exchange

Nurses should:

• Preform respiratory assessment (reporting any increased shortness of breath, cough or chest pain) and pulse oximetry
• administer and titrate oxygen to a physician-prescribed oxygen saturation level
• administering antibiotics and monitoring for side effects.
• organizing care to provide maximal periods of rest.
• repositioning the patient as necessary to facilitate excursion and promote postural drainage.
• educating the patient regarding purse-lipped breathing to decrease tachypnea and anxiety.

Diagnosis: Acute/chronic pain related to procedures, medications and/or tissue damage as evidenced by patient reports of pain.

Goal: Patient reports pain as relieved/controlled.

Nurses should:

• Use analgesics or other techniques to prevent/control pain along with evaluating their efficacy
• preform ongoing assessment for the presence and characteristics of pain (location, quality, and intensity on a 0-10 scale, and its aggravating and relieving factors)
• evaluating and preventing untoward side effects (constipation from chronic opiate or tricyclic antidepressant use
• using nonpharmacologic techniques as appropriate, such as assuring adequate periods of undisturbed rest, positioning, heat and cold applications, warm baths, massage, and other relaxation techniques

• instruct and encourage patient to report pain as it develops rather than waiting until level is severe.

Diagnosis: At risk for falls related to orthostatic hypotension (due to adrenal insufficiency, dehydration, medication side effects and sensory/perceptual problems), central nervous system lesions, and/or peripheral neuropathy as evidenced by weakness, fatigue, confusion, and/or incontinence.

Goal: Patient will experience no falls during hospital stay

Nurses should:

• assess for fall risk factors (confusion, mobility problems, incontinence, orthostatic hypotension
• informing all other caregivers about patients at risk for fall
• instructing the patient and family to request assistance when transferring or ambulating
• Keep the call light, bedpan urinal and belongings within the patient’s reach
• keeping the bed in low position with side rails up
• increasing direct observations and if necessary moving the patient’s room nearer to the nurses station
• offering frequent assistance with ADLs
• using safety devices (bed alarms)

One diagnosis I would like to go more indepth with is risk for infection:

Diagnosis: risk for infection

Potential or actual: potential

Related to: immune deficiency

Plan and outcome: Patient will show no signs of infection. The patient will be properly educated on handwashing and personal hygiene.

Nursing intervention:  Administer both prophylactic and suppressive therapy.

http://hivinsite.ucsf.edu/InSite?page=kb-03-03-04

http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=248

Nursing Care

Infection: There is an increased risk for nosocomial infections such as TB and central venous access device infections in those who are affected with HIV. The risk is greated when these patients are admitted with a fever. The higher risk for infection is related to the depression of the immune system. As nurses we must Identify/participate in behaviors to reduce risk of infection.

• Assess patient knowledge and ability to maintain opportunistic infection prophylactic regimen
• ongoing clinical assessment and monitoring, including vitals signs (especially temperature), Pulmonary and neurologic signs and symptoms, peripheral and central venous catheter sites, wounds and skin integrity, and changes in bowel and bladder management.

• meticulous compliance with infection control measures: intravenous site care and implementing institutional neutropenic precautions (single room assignment).
• administering antimicrobial agents.
• educating the patient and family regarding hand washing before and after toileting and for family before patient contact, avoid patient contact with children with viral illnesses, using a respirator mask for staff and family with respiratory or flu symptoms. and maintaining adequate fluid and nutritional intake.

Pain: Acute/chronic pain is significant for people with HIV. This can be due to procedures, medications, tissue damage. Nurses use analgesics or other techniques to prevent/control pain.

• ongoing assessment for the presence and characteristics of pain (location, quality, and intensity on a 0-10 scale, and its aggravating and relieving factors)
• administering analgesics and adjuvant agents and evaluating their efficacy
• advocating for around-the-clock dosing (versus as-needed dosing) of analgesics for chronic pain, preferably by the oral route
• evaluating and preventing untoward side effects (constipation from chronic opiate or tricyclic antidepressant use
• using nonpharmacologic techniques as appropriate, such as assuring adequate periods of undisturbed rest, positioning, heat and cold applications, warm baths, massage, and other relaxation techniques

• instruct and encourage patient to report pain as it develops rather than waiting until level is severe.

Impaired Gas Exchange: Despite prophylaxis for pneumocystis carinii pneumonia (PCP), it remains the most common AIDS-indicator opportunistic infection in adults across the country. Although, it is the most common cause of impaired gas exchange, people with HIV may have other respiratory condition that require hospitalization associated with problems of gas exchange.

Nursing management:

• ongoing respiratory assessment (reporting any increased shortness of breath, cough or chest pain) and pulse oximetry
• administering and titrating oxygen to a physician-prescribed oxygen saturation level
• administering antibiotics and monitoring for side effects.
• organizing care to provide maximal periods of rest.
• repositioning the patient as necessary to facilitate excursion and promote postural drainage.
• educating the patient regarding purse-lipped breathing to decrease tachypnea and anxiety.

Nutrition and fluid deficit: there are a number of disease and treatment related factors that contribute to nutritional and fluid deficits in people with HIV. This is a particular risk in the hospital. Many HIV infected patients in the hospital have fevers, secondary dehydration, and increased metabolic requirements. Nutritional deficit can manifest in weight loss and displaying weight gain is the desired goal. Fluid deficit can be related to excessive fluid loss and manifests as poor skin turgor. The goal here is to maintain hydration.

• Assessment and ongoing monitoring of weight, intake and output, ability to feed oneself, ability to swallow, symptoms interfering with food intake, orthostatic V.S., skin turgor, and cultural food preferences
• provide small, frequent meals and snacks of nutritionally dense food and non-acidic foods and beverages, with choice of foods palpable to patient.
• feeding the patient and encouraging oral intake
• administering intravenous hydration, appetite stimulants, antidiarrheals, and antiemetics as ordered.
• obtaining consultations from a dietician of specific diet prescriptions
• encouraging family and friends to bring patients favorite foods

• educating the patient regarding adequate fluid intake (at least 2 to 3 liters/day), the role of nutrition in acute illness recovery, and the clinically significant drug-nutrient interactions

Falls: Falls are a huge risk for patients with HIV, factors that contribute to falls are: weakness, fatigue, incontinence (urinary or fecal), urinary urgency, orthostatic hypotension (due to adrenal insufficiency, dehydration, medication side effects and sensory/perceptual problems), central nervous system lesions, and peripheral neuropathy. Nurses must be proactive when working with a fall risk.

• assess for fall risk factors (confusion, mobility problems, incontinence, orthostatic hypotension
• informing all other caregivers about patients at risk for fall
• instructing the patient and family to request assistance when transferring or ambulating
• Keep the call light, bedpan urinal and belongings within the patient’s reach
• keeping the bed in low position with side rails up
• increasing direct observations and if necessary moving the patient’s room nearer to the nurses station
• offering frequent assistance with ADLs
• using safety devices (bed alarms)
• consulting with the physician regarding need for sedation or physical restraints if the patient is a danger to himself or herself and one-on-one observation is impossible; providing the necessary care, support, and monitoring if physical restraints are used.

HIV Treatment

Antiviral therapy (ART) is the treatment of HIV with medications. Everyone with HIV is recommended to participate in ART. A combination of HIV medications (HIV regimen) is taken every day by people on ART. Initially people’s regimen includes taking three HIV medications from at least two different drug classes. Taking this combination does the best job at controlling the amount of virus in your body and protecting your immune system. Taking more than one drug also protects against HIV drug resistance. It is important to know that while ART can’t cure HIV, it can help people infected with HIV live longer and healthier lives (it also helps reduce the risk of HIV transmission).

Each class (currently five different classes) of drug attacks the virus at different points in its life cycle. Antiretrovirals are separated by the way an individual drug stops HIV from replicating in the body. These classes include:

• Nucleoside Reverse Transcriptase Inhibitors (NRTIs): block reverse transcriptase (an enzyme HIV needs to make copies of itself)
• Non-Nucleoside Reverse Transcriptase (NNRTIs): Bind to and later alter reverse transcriptase.
• Protease Inhibitors (PIs): block HIV protease (an enzyme HIV needs to make copies of itself)
• Fusion/Early Inhibitors: block HIV from entering the CD4 cells of the immune system in the first place.
• Integrase Inhibitors: block HIV integrase (an enzyme HIV needs to make copies of itself)

• Pharmacokinetic Enhancers: are used in HIV treatment to increase the effectiveness of an HIV medicine (included in HIV regimen)
• Combination: HIV medicines contain two or more HIV medicines from one or more drug classes into one single pill

http://aidsinfo.nih.gov/education-materials/fact-sheets/21/58/fda-approved-hiv-medicines

https://www.aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/treatment-options/overview-of-hiv-treatments/

Signs and symptoms of HIV

The symptoms of HIV vary, depending on the individual and what stage of the disease the person is in. Each of these symptoms can be related to other illnesses, so it is important to get tested. Many people who are infected with HIV may not develop symptoms for over 10 years. Since the body’s immune system becomes damaged, opportunistic infections occur, these can cause many of the severe symptoms and illnesses of HIV.

Early stage: Occurs within 2-4 weeks after HIV infection. During this time many, but not all, people experience flu-like symptoms. This is called acute retroviral syndrome (ARS), it is the body’s natural response to the infection. Symptoms can last anywhere from a few days to several weeks. During this time people are very infectious as HIV is present in large quantities in genital fluid. Symptoms include:

• Fever (this is the most common symptom)
• Enlarged or swollen glands
• Sore throat
• Rash
• Fatigue
• Muscle and joint aches and pains
• Headache
• Diarrhea
• Nausea and vomiting
• Fungal infection of the mouth called thrush which is caused by yeast

The clinical latency stage (asymptomatic period): Occurs after the early stage of HIV. Although the virus is still active, HIV is being produced at very low levels. People in this stage may not experience symptoms, or have mild symptoms (although they are asymptomatic, they are still able to transmit HIV). Those who take antiretrovirals may live in this stage for several decades (treatment keeps virus in check). This stage lasts about 10 years (some people may progress faster) for those who do not take antiretrovirals.  Antiretroviral therapy can greatly reduce the risk of transmission.

Acquired Immunodeficiency Syndrome (AIDS): The transition from the clinical latency stage to AIDS is seen with the onset of symptoms. Those who have HIV and do not take antiretrovirals, eventually have their immune system weakened by the virus. This is the late stage and symptoms during this time may include:

• Rapid weight loss
• Recurring fever or profuse night sweats
• Extreme and unexplained tiredness
• Prolonged swelling of the lymph glands in the armpits, groin, or neck (usually first signs)
• Diarrhea that lasts for more than a week
• Sores of the mouth, anus, or genitals
• Pneumonia
• Red, brown, pink, or purplish blotches on or under the skin or inside the mouth, nose, or eyelids
• Memory loss, depression, and other neurologic disorders.
• Herpes infections causing severe mouth, genital, and anal sores.

https://www.aids.gov/hiv-aids-basics/hiv-aids-101/signs-and-symptoms/

http://www.ucsfhealth.org/conditions/hiv/signs_and_symptoms.html

Diagnosis of HIV

Why get tested?

One in seven people with HIV are unaware of their infection. It is very important to get tested for HIV. People who know they are HIV positive can seek medical care which involves taking antiretroviral medication. Knowing if you have HIV can make a difference on decision making regarding sex, drug use, and healthcare.

• Studies indicate that all people with HIV infection, including those with early infection, benefit from antiretroviral medications.
• Effective treatment lowers the level of HIV in the blood (viral load), reduces HIV-related illness, and reduces the spread of HIV to others. This results in HIV infected people living healthier and longer.
• HIV treatment can reduce HIV spread by 96%.
• Knowledge of infection allows HIV infected people to protect others from becoming infected. Studies have shown that many people with HIV who know that they are infected avoid behaviors that spread infection to others with whom they have sex or share drugs and needle5.
• HIV-infected persons who do not know that they are infected do not avoid unsafe behaviors.

Who should get tested?

The CDC recommends that everyone between the ages of 13 and 64 get tested at least once and that high-risk groups get tested more often. Behaviors that put people at risk for HIV are having vaginal or anal sex without a condom or sharing injection drug equipment with someone who has HIV. For those who continue having unsafe sex or sharing injection drug equipment, you should get tested at least once a year. Sexually active gay and bisexual men may benefit from more frequent testing (e.g., every 3 to 6 months).

What tests are available?

There are three types of HIV diagnostic tests. If initial test is positive, follow up testing is done.  Tests can be done in the clinic or at home. Currently there are only two home HIV tests: the Home Access HIV-1 Test System and the OraQuick In-home HIV test. If you buy your home test online make sure the HIV test is FDA-approved.

• Antibody tests: detect antibodies (proteins) that your body makes against HIV, not HIV itself. May be done in a lab or as a rapid test at the testing site. It can be done using blood or oral fluid (not saliva). Blood will have higher levels of antibodies and will find infection sooner than an oral fluid test
• A rapid test is a type of antibody test used for screening. The results are produced quickly (30 min or less). Use blood or oral fluid.  Most blood-based lab tests find infection sooner after exposure than rapid HIV tests.
• Antigen/antibody tests: detect HIV directly. Find recent infection sooner than tests that only detect antibodies. They can detect HIV as soon as 3 weeks after exposure to the virus. Can only be done using blood.
• RNA (nucleic acid) tests: detect HIV directly. Can detect HIV at around 10 days after infection (as soon as it appears in the bloodstream). More costly than antibody tests and are generally not used for screening (more as a follow up test after a positive antibody test or as part of a clinical workup).

http://www.cdc.gov/hiv/testing/index.html

http://www.cdc.gov/hiv/testing/lab/index.html

http://www.cdc.gov/hiv/basics/testing.html

Etiology/Pathophysiology

HIV only infects humans and  is not able to survive long outside the human body. Therefore, transmission happens human to human. Only certain body fluids (semen, blood, pre-seminal fluid, rectal fluid, vaginal fluids, and breast milk) can transmit HIV. To get HIV, these fluids from an HIV-infected person must come in contact with a mucous membranes (mouth, rectum, vagina, and the opening of the penis), damaged tissue, or be directly injected into the bloodstream of someone who is not infected. In the US, HIV is spread mainly by having sex or sharing needles with individuals infected with HIV.

HIV weakens the body’s immune system by destroying a certain type of white blood cell (CD4). These cells are important in fighting disease and infection. Viruses can only replicate by taking over a host’s cell. HIV hijacks the CD4 cells in the body and uses it to make copies of itself at an extraordinary rate (as many as 10 million to 10 billion individual viruses are produced daily). As the new viruses are released the CD4 cell is destroyed. Our own cells become HIV factories and as more viruses are produced,  the immune system becomes compromised. HIV cannot be cleared out of the body (the immune system can’t seem to get rid of HIV). After so many cell have been destroyed, the body loses the ability to fight infections and disease, this leads to AIDS (the final stage). Once a person has HIV, they have it for life. It can hide for long periods of time and not everyone who gets HIV has it progress to AIDS. Treatments can keep the level of virus in the body low.

https://www.aids.gov/hiv-aids-basics/hiv-aids-101/what-is-hiv-aids/

file:///home/chronos/u-29a76c2305cd3bf5f919ac8a0ba66b8ac2664bc8/Downloads/2-Pathophysiology-of-HIV%20(1).pdf

http://www.cdc.gov/hiv/basics/transmission.html

HIV epidemiology, globally and in the United States:

What is epidemiology?

According to the National Institute of Health “Epidemiology is a branch of medical science that investigates all the factors that determine the presence or absence of diseases and disorders. Epidemiological research helps us to understand how many people have a disease or disorder, if those numbers are changing, and how the disorder affects our society and our economy”.

http://www.nidcd.nih.gov/health/statistics/Pages/epidemiology.aspx

Globally:

• At the end of 2013 there were 35.0 million people living with HIV.
• It is estimated that 0.8% of adults aged 15–49 years worldwide are living with HIV
• 1.5 million people died of aids related illness in 2013
• Sub-Saharan Africa remains most severely affected, with nearly 1 in every 20 adults living with HIV and accounting for nearly 71% of the people living with HIV worldwide.

http://www.who.int/gho/hiv/en/

United States:

• 1,201,100 persons aged 13 years and older are living with HIV, 168,300 (14% or 1 in 7) are unaware they are infected.
• Gay and bisexual men of all races are most affected.
• By race, blacks/African Americans face the most severe burden of HIV.
• About 50,000 new HIV infections per year.
• in 2013 47,352 people were diagnosed with HIV and 26,688 people were diagnosed with AIDS.
• 13,712 people with an AIDS diagnosis died in 2012 (death may or may not have been related to AIDS).

Estimated New HIV Infections in the United States, 2010, for the Most Affected Subpopulations

*Subpopulations representing 2% or less are not reflected in this chart. Abbreviations: MSM, men who have sex with men; IDU, injection drug user.

https://www.aids.gov/hiv-aids-basics/hiv-aids-101/statistics/