Presentation on theme: "Ch 56- Care of the Patient with HIV/AIDS"— Presentation transcript:
1Ch 56- Care of the Patient with HIV/AIDS Therapeutic Management to Acute Intervention: Wasting and Lipodystrophy SyndromesCh 56- Care of the Patient with HIV/AIDS
2Basic Information from CDC HIV stands for human immunodeficency virus. This is the virus that causes AIDS. HIV is different from most other viruses because it attacks the immune system. The immune system gives our bodies the ability to fight infections. HIV finds and destroys a type of white blood cell (T Cells or CD4 Cells) that the immune system must have to fight disease.
3Organization of the HIV-1 Virion Structure of the Human Immunodeficiency Virus, courtesy of the NIAID.
4Basic Information from CDC (cont) AIDS stands for acquired immunodeficiency syndrome. AIDS is the final stage of HIV infection. It can take years for a person infected with HIV, even without treatment, to reach this stage. Having AIDS means that the virus has weakened the immune system to the point at which the body has a difficult time fighting infection. When someone has one or more specific infections, certain cancers, or a very low number of T cells, he or she is considered to have AIDS.
5HIV VirusElectron microscope image of HIV, seen as small spheres on the surface of white blood cells
6Origin of HIVScientists identified a type of chimpanzee in West Africa as the source of HIV infection in humans. The virus most likely jumped to humans when humans hunted these chimpanzees for meat and came into contact with their infected blood. Over several years, the virus slowly spread across Africa and later into other parts of the world.
7Origins of HIVSpecies of Chimpanzee foundIn Western Africa
8Brief History of HIV in the U.S. HIV was first identified in the United States in 1981 after a number of homosexual men started getting sick with a rare type of cancer. It took several years for scientists to develop a test for the virus, to understand how HIV was transmitted between humans, and to determine what people could do to protect themselves.
9Brief History (cont)In 2008, CDC adjusted its estimate of new HIV infections because of new technology developed by the agency. Before this time, CDC estimated there were roughly 40,000 new HIV infections each year in the United States. New results shows there were dramatic declines in the number of new HIV infections from a peak of about 130,000 in the mid 1980s to a low of roughly 50,000 in the early 1990s. Results also shows that new infections increased in the late 1990s, followed by a leveling off since 2000 at about 55,000 per year. In 2006, an estimated 56,300 individuals were infected with HIV.
10Brief History (cont)AIDS cases began to fall dramatically in 1996, when new drugs became available. Today, more people than ever before are living with HIV/AIDS. CDC estimates that about 1 million people in the United States are living with HIV or AIDS. About one quarter of these people do not know that they are infected: not knowing puts them and others at risk.
11How HIV Is and Is Not Transmitted HIV is a fragile virus. It cannot live for very long outside the body. As a result, the virus is not transmitted through day-to-day activities such as shaking hands, hugging, or a casual kiss. You cannot become infected from a toilet seat, drinking fountain, doorknob, dishes, drinking glasses, food, or pets. You also cannot get HIV from mosquitoes.
12How HIV is and is not transmitted (cont) HIV is primarily found in the blood, semen, or vaginal fluid of an infected person. HIV is transmitted in 3 main ways:Having sex (anal, vaginal, or oral) with someone infected with HIVSharing needles and syringes with someone infected with HIVBeing exposed (fetus or infant) to HIV before or during birth or through breast feeding
13How HIV is or is not transmitted (cont) HIV also can be transmitted through blood infected with HIV. However, since 1985, all donated blood in the United States has been tested for HIV. Therefore, the risk for HIV infection through the transfusion of blood or blood products is extremely low. The U.S. blood supply is considered among the safest in the world.
14Risk Factors for HIV Transmission You may be at increased risk for infection if you have:Injected drugs or steroids, during which equipment (such as needles, syringes, cotton, water) and blood were shared with othersHad unprotected vaginal, anal, or oral sex (that is, sex without using condoms) with men who have sex with men, multiple partners, or anonymous partnersExchanged sex for drugs or money
15Risk Factors (cont)Been given a diagnosis of, or been treated for, hepatitis, tuberculosis (TB), or a sexually transmitted disease (STD) such as syphilisReceived a blood transfusion or clotting factor duringHad unprotected sex with someone who has any of the risk factors listed above
16Preventing Transmission Your risk of getting HIV or passing it to someone else depends on several things. You might want to talk to someone who knows about HIV. You can also do the following:Abstain from sex (do not have oral, anal, or vaginal sex) until you are in a relationship with only one person, are having sex with only each other, and each of you knows the other’s HIV status
17Preventing Transmission (cont) If both you and your partner have HIV, use condoms to prevent other sexually transmitted diseases (STDs) and possible infection with a different strain of HIVIf only one of you has HIV, use a latex condom and lubricant every time you have sexIf you have, or plan to have, more than one sex partner, consider the following:
18Preventing Transmission (cont) Get tested for HIVIf you are a man who has had sex with other men, get tested at least once a yearIf you are a woman who is planning to get pregnant or who is pregnant, get tested as soon as possible, before you have your babyTalk about HIV and other STDs with each partner before you have sexLearn as much as you can about each partner’s past behavior (sex and drug use), and consider the risks to your health before you have sex
19Preventing Transmission (cont) Ask your partners if they have recently been tested for HIV; encourage those who have not been tested to do soUse a latex condom and lubricant every time you have sexIf you think you may have been exposed to another STD such as gonorrhea, syphilis, or chlamydia trachomatis infection, get treatment. These diseases can increase your risk of getting HIV
20Preventing Transmission (cont) Get vaccinated against hepatitis B virusEven if you think you have low risk for HIV infection, get tested whenever you have a regular medical check-upDo not inject illicit drugs (drugs not prescribed by your doctor). You can get HIV through needles, syringes, and other works if they are contaminated with the blood of someone who has HIV. Drugs also cloud your mind, which may result in riskier sex.
21Preventing Transmission (cont) If you do inject drugs, do the following:Use only clean needles, syringes, and other worksNever share needles, syringes, or other worksBe careful not to expose yourself to another person’s bloodGet tested for HIV at least once a yearConsider getting counseling and treatment for your drug useGet vaccinated against hepatitis A and B viruses
22Preventing Transmission (cont) Do not have sex when you are taking drugs or drinking alcohol because being high can make you more likely to take risksTo protect yourself, remember these ABCs:A=AbstinenceB=Be FaithfulC=Condoms
23Symptoms of HIV Infection The only way to know whether you are infected is to be tested for HIV. You cannot rely on symptoms alone because many people who are infected with HIV do not have symptoms for many years. Someone can look and feel healthy but can still be infected. In fact, one quarter of the HIV-infected persons in the United States do not know that they are infected.
24HIV TestingOnce HIV enters the body, the body starts to produce antibodies- substances the immune system creates after infection. Most HIV tests look for these antibodies rather than the virus itself. There are many different kinds of HIV tests, including rapid tests and home test kits. All HIV tests approved by the U.S. government are very good at finding HIV.
25Finding a Testing SiteMany places offer HIV testing: health departments, doctors’ offices, hospitals, and sites specifically set up to provide HIV testing.You can locate a testing site by visiting the CDC HIV testing database or by calling CDC-INFO (formerly the CDC National AIDS Hotline) at CDC-INFO ( ) 24/7. You do not have to give any personal information about yourself to use these services to find a testing site
27Therapeutic Management Focuses of Therapeutic ManagementMonitoring HIV disease progression and immune functionPreventing the development of opportunistic diseasesInitiating and monitoring antiretroviral therapyDetecting and treating opportunistic diseasesManaging symptomsPreventing complications of treatment
28Therapeutic Management (cont) HIV-positive individuals need to be linked to various points of intervention, depending on their individual needs. Individuals often deny the infection, neglect their mental and physical health, and continue behaviors that put themselves and others at risk.Interventions need to be sustained and reinforcedProviders need to stress safer behaviors and the need for medical and emotional support
29Therapeutic Management (cont) Types of assistance may include but are not limited to:Family planningTreatment for substance abuseTreatment for STDsTreatment for Tuberculosis (TB)immunizations
30Therapeutic Management (cont) A transdisciplinary care approach is the most appropriate method of care for patients with HIV disease because of their complex medical and psychosocial needsThe HIV-infected person should be the primary member of this team working alongside with a physician who specializes in HIV and AIDS, a social worker, case manager, dietician, and nurse
31Therapeutic Management (cont) Other team members may include:DentistPCP (medical doctor, doctor of osteopathy, nurse practitioner, or physician assistant)Mental health workerSubstance abuse counselorNontraditional therapist (massage therapist or acupuncturist)Individual’s family and significant other
32Pharmacological Management Opportunistic Diseases Associated with HIV – Alternative and Complementary TherapiesPharmacological Management
33Opportunistic Diseases Associated with HIV A number of opportunistic diseases and debilitating problems associated with HIV can be delayed or prevented through the use of antiretrovirals and prophylactic interventions.Prophylactic medications have contributed to the decreased morbidity and mortality associated with HIV infection during the past several years.Prophylactic medications are recommended according to established parameters
34Opportunistic Diseases Associated with HIV (cont) The most difficult aspect of the medical management of HIV is dealing with the many opportunistic diseases that develop as the immune system degeneratesAlthough it is usually impossible to totally eradicate opportunistic diseases, there are treatments that can control their emergence or progressionRegimen must continue throughout the patient’s life or the disease will returnAdvances in the diagnosis and treatment of opportunistic diseases have contributed significantly to increased life expectancy
35Common Opportunistic Diseases Associated with HIV/AIDS Table 56-6 pg 2028 to 2029Common Opportunistic Diseases Associated with HIV/AIDS
36Respiratory System Pneumocystis jiroveci pneumonia (PCP) Clinical manifestations:Fever, night sweats, nonproductive cough, progressive shortness of breathDiagnostic Tests:Chest radiograph, induced sputum for culture, bronchoalveolar lavageTreatment:Trimethoprim-sulfamethoxazole, dapsone+pyrimethamine+ leucovorin, clindamycin, atovaquone, pentamidine, steroids, trimetrexate, and folinic acidMycobacterium tuberculosisClinical manifestations:Productive cough, fever, night sweats, fatigue, weight lossDiagnostic Tests:Chest radiograph, sputum for acid-fast bacteria (AFB) stain and culture, skin testTreatment:Isoniazid, ethambutol, rifampin, pyrazinamide, streptomycin, azithromycin, clarithromycin
42Strongly Recommended as Standard of Care Problem:Mycobacterium tuberculosisIndication:Skin test (PPD) is greater than or equal to 5 mm or prior positive skin testPreventive Regimens:First Choice: isoniazid + pyridoxine for 9 monthsAlternative Choices: refampin, 600 mg qid (four times a day) for 6 monthsComments: r/o active or extrapulmonary disease which requires multidrug therapy; remember that a negative PPD in the presence of HIV does not exclude a diagnosis of tuberculosis
43Generally Recommended Problem:Hepatitis A Virus (HAV)Indication:All susceptible patients at risk for HAV infection: illicit drug users, men who have sex with men (MSM), hemophiliacs, chronic liver diseasePreventive regimensFirst choice: Hepatitis A vaccine (2doses)Alternative choices: noneComments: combination vaccine available for hepatitis A and hepatitis B (Twinrix)
44Antiretroviral Therapy Combination antiretroviral therapy is an important component in the management of HIV infectionThere are many antiretroviral medications approved by the U.S. FDA for treatment of HIV diseaseIn 1987, zidovudine was the only medication available to treat patients with HIV diseaseToday, there are 18 approved anti-HIV medications available, with significantly more in development
45Antiretroviral Therapy : Cocktails At least two, but generally three or more compounds given togetherMost effective medication regimen that scientists have discoveredMakes it much more difficult for the virus to develop resistance to the drugsMay also slow the progression from asymptomatic or mildly symptomatic HIV infection to a more advanced diseaseCombination therapies offer renewed optimism for successful disease management and improvements in the quality and duration of life
46Antiretroviral Therapy (cont) Recent developments include therapies that can dramatically reduce the quantity of circulating virus in the blood; in many cases, blood circulating levels become undetectableProtease inhibitors directly reduce the ability of HIV to replicate, or make copies of itself inside cellsAs increasing numbers of therapeutic agents and clinical trial results become available, decisions about antiretroviral therapy have become increasingly complex
47Antiretroviral Therapy (cont) It is important for the nurse to administer anti-HIV medications around the clockExample: medication ordered three times per day (TID) should be given as close to every 8 hours as possible, not 3 times while the patient is awakeWhen medications are not given regularly, the drug levels in the blood fall low enough to allow HIV to develop resistanceThis is a critical teaching point for nurses to communicate to patients
48Antiretroviral Therapy: Considerations Combination therapy is now the standard of care. A single drug (monotherapy) is no longer recommended due to the likelihood of the development of viral and therapeutic resistance. Cocktails are more effective than single-drug therapy. This is referred to as “highly active antiretroviral therapy” or HAART.Previous antiretroviral experience may affect the efficacy of a proposed therapy, because previous drug therapy may have allowed the HIV to become resistant to those medications taken by the patient in the past (e.g. AZT, 3TC)Certain combinations of antiretrovirals may reverse the resistance built up against a single drug. Recycling drugs previously taken can sometimes lead to improved viral suppression. Incorrect dosing (timing) or usage (missed doses) can cause drug resistance
49Antiretroviral Therapy: Considerations (cont) Drug incompatibilities, similar side effect profiles, and toxicities must be considered when choosing a regimenThe individual’s commitment and ability to adhere with complex drug regimens must be considered. Inadequate adherence can lead to drug resistance and, ultimately, to drug failure. This point must be stressed to the patient. Adherence is paramount to survival and success of treatment
50Antiretroviral Therapy (cont) There is considerable difference of opinion as to when to initiate antiretroviral therapyA provider with expertise in HIV should supervise the care of the HIV-infected personWith regard to specific recommendations, treatment should be offered to all patients with acute HIV syndrome (seroconversion illness), those within 6 months of HIV seroconversion, and all patients with symptoms credited to HIV infectionIn general, treatment should be offered to individuals with fewer than 350 CD4+ T Cells per millimeter cubed or plasma HIV viral loads exceeding 30,000 copies per mL (bDNA method) or 55,000 copies per mL (PCR method)
51Antiretroviral Therapy (cont) The strength of the recommendation to treat an asymptomatic patient should be based on:Willingness and readiness of the individual to begin therapyDegree of existing immunodeficiency as determined by the CD4+ cell countRisk of progression as determined by the CD4+ cell count and viral loadPotential benefits and risks of initiating therapy in asymptomatic individualsLikelihood, after counseling and education, of adherence to the prescribed treatment regimen
52Antiretroviral Therapy: Goals Once decision has been made to begin therapy, the goals are:Maximal and durable suppression of viral loadRestoration or preservation of immunological functionImprovement in the quality of lifeReduction of HIV-related morbidity and mortality
53Antiretroviral Therapy (cont) Clinical trials are being conducted by the AIDS Clinical Trials Group (ACTG) and the National Institutes of Health in conjunction with universities, pharmaceutical companies, and other agenciesThis may be of important consideration for people with the HIV virusBenefits include:Access to new and potentially beneficial treatments before they are released to the publicChance to have physician visits and labwork paid for by the research study
54Pros and Cons of Highly Active Antiretroviral Therapy Table 56-8 pg 2031Pros and Cons of Highly Active Antiretroviral Therapy
55HAART Minimize chance of emergence of resistant virus PROSCONSMinimize chance of emergence of resistant virusMay play a role in the reduction of HIV transmissionSlows disease progressionImproves quality of lifeDrugs can be toxicFrequent side effectComplexity of drug and dosing regimensImpact of nonadherence on treatment failureexpensive
56Medications: HIV Disease (antiretrovirals) Page 2032 to 2035Medications: HIV Disease (antiretrovirals)
57Abacavir (Ziagen)Nucleoside Reverse Transcriptase Inhibitors (nucleoside analogs, “nukes”)Dose:300 mg po every 12 hoursSide Effects:Nausea, vomiting, headache, fatigue, rashComments:About 3% of people develop a hypersensitivity, which results in flulike symptoms. Can be life threatening development of Stevens-Johnson syndrome- stop drug immediately and do not rechallenge- death may occur. Avoid alcohol (increases abacavir levels in blood). No dietary restrictions.
58Emtricitabine (FTC, Emtriva) Combination MedicationsDose:200-mg capsule once dailySide Effects:Headache, diarrhea, nausea, rash, lactic acidosis, “fatty liver”Comments:No food restrictions, also active against hepatitis B virus infection, should not be combined with lamivudine/epivir (3TC)
59Tenofovir (Viread)Nucleotide Reverse Transcriptase Inhibitors (NTARTI)Dose:300 mg po once per daySide Effects:None listedComments:
60Nevirapine (Viramune) Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIS)Dose:200 mg po every day for 14 days, then 200 mg po every 12 hoursSide Effects:Rash, thrombocytopenia, fever, headaches, nauseaComments:Used in combination therapy. Report any new rash immediately; rash may progress to Stevens-Johnson syndrome, which may result in death
61Saquinavir (Fortovase) Protease inhibitorDose: (soft gel capsule)1800 mg po every 12 hoursSide Effects:Nausea, vomiting, neutropenia, elevated CPK, AST elevation, diarrheaComments:Generally well tolerated because of low absorption rate (4-5%). Used in combination with nucleoside analogs, NNRTIs, and in combination with other protease inhibitors. Dose reduction made when given with ritonavir ( mg po every 12 hours). Take within 2 hours of a high-fat meal (increases absorption)
62Enfuvirtide (T-20, Fuzeon) Fusion inhibitorsDose:90 mg (1 mL) injected subQ twice daily in upper arm, thigh, or abdomen (for patients weighing more than 94 lbs or 42.6 kg)Side Effects:Skin reactions where drug is injected, ranging from redness and itching to hard lumpsOther side effects include headache, pain and numbness in feet or legs, dizziness, and loss of sleepComments:Almost everybody who uses enfuvirtide gets these skin reactions. They can be very mild, such as slight redness. They can include itching, swelling, pain, hardened skin, or hard lumps. Each reaction might last up to a week. With 2 injections each day, people using enfuvirtide might have reactions at several spots on their body at the same time. Very few patients have stopped using it because of skin reactions
63Alternative and Complementary Therapies Nontraditional or complementary therapies are commonly used by people with HIV diseaseAdjunctive activities such as:MassageAcupressureAcupunctureBiofeedbackSome patients use nutritional supplements or herbal remedies with the hope of alleviating the side effects of the disease and the medications
64Alternative and Complementary Therapies (cont) Many patients prefer these therapies because:Limitations or side effects of approved drugsMistrust of the health care systemEasier accessLack of adequate insurance coverageHigh cost of anti-HIV medicationsThese alternatives are best used in conjunction with approved therapeutic intervention
65Nursing Interventions Adherence to Acute Intervention: Wasting and Lipodystrophy SyndromesNursing Interventions
66Nursing Interventions Nurse needs to establish a comfort level in interacting with people with HIV diseasePatients need to be treated in a nonjudgmental, empathic, and caring manner regardless of their sexual practices or history of drug useAttitude, values, and beliefs of a nurse should not interfere with the care a patient with HIV disease needsNurse must see the patient as a unique individual with a need to be cared for with compassion, consideration, and dignityKnowledge of HIV transmission and competence in standard precautions and body substance isolation will minimize the fear of caring for HIV-infected patients
67Nursing DiagnosisRisk for caregiver role strain, related to advancing disease in care receiver and lack of caregiver coping patternsAssess needs and capabilities of patient and caregiverAssess factors that contribute to caregiver strainDevelop supportive and trusting relationship with the caregiverEnlist the help of family members, significant others, and friends to assist caregivers
68Nursing Diagnosis (cont) Diarrhea, related to gastrointestinal infections, malabsorption, or medication side effectsDocument quantity, quality, and frequency of stoolsMonitor intake and output, vital signs, and daily weightAssess for skin impairmentAdminister antidiarrheals on a routine scheduleEncourage high-protein, high-calorie, and low-residue diet
69Box 56-4 pg 2038Nursing Interventions for the Patient with HIV Infection or HIV Disease
70Prevent InfectionWash hands frequently and use skin lubricants for patient and caregiver to prevent skin breakdownUse a gentle liquid soap (such as castile); avoid bar soaps, which may irritate skinUse a separate washcloth for lesionsUse soft toothbrushes; nonabrasive toothpaste; and mouth rinses with sodium bicarbonate, saline, or lemon and hydrogen peroxide before meals and at bedtimeUse measures to prevent skin impairment, such as turning sheets, air mattressesAvoid sources of microbes, such as plants or ingestion of uncooked fresh fruits and vegetables
71Modify Alterations in Body Temperature Administer prescribed antibiotics, IV fluids, or antipyreticsEncourage fluid intake greater than 2500 mLMaintain daily I & O recordsWeigh dailyProvide tepid sponge baths and linen changes as necessaryInstruct patient in deep-breathing and coughing exercises to prevent atelectasis and additional fever
72Promote Good Nutrition Provide instruction for high-calorie, high-protein, high-potassium, low-residue dietEncourage high-calorie, high-potassium snacksSuggest foods that are easy to swallow (gelatin, yogurt, puddings) when dysphagia is presentAvoid foods that are spicy or acidic, rare meats, and raw fruits and vegetablesProvide oral care before patient eatsEncourage patient to get out of bed and sit up for meals if possibleAvoid odors by aerating roomMake appropriate dietary consultations
73Promote Self-Care Assess realistic functional ability Plan, supervise, and assist with ADLs as necessaryEncourage patient to be as active and independent as possibleAssist patient with range-of-motion exercise to prevent contracturesProvide equipment such as assistive eating devices, walkers, and commodes to promote patient independencePace activities and schedule rest periods to prevent fatigue
74Provide Counseling Assess and support patient coping mechanisms Explore with patient and significant others normalcy of griefAssist patient and significant others in acknowledging and planning for anticipated lossesProvide information as desired and as necessary, depending on patient’s ability to understandSuggest appropriate religious supportFacilitate participation in support groups or individual counseling as pertinent
75Nursing Interventions: Adherence Following a prescribed regimen of therapy or treatment for diseaseAdherence to a prescribed regimen is of paramount importance to survival and the success of treatmentNurse is in a unique position to help patients adapt and maintain vigilance with their treatmentIt is important for the patients to understand that antiretroviral treatment is a lifelong, complex undertaking
76Nursing Interventions: Adherence (cont) Multiple factors affect the ability to incorporate anti-HIV treatment into a lifestyle:Treatment knowledgeUnderlying psychiatric or psychological pathologyPhysical statusFamily/caregiver supportHealth care viewsCultureFear of side effectsMisinformation about therapyDenialPossessing skills necessary to care out a medical regimen
77Nursing Interventions: Adherence (cont) Strategies the nurse can employ to increase adherence:Assessing level of comfort with HIVLearning to listenHaving knowledge and skillsGiving permission to grieve and allow sadnessAcknowledging frustration and helplessnessProviding a safe environmentSeeking expert assistance as needed
78Factors Related to Nonadherent Behavior Psychosocial FactorsLocus of control, ineffective communication, mental health problems, trust, internal conflict, social stress, stigma, paternalistic behavior of the health care providerMedications and TreatmentsComplex regimens, inconvenient dosing schedules, skepticism about treatment effectiveness
79Factors Related to Nonadherent Behavior (cont) Cultural IssuesLack of understanding of cultural influences, different worldviewSubstance Usecontinuing substance use, lack of social support, tenuous living arrangements, negative view of addiction
80Nursing Interventions: Palliative Care According to WHO, palliative care is the active, total care of patients whose disease is not responsive to curative treatmentNot seen as hastening the dying process or postponing deathThe goal of palliative care is to address physical, psychological, social, spiritual, and existential needs of patients with progressive, life-threatening illnesses, with the overall goal of improving the quality of lifeMost hospice programs use this type of approach; from curative to caringThe important concept to remember with palliative care is that the goal is to relieve suffering through pain and symptom management at any point in the patient’s disease process
81Nursing Interventions: Palliative Care (cont) Palliative care for the patient with HIV is different from the care provided to a patient with a cancer diagnosisPatients are treated for the chronic debilitating conditions associated with the HIV disease, but also for superimposed acute exacerbations of opportunistic infections and related symptomsIV therapy, blood transfusions, and antibiotic usage may be considered palliative in the end stage of HIV disease because these interventions keep the patient comfortable and help maintain a relative quality of life
82Nursing Interventions: Palliative Care (cont) In AIDS care, short-term aggressive curative therapy is often important in treating acute infections, whereas the overall goal may remain palliationIt is important for the nurse to be comfortable discussing treatment issues and options with patients, as well as being respectful of those decisionsAlthough this phase of life is difficult for both patient and nurse to experience, many nurses express significant satisfaction with these interactions, relationships, and their outcomes
83Nursing Interventions: Psychosocial Issues Psychosocial implications for the patient with HIV disease are generally complexHIV infected patients have considerably more psychosocial problems than patients with other terminal illnessesThey face uncertainty, isolation, fear, and depressionHIV infected patients also fear the potential abandonment and isolation from family and friends; some may have already experienced itThis is due to the contagious and incurable (yet, treatable) nature and the stigma of the disease
84Nursing Interventions: Psychosocial Issues (cont) Due to the many different types of individuals who becomes infected with this disease, the nurse needs to offer their own feelings of sympathy in these difficult situationsWords are one way to convey caring; listening is another important toolThe nurse can develop a good therapeutic relationship with the patient by allowing the patient to assist with and participate in the planning and decision making process of the care programThe nurse should always be supportive of any decision the patient makes
85Nursing Interventions: Assisting with Coping The role of the nurse in this stage of the disease process is to provide continued education about HIV disease and prevention, as well as to assist in realistic goal settingPatients are encouraged to participate in their own care and to maintain positive relationshipsNursing interventions should focus on a philosophy of facing life a day at a time and living each day to the fullest extent possible by resolving multiple conflictsThis may be a time to strengthen personal and spiritual relationshipsEmpathic listening and the ability to help patients find meaning in life become critical nursing interventions
86Nursing Interventions: Assisting with Coping (cont) Assisting families and significant others in providing support to the terminally ill patient despite their own anger and grief is a unique nursing challengeSuch care can provide positive feelings of professional accomplishment even though it can be emotionally drainingNursing interventions to promote effective coping focus on exploring and strengthening healthy coping strategies and maintaining sources of psychological support
87Nursing Interventions: Reducing Anxiety Individuals, families, and significant others experiencing the anxiety of HIV disease are often in a state of crisisContinued clarification and education about HIV disease, complications, and treatment are criticalEvery effort should be made to include the patient and his or her support system in the planning of medical and nursing interventionsHealthy patterns of coping, such as talking or relaxation and meditation, are encouragedThe nurse must be able to assess normal periods of anxiety, depression, and grief, as well as refer patients and significant others for psychological evaluation and counseling for ineffective coping patterns
88Nursing Interventions: Reducing Anxiety (cont) A schedule of activities developed by the patient with guidance from health care professionals may decrease anxiety and feelings of powerlessnessPlanned, uninterrupted time with only the nurse, patient, and significant other may create a supportive environment that decreases anxiety and promotes healthy coping
89Nursing Interventions: Minimizing Social Isolation Because no cure currently exists, the diagnosis of HIV infection brings denial, fear, depression, and angerThe social stigma of HIV disease based on associations with homosexuality, drug use, and sexual transmission cannot be minimizedA tremendous fear of family, significant others, and friends reacting with anger, rejection, or abandonment is a real concernOften family and friends who are struggling with their own anxieties and fears do abandon the patient
90Nursing Interventions: Minimizing Social Isolation (cont) When abandonment happens, the nurse should try to assist the patient to find other sources of social support
91Nursing Interventions: Assisting with Grieving Patients diagnosed with HIV disease experience strong emotionsSome patients benefit from individual empathic listening and exploring feelings, fears and treatment optionsOthers may benefit from support groups consisting of patients experiencing similar feelingsIndividual counseling and support groups may help loved ones be a source of support for the patientReferrals to social workers and appropriate community agencies can alleviate many concerns that plague acute or terminally ill patients
92Nursing Interventions: Confidentiality Respect for the patient’s right to confidentiality is particularly important for the patient with HIV diseaseThe diagnosis needs to be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatmentNot all healthcare providers need to knowExample: if a phlebotomist needs to know so that she or he can wear two pairs of latex glovesWhat if it’s a nurse that needs to know so that she can create an appropriate care plan for her shift?Ancillary personnel such as lab or radiology technicians, dietary personnel, and housekeeping staff generally does not need to knowThe nurse should never discuss patient’s diagnosis at mealtime, during breaks, or in elevators with coworkers, friends or family
93Nursing Interventions: Duty to Treat A nurse’s professional obligation to treat patients in need transcends concerns about the diseases or conditions of the patientsIf a nurse’s primary concern is personal safety, the nurse needs to reexamine his or her commitment to the professionThe patient with HIV disease can provide valuable lessons in issues related to infectious disease control, the stereotyping of patients, and an understanding of the dedication of health care providersA spirit of compassion stemming from a genuine willingness to serve the needs of others is essential in caring for the patient with HIV disease
94Ethical and Legal Principles The Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) prohibit discrimination against the handicapped and the disabled. HIV-infected people or those with AIDS are included under these acts.Refusal to treat or care for people who are HIV-infected or have AIDS, when that refusal is not based on a medical judgment, is as unethical as discrimination based on race, gender, or other characteristics.Health care professionals may not pick and choose their patients, if they are true to their oaths to provide care to all those in need
95Nursing Interventions: Acute Intervention Early intervention after detection of an HIV infection can promote health and limit or delay disabilityNursing interventions will be based on and tailored to any patient needs noted during assessmentNursing assessment of HIV disease should focus on the early detection of constitutional symptoms, opportunistic diseases, and psychosocial problems
96Useful Interventions for HIV-Infected Patient Nutritional changes that maintain lean body mass, increase weight, and ensure appropriate levels of vitamins and micronutrientsElimination of smoking and drug useElimination or moderation of alcohol intakeRegular exerciseStress reductionAvoidance of exposure to new infectious agentsMental health counselingInvolvement in support groupsSafer sex practice
97Nursing Interventions: Acute Intervention (cont) Nurse needs to help patients gain control of the situation and their emotionsFacilitating empowerment is particularly importantThis is facilitated through education and honest discussions about the patient’s health statusPatient should be taught to recognize clinical manifestations that may indicate progression of the diseaseThis ensures that prompt medical care is initiated
98Nursing Interventions: Acute Intervention (cont) Early manifestations that need to be reported:Unexplained weight loss, night sweats, diarrhea, persistent fever, swollen lymph nodes, oral hairy leukoplakia (OHL), oral candidiasis (thrush), persistent vaginal yeast infectionsPatients should also report:Unusual headaches, changes in vision, nausea and vomiting, numbness or tingling in the extremitiesPatient should be given as much information as needed to make health care decisionsThese decisions will dictate the appropriate medical and nursing interventions
99Nursing Interventions: Acute Intervention (cont) Nursing interventions become more complicated as the patient’s immune system deteriorates and new problems arise to compound existing difficultiesNursing focus should be on quality-of-life issues and symptom management, rather than on issues regarding a cureWhen opportunistic diseases develop, symptomatic nursing interventions, education, and emotional support are necessary