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Ch 56- Care of the Patient with HIV/AIDS

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1 Ch 56- Care of the Patient with HIV/AIDS
Therapeutic Management to Acute Intervention: Wasting and Lipodystrophy Syndromes Ch 56- Care of the Patient with HIV/AIDS

2 Basic 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.

3 Organization of the HIV-1 Virion
Structure of the Human Immunodeficiency Virus, courtesy of the NIAID.

4 Basic 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.

5 HIV Virus Electron microscope image of HIV, seen as small spheres on the surface of white blood cells

6 Origin of HIV Scientists 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.

7 Origins of HIV Species of Chimpanzee found In Western Africa

8 Brief 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.

9 Brief 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.

10 Brief 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.

11 How 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.

12 How 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 HIV Sharing needles and syringes with someone infected with HIV Being exposed (fetus or infant) to HIV before or during birth or through breast feeding

13 How 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.

14 Risk 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 others Had unprotected vaginal, anal, or oral sex (that is, sex without using condoms) with men who have sex with men, multiple partners, or anonymous partners Exchanged sex for drugs or money

15 Risk Factors (cont) Been given a diagnosis of, or been treated for, hepatitis, tuberculosis (TB), or a sexually transmitted disease (STD) such as syphilis Received a blood transfusion or clotting factor during Had unprotected sex with someone who has any of the risk factors listed above

16 Preventing 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

17 Preventing 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 HIV If only one of you has HIV, use a latex condom and lubricant every time you have sex If you have, or plan to have, more than one sex partner, consider the following:

18 Preventing Transmission (cont)
Get tested for HIV If you are a man who has had sex with other men, get tested at least once a year If you are a woman who is planning to get pregnant or who is pregnant, get tested as soon as possible, before you have your baby Talk about HIV and other STDs with each partner before you have sex Learn 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

19 Preventing Transmission (cont)
Ask your partners if they have recently been tested for HIV; encourage those who have not been tested to do so Use a latex condom and lubricant every time you have sex If 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

20 Preventing Transmission (cont)
Get vaccinated against hepatitis B virus Even if you think you have low risk for HIV infection, get tested whenever you have a regular medical check-up Do 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.

21 Preventing Transmission (cont)
If you do inject drugs, do the following: Use only clean needles, syringes, and other works Never share needles, syringes, or other works Be careful not to expose yourself to another person’s blood Get tested for HIV at least once a year Consider getting counseling and treatment for your drug use Get vaccinated against hepatitis A and B viruses

22 Preventing Transmission (cont)
Do not have sex when you are taking drugs or drinking alcohol because being high can make you more likely to take risks To protect yourself, remember these ABCs: A=Abstinence B=Be Faithful C=Condoms

23 Symptoms 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.

24 HIV Testing Once 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.

25 Finding a Testing Site Many 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

26 Therapeutic Management
Pharmacological Management Therapeutic Management

27 Therapeutic Management
Focuses of Therapeutic Management Monitoring HIV disease progression and immune function Preventing the development of opportunistic diseases Initiating and monitoring antiretroviral therapy Detecting and treating opportunistic diseases Managing symptoms Preventing complications of treatment

28 Therapeutic 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 reinforced Providers need to stress safer behaviors and the need for medical and emotional support

29 Therapeutic Management (cont)
Types of assistance may include but are not limited to: Family planning Treatment for substance abuse Treatment for STDs Treatment for Tuberculosis (TB) immunizations

30 Therapeutic 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 needs The 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

31 Therapeutic Management (cont)
Other team members may include: Dentist PCP (medical doctor, doctor of osteopathy, nurse practitioner, or physician assistant) Mental health worker Substance abuse counselor Nontraditional therapist (massage therapist or acupuncturist) Individual’s family and significant other

32 Pharmacological Management
Opportunistic Diseases Associated with HIV – Alternative and Complementary Therapies Pharmacological Management

33 Opportunistic 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

34 Opportunistic 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 degenerates Although it is usually impossible to totally eradicate opportunistic diseases, there are treatments that can control their emergence or progression Regimen must continue throughout the patient’s life or the disease will return Advances in the diagnosis and treatment of opportunistic diseases have contributed significantly to increased life expectancy

35 Common Opportunistic Diseases Associated with HIV/AIDS
Table 56-6 pg 2028 to 2029 Common Opportunistic Diseases Associated with HIV/AIDS

36 Respiratory System Pneumocystis jiroveci pneumonia (PCP)
Clinical manifestations: Fever, night sweats, nonproductive cough, progressive shortness of breath Diagnostic Tests: Chest radiograph, induced sputum for culture, bronchoalveolar lavage Treatment: Trimethoprim-sulfamethoxazole, dapsone+pyrimethamine+ leucovorin, clindamycin, atovaquone, pentamidine, steroids, trimetrexate, and folinic acid Mycobacterium tuberculosis Clinical manifestations: Productive cough, fever, night sweats, fatigue, weight loss Diagnostic Tests: Chest radiograph, sputum for acid-fast bacteria (AFB) stain and culture, skin test Treatment: Isoniazid, ethambutol, rifampin, pyrazinamide, streptomycin, azithromycin, clarithromycin

37 Integumentary System HSV-1 Clinical manifestations: Diagnostic tests:
Vesicular eruptions on mouth Diagnostic tests: Viral culture Treatment: Acyclovir, foscarnet, famciclovir, valacyclovir Varicella Zoster Virus (VZV) Clinical manifestation: Shingles: erythematous macules, rash, pain, pruritis Diagnostic tests: Viral culture Treatment: Acyclovir, foscarnet, valacyclovir

38 Eye CMV Retinitis Clinical manifestations: Diagnostic tests:
Lesions on the retina, blurred vision, loss of vision Diagnostic tests: Ophthalmoscopic examination Treatment: Ganciclovir, foscarnet, cidofovir VZV Clinical manifestations: Ocular lesions, acute retinal necrosis Diagnostic tests: Ophthalmoscopic examination, culture Treatment: Acyclovir, foscarnet, valacyclovir, famciclovir

39 Gastrointestinal System
Candida albicans Clinical manifestations: Whitish yellow patches in mouth, esophagus, gastrointestinal (GI) tract Diagnostic tests: Microscopic examination of scraping from lesion Treatment Nystatin, clotrimazole, ketoconazole, fluconazole, itraconazole, amphotericin B Non-Hodgkin’s Lymphoma Clinical manifestations: Abdominal pain, fever, night sweats, weight loss Diagnostic tests: Lymph node biopsy Treatment: Chemotherapy, HAART (highly active antiretroviral therapy)

40 Neurological System Jamestown Canyon (JC) virus
Clinical manifestations: Progressive multifocal leukoencephalopathy, mental and motor declines Diagnostic tests: MRI, CT Scan, brain biopsy, autopsy Treatment: No proven therapy, but HAART may help, cutosine arabinoside Central Nervous System Lymphomas Clinical manifestations: Cognitive dysfunction, motor impairment, aphasia, seizures, personality changes, headache Diagnostic tests: MRI, CT Scan Treatment: Radiation, chemotherapy

41 Opportunistic Illness Prophylaxis Guidelines
Table 56-7 pg 2030 to 2031 Opportunistic Illness Prophylaxis Guidelines

42 Strongly Recommended as Standard of Care
Problem: Mycobacterium tuberculosis Indication: Skin test (PPD) is greater than or equal to 5 mm or prior positive skin test Preventive Regimens: First Choice: isoniazid + pyridoxine for 9 months Alternative Choices: refampin, 600 mg qid (four times a day) for 6 months Comments: 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

43 Generally 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 disease Preventive regimens First choice: Hepatitis A vaccine (2doses) Alternative choices: none Comments: combination vaccine available for hepatitis A and hepatitis B (Twinrix)

44 Antiretroviral Therapy
Combination antiretroviral therapy is an important component in the management of HIV infection There are many antiretroviral medications approved by the U.S. FDA for treatment of HIV disease In 1987, zidovudine was the only medication available to treat patients with HIV disease Today, there are 18 approved anti-HIV medications available, with significantly more in development

45 Antiretroviral Therapy : Cocktails
At least two, but generally three or more compounds given together Most effective medication regimen that scientists have discovered Makes it much more difficult for the virus to develop resistance to the drugs May also slow the progression from asymptomatic or mildly symptomatic HIV infection to a more advanced disease Combination therapies offer renewed optimism for successful disease management and improvements in the quality and duration of life

46 Antiretroviral 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 undetectable Protease inhibitors directly reduce the ability of HIV to replicate, or make copies of itself inside cells As increasing numbers of therapeutic agents and clinical trial results become available, decisions about antiretroviral therapy have become increasingly complex

47 Antiretroviral Therapy (cont)
It is important for the nurse to administer anti-HIV medications around the clock Example: 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 awake When medications are not given regularly, the drug levels in the blood fall low enough to allow HIV to develop resistance This is a critical teaching point for nurses to communicate to patients

48 Antiretroviral 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

49 Antiretroviral Therapy: Considerations (cont)
Drug incompatibilities, similar side effect profiles, and toxicities must be considered when choosing a regimen The 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

50 Antiretroviral Therapy (cont)
There is considerable difference of opinion as to when to initiate antiretroviral therapy A provider with expertise in HIV should supervise the care of the HIV-infected person With 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 infection In 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)

51 Antiretroviral Therapy (cont)
The strength of the recommendation to treat an asymptomatic patient should be based on: Willingness and readiness of the individual to begin therapy Degree of existing immunodeficiency as determined by the CD4+ cell count Risk of progression as determined by the CD4+ cell count and viral load Potential benefits and risks of initiating therapy in asymptomatic individuals Likelihood, after counseling and education, of adherence to the prescribed treatment regimen

52 Antiretroviral Therapy: Goals
Once decision has been made to begin therapy, the goals are: Maximal and durable suppression of viral load Restoration or preservation of immunological function Improvement in the quality of life Reduction of HIV-related morbidity and mortality

53 Antiretroviral 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 agencies This may be of important consideration for people with the HIV virus Benefits include: Access to new and potentially beneficial treatments before they are released to the public Chance to have physician visits and labwork paid for by the research study

54 Pros and Cons of Highly Active Antiretroviral Therapy
Table 56-8 pg 2031 Pros and Cons of Highly Active Antiretroviral Therapy

55 HAART Minimize chance of emergence of resistant virus
PROS CONS Minimize chance of emergence of resistant virus May play a role in the reduction of HIV transmission Slows disease progression Improves quality of life Drugs can be toxic Frequent side effect Complexity of drug and dosing regimens Impact of nonadherence on treatment failure expensive

56 Medications: HIV Disease (antiretrovirals)
Page 2032 to 2035 Medications: HIV Disease (antiretrovirals)

57 Abacavir (Ziagen) Nucleoside Reverse Transcriptase Inhibitors (nucleoside analogs, “nukes”) Dose: 300 mg po every 12 hours Side Effects: Nausea, vomiting, headache, fatigue, rash Comments: 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.

58 Emtricitabine (FTC, Emtriva)
Combination Medications Dose: 200-mg capsule once daily Side 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)

59 Tenofovir (Viread) Nucleotide Reverse Transcriptase Inhibitors (NTARTI) Dose: 300 mg po once per day Side Effects: None listed Comments:

60 Nevirapine (Viramune)
Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIS) Dose: 200 mg po every day for 14 days, then 200 mg po every 12 hours Side Effects: Rash, thrombocytopenia, fever, headaches, nausea Comments: Used in combination therapy. Report any new rash immediately; rash may progress to Stevens-Johnson syndrome, which may result in death

61 Saquinavir (Fortovase)
Protease inhibitor Dose: (soft gel capsule) 1800 mg po every 12 hours Side Effects: Nausea, vomiting, neutropenia, elevated CPK, AST elevation, diarrhea Comments: 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)

62 Enfuvirtide (T-20, Fuzeon)
Fusion inhibitors Dose: 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 lumps Other side effects include headache, pain and numbness in feet or legs, dizziness, and loss of sleep Comments: 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

63 Alternative and Complementary Therapies
Nontraditional or complementary therapies are commonly used by people with HIV disease Adjunctive activities such as: Massage Acupressure Acupuncture Biofeedback Some patients use nutritional supplements or herbal remedies with the hope of alleviating the side effects of the disease and the medications

64 Alternative and Complementary Therapies (cont)
Many patients prefer these therapies because: Limitations or side effects of approved drugs Mistrust of the health care system Easier access Lack of adequate insurance coverage High cost of anti-HIV medications These alternatives are best used in conjunction with approved therapeutic intervention

65 Nursing Interventions
Adherence to Acute Intervention: Wasting and Lipodystrophy Syndromes Nursing Interventions

66 Nursing Interventions
Nurse needs to establish a comfort level in interacting with people with HIV disease Patients need to be treated in a nonjudgmental, empathic, and caring manner regardless of their sexual practices or history of drug use Attitude, values, and beliefs of a nurse should not interfere with the care a patient with HIV disease needs Nurse must see the patient as a unique individual with a need to be cared for with compassion, consideration, and dignity Knowledge of HIV transmission and competence in standard precautions and body substance isolation will minimize the fear of caring for HIV-infected patients

67 Nursing Diagnosis Risk for caregiver role strain, related to advancing disease in care receiver and lack of caregiver coping patterns Assess needs and capabilities of patient and caregiver Assess factors that contribute to caregiver strain Develop supportive and trusting relationship with the caregiver Enlist the help of family members, significant others, and friends to assist caregivers

68 Nursing Diagnosis (cont)
Diarrhea, related to gastrointestinal infections, malabsorption, or medication side effects Document quantity, quality, and frequency of stools Monitor intake and output, vital signs, and daily weight Assess for skin impairment Administer antidiarrheals on a routine schedule Encourage high-protein, high-calorie, and low-residue diet

69 Box 56-4 pg 2038 Nursing Interventions for the Patient with HIV Infection or HIV Disease

70 Prevent Infection Wash hands frequently and use skin lubricants for patient and caregiver to prevent skin breakdown Use a gentle liquid soap (such as castile); avoid bar soaps, which may irritate skin Use a separate washcloth for lesions Use soft toothbrushes; nonabrasive toothpaste; and mouth rinses with sodium bicarbonate, saline, or lemon and hydrogen peroxide before meals and at bedtime Use measures to prevent skin impairment, such as turning sheets, air mattresses Avoid sources of microbes, such as plants or ingestion of uncooked fresh fruits and vegetables

71 Modify Alterations in Body Temperature
Administer prescribed antibiotics, IV fluids, or antipyretics Encourage fluid intake greater than 2500 mL Maintain daily I & O records Weigh daily Provide tepid sponge baths and linen changes as necessary Instruct patient in deep-breathing and coughing exercises to prevent atelectasis and additional fever

72 Promote Good Nutrition
Provide instruction for high-calorie, high-protein, high-potassium, low-residue diet Encourage high-calorie, high-potassium snacks Suggest foods that are easy to swallow (gelatin, yogurt, puddings) when dysphagia is present Avoid foods that are spicy or acidic, rare meats, and raw fruits and vegetables Provide oral care before patient eats Encourage patient to get out of bed and sit up for meals if possible Avoid odors by aerating room Make appropriate dietary consultations

73 Promote Self-Care Assess realistic functional ability
Plan, supervise, and assist with ADLs as necessary Encourage patient to be as active and independent as possible Assist patient with range-of-motion exercise to prevent contractures Provide equipment such as assistive eating devices, walkers, and commodes to promote patient independence Pace activities and schedule rest periods to prevent fatigue

74 Provide Counseling Assess and support patient coping mechanisms
Explore with patient and significant others normalcy of grief Assist patient and significant others in acknowledging and planning for anticipated losses Provide information as desired and as necessary, depending on patient’s ability to understand Suggest appropriate religious support Facilitate participation in support groups or individual counseling as pertinent

75 Nursing Interventions: Adherence
Following a prescribed regimen of therapy or treatment for disease Adherence to a prescribed regimen is of paramount importance to survival and the success of treatment Nurse is in a unique position to help patients adapt and maintain vigilance with their treatment It is important for the patients to understand that antiretroviral treatment is a lifelong, complex undertaking

76 Nursing Interventions: Adherence (cont)
Multiple factors affect the ability to incorporate anti-HIV treatment into a lifestyle: Treatment knowledge Underlying psychiatric or psychological pathology Physical status Family/caregiver support Health care views Culture Fear of side effects Misinformation about therapy Denial Possessing skills necessary to care out a medical regimen

77 Nursing Interventions: Adherence (cont)
Strategies the nurse can employ to increase adherence: Assessing level of comfort with HIV Learning to listen Having knowledge and skills Giving permission to grieve and allow sadness Acknowledging frustration and helplessness Providing a safe environment Seeking expert assistance as needed

78 Factors Related to Nonadherent Behavior
Psychosocial Factors Locus of control, ineffective communication, mental health problems, trust, internal conflict, social stress, stigma, paternalistic behavior of the health care provider Medications and Treatments Complex regimens, inconvenient dosing schedules, skepticism about treatment effectiveness

79 Factors Related to Nonadherent Behavior (cont)
Cultural Issues Lack of understanding of cultural influences, different worldview Substance Use continuing substance use, lack of social support, tenuous living arrangements, negative view of addiction

80 Nursing Interventions: Palliative Care
According to WHO, palliative care is the active, total care of patients whose disease is not responsive to curative treatment Not seen as hastening the dying process or postponing death The 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 life Most hospice programs use this type of approach; from curative to caring The 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

81 Nursing Interventions: Palliative Care (cont)
Palliative care for the patient with HIV is different from the care provided to a patient with a cancer diagnosis Patients are treated for the chronic debilitating conditions associated with the HIV disease, but also for superimposed acute exacerbations of opportunistic infections and related symptoms IV 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

82 Nursing 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 palliation It is important for the nurse to be comfortable discussing treatment issues and options with patients, as well as being respectful of those decisions Although 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

83 Nursing Interventions: Psychosocial Issues
Psychosocial implications for the patient with HIV disease are generally complex HIV infected patients have considerably more psychosocial problems than patients with other terminal illnesses They face uncertainty, isolation, fear, and depression HIV infected patients also fear the potential abandonment and isolation from family and friends; some may have already experienced it This is due to the contagious and incurable (yet, treatable) nature and the stigma of the disease

84 Nursing 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 situations Words are one way to convey caring; listening is another important tool The 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 program The nurse should always be supportive of any decision the patient makes

85 Nursing 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 setting Patients are encouraged to participate in their own care and to maintain positive relationships Nursing 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 conflicts This may be a time to strengthen personal and spiritual relationships Empathic listening and the ability to help patients find meaning in life become critical nursing interventions

86 Nursing 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 challenge Such care can provide positive feelings of professional accomplishment even though it can be emotionally draining Nursing interventions to promote effective coping focus on exploring and strengthening healthy coping strategies and maintaining sources of psychological support

87 Nursing Interventions: Reducing Anxiety
Individuals, families, and significant others experiencing the anxiety of HIV disease are often in a state of crisis Continued clarification and education about HIV disease, complications, and treatment are critical Every effort should be made to include the patient and his or her support system in the planning of medical and nursing interventions Healthy patterns of coping, such as talking or relaxation and meditation, are encouraged The 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

88 Nursing Interventions: Reducing Anxiety (cont)
A schedule of activities developed by the patient with guidance from health care professionals may decrease anxiety and feelings of powerlessness Planned, uninterrupted time with only the nurse, patient, and significant other may create a supportive environment that decreases anxiety and promotes healthy coping

89 Nursing Interventions: Minimizing Social Isolation
Because no cure currently exists, the diagnosis of HIV infection brings denial, fear, depression, and anger The social stigma of HIV disease based on associations with homosexuality, drug use, and sexual transmission cannot be minimized A tremendous fear of family, significant others, and friends reacting with anger, rejection, or abandonment is a real concern Often family and friends who are struggling with their own anxieties and fears do abandon the patient

90 Nursing Interventions: Minimizing Social Isolation (cont)
When abandonment happens, the nurse should try to assist the patient to find other sources of social support

91 Nursing Interventions: Assisting with Grieving
Patients diagnosed with HIV disease experience strong emotions Some patients benefit from individual empathic listening and exploring feelings, fears and treatment options Others may benefit from support groups consisting of patients experiencing similar feelings Individual counseling and support groups may help loved ones be a source of support for the patient Referrals to social workers and appropriate community agencies can alleviate many concerns that plague acute or terminally ill patients

92 Nursing Interventions: Confidentiality
Respect for the patient’s right to confidentiality is particularly important for the patient with HIV disease The diagnosis needs to be carefully protected and shared only with caregivers who need to know for the purpose of assessment and treatment Not all healthcare providers need to know Example: if a phlebotomist needs to know so that she or he can wear two pairs of latex gloves What 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 know The nurse should never discuss patient’s diagnosis at mealtime, during breaks, or in elevators with coworkers, friends or family

93 Nursing Interventions: Duty to Treat
A nurse’s professional obligation to treat patients in need transcends concerns about the diseases or conditions of the patients If a nurse’s primary concern is personal safety, the nurse needs to reexamine his or her commitment to the profession The 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 providers A spirit of compassion stemming from a genuine willingness to serve the needs of others is essential in caring for the patient with HIV disease

94 Ethical 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

95 Nursing Interventions: Acute Intervention
Early intervention after detection of an HIV infection can promote health and limit or delay disability Nursing interventions will be based on and tailored to any patient needs noted during assessment Nursing assessment of HIV disease should focus on the early detection of constitutional symptoms, opportunistic diseases, and psychosocial problems

96 Useful Interventions for HIV-Infected Patient
Nutritional changes that maintain lean body mass, increase weight, and ensure appropriate levels of vitamins and micronutrients Elimination of smoking and drug use Elimination or moderation of alcohol intake Regular exercise Stress reduction Avoidance of exposure to new infectious agents Mental health counseling Involvement in support groups Safer sex practice

97 Nursing Interventions: Acute Intervention (cont)
Nurse needs to help patients gain control of the situation and their emotions Facilitating empowerment is particularly important This is facilitated through education and honest discussions about the patient’s health status Patient should be taught to recognize clinical manifestations that may indicate progression of the disease This ensures that prompt medical care is initiated

98 Nursing 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 infections Patients should also report: Unusual headaches, changes in vision, nausea and vomiting, numbness or tingling in the extremities Patient should be given as much information as needed to make health care decisions These decisions will dictate the appropriate medical and nursing interventions

99 Nursing Interventions: Acute Intervention (cont)
Nursing interventions become more complicated as the patient’s immune system deteriorates and new problems arise to compound existing difficulties Nursing focus should be on quality-of-life issues and symptom management, rather than on issues regarding a cure When opportunistic diseases develop, symptomatic nursing interventions, education, and emotional support are necessary

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