Medical-Surgical Nursing: An Integrated Approach, 2E

Chapter 23

NURSING CARE OF THE CLIENT: HIV AND AIDS

HIV and AIDS

The human immunodeficiency virus (HIV), first reported in the U.S. in 1981, is a retrovirus that causes acquired immunodeficiency syndrome (AIDS), a progressively fatal disease that destroys the immune system and the body’s ability to fight infection.

HIV/AIDS Statistics

By the end of 1998, an estimated 33.4 million people in the world were living with HIV/AIDS.

In the U.S., 688,200 cases of AIDS reported by the end of 1998, with as many as 900,000 infected with HIV.

Continuum of HIV Disease

Advanced HIV disease (AIDS)

Early HIV disease (Symptomatic infection)Persistent, unexplained fever, night sweats, diarrhea, weight loss, fatigue, and lymphadenopathy;

signs and symptoms may not occur until 10 years or more after initial exposure

Asymptomatic HIV Infection (HIV Seropositivity)Infectious but no evidence of illness except positive HIV antibody test

Primary HIV infection (acute infection)Flu-like s ymptoms; develop antibodies to HIV in 1 to 6 months

Initial Exposure

AIDS-Defining Conditions

Most AIDS-defining conditions are opportunistic infections (infections in persons with a defective immune system that rarely cause harm in healthy individuals).

Pneumocytis carinii pneumonia is the most frequent AIDS-defining condition in the U.S. and Europe.

AIDS Testing The enzyme-linked immunosorbent assay

(ELISA) is the basic screening test to detect antibodies of HIV.

A confirmatory test, the Western blot, is always employed when the ELISA is positive.

The two taken together have an extremely high accuracy rate.

Obtaining a signed informed consent for testing is often a nursing responsibility.

Demographics of AIDS in the United States

Age (AIDS affects mainly people during the most productive years of their life).

Gender (More men from women, though women’s rates are increasing).

Race (The HIV/AIDS epidemic is growing most rapidly among some minority populations and is a leading cause of death of African American males).

Modes of Transmission

The virus may be found in blood, semen, vaginal secretions, and breast milk of infected individuals.

No evidence that HIV is spread through sweat, tears, urine, or feces. Risk of infection from “deep kissing” or oral sex is unknown.

Medical-Surgical Management

MEDICAL Goal is to keep

disease from progressing as long as possible.

Patient monitored by viral load test.

PHARMACOLOGICAL Goal of anti-HIV

treatment is to keep viral load as low as possible for as long as possible.

Use of protease inhibitors.

Common Diagnostic Tests for HIV and AIDS

CD4-T-cells ELISA Polymerase chain reaction (PCR) Western blot

Pulmonary Opportunistic Infections

Pneumocystis Carinii Pneumonia. Histoplasmosis. Tuberculosis.

Pneumocystis Carinii Pneumonia The most common opportunistic infection

associated with advanced HIV disease. Found primarily in the lungs, but also

reported in the adrenal glands, bone marrow, skin, thyroid, kidneys, and spleen.

Clinical signs include fever, shortness of breath, nonproductive cough, and crackles.

Initial diagnosis made by chest x-ray.

Histoplasmosis

An infection caused by the fungus Histoplasma capsulatum. The fungus has been isolated in bird droppings, dirt from chicken coops, and caves.

Histoplasmosis should be suspected if the person presents with fever of uncertain origin, cough, and malaise.

Gastrointestinal Opportunistic Infections

Mycobacterium avium complex. Cytomegalovirus. Cryptosporidiosis. Hepatitis. HIV-wasting syndrome.

Mycobacterium avium complex

In persons with AIDS, involvement of the bowel is usually extensive. The microorganism can fill the bone marrow and lymph nodes.

Most common symptoms are chronic fever, malaise, anemia, weight loss, diarrhea, and abdominal pain.

Cytomegalovirus (CMV)

Belongs to the herpes virus group. Causes disease by destroying the brain,

lung, retina, and liver. Signs and symptoms include weight loss,

fever, diarrhea, and malaise.

Cryptosporidosis Caused by a protozoan that usually

infects the epithelial cells that line the digestive tract.

Clinical signs include profuse water diarrhea, up to 20 liters a day. Abdominal pain, serious weight loss, abdominal cramping, anorexia, low-grade fever, dehydration, electrolyte imbalance and malaise may also be present.

Hepatitis

Hepatitis B virus, C virus, and D virus are commonly seen with HIV infection.

Signs and symptoms include malaise, weakness, anorexia, nausea, vomiting, and right upper quadrant pain.

HIV-Wasting Syndrome Defined as unexplained weight loss of

more than 10% of body weight accompanied by weakness, chronic diarrhea, and fever in those affected with HIV.

Signs and symptoms include anorexia, diarrhea, nausea, vomiting, changes in taste and smell, aphthous ulcers of mouth and esophagus, and abdominal pain.

Oral Opportunistic Infections Oral candidiasis (thrush), a fungal

infection, is seen in more than 90% of AIDS clients. Symptoms include unpleasant taste, mouth dryness, and creamy, white oral plaques.

Oral Hairy Leukoplakia (OHL) usually appears as a white patch on the lateral borders of the tongue. OHL is not usually bothersome to the client and may regress spontaneously.

Gynecological Opportunistic Infections

Vaginal Candidiasis is the most common initial infection occurring in HIV-infected women.

Cervical Intraepithelial Neoplasia (CIN) is of a much higher incidence in women affected with HIV.

Central Nervous System Opportunistic Infections

AIDS dementia complex. Toxoplasmosis. Cryptococcosis.

AIDS Dementia Complex

The most common central nervous system complication in persons with AIDS.

This disorder is chronic and progressive with cognitive, motor, and behavioral dysfunction.

Toxoplasmosis

Caused by the protozoan Toxoplasma gondii, found in cats and other animals.

Clinical signs may be vague and nonspecific, ranging from mild headache, fever, and lethargy to poor coordination, seizures, and coma.

Cryptococcosis

A fungal infection caused by Cryptococcus neoformans.

The most life-threatening fungal infection associated with AIDS.

Clinical symptoms include fever, headache, nausea, vomiting, dizziness, photophobia, mental status changes, seizures, and stiff neck.

Opportunistic Malignancies:

Kaposi’s Sarcoma

A vascular malignancy that can occur any place in the body, including the internal organs.

First lesions often appear subtly on the face or in the oral cavity.

Opportunistic Malignancies:

Non-Hodgkin’s Lymphoma

Clinical manifestations include fever, night sweats, and weight loss.

Treatment of NHL in clients with advanced HIV disease is often withheld, because it is not tolerated well and may even lead to earlier death.