Acquired Immune Deficiency Syndrome (AIDS)

  1. General information
    1. Characterized by severe deficits in cellular immune function; manifested clinically by opportunistic infections and/or unusual neoplasms
    2. Etiologic factors
      1. Results from infection with human immunodeficiency virus (HIV), a retrovirus that preferentially infects helper T-lymphocytes (T4 cells)
      2. Transmissible through sexual contact, contaminated blood or blood products, and from infected woman to child in utero or possibly through breast-feeding
      3. HIV is present in an infected person's blood, semen, and other body fluids
    3. Epidemiology is similar to that of hepatitis B; increased incidence in populations in which sexual promiscuity is common and in IV drug abusers
  2. Medical management
    1. No effective cure for AIDS at present; several categories of antiretroviral drugs now available
      1. Nucleoside Analogues: Didanosine (Videx) (ddl), Lamivudine (3TC) (Epivir), Stavudine (d4T) (Zerit), Zidovudine (AZT) (Retrovir)
      2. Nucleoside Analogues: Didanosine (Videx) (ddl), Lamivudine (3TC) (Epivir), Stavudine (d4T) (Zerit), Zidovudine (AZT) (Retrovir)
      3. Non Nucleoside Analogues: Delavirdine (DLV) (Rescriptor), Nevirapine (NVP) (Viramune)
      4. Protease Inhibitors: Indinavir (Crixivan), Nelfinavir (Viracept), Ritonavir (Norvir), Saquinavir (Invirase)
    2. Primary goal of treatment is to treat opportunistic infections and cancers that develop and provide supportive care for the effects of the disease, e.g., diarrhea, malnutrition, mental changes, etc.
    3. Drugs used to treat PCP include
      1. PO or IV trimethoprim-sulfamethoxazole (Bactrim, Septra); side effects include rash, leukopenia, fever
      2. IM or IV pentamidine (Pentam 300); side effects include hepatotoxicity, nephrotoxicity, blood sugar imbalances, abscess or necroses at IM injection site, hypotension
  3. Assessment findings (see Table 4.18)
    1. Fatigue, weakness, anorexia, weight loss, diarrhea, pallor, fever, night sweats
    2. Shortness of breath, dyspnea, cough, chest pain, and progressive hypoxemia secondary to infection (pneumonia)
    3. Progressive weight loss secondary to anorexia, nausea, vomiting, diarrhea, and a general wasting syndrome; fatigue, malaise
    4. Temperature elevations (persistent or intermittent); night sweats
    5. Neurologic dysfunction secondary to acute meningitis, progressive dementia, encephalopathy, encephalitis
    6. Presence of opportunistic infection, for example
      1. Pneumocystis carinii pneumonia
      2. Herpes simplex, cytomegalovirus, and Epstein-Barr viruses
      3. Candidiasis: oral or esophageal
      4. Mycobacterium-avium complex
    7. Neoplasms
      1. Kaposi's sarcoma
      2. CNS lymphoma
      3. Burkitt's lymphoma
      4. Diffuse undifferentiated non-Hodgkin's lymphoma
    8. Laboratory findings: diagnosis based on clinical criteria and positive HIV antibody test--ELISA (enzyme-linked immunosorbent assay) confirmed by Western blot assay. Other lab findings may include
      1. Leukopenia with profound lymphopenia
      2. Anemia
      3. Thrombocytopenia
      4. Decreased circulatory T4 lymphocyte cells
      5. Low T4:T8 lymphocyte ratio
  4. Nursing interventions
    1. Administer medications as ordered for concomitant disease; monitor for signs of medication toxicity.
    2. Monitor respiratory status; provide care as appropriate for respiratory problems, e.g., pneumonia.
    3. Assess neurological status; reorient client as needed; provide safety measures for the confused/disoriented client.
    4. Assess for signs and symptoms of fluid and electrolyte imbalances; monitor lab studies; ensure adequate hydration.
    5. Monitor client's nutritional intake; provide supplements, total parenteral nutrition, etc., as ordered.
    6. Assess skin daily (especially perianal area) for signs of breakdown; keep skin clean and dry; turn q4 hours while in bed.
    7. Inspect oral cavity daily for ulcerations, signs of infection; instruct client to rinse mouth with normal saline and hydrogen peroxide or normal saline and sodium bicarbonate rinses.
    8. Observe for signs and symptoms of infection; report immediately if any occur.
    9. If severe leukopenia develops, institute neutropenic precautions
      1. Prevent trauma to skin and mucous membranes, e.g., avoid enemas, rectal temperatures; minimize all parenteral infections
      2. Do not place client in a room with clients having infections
      3. Screen visitors for colds, infections, etc.
      4. Do not allow fresh fruits, vegetables, or plants in client's room.
      5. Mask client when leaving room for walks, x-rays, etc.
    10. Institute blood and body fluid precautions (see Nursing Responsibilities in Prevention of Spread of Infection)
    11. Provide emotional support for client/significant others; help to decrease sense of isolation
    12. Provide client teaching and discharge planning concerning
      1. Importance of observing for signs of infections and notifying physician immediately if any occur
      2. Ways to reduce chance of infection
        1. Clean kitchen and bathroom surfaces regularly with disinfectants.
        2. Avoid direct contact with pet's litter boxes or stool, bird cage droppings, and water in fish tanks.
        3. Avoid contact with people with infections, e.g., cold, flu.
        4. Importance of balancing activity with rest.
        5. Need to eat a well-balanced diet with plenty of fluids.
      3. Prevention of disease transmission
        1. Use safer sex practices, e.g., condoms for sexual intercourse.
        2. Do not donate blood, semen, organs.
        3. Do not share razors, toothbrushes, or other items that may draw blood.
        4. Inform all physicians, dentists, sexual partners of diagnosis.
      4. Resources include Public Health Service, National Gay Task Force, American Red Cross, local support groups



TABLE 4.18 Classification System for HIV Infection


CD4 + T-cell categories

A
Asymptomatic, acute HIV or PGL

B
Symptomatic, not (A) or (C) conditions

C
AIDS-indicator conditions

(1) 500/uL

A1

B1

C1

(2) 200-499/uL

A2

B2

C2

(3) <200/ul

A3

B3

C3

Clinical Category A

Clinical Category B

Clinical Category C

1 or more of the following, confirmed HIV infection, and without conditions in B and C
* Asymptomatic HIV infection
* Persistent Generalized Lymphadenopathy (PGL)
* Acute (primary) HIV infection with accompanying illness or history of acute HIV infection

* Candidiasis (oral or vaginal), frequent or poorly resistant to therapy
* Cervical dysplasia/cervical carcinoma in situ
* Fever or diarrhea exceeding 1 month
* Hairy leukoplakia, oral
* Herpes zoster, involving 2 episodes or more than one dermatome
* ITP
* PID
* Peripheral neuropathy

* Candidiasis of bronchi, trachea, or lungs
* Cervical cancer, invasive
* Coccidiomycosis
* Cryptosporidiosis
* Cytomegalovirus
* Encephalopathy
* Herpes simplex: chronic ulcer - exceeding 1 month duration
* Histoplasmosis
* Kaposi's sarcoma
* Lymphoma
* Mycobacterium - avium complex
* Mycobacterium tuberculosis
* Pneumocystis carinii pneumonia
* Salmonella
* Toxoplasmosis of brain
* Wasting syndrome due to HIV

Adopted from Centers for Disease Control, U.S. Dept. of Health and Human Services, 1993 revised classification system for HIV infections and expanded surveilance case definition for AIDS among adolescents and adults.

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