Chapter 56: Care of the patient with HIV/AIDs

1. Chapter 56: Care of the patient with HIV/AIDs Acute Interventions to Outlook For The Future

2. Acute Interventions

3. Acute Interventions • Early intervention after detection of an HIV infection can promote health and limit or delay disability • Assessment is of primary importance because the course of HIV is extremely variable • 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

4. Box 56-6: Conducting a Risk Assessment Pg 2043

5. Conducting a Risk Assessment • Risk assessment specific to HIV and sexually transmitted diseases (STDs), as well as blood borne diseases, is crucial in health care delivery today. Risk assessment should be done on a regular basis with all patients and performed with the evaluation of any new patient. Sexual and drug use risks should be determined along with other risks during routine history taking.

6. Key Questions To Ask Any “yes” responses require further assessment and evaluation: • Have you ever had a blood transfusion? Have you ever received any other kind of blood product? Before 1985? • Do you now or have you ever shared injection equipment? • Are you now or have you ever been sexually active?

7. Key Points to Consider Begin by assuring confidentiality and telling the patient why asking these questions is important: • “I am going to ask some personal questions. I ask all my patients these questions so I can provide better care. All of your responses will be kept confidential. Is it OK to proceed?”

8. Key Points to Consider (cont) Ask direct questions about specific behaviors: • “When was the last time you….?” • “How often do you….?” • “Have you ever exchanged sex for money or drugs?”

9. Key Points to Consider (cont) Exploratory questions may help (especially with adolescents and young adults): • “Do your friends use condoms?” • “What happens at parties?” • “How easy is it to get drugs?”

10. Key Points To Consider (cont) Honest responses may be more forthcoming if the behaviors are normalized: • “Some of my patients who use drugs inject them. Do you inject drugs or other substances? • “Sometimes people have anal intercourse. Have you ever had anal intercourse?”

11. Drug Use Assessment It is important to be nonjudgmental and nonmoralistic: • Injection drug use is illegal in the U.S. and many patients are afraid to be honest unless trust is established

12. Drug Use Assessment (cont) Start with less threatening questions: • “What over-the-counter (OTC) or prescription medications are you taking?” • “How often do you use alcohol? Tobacco?” • “Have you ever used drugs from a nonmedical source?” • “Have you ever injected any kind of drug?”

13. Drug Use Assessment (cont) Do not assume anything: • Drug use occurs in all socioeconomic strata. Do not forget that people inject substances such as insulin, steroids, and vitamins. Any sharing, even one time, can result in HIV exposure

14. Drug Use Assessment (cont) Look for other clue in the history and physical exam: • Antisocial behavior, recurrent criminal arrests, needle tracks

15. Drug Use Assessment (cont) If there is a positive history of drug injection use, get more information: • “Do/Did you share needles/other equipment?” • “Is/Was the equipment you use(d) clean? How did you know it was clean?” • “What drugs did you inject?”

16. Sexual Risk Assessment Direct and nonjudgmental questions work best: • “Do you have sex with men, women, or both?” • “Do you have oral sex? Vaginal sex? Anal sex?” • “What do you know about the sexual activities of your partners?” • “What do you do to protect yourself during sex? • “Do you use condoms? How often?” • “Have you ever had sex with someone you didn’t know or just met?”

17. Sexual Risk Assessment (cont) Ask for an explanation of sexual practices: • “When you say you had sex, what exactly do you mean?” • “I don’t know what you mean; could you explain….?”

18. Sexual Risk Assessment (cont) Do not assume anything: • Marriage does not always mean an individual is monogamous or heterosexual • People who identify as homosexual may also have heterosexual sex

19. Sexual Risk Assessment (cont) Use specific terms: • Use “men who have sex with men” or “women who have sex with women” instead of gay. Some men do not consider themselves “gay” if they practice anal insertive intercourse, but their receptive partners are considered to be gay (can be culturally related).

20. Clinical Risk Assessment Assess the patient for constitutional signs, history of chronic infection and HIV, and associated problems: • Headaches; diarrhea; fatigue; shingles; history of STD, hepatitis, or TB; fever, chills, night sweats; skin lesions; weight loss; oral thrush; generalized lymphadenopathy

21. Acute Interventions continuation

22. Acute Interventions • HIV disease progression may be delayed by promoting a healthy immune system • Useful interventions for the HIV infected patient include the following: • 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 sexual practices

23. Acute Interventions (cont) • Nurse needs to help patients gain control of the situation and their emotions • Facilitating empowerment is particularly important, because the individual with an HIV infection often experience loss, including an overwhelming feeling of loss of control • Empowerment is facilitated through education and honest discussions about the patient’s health status

24. Acute Interventions (cont) • Patient should be taught to recognize clinical manifestations that may indicate progression of the disease • This will ensure that prompt medical care is initiated • 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

25. Acute Interventions (cont) • Patients should also report: • Unusual headaches, changes in vision, nausea and vomiting, numbness and tingling in the extremities • Patient should be given as much information as needed to make health care decisions • Decisions will dictate the appropriate medical and nursing interventions

26. Acute Interventions (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

27. Acute Interventions (cont) • When opportunistic diseases develop, symptomatic nursing interventions, education, and emotional support are necessary • Example: acute case of PCP • Interventions include monitoring the respiratory status, administering medications and oxygen, positioning the patient to facilitate breathing, managing anxiety, promoting nutritional support, and helping the patient conserve energy to decrease oxygen demand • Because the potential for death is associated with advanced HIV disease, emotional support for the patient, caregiver, or significant other is particularly important

28. Nursing Care Plan Box Pg 2044 to 2045

29. Nursing Diagnosis #1 Risk for caregiver role strain, r/t advancing disease in care receiver, lack of caregiver • Patient Goals/Expected Outcomes: • Caregiver will use available community and personal resources • Caregiver will have the ability to complete necessary care giving tasks • Effective support for caregiver

30. Nursing Diagnosis #1 (cont) • Nursing Intervention: • Assess needs and capabilities of patient and caregiver • Assess factors that contribute to caregiver strain (unrealistic expectations, poor insight, inability to use resources, unsatisfactory relationship with care receiver, insufficient financial and psychosocial resources) • Develop supportive and trusting relationship with caregiver

31. Nursing Diagnosis #1 (cont) • Nursing Interventions (cont): • Enlist help of other family members or friends to assist • Teach caregiver to perform care activities in a safe, efficient, and energy-conserving manner • Teach stress-reduction techniques • Encourage caregiver to attend to own personal and health needs

32. Nursing Diagnosis #1 • Evaluation: • The caregiver: • Provides safe, supportive care to the HIV-infected patient • Acknowledges need for personal support and accesses resources in family and community • Shares frustrations about difficulty of care for significant other • Receives assistance from family members and/or professional caregivers

33. Nursing Diagnosis #2 Imbalanced nutrition: less than body requirements, r/t chronic infections and/or malabsorption, nausea/vomiting/diarrhea, fatigue, or side effects of medications as e/b 10% or greater loss of ideal body mass • Patient Goals/Expected Outcomes: • Patient’s weight will remain stable • Patient’s nutritional intake will exceed metabolic needs • Patient will regain lost weight

34. Nursing Diagnosis #2 (cont) • Nursing Intervention: • Assist with diagnosis of underlying opportunistic infections • Assess patient’s knowledge of optimal nutritional intake • Increase protein, calorie, and fat intake • Offer nutritional supplements (Carnation Instant Breakfast, Boost, Sustacal, etc.)

35. Nursing Diagnosis #2 (cont) • Nursing Intervention (cont): • Schedule procedures that are painful, stressful, or nauseating so they do not interfere with mealtimes • Eat several small meals throughout day as opposed to three larger meals • Provide referrals to dietitians, social workers, and case managers • Weigh patient daily

36. Nursing Diagnosis #2 (cont) • Evaluation: • Weight will remain stable or increase • Patient reports increased energy level • Patient able to complete ADLs • Patient experiences increase in lean muscle mass

37. Acute Interventions continuation

38. Acute Interventions • Nursing interventions for diarrhea, which is a long-term problem for HIV-infected people include: • Recommending dietary interventions • Encouraging adequate fluid intake to prevent dehydration • Instructing the patient about skin care • Managing excoriation around the perianal area • In some cases, nurse must administer antidiarrheals to help control and prevent further complications • Recommend use of incontinence products to prevent soiling of the clothes and bed linens

39. Table 56-11: Nutritional Management for HIV Infection Pg 2045

40. Dietary Recommendation • Diarrhea • Lactose-free, low-fat, low-fiber, and high-potassium foods • Constipation • High-fiber foods • Nausea and Vomiting • Low-fat foods • Candidiasis • Soft or pureed foods

41. Dietary Recommendation (cont) • Fever • High-calorie, high-protein foods • Altered Taste • Diet as tolerated • Anemia • High-iron foods • Fatigue • High-calorie foods

42. Intervention • Diarrhea • Avoid dairy products, red meat, margarine, butter, eggs, dried beans, peas, raw fruits and vegetables. Cooked or canned fruits and vegetables will provide needed vitamins. Eat potassium-rich foods such as bananas and apricot nectar. Discontinue foods, nutritional supplements, and medications that may make diarrhea worse (Ensure, antacids, stool softeners). Avoid gas-producing foods. Serve warm, not hot foods. Plan small, frequent meals. Drink plenty of fluids between meals.

43. Intervention (cont) • Constipation • Eat fruits and vegetables (beans, peas), cereal, and whole wheat breads. Gradually increase fiber. Drink plenty of fluids. Exercise. • Nausea and Vomiting • Avoid dairy products and red meat. Plan small, frequent meals. Prepare nonodorous foods. Eat dry, salty foods. Serve food cold or at room temperature. Drink liquids between meals. Avoid gas-producing, greasy, spicy foods. Eat slowly in a relaxed atmosphere. Rest after meals with head elevated. Take antiemetics 30 minutes before meals.

44. Intervention (cont) • Candidiasis • Serve moist foods. Drink plenty of fluids. Avoid acidic and spicy foods. Use straw and tilt head back and forth when drinking. To decrease discomfort, eat soft foods, such as puddings and yogurt. • Fever • Use nutritional supplements. Increase fluid intake.

45. Intervention (cont) • Altered Taste • Try herbs and spices. Marinate meat, poultry, and fish. Serve food cold or at room temperature. Drink plenty of fluids. Add salt or sugar. Introduce alternative protein sources. • Anemia • Eat organ meats and raisins. Drink orange juice when taking iron supplements to facilitate absorption.

46. Intervention (cont) • Fatigue • Cook in large quantities and freeze in meal-size packets. Use microwave and convenience foods. Use easy-to-fix snack foods. Use social support system to assist with meal planning and preparation. Access in-home homemaker services. Access community Meals on Wheels programs.

47. Acute Intervention Wasting and Lipodystrophy Syndromes

48. Wasting and Lipodystrophy Syndromes • AIDS wasting has been a common clinical manifestation of HIV disease since early in the epidemic • Wasting is due to disturbances in metabolism, which interferes with the effective use of nutrients, resulting in the loss of lean (muscle) body mass • Wasting is characterized by depletion of lean body mass, without reduction of body fat • This loss of lean body mass is a primary cause of functional decline in wasting

49. Wasting and Lipodystrophy Syndromes (cont) • Loss of lean body mass increases the risk for opportunistic infections, reduces quality of life, and reduces survival • Causes of Wasting • Most likely multifactorial • Food intake may be inadequate because of mechanical difficulties • Loss of appetite • Psychological factors such as depression and anxiety • Decreased absorption in intestines due to infections and a damaged mucosal barrier • Some patients just stops eating to decrease the number of bowel movements per day

50. Wasting and Lipodystrophy Syndromes (cont) • Wasting causes disturbances in self-concept and self image • Useful interventions for these disturbances • Creating an atmosphere of acceptance and reassurance • Encouraging a focus on past accomplishments and personal strengths • Facilitating the use of positive affirmation • Decreased levels of testosterone have been reported in 35 to 50% of HIV-infected men