Chapter 51 Management of Patients With Immunodeficiency

1. Chapter 51Management of Patients With Immunodeficiency

2. Learning Objectives • Compare the different types of primary immunodeficiency disorders and their causes, clinical manifestations, potential complications, and treatment modalities. • Describe the nursing management of the patient with an immunodeficiency. • Identify the essential teaching needs for a patient with an immunodeficiency.

3. Primary Immunodeficiencies • Usually seen in infants and young children • Manifestations: vary according to type, severe or recurrent infections, failure to thrive or poor growth, positive family history • Potential complications: recurrent, severe, potentially fatal infections; related blood dyscrasias or malignancies • Treatment: varies by type, treatment of infection, pooled plasma or immunoglobulin, GM-CSF or GCSF, thymus graft, stem cell or bone marrow transplant

4. Immunodeficiency Disorders • Primary • Genetic • May effect phagocytic function, B cells and/or T cells, or the complement system • Secondary • Acquired • HIV/AIDS • Related to underlying disorders, diseases, toxic substances, or medications

5. Nursing Management • Monitor for signs and symtoms of infections • Note symptoms of inflammatory response may be blunted • Monitor lab values • Promote good nutrition • Address anxiety, stress, and coping • Strategies to reduce risk of infection • Handwashing and strict aseptic technique • Patient protection and hygiene measures: skin care, promote normal bowel and bladder function, pulmonary hygiene

6. Patient Teaching • Signs and symptoms of infection • Medication teaching • Prevention of infection • Handwashing • Avoid crowds and persons with infections • Hygiene and cleaning • Nutrition and diet • Lifestyle modifications to reduce risk • Follow-up care

7. Question Is the following statement True or False? Severe combined immunodeficiency disease (SCID) is an disorder involving a complete absence of humoral and cellular immunity resulting from an X-linked or autosomal genetic abnormality.

8. Answer True Severe combined immunodeficiency disease (SCID) is an disorder involving a complete absence of humoral and cellular immunity resulting from an X-linked or autosomal genetic abnormality.

9. Chapter 52Management of Patients With HIV Infection and AIDS

10. Learning Objectives • Describe the modes of transmission of HIV infection and prevention strategies. • Describe the host/HIV interaction during primary infection. • Explain the pathophysiology associated with the clinical manifestations of HIV/AIDS. • Describe the clinical management of patients with HIV/AIDS. • Discuss the nursing interventions appropriate for patients with HIV/AIDS. • Use the nursing process as a framework for care of the patient with HIV/AIDS.

11. Transmission of HIV • Transmitted by body fluids containing HIV or infected CD4 lymphocytes • Blood, seminal fluid, vaginal secretions, amniotic fluid, and breast milk • Most prenatal infections occur during delivery • Casual contact does not cause transmission • Breaks in skin or mucosa increase risk

12. High-Risk Behaviors • Sharing infected injection equipment • Having sexual relations with infected individuals

13. Question Is the following statement True or False? The major means of HIV transmission are unprotected sex and the sharing of injection drug use equipment.

14. Answer True The major means of HIV transmission are unprotected sex and the sharing of injection drug use equipment.

15. Prevention • Standard precautions • Safer sex practices and safer behaviors • Abstain from sharing sexual fluids • Reduce the number of sexual partners to one • Always use latex condoms; if allergic to latex, use non-latex condoms • Do not share drug injection equipment • Blood screening and treatment of blood products

16. HIV Life Cycle • Attachment • Uncoating • DNA synthesis • Integration • Transcription • Translation • Cleavage • Budding

17. Structure of HIV-1

18. Life Cycle of HIV-1

19. Stages of HIV Disease • Primary infection • HIV asymptomatic • HIV symptomatic • AIDS

20. Primary Infection • AKA acute HIV infection/acute HIV syndrome • Part of CDC category A • Symptoms: none to flu-like syndrome • Window period: lack of HIV antibodies • Period of rapid viral replication and dissemination through the body • Viral set point: balance between amount of HIV and the immune response

21. HIV Asymptomatic • CDC category A • More than 500 CD4+ T lymphpocytes/mm3 • Upon reaching the viral set point, chronic asymptomatic state begins • Body has sufficient immune response to defend against pathogens

22. HIV Symptomatic • CDC category B • 200–499 CD4+ lymphpocytes/mm3 • CD4 T cells gradually fall • The patient develops symptoms or conditions related to the HIV infection, which are not classified as category C conditions • Patients who are once treated for a category B condition are considered category B

23. AIDS • CDC category C • Less than 200 CD4+ lymphocytes/mm3 • As levels drop below 100 cell/mm3 the immune system is significantly impaired • Development of listed conditions

24. Treatment • Treatment and protocols are continually evolving • Antiretroviral agents • Nucleoside reverse transcriptase inhibitors (NRTIs) • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) • Protease inhibitors (PIs) • Fusion inhibitors • Use of combination therapy • Management also focuses upon the treatment of specific manifestations and conditions related to the disease

25. Question Is the following statement True or False? A fungal infection present in almost all patients with HIV/AIDS is Kaposi’s sarcoma.

26. Answer False A fungal infection present in almost all patients with HIV/AIDS is candidiasis, not Kaposi’s sarcoma.

27. Clinical Manifestations of HIV/AIDS: Respiratory • Pneumocystic carini pneumonia (PCP): • Most common infection • Initial symptoms may be nonspecific and may include nonproductive cough, fever chills, dyspnea, and chest pain • If untreated, progresses to pulmonary impairment and respiratory failure • Treatment: TMP-SMZ or pentamidine, prophylactic TMP-SMZ • Mycobacterium avium complex (MAC) • Tuberculosis

28. Clinical Manifestations of HIV/AIDS: GI • Oral candidiasis • May progress to esophagus and stomach • Treatment with Mycelex troches or nystatin, ketoconazole • Diarrhea related to HIV infection or enteric pathogens • Octretide acetate for severe chronic diarrhea • Wasting syndrome • 10% weight loss and chronic diarrhea or chronic weakness and fever with absence of other cause • Protein energy malnutrition • Anorexia, diarrhea, GI malabsorption, and lack of nutrition may contribute

29. Clinical Manifestations of HIV/AIDS: Oncologic • Kaposi's sarcoma • Cutaneous lesions, but may involve multiple organ systems • Lesions cause discomfort, disfigurement, ulceration, and potential for infection • B-cell lymphomas

30. Lesions of Kaposi’s Sarcoma

31. Manifestations of HIV/AIDS: Neurologic • HIV encephalopathy • Progressive cognitive, behavioral, and motor decline • Probably directly related to the HIV infection • Cryptococcus neoformans • Other neurologic disorders • Depression

32. Nursing Process: The Care of the Patient with HIV/AIDS—Assessment • Assess physical and psychosocial status • Identify potential risk factors: IV drug abuse, risky sexual practices • Immune system function • Nutritional status • Skin integrity • Respiratory status neurologic status • Fluid and electrolyte balance • Knowledge level

33. Nursing Process: The Care of the Patient with HIV/AIDS- Diagnosis • Impaired skin integrity • Diarrhea • Risk for infection • Activity intolerance • Disturbed thought processes • Ineffective airway clearance • Pain • Imbalanced nutrition • Social isolation • Anticipatory grieving • Deficient knowledge

34. Collaborative Problems/Potential Complications • Opportunistic infections • Impaired breathing or respiratory failure • Wasting syndrome • Fluid and electrolyte imbalance • Adverse reaction to medication

35. Nursing Process: The Care of the Patient with HIV/AIDS—Planning • Goals may include: • Achievement and maintenance of skin integrity • Resumption of usual bowel patterns • Absence of infection • Improved activity tolerance • Improved thought processes • Improved airway clearance • Increased comfort, improved nutritional status • Increased socialization • Expression of grief • Increased knowledge regarding disease prevention and self-care • Absence of complications

36. Skin Integrity • Frequent routine assessment of skin and mucosa • Encourage patient to maintain balance between rest and activity • Reposition at least every 2 hours and as needed • Pressure reduction devices • Instruct patient to avoid scratching • Use gentle, nondrying soaps or cleansers • Avoid adhesive tape • Perianal skin care

37. Promoting Usual Bowel Pattern • Assess bowel pattern and factors that may exacerbate diarrhea • Avoid foods that act as bowel irritants, such as raw fruits and vegetables, carbonated beverages, spicy foods, and foods of extreme temperatures • Small, frequent meals • Administer medications as prescribed • Assess and promote self-care strategies to control diarrhea

38. Activity Intolerance • Maintain balance between activity and rest • Instruction regarding energy conservation techniques • Relaxation measures • Collaboration with other members of the health care team

39. Maintaining Thought Processes • Assess mental and neurologic status • Use clear, simple language if mental status is altered • Establish and maintain a daily routine • Orientation techniques • Ensure patient safety and protect from injury • Strategies to maintain and improve functional ability • Instruct and involve family in communication and care

40. Nutrition • Monitor weight, I&O, dietary intake, and factors that interfere with nutrition • Dietary consult • Control of nausea with antiemetics • Oral hygiene • Treatment of oral discomfort • Dietary supplements • May require enteral feedings or parenteral nutrition

41. Decreasing Isolation • Promote an atmosphere of acceptance and understanding • Assess social interactions and monitor behaviors • Allow patient to express feelings • Address psychosocial issues • Provide information related to the spread of infection • Educate ancillary personnel, family, and partners

42. Other Interventions • Improving airway clearance • Position in semi-Fowler's or high Fowler’s • Pulmonary therapy; coughing and deep breathing, postural drainage, percussion, and vibration • Ensure adequate rest • Pain • Medications as prescribed • Skin and perianal care

43. Question What antiretroviral medication when taken with a high-fat/high-caloric meal increases peak plasma concentrations of capsules? • Delavirdine (Rescriptor) • Efavirenz (Sustiva) • Nevirapine (Viramune)

44. Answer B The antiretroviral medication that when taken with a high- fat/high-caloric meal increases peak plasma concentrations of capsules is efavirenz (Sustiva).

45. Chapter 54Management of Patients With Autoimmune Disorders • Rheumatoid Arthritis • Lupus • Scleroderma

46. Learning Objectives • Explain the pathophysiology of selected autoimmune disorders (diffuse connective tissue disease). • Describe the assessment and diagnostic findings that may be seen in patients with a suspected diagnosis of diffuse connective tissue disease. • Discuss appropriate nursing interventions based on nursing diagnoses and collaborative problems that commonly occur with diffuse connective tissue disease. • Describe the systemic effects of a diffuse connective tissue disease. • Identify modifications in interventions to accommodate changes in patients’ functional ability that may occur with disease progression.

47. Question Is the following statement True or False? Diarthrodial is bleeding into a joint.

48. Answer False Diarthrodial is a joint with two freely movable parts. Hemarthrosis is bleeding into a joint.

49. Diffuse Connective Tissue Diseases • A group of chronic disorders characterized by diffuse inflammation and degeneration in the connective tissue • Cause is unknown but thought to have an immunologic basis • Characterized by a clinical course of exacerbations and remissions • Includes SLE, scleroderma, polymyositis, and polymyalgiarheumatica

50. Rheumatoid Arthritis • More than 100 different disorders • Affect primary the joints, but also muscles, bone, ligament, tendons, cartilage • Classification: • Monoarticular or polyarticular • Inflammatory or noninflammatory