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Immunodeficient Patients

Brunner Text - Chapter 50, 51, 52

Catherine Manno

on 27 January 2013

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Transcript of Immunodeficient Patients

Chapter 52

Management of Patients With
HIV Infection and AIDS Chapter 51

Management of Patients With Immunodeficiency
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 Clinical Manifestations of HIV/AIDS: GI False

A fungal infection present in almost all patients with HIV/AIDS is candidiasis, not Kaposi’s sarcoma. Answer
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 Treatment
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 Prevention Signs and symptoms of infection
Medication teaching
Prevention of infection
Avoid crowds and persons with infections
Hygiene and cleaning
Nutrition and diet
Lifestyle modifications to reduce risk
Follow-up care Patient Teaching 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 Primary Immunodeficiencies True

Autoimmune disorders are more common in females than males. Answer Is the following statement True or False?

Autoimmune disorders are more common in females than males. Question
Age and gender
Presence of conditions or disorders: cancer/neoplasm, chronic illness, autoimmune disorders, surgery/trauma
History of infection or immunization
Genetic factors
Medications and transfusions
Pyschoneuroimmunologic factors Variables That Effect Immune System Function
Agglutination of antigens
Opsonization - mark for digestion of phagocyte
Promote release of vasoactive substances; activation of complement system and phagocytosis
Act in concert with other components of the immune system
Types of immunoglobulins: IgA, IgD, IgE,IgG, and IgM Role of Antibodies Which leukocytes arrive FIRST at the inflammation site?
A. Basophils
B. Eosinophils
C. Monocytes
D. Neutrophils Question Development of Cells of the Immune System
Immunity: the body’s specific protective response to invading foreign agent or organism
Immunopathology: the study of diseases that result from dysfunction the immune system
Immune disorders
Immune deficiencies: primary and secondary The Immune System Is the following statement True or False?

Immunity refers to the body’s nonspecific protective response to an invading foreign agent or organism. Question NURS 220
Mercyhurst University North East
Catherine Manno MSN/Ed Nursing Care of Clients with Immune Suppression Including HIV B

The antiretroviral medication that when taken with a high- fat/high-caloric meal increases peak plasma concentrations of capsules is efavirenz (Sustiva). Answer What antiretroviral medication when taken with a high-fat/high-caloric meal increases peak plasma concentrations of capsules?
Delavirdine (Rescriptor)
Efavirenz (Sustiva)
Nevirapine (Viramune) Question
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
Medications as prescribed
Skin and perianal care Other Interventions
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 Decreasing Isolation
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 Nutrition
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 Maintaining Thought Processes
Maintain balance between activity and rest
Instruction regarding energy conservation techniques
Relaxation measures
Collaboration with other members of the health care team Activity Intolerance 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 Promoting Usual Bowel Pattern 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 Skin Integrity 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 Nursing Process: The Care of the Patient with HIV/AIDS—Planning

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

Impaired skin integrity
Risk for infection
Activity intolerance
Disturbed thought processes
Ineffective airway clearance
Imbalanced nutrition
Social isolation
Anticipatory grieving
Deficient knowledge Nursing Process: The Care of the Patient with HIV/AIDS- Diagnosis 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 Nursing Process: The Care of the Patient with HIV/AIDS—Assessment
HIV encephalopathy
Progressive cognitive, behavioral, and motor decline
Probably directly related to the HIV infection
Cryptococcus neoformans
Other neurologic disorders
Depression Manifestations of HIV/AIDS: Neurologic Lesions of Kaposi’s Sarcoma

Kaposi's sarcoma
Cutaneous lesions, but may involve multiple organ systems
Lesions cause discomfort, disfigurement, ulceration, and potential for infection
B-cell lymphomas Clinical Manifestations of HIV/AIDS: Oncologic 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 Clinical Manifestations of HIV/AIDS: Respiratory Kaposi’s sarcoma Is the following statement True or False?

A fungal infection present in almost all patients with HIV/AIDS is Kaposi’s sarcoma. Question
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 AIDS
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 HIV Symptomatic
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 HIV Asymptomatic
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 Primary Infection http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm
Category A, B, C Classifying HIV and AIDS
Primary infection
HIV asymptomatic
HIV symptomatic
AIDS Stages of HIV Disease Attachment
DNA synthesis
Budding HIV Life Cycle True

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

The major means of HIV transmission are unprotected sex and the sharing of injection drug use equipment. Question
Sharing infected injection equipment

Having sexual relations with infected individuals High-Risk Behaviors
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 Transmission of HIV True

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

Severe combined immunodeficiency disease (SCID) is a disorder involving a complete absence of humoral and cellular immunity resulting from an X-linked or autosomal genetic abnormality. Question 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 Nursing Management Primary
May effect phagocytic function, B cells and/or T cells, or the complement system
Related to underlying disorders, diseases, toxic substances, or medications Immunodeficiency Disorders WBC count and differential
Bone marrow biopsy
Humoral and cellular immunity tests
Phagocytic cell function test
Complement component tests
Hypersensitivity tests
Specific antigen-antibody tests
HIV infection tests Tests to Evaluate Immune Function Null cells
Destroy antigen coated with antibody
Natural killer cells
Defend against microorganisms and some malignant cells Non-T and Non-B Lymphocytes Involved in Immune Response B lymphocytes: humoral immunity
Produce antibodies or immunoglobulins
T lymphocytes: cellar immunity
Attack invaders directly, secrete cytokines, and stimulate immune system responses
Helper T cells
Cytotoxic T cells
Memory cells
Suppressor T cells (suppress immune response) Cellular Immune Response Antigen-Antibody Binding D

Neutrophils arrive first at a site where inflammation occurs. Answer
Phagocytic immune response
Humoral or antibody response
Cellular immune response Defenses 1.) Natural immunity: nonspecific response to any foreign invader
White blood cell action: release cell mediators such as histamine, bradykinin, and prostaglandins, and engulf (phagocytize) foreign substances
Inflammatory response
Physical barriers, such as intact skin, chemical barriers, and acidic gastric secretions or enzymes in tears and saliva
2.) Acquired immunity: specific against a foreign antigen
Result of prior exposure to an antigen
Active or passive Immune Function Lymphocytes: B lymphocytes mature in the bone marrow; T lymphocytes mature in the thymus, where they also differentiate into cells with various functions Central and Peripheral Lymphoid Organs False

Immunity refers to the body’s specific, not nonspecific, protective response to an invading foreign agent or organism. Answer VIDEO YouTube
http://youtu.be/z3M0vU3Dv8E Chapter 50
Assessment of Immune Function Life Cycle of HIV-1 Structure of HIV-1
*Erythrocytes (RBC) 4-6 million; oxygen-carbon dioxide transport Because of hemoglobin
*Neutrophils 3-7 thousand; active phagocytes
*Eosinophils1-4 hundred; increased during allergies
*Basophils 20-50; releases histamine, inflammation
*Lymphocyte 1500-3000; immune system
*Monocyte 100-500; phagocytes
*Leukocytes 4-11 thousand total
Cell type, #, & function
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