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71 Cards in this Set

  • Front
  • Back
Immune System Basics
*Function of the Immune System:
-Defense-against microorganisms, prevents infection by destroying them
-Surveillance-protection from internal invaders, i.e., malignant cells
-Homeostasis-provides the body with clean up operations (removes dead and damaged cells-mutations)
Major Features of the Immune System
*Specificity: able to discriminate various antigens or other invaders
*Diversity: has extensive number of receptors to recognize invaders
*Memory-able to mount long lasting reactions to antigens
*Self-vs-self recognition-autoimmune disease occurs if this breaks down (body attacks own tissues)
General Primary (Central) Lymphoid Organs
*Thymus: central lymphoid organ in mediastinal area above heart, responsible for differentiation and maturation of T-lymphocytes
*Bone Marrow: undifferentiated stem cells originate here and mature before entering circulation
Peripheral (Secondary) Lymphoid Organs
*Lymph nodes: part of lymphatic system, filters foreign particles, ex. bacteria
*Spleen: largest single collection of lymphocytes, largest filter of foreign tissue
*Liver: filters foreign tissue from blood
*Tonsils: lymphoid tissue
*Peyer's Patches: lymphoid tissue that lines wall of ileum, has macrophages
-Innate (inborn) genetic factors
1. Active (own antibodies)
-Natural (exposure to infectious agent)
-Artificial (immunization)
2. Passive (ready-made antibodies)
-Natural (maternal antibodies)
-Artificial (antibodies from other sources)
Location of lymph nodes and lymph organs
Tonsils and adenoids
Lymph nodes
Peyer's Patches
Bone Marrow
Types of Immunity
*Humoral: B-lymphocyte mediated, responsible for antibody (immuneglobulin) production antibody-mediated immunity.
*Antibodies, dissolved in blood, lymph, and other body fluids bind the antigen and trigger a response to it. (This form of immunity is also called humoral immunity.)
Types of Immunity
*Cell-mediated immunity (CMI) T cells (lymphocytes) bind to the surface of other cells that display the antigen and trigger a response. The response may involve
*other lymphocytes and
*any of the other white blood cells (leukocytes)
Disorders of the Immune System
*Immunodeficiency disorders: incompetent immune system: SCIDS (severe combined immunodeficiency syndrome no T cells or B lymphocytes), AIDS
*Hypersensitivity disorders: allergic reaction, anaphylaxis
*Autoimmune disorders: body doesn't recognize self as self -rheumatoid arthritis, MS, Lupus, diabetes
Introduction to HIV/AIDS
*Human Immunodeficiency Virus (HIV)
*Discovered in 1983
*No longer considered a death sentence but a chronic disease
-Communicable via blood and body fluids: cerebral spinal fluid, semen, vaginal secretions and breast milk
-Will eventually lead to AIDS
-Occurs as HIV1 (95% of US cases)
-HIV2 (most prevalent in West Africa)
Incidence and Epidemiology
*21st Century Plague - since 1981 worldwide: 58 million people infected with 22 million dying from AIDS
*A disease of disenfranchised by gender, race, sexual orientation, poverty and access to health care
*2005 - 1 million infected in US
Adults and children estimated to be living with HIV/AIDS as of end 2003
Total: 34-46 million
The most common methods of transmission of HIV are:
-Unprotected sex with an infected partner
-Sharing needles with infected person
Almost eliminated as risk factors for HIV transmission are:
-Transmission from infected mother to fetus
-Infection from blood products (in the US 1 in 12,000,000)
Methods of Transmission
*Sexual transmission - most common
*Blood and blood products - needle sticks, IV drug abuse, potentially transmitted via transfusion
*Pregnancy and delivery
*Breast milk
Factors that Effect Transmission
*Viral load
*Susceptible Host (ex: Hep B or C)
*Virulence of the virus
*Concentration of the virus (viral load)
*Frequency of contact
*Volume of fluid
*Depth of wound
*.3-.4% risk for health care workers
*Extremely fragile virus - hard to keep alive
*Probability of infection is based on:
-concentration and strain of virus
-amount of fluid transmitted
-duration and frequency of exposure as well as host immune system
Risk Factors: Sexual Practices
*Unprotected Sex (most common mode of transmission)
*Multiple partners
*Anal and oral sexual activities
*Improper condom use/breakage
*Open sores, lesions, infections in genital area
Risk Factors: Contaminated Blood and Blood Products
*Minute possibility in US for transfusion related transmission-all blood and blood products screened
*Only 20% of world's blood screened
*Health care workers
*Correctional officers and law enforcement personnel
*IV drug abuse, sharing of syringes and drug equipment
Risk Factors: Pregnancy and Breast Feeding
*Approximately 120,000 to 160,000 women living in US with HIV infection
*6,000 to 7,000 infected women give birth each year in US
*600,000 babies contract HIV worldwide each year
*Breastfeeding not advised
Pathophysiology of HIV
*Classified as retrovirus, can't make copies of itself on its' own
*Must invade healthy T cell (CD4) in host
*Has a special chemical to allow entrance into CD4 cell
*Releases enzyme reverse transcriptase to convert HIV RNA to DNA
*Inside cell nucleus the DNA replicates the HIV virus using protease
*New copies of virus formed, cell dies
*Up to 10 billion HIV particles produced daily
*Over 2 billion new CD4 cells needed to keep up, not possible for body to do
*Inside CD4, HIV uses 3 enzymes to replicate itself:
-Reverse transcriptase
*Treatment based on interfering with enzyme activity, thus preventing replication
-All daughter cells from infected cell are infected
-Genetic codes can direct the cell to make HIV
Nursing Management
Nursing Assessment
*For persons at risk, ask
-Have you had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person?
-Have you ever had a sexually transmitted disease (STD)?
-Have you ever shared (equipment) needles with anyone?
Diagnostic Tests for HIV
*ELISA (Enzyme-linked immunosorbent assay) most common, confirms presence of HIV antibodies
*Western Blot can identify 1 protein in a mixture of many proteins (looks at antibody classes) more specific
*IFA (Immunofluorescence Assay) tests for p17 and p24 antigen found on HIV (looks at infected cells)
Newer Diagnostic Tests
*Ora-Sure - Saliva test, approved March, 2004
*Mouth is swabbed, if turns red = positive (confirmed by blood test)
*Home access test - FDA approved, but sample must be sent back to company
Diagnostic Testing for HIV
*Both ELISA and Western Blot depend on antibody formation
*About 90% of people exposed to HIV will develop antibodies in 6 weeks to 3 months following exposure; it may be as long as 6 months to 1 year
*IFA tests for specific protein
"Window period"" 6 wks to 1 year HIV infected but have not developed antibodies yet
Spectrum of HIV Infection
*Viral transmission with Primary HIV infection
*Seroconversion with antibodies
*Asymptomatic chronic infection
*Symptomatic HIV infection
*AIDS - based on CDC definition
*Advanced HIV disease CD4 <50
Spectrum of HIV Infection
*ACUTE INFECTION: process of seroconversion (often mistaken for mononucleosis) "flu-like" symptoms acute retroviral syndrome
*May last days to months
*Known as the "WINDOW" period, infectious without antibodies until seroconversion takes place
*Occurs 1-3 weeks post exposure (high viral load in blood)
Spectrum of HIV Infection
*Majority of those exposed develop antibodies within 3 months
*May take up to a year in small percentage of people
*Body produces antibodies to the HIV virus
Spectrum of HIV Infection
*EARLY CHRONIC INFECTION: May last up to 10 years "asymptomatic disease"
*None to minimal symptoms: fatigue, anemia, night sweats, persistent generalized lymphadenopathy
*CD4 counts remain above 500 cells/mm (persistent level)
Spectrum of HIV Infection
*INTERMEDIATE CHRONIC INFECTION: More severe symptoms, CD4 count drop to 200-500 cells/mm
*Viral load increases
*More evidence of disease progression with opportunistic diseases: Kaposi's Sarcoma (KS), candida (thrush), shingles, hairy leukoplakia (raised white lesions on tongue)
Spectrum of HIV Infection
*LATE CHRONIC INFECTION (AIDS): Diagnosis of AIDS not made until CDC criteria met
*CD4 count declines <200 cells/mm
*Presence of Ol's wasting syndrome with >10% weight loss
*Malignancies and dementia common
Spectrum of HIV Infection
*Overwhelming opportunistic infections and diseases that resist treatment
*Period preceding death from AIDS (weeks to months)
*CDC classification for AIDS diagnosis:
1. CD4 count <200
2. Presence of Opportunistic Infection
3. Development of opportunistic cancers
A. Invasive cervical cancer (HPV)
B. Kaposi's sarcoma (KS)
C. Burkitt's lymphoma
4. Wasting Syndrome
5. dementia
Opportunistic Infections and Diseases
*FUNGAL: candidiasis of respiratory tract, Pneumocystis carinii pneumonia (PCP)-treated with bactrim
*VIRAL: cytomegalovirus (CMV) retinitis - loss of vision, herpes simplex - chronic
*PROTOZOAL: toxoplasmosis of the brain
*BACTERIAL: Mycobacterium tuberculosis, Salmonella septicemia
Opportunistic Infections and Diseases
-AIDS associated lymphomas
-Invasive cervical cancer
-Kaposi's sarcoma
Clinical Manifestations of HIV
*Chills and fever
*Night sweats
*Productive cough
*Stiff neck
*Persistant vaginal candida
*Oral candida
*Oral lesions
*Abdominal pain
*Weight loss
*Skin rash
Effects on Body Systems
*Often first manifestation of HIV infection
*TB in HIV infection global problem
*Pneumocystis carinii pneumonia (PCP) common Ol
*Has both prophylaxis and treatment: Trimethoprin-sulfamethoxazole (Bactrim)
Effects on Body Systems
*Cryptosporidium (parasite) most widely recognized pathogen in AIDS infection
*Causes massive diarrhea (dehydration)
*Candida may be first sign of suppressed immune system, can affect entire GI tract mouth to anus
Effects on Body Systems
*HIV crosses blood-brain barrier
*Can cause encephalopathy with loss of cognitive and motor function
*Peripheral neuropathy is common
*CNS lymphoma-resistant to treatment (brain tumor associated with impending death)
*AIDS Dementia Complex (ADC) confussion, agitation whole spectrum of mental status changes
Effects on Body Systems
*Kaposi's sarcoma - common in men, aggressive in HIV disease (lungs, oral mucosa, entire GI tract)
*Herpes zoster-resistant to treatment
*Rashes - seborrheic dermatitis psoriasis
Effects on Body Systems
*Anemia, thrombocytopenia and neutropenia due to decreased blood production and increased lymphocyte destruction
*Body not able to keep up with losses
*Medications can be immunosuppressive
Effects on Body Systems
*Vaginal candida may be first sign of HIV disease in women
*Human papilloma virus (HPV)
*Cervical dysplasia
*Cervical cancer
Effects on Body Systems
*CARDIOVASCULAR - OI of pericardium (OI = opportunistic infection)
*MUSCULOSKELETAL - arthralgias, weakness
*RENAL - renal failure
*ENDOCRINE - risk of diabetes with HIV medications (antiviral drugs)
*SENSORY - CMV retinitis, neuropathies
Determining Immune Damage
*CD4 and T cell counts are measured to determine extent of immune damage
*Viral load determines "viral burden" or amount of virus particles per mL of blood
*Both should be measured at diagnosis and routinely after - depends on client and treatment
Management of HIV/AIDS
*There is no cure for AIDS
*Current medical management is:
-Treating/preventing infections
-Treating malignancies
-Administration of medications that block or inhibit replication
HAART (Highly Active Antiretroviral Therapy)
*1. HIV fusion inhibitors (inhibit HIV from binding on CD4 cell)
*2. Reverse transcriptase inhibitors
-Nucleoside reverse transcriptase inhibitors (NRTI)
-Non-nucleoside reverse transcriptase inhibitors (NNRTI) (prevent RNA-DNA conversion
*3. Protease inhibitors
Examples of HAART
*NRTI: Zidovudine (AZT), Stavudine (Zerit)
*NNRT: Efavirenz (Sustiva), Nevirapine (Viramune)
*Fusion Inhibitor: Enfuvirtide (Fuzeon) (BID Subcutaneous very expensive)
Goals of Antiretroviral Therapy
*Maximal HIV suppression
*Undetectable viral load (<50 copies)
*Effective combination therapy (3 agents)
*Select tolerable regimen
*Individualize treatment
*Educate client
*Assure adherence
*Consider viral genotyping
*Prevent development of viral resistance
*Maintain or raise CD4 T cell counts to >200
*Reduce HIV related morbidity & mortality
*Improve quality of life
Assuring HAART Compliance
*Probably most difficult aspect of HAART therapy (30,40,50,60 drugs/day)
*Missed dose(s) lead to viral replication and resistance
*Eventually no adequate treatment left due to multi-drug resistance
Assuring HAART Effectiveness
*3 classes of antiretrovirals used
*May be as many as 60 pills per day
*Must be taken at specific times, with and without food
*Prescribed at full strength
*Potentially lethal side effects when combined with OTC and herbal therapy
Complications and Long-term Effects of HAART
*Lipodystrophy and lipoatrophy
*Development of Type II Diabetes (protease inhibitors)
*Osteonecrosis and osteoporosis
*Hepatic Steatosis
*Lactic Acidosis
Lipodystrophy and Lipoatrophy (Loss of facial fat tissue)
*Complication of long term HAART
*Affects Caucasian men over 40 who had HIV infection >7 years
*Affects those with higher viral load
*AZT (NRTI) and protease inhibitors are implicated
*Cause still not known, just suspected
Diabetes Mellitus
*HAART in HIV positive population raises risk of diabetes by nearly 2-3 times over non HIV infected males
*No single drug implicated, cause not known
*HAART therapy changes glucose metabolism, raises blood sugars
*Elevated cholesterol and triglycerides increase risk of heart attack, stroke and PVD
*More HIV infected clients dying from side effects of medications - rather than from AIDS
*High rate of virus mutation with drug resistance
*The earlier resistance occurs, the more likely treatment will fail
*Resistance is one reason it's important to continue developing new drugs
*Research to develop a vaccine against resistance
Complications, continued
*Osteonecrosis and osteoporosis
*Hepatic Steotosis
Evaluation of Treatment
*Measure viral load-goal is for undetectable level-client still infectious <50 copies
*Measure CD4 count
*Monitor CBC, LFT's, amylase, lipids, cholesterol and glucose
Deciding to Treat or Not
*Cost: up to $12,000/year in MA
*Pill burden and adherence
*End of life issues
*Planned pregnancies
*Aging issues
*Substance abuse issues
HIV Disease Stages and CD4 Count
CD4 CELL/mm = 750-1000
CD4 CELL/mm = 500-750
CD4 CELL/mm = <500
CD4 CELL/mm = <200 = AIDS
CD4 CELL/mm = <50
Nursing Diagnosis
**See Handout**
Nursing Interventions
*Smoking education
*Teach relaxation and stress reduction
*Encourage routine exercise
*Nutritional education
*Infection control guidelines
*Avoid all animal droppings/cat litter, etc.
*Teach safe/safer sex
Health Promotion
*Prevention of HIV
-Decreasing risks related to:
Sexual intercourse
Drug use
Perinatal transmission
Health Promotion
*Prevention of HIV
-Decreasing risks related to sexual intercourse
Health Promotion
*Prevention of HIV
-Decreasing risks related to sexual intercourse
*Use barriers (e.g., condoms) when engaging in insertive sexual activity
Health Promotion
*Prevention of HIV
-Decreasing risks related to drug use
*Do not use drugs
*Do not share equipment
*Do not have sexual intercourse when under the influence of any drug (including alcohol) that impairs decision making ability
Health Promotion
*Prevention of HIV
-Decreasing risks related to perinatal transmission
*Prevent HIV infection in women
*Treat HIV pregnant women with zidovudine (ZDV, AZT, Retrovir)
*Combination ART for the mother's HIV infection can decrease transmission to fetus to less than 2%
*Viral load >1000 = C Section
Health Promotion
*Prevention of HIV
-Decreasing risks related to work
*Greatest risk is through puncture wounds
*Splash exposure of blood on skin with open lesion present some risk, though much lower than puncture
*Exposure to HIV-infected fluids require post-exposure prophylaxis with combination ART (2-3 drugs for 4 weeks - trying to prevent seroconversion)
Current Trends
*CDC will soon recommend every American aged 13-64 to have HIV testing as part of routine exam
*? Vaccine to prevent or slow progression of HIV within a decade (Dr. Tony Fauci, NIH)
*Darunavir - accelerated approval by FDA as a new protease inhibitor for clients with resistance to other protease inhibitors