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Pathophysiology of HIV

• HIV is a ribonucleic acid virus
  • Called retroviruses because they replicate in a “backward” manner going from RNA to DNA
  • CD4+T cell is the target cell for HIV
    • Type of lymphocyte
    • HIV binds to the cell through fusion
• Immune problems start when CD4+ T cell counts drop to < 500 cells/μL
  • Severe problems develop when < 200 CD4+ T cells/μL
  • Normal range is 800 to 1200 cells/μL
• Insufficient immune response allows for opportunistic diseases

Clinical Manifestations and complications

• Acute Infection
  • Flulike symptoms
  • Fever, swollen lymph nodes, sore throat, headache, malaise, nausea, muscle and joint pain, diarrhea, or a diffuse rash
  • Occurs about 2 to 4 weeks after infection
  • Highly infectious
• Asymptomatic Infection
  • Left untreated, a diagnosis of AIDS is made about 10 years after initial HIV infection
  • Symptoms are generally absent or vague
  • High risk behaviors may continue
• Symptomatic Infection
  • CD4+ T cells decline closer to 200 cells/μL
  • Symptoms become worse
  • HIV advances to a more active stage
  • Oral thrush
    • One of the more common infections associated with symptomatic infection is oropharyngeal candidiasis (thrush).
    • Candida organisms rarely cause problems in healthy adults, but are more common in HIV-infected people.
  • Shingles
  • Persistent vaginal candidal infections
  • Herpes
  • Bacterial infections
  • Kaposi Sarcoma
    • Malignant vascular lesions such as Kaposi sarcoma lesions can appear anywhere on the skin surface or on internal organs.
    • Kaposi sarcoma is caused by human herpes virus VIII.
    • Lesions vary in size from pinpoint to very large and may appear in a variety of shades.
  • Oral hairy leukoplakia
    • Epstein-Barr virus infection that causes painless, white, raised lesions on the lateral aspect of the tongue, can occur at this phase of the infection and is another indicator of disease progression

Human Immunodeficiency Virus Infection

• Retrovirus that causes immunosuppression making persons more susceptible to infections
  • More than 1 million currently living with HIV
  • About 50,000 new infections occur in United States each year
  • Effective treatment has led to a significant drop in death rates

Transmission of HIV

• HIV can be transmitted through contact with certain body fluids
  • Blood, semen, vaginal secretions, and breast milk
  • HIV is not spread through casual contact
• Sexual Transmission
  • Unprotected sex with an HIV-infected partner is most common mode of transmission
  • Greatest risk is for partner who receives semen
    • Prolonged contact with infected fluids
    • Women at higher risk
    • Trauma increases likelihood of transmission
• Contact with blood
  • Sharing drug-using paraphernalia is highly risky
  • Screening measures have improved blood supply safety
  • Puncture wounds are most common means of work-related HIV transmission
• Perinatal transmission
  • Can occur during pregnancy, delivery, or breastfeeding
  • An average of 25% of infants born to women with untreated HIV will contract the infection
  • Treatment can reduce rate of transmission to less than 2%

Wound Classification

• Wounds are classified according to
  • Cause
    • Surgical or nonsurgical
    • Acute or chronic
  • Depth of tissue affected
    • Superficial, partial thickness, full thickness

Nursing Assessment

• Assess on admission and on a regular basis
• Identify factors that may delay healing

Nursing Implementation

• Purposes of wound management
  • Protecting a clean wound
  • Cleaning a wound
  • Treating infection
• Clean wound
  • Clean wounds that are granulating and re-epithelializing should be kept slightly moist and protected
  • Dryness is an enemy of wound healing
  • Topical antimicrobials and antibactericidals used with caution
  • Transparent film may be used
• Contaminated wound
  • Debridement may be necessary
  • Absorption or hydrocolloid dressing may be used
• Negative-pressure wound therapy (NPWT)
  • Suction removes drainage and speeds healing
  • Monitor serum protein levels, fluid and electrolyte balance, and coagulation studies
• Hyperbaric O2 therapy (HBOT)
  • Delivery of O2 at increased atmospheric pressure
  • Allows O2 to diffuse into serum
  • Last 90 to 120 minutes, with 10 to 60 treatments
• Drug  Therapy
  • Becaplermin (Regranex)
• Nutritional Therapy
  • Diet high in protein, carbohydrates, and vitamins with moderate fat
• Infection prevention
  • Do not touch recently injured area
  • Culture may be ordered
  • Keep environment free from possibly contaminated items
  • Antibiotics may be given prophylactically
• Psychologic implications
  • Fear of scar or disfigurement
  • Drainage or odor concerns
  • Be aware of your facial expressions while changing dressing

Patient teaching

• Teach signs and symptoms of infection
• Note changes in wound color or amount of drainage
• Provide medication teaching

Wound and Healing process

• A wound is a break or opening into the skin
  • Often occur because of accidents or injury
  • Range from minor scrapes to deep wounds involving bones, blood vessels, and nerves
• Regeneration
  • Replacement of lost cells and tissues with cells of same type
• Repair
  • Healing as a result of lost cells being replaced with connective tissue
  • More common than regeneration
  • More complex than regeneration
  • Occurs by primary, secondary, or tertiary intention

Repair

Primary intention

• Includes 3 phases
  • Initial phase
    • Lasts 3 to 5 days
    • Edges of incision are aligned
    • Blood fills the incision area, which forms matrix for WBC migration
    • Acute inflammatory reaction occurs
  • Granulation phase
    • Fibroblasts migrate into site and secrete collagen
    • Wound is pink and vascular
    • Surface epithelium begins to regenerate
  • Maturation phase and scar contraction
    • Begins 7 days after injury and continues for several months/years
    • Fibroblasts disappear as wound becomes stronger
    • Mature scar forms

Secondary intention

• Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss
• Edges cannot be approximated
• Results in more debris, cells, and exudate

Tertiary intention

• Delayed primary intention due to delayed suturing of the wound
• Occurs when a contaminated wound is left open and sutured closed after the infection is controlled

Nursing Implementation

• Health promotion
  • Prevention is the best treatment for pressure ulcers
    • Identification of patients at risk for developing pressure ulcers
    • Implementation of pressure ulcer prevention strategies for those who are at risk.
    • Teach the patient about the etiology of pressure ulcers, prevention techniques, early signs, nutritional support, and care techniques for actual pressure ulcers.
  • Remove excessive moisture
  • Avoid massage over bony prominences
  • Use lift sheets
  • Skin care
    • Position with pillows or elbow and heel protectors
    • Use specialty beds
    • Cleanse skin if incontinence occurs
      • Use pads or briefs that are absorbent
  • Ulcer care
    • Document and describe stage, size, location, exudate, infection, pain, and tissue appearance
      • Measure length and width
      • Measure depth
    • Relieve pressure
    • Debride
    • Cleanse with nontoxic solutions
    • Caloric intake elevated to 30 to 35 cal/kg/day or
      1.25 to 1.50 g protein/kg/day
      • Supplements, enteral, or parenteral feedings may be necessary
• Acute care
  • Care of a patient with a pressure ulcer requires local care of the wound and support measures of the whole person, like:-
    • Adequate nutrition
    • Pain management
    • Control of other medical conditions
    • Pressure relief
  • Initiate interventions based on the ulcer characteristics (e.g., stage, size, location, amount of exudate, type of wound, presence of infection or pain) and the patient’s general status (e.g., nutritional state, age, cardiovascular status, level of mobility).
  • Carefully document the size of the pressure ulcer
    • Wound-measuring card or tape (length and width)
    • Sterile cotton-tipped applicator (depth)

Evaluation

• Healing of pressure ulcer
• Intact skin with no further breakdown

Contributing factors

• Amount of pressure (intensity)
• Length of time pressure is exerted (duration)
• Ability of tissue to tolerate externally applied pressure
• Shearing force: Pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement
• Moisture:  Excessive increases risk for skin breakdown

Types of ulcers stages/categories

Nonblanchable erythema

Intact skin with nonblanchable redness of a localized area usually over a bony prominence

The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

Partial thickness

Loss of dermis

Shallow open ulcer with a red-pink wound bed, without slough (looks like a serosanguinous- filled blister)

Full-thickness skin loss

Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed

Include undermining and tunneling

Depth ulcer varies by location

Full-thickness tissue loss

Exposed bone, tendon, or muscle that are visible or directly palpable, and includes undermining and tunneling

Can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur

Other stages

Suspected deep tissue injury

Unknown depth

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

May be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

Clinical manifestation

Signs

Leukocytosis

Fever

Increased ulcer size, odor, or drainage

Necrotic tissue

Indurated, warm, painful

Complications

Most common and keeps recurring

Cellulitis

Chronic infection

Osteomyelitis

Possible death