Auto/Immune- RA, Gout, SLE, HIV, & AIDs

• Rheumatoid Arthritis (RA)


  A connective tissue disease that is: Chronic, Inflammatory, With systemic manifestations
• Etiology of RA


  Autoimmune process attacking the synovium
• HIV Pathophysiology


  1. HIV binds to protein receptors on the outside of the CD4+ T cell

  2. HIV RNA enters the CD4+ T cell

  3. Reverse transcriptase is released

  4. RNA single strand DNA

  5. Becomes double-stranded viral DNA

  6. Integrase allows the double-stranded DNA into the host's gene structure

  7. Daughter cells become infected

  8. New HIV is made
• HIV Pathophysiology


  1. Protease enzyme causes new HIV to split into smaller pieces

  2. New HIV virions formed and released

  3. CD4+ T cell is destroyed after HIV virions released

  4. New CD4+ T cells are produced, but eventually the body cannot keep up

  5. Decrease in CD4+ T cells

  6. Immune function decreases

  7. Opportunistic diseases occur
• Stages of HIV Infection

  • Acute HIV Infection
  • Chronic HIV Infection
  • AIDS
• Acute HIV Infection


  Occurs 2-4 weeks after the person is infected with HIV; produces flu-like symptoms
• Chronic HIV Infection


  The immune system increases the CD4 count and keeps HIV under control
• AIDS


  CD4 count < 200 or when patient is diagnosed with an AIDS defining illness (e.g. Pneumocystis jirovecii pneumonia, lymphoma)
• A patient exposed to HIV approximately 3 months ago has seroconverted to an HIV positive status. The nurse anticipates that the patient will experience no signs and symptoms
• Why is HIV screening important?
• Who should be screened for HIV?

  • CDC recommends that everyone between the ages of 13 and 64 get tested for HIV at least once as part of routine health care
• Who is most at risk for HIV?

  • Men having sex with men (MSM)
  • Sexual relations with an HIV-positive partner
  • More than 1 sex partner
  • Injecting and sharing needles
  • Prostitution
  • History of hepatitis or tuberculosis
  • Those who had sex with someone who could answer yes to any of the above questions or whose sexual history is not known
• HIV/AIDS Diagnosis


  • HIV rapid Ab test (e.g. OraQuick)
  • HIV -1/2 Antigen/Antibody test (Ag/Ab) – can detect HIV infection as early as 18 days from exposure
  • HIV 1 Nucleic acid test (NAT) – detects HIV RNA as early as 10 days from exposure
  • HIV-1/HIV-2 antibody differentiation immunoassay
  • Viral load (RNA PCR) test
  • CD4 count lymphocyte count
  • HIV drug resistance testing-HLA B5701 allele test
• HIV testing is voluntary
• Obtain verbal consent prior to testing
• If HIV+, sexual partners should be notified of possible exposure
• Failure of HIV+ person to disclose HIV status to sexual partners is considered a felony in the state of Michigan
• HIV + healthcare workers can continue to work
• An HIV + diagnosis can lead to discrimination even though prohibited by federal law
• Behaviors that would be placed in the "not safe" column for preventing HIV transmission

  • Use of "natural skin" condoms
  • Abstinence
  • Mutual monogamy
• PrEP (Pre-exposure Prophylaxis)


  Recommended for those at high risk of acquiring HIV, must take daily HIV medication, risk reduction of 70-90%
• Undetectable (viral load) = Untransmittable (U=U)
• Factors impacting patient's management of medications

  • Ability to adhere must be assessed first
  • Cognitive impairment
  • Difficulty swallowing (dysphagia)
  • Polypharmacy
  • Financial issues-most health insurances cover HIV meds
  • Side effects
  • Drug-drug interactions
• Complications of HIV/AIDS


  • Opportunistic infections: Pneumocystis Pneumonia, Tuberculosis, Candida
  • Secondary cancers: Kaposi's sarcoma, Lymphomas, Cervical cancer
  • Coronary artery disease, Liver disease, HIV-associated nephropathy, AIDS dementia Complex
• A patient with AIDS has a respiratory infection from Pneumocystis carinii. Limiting fluid intake would not be considered a positive outcome criterion for the nursing diagnosis Impaired Gas Exchange
• A patient with AIDS has raised, dark purplish lesions on the trunk of the body. The nurse anticipates that a skin biopsy will be done to confirm whether these lesions are due to Kaposi's sarcoma
• Patient education - teach patient to monitor for signs & symptoms of opportunistic infections

  • weight loss
  • chronic diarrhea
  • night sweats
  • a fever
  • a persistent cough
  • mouth and skin problems (e.g. rashes, lumps)
• Patient education - encourage patient to attend routine screenings

  • General physical exam
  • Ophthalmologic exams
  • Dental exams
  • Blood tests
  • Mammograms
  • Pap smears
  • Colonoscopy
• Nursing Care of the Patient with AIDS

  • Skin integrity – assess oral mucosa for infection, assess for pressure ulcers, assist patient with turning & repositioning q2h
  • Elimination – assess frequency & consistency of stools, if patient has diarrhea, ensure adequate perineal care to prevent skin breakdown; may need to obtain stool culture if multiple episodes of diarrhea; may need anti-diarrheal med
  • Prevent infection – monitor for s&s of infection (especially for GI & respiratory symptoms), monitor WBC
  • Activity intolerance – teach patient about energy conservation techniques (e.g. wash while sitting); keep frequently used items in reach
  • Mental status – assess for abnormalities in memory, thought process, behavior – if any abnormalities, keep communication simple and calm; provide patient with same daily routine; may need 24 hr supervision
  • Respiratory status - assess for signs & symptoms of respiratory infection, teach patient to use incentive spirometer, place in semi-Flower's position
  • Analgesia – pain may be produced by perineal skin breakdown due to frequent diarrhea, Kaposi's sarcoma lesions or peripheral neuropathy
  • Decreasing isolation & enhancing coping - the patient may experience anger, guilt & shame, depression, loss of relationships; the nurse must provide an environment of acceptance
• Factors impacting the nutritional status of the HIV/AIDS patient

  • Nausea due to the disease or ART
  • Altered taste perception
  • Diarrhea (acute and chronic)
  • Fatigue
  • Kaposi's sarcoma in the GI tract
  • Oral and esophageal candidiasis
  • Depression
  • Wasting syndrome - involuntary loss >10% of body weight (especially muscle mass), plus at least 30 days of either diarrhea or weakness and fever
• An appropriate diet in patients with HIV/AIDS can improve response to treatment, reduce length of hospitalization, and improve quality of life
• General Dietary Recommendations


  • Eat a variety of foods from the 5 food groups: fruits, vegetables, grains, protein foods, and dairy
  • Eat the right amount of food to maintain a healthy weight
  • Choose foods low in saturated fat (found in animal products such as meat and dairy products), sodium (salt), and added sugars
  • Eat safely – avoid raw meat, seafood and eggs; wash fruits and vegetables thoroughly; avoid drinking water from lakes, ponds, rivers, or streams
• Dietary recommendations during ACUTE illness

  • High protein
  • Soft foods in small portions
  • Supplements (e.g. Ensure)
  • If experiencing diarrhea: avoid high fiber foods, spicy foods, most dairies and caffeine
• Dietary recommendations - teach caregiver to

  • Assist weak patient with feedings
  • Provide/assist with oral hygiene
  • Use appetite stimulants (e.g. Megace or Marinol)
  • Involve patient in meal planning