HIV & AIDS Hepatitis Herpes Virus Influenza Chapter 36
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Demographics World-wide in 2006: 65 Million people living with
HIV/AIDS U.S.: 1.1 Million cases to date: 40,000 new cases each
year 2 nd leading cause of death among 25-44 y.o.s 1/5 unaware of
being infected African Am. 7 X more likely to be infected. CDC 2009
Pharmacology for Nurses 3 rd Ed. 2011 2
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Landscape World-wide demand to continue the development of new
antiviral drugs HIV Transmission: exposed to contaminated body
fluids (blood, vaginal/ seminal), sharps & needle punctures,
splash to broken skin/mucus membrane. Newborns can be infected
during pregnancy, birthing or from brest milk. 3
Slide 4
HIV Disease Landscape Causes a gradual destruction of host
immune system, uniformly fatal when untreated, demands continuous
supply of medications for survival. Rapid rebound of virus if meds
are stopped Rapid mutation requires novel approaches of treatment
Pharmacology for Nurses 3 rd Ed. 2011 4
Slide 5
Pharmacotherapy: Highly Active AntiRetroviral Therapy (HAART)
Goal: Lower Viral Load (HIV RNA assay) to undetectable levels or
below 50 copies/ml Goal: Maintain CD4 counts >500 cells/ml Goal:
Begin HAART if CD4 Count
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HAART Continued Goal: Maintain or increase Quality of Life
Goal: Decrease Transmission from Mother to Fetus/New Born 6
Slide 7
HAART Profile Each Drug Class disrupts a specific phase of the
HIV cell replication cycle Multiple Drug Regimen to reduce drug
resistance HAART Drugs are specific to HIV Treatment is for
remainder of the clients life 7
Slide 8
HAART Profile Continued Rapid mutation of HIV can make HAART
ineffective. HAART can damage the host cell while seeking to kill
the intracellular virus or parasite. 70% decline in death rate in
U.S. since HAART was instituted. Pharmacology for Nurses 3 rd Ed.
2011 8
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Case Study Mr. S. is a 56 y.o. male recently admitted to the
Medical/Surgical Unit for Left Total Knee Replacement (Lt TKR). He
has a history of Coronary Artery Disease, Peptic Ulcer Disease, and
smoking. He is HIV+. 9
Slide 10
Case Study Conted He had his surgery yesterday (2nd day post
op) and is resuming his HIV medications: Zidovudine, Tenofovir
& Kaletra. Todays lab results: WBCs 4.5, Hemoglobin 11,
Hematocrit 30, Platelets 45,000, Na+ 135, K+ 4.5. 10
Slide 11
Drug Classifications: 1) Nucleoside & Nucleotide Reverse
Transcriptase Inhibitors (NRTI/NtRTI) 1) Zidovudine (Retrovir, AZT)
(NRTI prototype drug) 100mg PO Q4H on empty stomach Used in
combination with other HAART Medications to be effective due to
widespread resistance 2) Tenofovir (Viread) 300 mg PO daily 11
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Adverse Effects Common: Fatigue, generalized weakness, myalgia,
n/v/, headache, abdominal pain, anorexia, rash. Serious: bone
marrow suppression, neutropenia, anemia, granulocytopenia, lactic
acidosis, steatorrhea, neurotoxicity. Contraindications:
Hypersensitivity. Use cautiously in patients with pre-existing
anemia or neutropenia 12
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NRTIs: How do they work? NRTIs resemble human nucleosides, the
building blocks of DNA. The HIV virus incorporates the medications,
which are nonfunctioning units, into its DNA chain, stopping HIV
synthesis. This action prevents the HIV virus from inserting itself
into the human chromosome. Note: High degree of Cross-Resistance
among NRTIs 13
Slide 14
NtRTIs: How do they work? NtRTIs method of action disrupts the
transcriptase enzyme of the HIV virus, thus stopping viral
replication. Nursing 2008 Drug Handbook Pharmacology for Nurses 3
rd Ed. 2011 Davis Drug Guide 2011 14
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Lopinavir/ritonavir (Kaletra) Protease Inhibitor (Prototype
drug): 400mg/100mg PO BID with food or after meals (ritonavir
prevents hepatic breakdown of lopinavir, increasing its blood level
and half-life). 15
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Protease Inhibitors (PIs) Block the viral enzyme Protease,
which is responsible for the final assembly or cleavage of the HIV
polyprotein, keeping the HIV virion noninfectious. 16
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Lopinavir/ritonavir (Kaletra) Common Adverse Effects: Nausea,
vomiting, diarrhea, abdominal pain, headache, dyspepsia. Serious
Adverse Effects: Anemia, leukopenia, Deep Vein Thrombosis,
pancreatitis, lymphadenopathy, hemorrhagic colitis, hyperglycemia,
lipodystrophy. Cautious Use: Hepatic Impairment, Diabetes.
Pharmacology for Nurses 3 rd Ed. 2011 Prentice Hall Nurses Drug
Guide 2009 17
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Tulane University 18
Slide 19
Mr. S. Prior to providing routine 9 AM oral medications and
breakfast, the nurse administers Odansetron (Zofran), 4mg IV to
help prevent nausea and vomiting, a common side effect of HAART.
The nurse begins evaluating the level of understanding Mr. S. and
his significant other has regarding goals and expected outcomes,
potential and actual nursing diagnosis, and their implementations
(interventions and rationales). 19
Slide 20
Mr. S. Mr. S. states he would like to spend some quiet time
with his partner at this time and asks the nurse if it would be
alright to talk about his disease and drug therapy later today. The
nurse reply's certainly that it is quite alright and she will come
back this afternoon to talk. Mr. S. tolerated his medications and
his breakfast well. 20
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Quality and Safety Education for Nurses (QSEN) QSEN Competency:
Patient-centered Care. Recognize the patient or designee as the
source of control and full partner in providing compassionate and
coordinated care based on respect for the patients preferences,
values, and needs. 21
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QSEN Continued Knowledge: Integrate understanding of multiple
dimensions of patient-centered care: education, physical and
emotional support, involvement of family and friends. Skills:
Elicit pt. values, preferences and needs when implementing and
evaluating outcomes of care. Attitudes: Respect and encourage pt.s
/ significant others expression of needs, preferences, values.
Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007. 22
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Actual/Potential Nursing Diagnosis: Infection Risk for Falls /
Risk of Injury Activity Intolerance / Fatigue Pain / Anxiety /
Insomnia Imbalanced Nutrition, Less than Body Requirements
Deficient Fluid Volume / Diarrhea Ineffective Therapeutic Regimen
Management Deficient Knowledge 23
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3 rd Day Post Op for Mr. S. Mr. S. has been tolerating his
medication and diet well. However, the nurse received a call from
the laboratory technician stating his am lab results are:
Hemoglobin is 8, Hematocrit is 26. His WBCs are 2 and his Platelets
are 20,000. (All these values are below his baseline). What do we
do now? 24
Slide 25
1 st : Verify the lab results (critical values are-by
policy-called to the nursing station by the reporting lab). Nurse
notifies the Surgeon As the nurse, what orders would you expect to
receive? 25
Slide 26
Next The Nurse would anticipate: 1) possible transfusion with
1-2 units of Packed Red Blood Cells (PRBCs) 2)possible
change/addition in HAART medications 3) institute protective
isolation and observe for signs/symptoms of bleeding and infection
4) continue to assess Mr. S. of his understanding of his condition,
educate him as needed, and what is being done to help him 26
Slide 27
Ongoing Assessments Assess for Desired Therapeutic Effects: HIV
RNA assay (Viral Load) and CD4 levels, CBC, Hepatic and Renal
Function, Lipids, Amylase, Glucose remain WNL Tolerate activities
of daily living (ADLs) Absence of signs and symptoms of Infection
Watch for Adverse Effects: n/v/d, anorexia, cramping, mental
changes, pain, jaundice, dark urine, rash, blistering, 27
Slide 28
Neuman System Model Discuss the stressors, Basic Structure and
protective concentric rings Flexible and Normal Line of Defense and
Lines of Resistance. 28
Slide 29
Follow Up Next Day Mr. S. tolerated a transfusion of 2 Units of
PRBCs, and the AM lab results showed his H&H has increased to
12/32. His WBCs and Platelets remain low. He is avoiding the use of
a razor and is careful to avoid falling/injuring himself by calling
for assistance when getting up. He is taking up to 900ccs of PO
fluids each shift and making adequate urine. The hospital staff is
maintaining Reverse Isolation to prevent exposing Mr. S. to
infections. 29
Slide 30
Next Day Continued The Surgeon consulted with Mr. S.s Attending
MD who recommended adding a Nonnucleoside Reverse Transcriptase
Inhibitor (NNRTI) to his medication regimen and continue to monitor
his lab values. The Nurse informs the Attending MD that Mr. S. is
compliant with his medications and has a good understanding of his
current condition, his vital signs are stable (VSS), he is
afebrile, and is not excessively fatigued. 30
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3) Nonnucleoside Reverse Transcriptase Inhibitors (NNRTI)
efavirenz (Sustiva), a prototype drug 600mg PO HS Daily on empty
stomach. Adverse Effects: Common: Rash, fever, nausea, diarrhea,
headache, stomatitis, dizziness, sleep disorders, fatigue Serious:
Paresthesia, hepatotoxicity, neutropenia, Stevens-Johnson Syndrome,
CNS toxicity. Contraindications: teratogenicity- avoid use in the
pregnant pt., use reliable birth control methods. 31
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How Do NNRTIs Work? NNRTIs bind directly to the HIV viral
enzyme reverse transcriptase, blocking RNA & DNA dependant DNA
polymerase which disrupts its function. This drug action prevents
viral DNA construction. Pharmacology for Nurses 3 rd Ed. 2011
32
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Mr. S. Post Op Day 5 Mr. S. is progressing in his
rehabilitation s/p Lt. TKR. He is ambulating 200 feet in the hall
2X daily using his walker and stand-by assistance only. He knows to
take rest between each activity because of the possible side
effects of ART along with the fatigue due to being Hospitalized
(surgery, pain, prolonged bed rest, muscle wasting, sleep
disturbance, etc). 33
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5 th Day Continued Lab Values: H&H: 12/31 WBCs: 5
Platelets: 45,000 Viral Load: Not detectable CD4 Count: 800/ml
Liver & Kidney Function Tests: Within Normal Limits (WNL)
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Attending MD Had Considered adding a Fusion Inhibitor (FI)
Enfuvirtide (Fuzeon) SubQ 90mg BID Adverse Effects: Common: Pain
and inflammation at injection site, nausea, diarrhea, fatigue,
abdominal pain, cough, dizziness, musculoskeletal symptoms,
pyrexia, rash, upper respiratory tract infections Serious:
Hypersensitivity, myocardial infarction, neutropenia,
thrombocytopenia, nephrotoxicity, hepatotoxicity.
Contraindications: Hypersensitivity, lactation. Pharmacology for
Nurses 3 rd Ed. 2011 Prentice Hall Nurses Drug Guide 2009 35
Slide 36
Fuzeon Drug Action Interferes with entry of HIV-1 virus into
the host T4 lymphocyte cell by inhibiting fusion or linkage of the
virus to the CD4 receptor. 36
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Attending MD continued MD decides to hold off starting the F.I.
at this time due to stable CD4 cell counts and low viral load. He
will continue to monitor labs on an out- patient basis along with
office visits by Mr. S. every 3 months for now. 37
Slide 38
A Newer HIV Drug Class: Integrase Inhibitors Raltegravir
(Isentress) blocks HIV integrase, preventing HIV from inserting its
genes into uninfected host DNA. Dosage: 400mg PO BID Similar Common
and Serious Adverse Effects as the Fusion Inhibitors including
myopathy, (nephrotoxicity less common). Pharmacology for Nurses 3
rd Ed. 2011 38
Slide 39
Home Mr. S. is to be discharged home Post Operative Day 6. His
partner is taking off work for 2 weeks to assist him with ADLs. An
RN from the VNA will visit to remove the staples from his Knee on
Post Op. Day 10. He has an appointment with his surgeon in 2 weeks
for follow up. What important points need to be covered in the
Discharge Instructions by the Nurse prior to going home? 39
Slide 40
Discharge Instructions Include: Monitor for symptoms of
hypersensitivity or anaphylactic-type reactions Monitor VSS,
observe for signs/symptoms of infection, hypotension Watch for
mouth ulcers or white patches Comply with scheduled lab draws.
(They determine the effectiveness of HAART and/or drug toxicity)
40
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Discharge Instructions Conted Drug-Drug and Drug-Food
interactions (dosing times, no skipping, OTCs,) Immediately report
severe abdominal pain or distension, n/v or fever Support the
immune system (adequate rest, sleep, nutrition, hydration) Report
numbness/tingling of extremities, using caution to avoid injury
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Discharge Instructions Conted Multidisciplinary Care:
Nutritionist, Social Worker, Physical Therapist, etc. PRN Review
clients level of understanding regarding the use and effect of
medications. 42
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Nurse Follow Up Discharge Nurse asks client about HAV, HBV
& HCV status. Patient denies history, then nurse confirms via a
chart check for up-to-date Immunizations. 43
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Hepatitis A, B & C 44
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Viral Hepatitis Hepatitis A Virus(HAV)-acute disease (not
chronic) Oral/Fecal Transmission-rare fatalities, few patients
develop severe liver disease HAV vaccine (Havrix, VAQTA). 2 step
vaccination process-booster giver 6-12 months after initial dose
Almost 100% immunity results, lasting 5-8 years, up to 20 years.
Pharmacology for Nurses 3 rd Ed. 2011 45
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Hepatitis B Hepatitis B Virus (HBV), a chronic disease
Transmission via Blood/Body Fluid Greater morbidity and mortality
rate than HAV. 10% develop chronic disease (cirrhosis/Liver CA)
High Risk factors: IVDU, MSM, Sex with infected partner, health
care workers, perinatal & child to child. HBV vaccination
(Recombivax HB, Engerix-B): 3 doses confer up to 90% of clients
with protection if exposed (Twinrix contains both HAV & HBV
vaccine). 46
Slide 47
Hepatitis C Virus (HCV) Blood/Body Fluids are primary mode of
transmission 70% develop chronic hepatitis, 1/3 of these clients go
on to develop end stage cirrhosis Nearly 50% of all clients
infected with HIV-AIDS are co-infected with HCV No vaccine yet
available 47
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Chronic Hepatitis C Therapy When the chronic disease becomes
active or symptoms appear drug treatment is initiated with:
Interferons NonInterferons 48
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INTERFERONS Interferon alfacon-1 (Infergen): SubQ 9mcg three
injections/week for 24 weeks Interferon alfa-2b: 3 million
international units SubQ 3 X per week (PEG 1 X week) Common Adverse
Effects: Flu-like symptoms, myalgia, fatigue, H/A, anorexia,
diarrhea Serious Adverse Effects: Myelosuppression,
thrombocytopenia, suicide ideation 49
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NonInterferons & Combinations Adefovir dipivoxil (Hespera):
10mg PO daily Lamivudine (Epivir HBV): 150mg PO BID Robetron:
Ribavirin 200mg PO 5-6 capsules Daily & Interferon alfa 2b Subq
3 million International Units TID/week 50
New Therapy for HCV Incivek, a Protease Inhibitor In Phase 3 of
a clinical research study, in combination with Pegylated-Interferon
and Ribaviron, Incivek increased the sustained viral response (SVR,
an undetectable level of HCV 24 weeks after completion of drug
therapy) from 44% to 79% for a group of 1095 patients. Sutter
Health June 23, 2011 52
Herpesvirus Family Continued Epstein-Barr virus:
mononucleosis/Burkitts lymphoma Herpesvirus 6: roseola in children,
hepatitis or encephalitis for immunocompromised clients 54
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Acyclovir (Zovirax) Prototype Drug For the Immunocompromised
patient (ex.: AIDS, geriatric) who develops Herpes Zoster: 800mg PO
5 X daily X 7-10 days. Can prevent or lessen early symptoms (pain,
tingling, itching) and lessen the later outbreak of herpes rash and
blisters (Shingles). topical preparations are less effective IV:
5-10 mg/kg q8h X 7-14 days 55
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Acyclovir (Zovirax) Conted Adverse Effects with
topical/oral/IV- generally minimal/infrequent : N/V/D, H/A,
fatigue, dizziness, tremors, confusion, pain/inflammation at
injection site Serious: seizures, acute renal failure,
thrombocytopenic purpura. Prentice Hall Nurses Drug Guide 2009
56
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References Adams, P., Holland, L., Urban, C., Pharmacology for
Nurses, A Pathophysiological Approach, 3rd Ed., 2011, Pearson
Education, Inc. Nursing 2008 Drug Handbook, 28 th Ed., Wolters
Kluwer/Lippincott Williams & Wilkins Prentice Hall Nurses Drug
Guide 2009, Wilson, B., Shannon, M., Shields, K. Tulane University,
Department of Microbiology and Immunology, Big Picture Book of
Viruses: RetroviridaeBig Picture Book of Viruses: Retroviridae
Cronenwett, L., Sherwood, G., Barnsteiner, J., et al. 2007, Quality
and safety education for nurses, Nursing Outlook, 55(3)122-131.
http://www.sutterhealth.org/about/news/news11_CPMC-New-Drug-
Helps-Hepatitis-C-Patie... Retrieved 7/3/11
http://www.sutterhealth.org/about/news/news11_CPMC-New-Drug-
Helps-Hepatitis-C-Patie... Daviss Drug Guide for Nurses, Deglin,
J., Vallerand, A., Sanoski, C., 12 th Ed., 2011 58