18. Special needs of the person with HIV/A1DS

Acquired immunodeficiency syndrome (AIDS) is an infectious disease caused by a retrovirus called the human immunodeficiency virus (HIV). This virus infects T lymphocytes that bear the CD4 antigen (CD4⁺ T cells). Once inside a CD4⁺ T cell, the virus survives by integrating itself into the DNA structure of the host, which it ultimately destroys. Because CD4⁺ T cells coordinate many immuno-logic functions, their destruction disrupts the body's cell-mediated and humoral immunity and even autoimmune functions. This predisposes the client to many opportunistic infections, such as Pneumocystis carinii pneumonia, Candida albicans (thrush), toxo-plasmosis, cryptococcal meningitis, herpes viruses (cytomegalovirus. herpes zoster, and herpes simplex), and certain types of cancers, primarily Kaposi's sarcoma and various lymphomas.

Dementia Due to HIV Disease

DSM-IV CATEGORIES

294.9 Dementia due to HIV disease (also code 043.1 HIV infection affecting central nervous system on Axis III)

AIDS is spread through sexual intercourse, the use of contaminated needles and syringes (often shared by I.V drug users), maternal-fetal transmission, and the use of contaminated blood products. The virus that causes AIDS has been found in various body fluids, such as blood, semen, vaginal secretions, cerebrospinal fluid and, less frequently, urine, breast milk, saliva, and tears. After initial exposure to the virus, the client may not test positive; in fact, it takes about 3 months for the antibody tests to detect the virus in the blood. Typical elapsed time from initial exposure to the development of AIDS is about 8 years. Although many people remain asymptomatic for long periods, almost all eventually develop AIDS.

PSYCHIATRIC SYMPTOMS ASSOCIATED WITH AIDS
Anorexia Anxiety Agitation Anger to the point of rage Depression Paranoid thoughts or behaviors Disorientation Inability to concentrate Insomnia Feelings of helplessness Feelings of hopelessness Psychomolor retardation Memory loss Inability to make decisions Delusions Suicidal ideation Difficulty communicating with others Personality changes

When AIDS became a major disease and a leading killer of young adults, it primarily affected homosexual men. More recently, the rate of transmission in homosexual men has decreased and the rate of heterosexual transmission has increases. Today, the categories of people most likely to be infected are l.V. drug users, heterosexual women, hemophiliacs, and children.

The clinical course for an acute H1V infection begins with the manifestation of flu like symptoms, such as fever, malaise. myalgia, Gl problems, arthralgia and, possibly, lymphadenopathy and rash. Over time, clients develop chronic symptoms of weight loss, fatigue, diarrhea, and fever. AIDS can also affect the central nervous system (CNS) and lead to AIDS dementia complex. Encephalopathy and neuropathy develop, evidenced by a general deterioration in motor coordination and thought, memory, and judgment processes. HIV-related pathologic changes in the CNS include cerebral atrophy, ventricular enlargement, and formation of spinal cord or brain cavities called vacuoles.

AIDS is a fatal illness. No cure is available. (For further information, see Psychiatric Symptoms Associated with AIDS, and Characteristic Phases ofHIV/AIDS.)

CHARACTERISTIC PHASES OF HIV/AIDS
Early Phase
Anxiety, possibly panic Anger Decreased self-esteem Strong sense of shame Expectation of multiple losses Depression "Diseased" feeling Periods of denial or wishful thinking Difficulty informing sexual or needle-sharing partners
Middle Phase
Appearance of symptoms of declining health Changes in physical appearance Overextended coping skills, relationships, and finances Increased anxiety Assistance with self-care required Feelings of uncertainty Loss of control Deepening sadness and depression Family strength mobilized or conflict intensifies Anticipatory grieving of family and friends Preference for death preparations, especially advanced directives
Late Phase
Declining health status Daily living influenced by physical and cognitive problems Intensified stressors (such as relationships, financial, and housing) Lite reviewed comprehensively Pain and suffering Dementia Fear of burdening others, especially caregivers

COMMUNICATION STRATEGIES

• Verbalize empathy and provide compassionate support.
• Listen attentively to the client's statements about fears, anxieties, pain, and problems.
• Provide opportunities for the client to discuss feelings. (See Losses Experienced by Clients with AIDS.)
• Explore the myths about AIDS in an attempt to decrease anxiety and prevent the client from experiencing further alienation.
• Express caring both verbally and nonverbally.
• Communicate through touch as appropriate.
• Reaffirm the client's self-worth.
• When appropriate, discuss strategies for coping with potential health problems, the possibility of using hospice care, and preparing for death.

LOSSES EXPERIENCED BY CLIENTS WITH AIDS
Self-esteem Family members Friends or support systems Health and physiologic functioning Body image Physical intimacy or sexual contact Lifestyle Employment Autonomy Pets Goals and dreams Financial resources Independence

NURSING DIAGNOSIS: ANTICIPATORY GRIEVING

Probable Causes	Defining Characteristics
Alteration in physical appearance and body functioning Loss of independence Loss of dreams Altered roles and relationships Loss of possessions	Evidence of various gneving stages, especially denial, anger, and bargaining with God Guilt about self and behavior Altered activities and daily functioning Social withdrawal Minimal communication with others

Long-Term Goal The client will express feelings and grieve perceived losses.

Short-Term Goal #1: The client will discuss thoughts and feelings related to potential losses.

Interventions and Rationales

• Discuss with the client the meaning and extent of the diagnosis, prognosis, treatment, and nursing care.This information reinforces reality and sets the stage for anticipatory grieving.
• Help the client define and discuss potential losses.This action is therapeutic because it can decrease the client's anxiety and foster the expression of feelings.
• Encourage the client to verbalize feelings, concerns, frustrations, and fears about losses.Expression of feelings is essential for facilitating the grieving process.
• Explain to the client all the emotional and cognitive stages that form the typical course of grieving.This action normalizes the grieving process and prevents the client from believing that personal reactions to grief are abnormal.
• Help the client focus on personal strengths during this stressful time. Emphasizing strengths gives the client a sense of self-confidence and control over the situation.
• Talk to the client about goals and dreams that won't come to fruition.This type of discussion can help the client integrate the loss and adjust to lifestyle changes.

Short-Term Goal #2: The client will communicate understanding about the grieving process as evidenced by a willingness to experience it.

Interventions and Rationales

• Discuss the stages of grief (denial, anger, bargaining, depression, and acceptance) with the client.Education about the stages of grief helps the client understand that grief is a universal experience.
• Encourage the client to talk about the intense emotional attachments to the identified losses.Grieving involves giving up the strong attachments a person has to the things that are lost.
• Work with the client to identify how the energy formerly used for intense emotional attachments can be directed to something different and currently useful.This process enables the client to reestablish a sense of meaning for the current experiences.
• Explain that grieving is self-limiting.This explanation can facilitate comfort and realistic hope during this painful time.
• Inform the client about therapy and support groups and the assistance they can provide with the grieving process.Support systems facilitate coping during the grieving period and can serve as important resources if a crisis occurs.
• Help the client develop a plan for the remaining period of life.A plan helps the client acknowledge impending death and exercise control over the remainder of life.

NURSING DIAGNOSIS: SPIRITUAL DISTRESS

Probable Causes	Defining Characteristics
Lack of cultural traditions to provide comfort Lack of or disengagement from spiritual beliefs Intense pain and suffering Long periods of feeling overwhelmed Distress associated with ethical dilemmas	Verbalization of futility arc inner conflicts Questions or doubts about the existence of God Verbalization of anguish over whether life has meaning Verbalization of inner conflict Episodes of crying

Long-Term Goal The client will demonstrate enhanced spiritual well-being as evidenced by verbalizations of comfort with existential issues, such as death and the meaning of life.

Short-Term Goal #1: The client will verbalize conflict about health situation and beliefs.

Interventions and Rationales

• Acknowledge the client's verbal and nonverbal cues that indicate spiritual distress. By acknowledging the client's spiritual distress, communication is facilitated.
• Encourage the client to express emotions and talk about feelings ofambivalence. This discussion can help the client discover ultimate life concerns and the meaning of life.
• Have the client talk about past and current religious beliefs and practices. This discussion facilitates the identification of spiritual practices that can be helpful to the client.
• Encourage the client to identify and discuss conflicts among spiritual beliefs or ethical values, past and current behaviors, and current life situation. The client needs to understand that attempting to handle a difficult situation such as AIDS produces spiritual distress.
• Help the client identify meaningful experiences that have occurred before and during the onset of illness. It's therapeutic for the client to acknowledge significant life experiences and see life as meaningful.

Short-Term Goal #2: The client will use coping strategies to enhance spiritual comfort.

Interventions and Rationales

• Establish with the client a series of opportunities for discussion of concerns and distress. Meeting with the client regularly establishes the opportunity to validate the client's strengths and offer appropriate hope.
• Discuss historical or contemporary people who've wrestled with and overcome spiritual difficulties. Role models can provide insights into problem solving and difficult predicaments, thus enabling the client to make an application to the current situation.
• Encourage the client to use or rekindle former religious practices. Use of spiritual practices can provide comfort and decrease distress.
• If the client desires, facilitate visits from clergy or other spiritual leaders. This action respects and reinforces the benefits that can be obtained from spiritual leaders.
• Encourage the client to use imagery, prayer, meditation, reading, devotional literature, and music to handle emotionally painful circumstances. These skills may help decrease inner conflict and help the client develop a more positive mind-set.
• Discuss with the client how it is possible for a coping strategy to be useful at some times and not at others. Because spiritual distress may change from day to day, the client needs to know that a specific coping method may not work at a specific time; therefore a repertoire of coping skills is needed.

THERAPIES

Clients with HIV/AIDS usually experience an initial period of denial, followed by depression and anxiety. Individual and group therapies are helpful treatments for the client to use in handling stressors, fears, anger, hopelessness, and loneliness.

Individual Therapy

• Work with the client to identify, discuss, and develop strategies for handling intense feelings and fears.
• Help the client manage depression, feelings of despair, and thoughts of suicide.
• Work with the client to facilitate acceptance of role changes and body image changes that accompany loss of health.
• Encourage the client to grieve.
• Help the client live each day as fully as possible, and talk about coping with AIDS as "living with dying."
• Facilitate decision making to promote the client's sense of control over life-threatening situations.
• Provide the client with information, and help the client develop a plan to meet future needs.
• Assist the client with establishing a support system.
• Help the client remain as independent as possible despite the worsening physical disabilities.
• Support the client in preparing for death. Discuss advanced directives, funeral arrangements, and the possible selection of possessions to be presented to others after the client dies.

Group Therapy

• Facilitate contact with others, thereby decreasing feelings of social isolation and rejection.
• Encourage the client to express feelings, problem solve, and obtain feedback from others.
• Provide the support necessary to manage personal situations and live life as fully as possible.
• Reinforce the awareness that others are struggling and are able to maintain some control over their personal situations.
• Disseminate information about resources, treatment options and legal and social services that the client may need as the disease progresses.

COMPONENTS OF AN AIDS EDUCATION PlAN
When teaching the client and family about AIDS, the following topics should be included:
disease process transmission of the virus control of infection safe sexual practices treatment available medications, including experimental protocols legal considerations, especially a will and designated power of attorney desire for hospice and specific terminal care requirements decision about resuscitation and other life-support measures.

MEDICATIONS

• Antianxiety drugs may be included in the treatment of the client who's severely anxious.
• Antidepressant medication may be used with the client who s depressed and exhibits suicidal ideation.
• Antipsychotic drugs are used in the treatment of psychosis or delirium that may accompany AIDS dementia complex. (See Appendix D for medication information.)

FAMILY CARE

• Assist the client with the difficult task of sharing the diagnosis of AIDS with family members and significant others.
• Educate the family about HIV/AIDS, and continue to provide the most up-to-date information available.
• Help family members acknowledge the difficulties that the client is experiencing as the disease progresses.
• Teach the family how to meet the client's emotional needs.
• Help the family handle the client's progressive deterioration.
• Help the family establish contact with case management services, community resources, and respite services to prevent the primary caregiver from becoming exhausted.
• Help the family with anticipatory grieving.
• Provide resources for family members to maintain their own mental health by referring them to a caregiver's or parents' support group. (For further information, see Components of an AIDS Education Plan.)