[music]
-What I plan to do is just to give youa few of the statistics.
I don't want to belabor the statistics.
You've all read the newspapersand The Time, and Newsweek articles,
probably.
Then I want to go into the type of personsthat are affected by this disease,
and then we will go a little tiny bitinto the immune system,
just to give you a backgroundof what is happening, and then go
into the nursing care.
I need to thank CDCfor these slides on statistics.
The rest of the slides were prepared
by the Crawford Long StaffDevelopment Department.
I'll show you justa few of the statistics,
just to start off.
Let me start by givinga definition of AIDS.
The CDC definition,
and this definition has to be utilizedin order to classify
as a patient with AIDS,
is that the patient must havea reliably diagnosed disease
that indicates cellular immune deficiencysuch as Kaposi's sarcoma,
Pneumocystis pneumonia,or something like that.
Also absence of other known causesof these diseases.
These two elements must be presentin order for the patient to be diagnosed
as having AIDS.
You may have many patientswho come in with FUO,
who are not diagnosed as having AIDS.
On the other hand, you may havea lot of patients coming in with FUO,
and just because of what you knowabout these people,
you may automatically assumethey have AIDS.
I'm going to speak to that later.
We are tendingto put people in categories,
and it tends to hamper our nursing care.
I'll speak about that later.
This is also a slide from CDC speakingto the reported cases through March of 83.
You see, we started out with very,very few,
and it has increased significantly.
I do not have the statisticson this slide for--
I got this slide in early August,so that's a little bit outdated.
We are up into--
Through August, we had another 360 cases.
This past month, there were 287 cases,to make a total of 2,259 people
have had AIDS.
Of that, 48% of the patientshave been diagnosed in 1983 alone.
We are seeing a great increase,
and I thinkwe have just seen the beginning.
We have seen the tip of the iceberg,so to speak.
That's on the last slide, I'll show you.
As we go along,
how many more people are coming alongand being diagnosed as having AIDS?
Of these patients, 41% have died,
so we're dealingwith a devastating illness,
and it's devastating not onlyin the mortality,
but in what it does to the patient.
It's very difficult to workwith this patient,
especially during the last few days,because many of these people are alert
and oriented upuntil the last few moments.
This shows you just demographically,
what states we have found,where patients have AIDS,
and you see that almost every statein the United States has had
at least one patient.
Again, this has been updated,and I believe we have a patient
in Mississippi.
Somebody's been diagnosed in Mississippi
and Utah, I believe.
It's being updated all the time.
One of the things that's frustratingabout presenting something about AIDS is
that we are finding out so much,so fast,
that I'm trying to give youas current information
as I have, but tonight,we'll probably find out something new.
I think you need to realizethat as healthcare providers,
things are changing, and the only wayto care for these patients is to keep up
to date.
Things change all the time,so some of my information
may be even outdated.
I've studied upuntil the last couple of days,
but it may be outdated already.
The risk groups that are being divided,it's interesting.
This slide was--
Again, I got it in August from CDC.
The percentage of cases are homosexual,bisexual men are 71%, IV drug users, 17%,
and the statistics in the latest MMWR,which is The Morbidity
and Mortality Weekly Report from the CDC,agree with these two percentages, again.
The last MMWR did not include Haitiansas a separate group.
What they said is that we are havingso much political problems with that,
that Haitians are probablyin some of the other groups also.
5%, actually 7%, now, of the peoplewith AIDS, have been Haitians,
but we are finding outmore and more that they do say
they have used drugs in the past,or homosexuality,
because of the taboos of their culture.
The Haitians in the past have not admittedto having had homosexual tendencies
or having used drugs.
Hemophiliacs, 0.8%,
and then the restare no apparent risk group.
Although the more and more we delveinto it,
we find that in most of the people,there is some risk involved.
They belong to one of those groups.
Okay, what I want to do,just as a background, is
to quickly go over, and this is very,very brief, go over the immune system.
I've not even includedthe entire immune system,
because I'm not even speakingto the phagocytic activity or any of that.
I'm just going to speakto the humoral and the T-cell activity
of the immune system.
The B- cells in the humoral partof the component
of the immune system create B-lymphocytesand antibodies.
They simply function to neutralizethe antigens to remove the foreign bodies
from the system.
The B-cells are the cells that send outthe immune globulins to get rid
of the foreign antibodies.
The cellular level,which is literally that,
it's on the cellular levelof the different cells,
is the T-lymphocytes.
What they do is, they are sensitizedto recognize and attack
the foreign antigen.
That's exactly what they do.
They regulate
and suppress the cells.
They have two different kinds of T-cells.
I know you've read about the T-cells.
Some of them are suppressor cells,and some of them are helper cells.
The helper cells help the B-cells.
They literally assist the B-cellsin destroying the foreign antigens.
The suppressor cells arrestthe B cell activity.
What it is, is they create a nice balance.
The normal ratio
of the helper to suppressor cellsare two helper cells
to one suppressor cell.
Normally, you have more helper cells,
which help with the humoral activity,or the B cell activity,
and one suppressor cell,which will decrease that stimulation,
and that keeps a balance.
The foreign antigen is removedbecause of both of those working together.
In the patient with AIDS,that may be totally reversed.
I'll show you a slide laterthat speaks to that.
The problem is with the T-cell activity,the ratio is changed.
When your immune system is intact,as our immune systems are intact,
the B-cellsand the T-cells function adequately.
If we were to be exposedto an opportunistic infection,
such as pneumocystis carinii,which is one of the usual ones,
we would ward off that infection,we wouldn't have
any problem with it at all.
However,if the patient is immunosuppressed,
if there's a problem with a T-cell,B-cell ratio, suppressor cell,
helper cell ratio,then they cannot ward off that problem,
so we'd speak of themas being immunosuppressed.
There's a potential triad.
One of the researchers speaks
to a potential triadof biological sequelae.
You have an immunodeficient state
that may lead to an autoimmune disorder
and it may leadto another neoplastic disorder.
That is often seen in patients with AIDS.
Nobody has said that this is true,that this is actual truth.
When you see the patientsthat you're dealing with,
you'll realize that almost always,with the immunodeficient state,
that you may have an autoimmune disorder,and often, the lymphoreticular
or neoplastic disorder,such as the Kaposi's sarcoma,
seen with a patient with AIDS,usually, immunosuppression
has a congenital component,which is right in the middle.
All of these things stemfrom congenital problems.
However, AIDS isjust what the name says, it is
an Acquired Immunodeficiency Syndrome.
Here, before,the patient has been healthy,
their immune system has worked correctly,and suddenly, the immune system
is impaired and you havewhat might be called
as a sick immune system,leading to these possible sequelae,
the immune disorder,and the neoplastic disorder.
Anticipate seeing one or all threeof those problems with your patients.
What happens whenyou're having immunosuppressed patient
is that the patient
can be called a compromised host.
That is simply any person whose resistanceto infection is impaired by disease,
or treatment, or both.
We frequently
have patients in hospitalswho are compromised hosts
because of the things we do.
They are compromised iatrogenicallybecause we give them steroids,
for example, that's a compromised hostjust as the AIDS patient is
a compromised host.
That patient cannot resist infection.
The key is,
with a compromised host,they cannot resist infection
because of either diseaseor the treatment.
We'll see as we go along,with the AIDS patient,
they have the combination of both.
Not only do they have a diseasedand impaired immune system,
but with the treatment modalities,cause more problems.
The defects that are presentin the compromised host are many.
You may havea decreased number of phagocytes.
Your phagocytic activityis greatly diminished.
You may havea decreased cell-mediated immunity,
and that is the problemwith the patient with AIDS.
The cell mediated immunity, again,speaks to the B-cell, T-cell function,
and it's the T-cells that are impaired.
May have faulty antibody production
that may stemfrom decreased cell-mediated immunity.
They all go hand-in-hand.
You may have a damaged mechanical barrieragainst infection.
This has been one of the thingsthat has been proposed by the CDC,
that there is some damagein the normal cellular level,
and the normal mechanical barriers,such as in the rectal mucosa.
This is one of the concerns that they haveabout homosexuality and the lifestyles,
that perhapsit's the damage mechanical barrier
that's causing a problem.
Again, what the major problem is,is a decreased cell-mediated immunity.
When you have a compromised host,two things happen.
You may haveopportunistic infection set in
and you may have nosocomial infections.
I'm not going into great detail,I could show how much they both compare.
Many of the opportunistic infections
are caused in the hospitalas nosocomial infections.
I'm not going to go into all of that.
Specifically, you need to be awarethat opportunistic infections, as I said,
are those that comebecause the immune system is sick.
We are exposed constantly
to opportunistic infections,
either here in the hospital,or out on the street.
We don't get thembecause we have normal immune systems.
They are literally opportunistic.
The nosocomial infections I speak to,in that, as hospital workers,
we can prevent some of those things.
They're not just airborne,they're often contact problems,
and problemsbecause of the devices that we use.
Okay, I want to really speak mostlyto the nosocomial area,
because that's the placewhere our nursing care
and prophylaxis comes in.
There are several causesof endogenous transmission,
you may have previous colonization,which simply means that you may have
a latent infectionthat is suddenly reactivated.
Probably, the most typical exampleof that is tuberculosis,
that has remained latent for years,and years, and years, and suddenly,
all of the activities are togetherand the patient has tuberculosis.
Another good example, either Cytomagalo,and the Varicella-Zoster viruses
that the patient has had before,and suddenly, they become active.
Another example of previous colonizationis prior exposure.
The patient has not been sick, and yet,
when the immune systemdiminishes its functioning,
will suddenly develop toxoplasmaor pneumocystis.
The P should be the pneumocystis.
Another type of endogenous transmissionare those things that comes straight
from the Normal Flora.
From the mechanismsthat are present on all of our bodies,
to prevent infection,
such as in surgical wounds, Staph aureus,is a prime example in surgical wounds.
Staph aureus is normal on our skin,but if we have a surgical intervention
and something happens during the surgery,you might get an infection
from Staph aureus.
Another prime example,and this is where we really need to think
of our care in nursing, is IV therapy.
A great cause of nosocomial infectionsfrom endogenous transmission
is IV therapy, again,from the Normal Flora on our skin,
the Staph epidermidis is
a good way to get IV-related sepsis.
Exogenous transmission, you see,the very top.
The key here is cross-contaminationby hospital personnel.
How do we do that
by contaminated invasive medical devices?
Such anything we do,IV therapy is linked with nursing,
NG tube therapy might be somethingthat causes it, if you have a breakdown
in the mucosal linings,
any type of testingthat the patient might be going for,
diagnostic testing, such as colonoscopy,ERCP.
Those types of things. Bronchoscopyis a prime example of how you might
have cross-contamination,how you might cause problems exogenously.
Contaminated medications and IV fluidsare pretty low on the list.
We don't usually find that many problems.
Airborne and waterborne infections,
usually, we find that pretty fast.
If we have a patient, say,in an intensive care area,
that ends up with an airborne infection,we're going to check out the others also.
The prime problem hereis cross-contamination
by hospital personnel.
The easiest way to fixit is simply hand washing.
Who is this person who's affected?
I think this will help us look reallyat how we take care of this patient.
In looking at the overall,
the majority of patients afflictedwith AIDS are in the 20s to 40s.
We're speaking of a young population.
These people are previously healthy,they're not used to being hospitalized,
they have not been chronically ill,they've had a good immune system
and they've warded off infection.
They're not used to being sick.
Usually,the onset of symptoms is very slow.
Someday you may wake up with a cold,who goes to a doctor with a cold?
It's not very often that you really getthat much treatment
for that type of thing.
Frequently, symptoms have been presentfor a long time before this patient
has gotten any medical care.
Usually, the patient is middle class,
very knowledgeable,
usually has a high degree of education.
This patient is going to lookinto what's going on.
As far as the homosexuals are concerned,they have chosen an alternate lifestyle
and really feel good about who they areand what they're doing.
Usually has an urban home setting.
You're speaking of an individualwho is very educated,
who knows what's going on,who has everything in the palm
of his hand, so to speak, as faras where he plans to go with his life.
Suddenly, just because of a few things,like a cold or maybe some diarrhea,
some things that usuallyyou don't even get treatment for,
suddenly he's facedwith a life-threatening illness.
I think we need to realize what that doesto an individual who is normally healthy.
They're interested in health maintenance,we've had patients who have come in
for treatment and for diagnosis
who will bringa running machine with them.
They're that interestedin keeping up and going on.
They feel like they can really keeptheir lifestyle in order.
We need to realizewhat's happened to them.
They're going to ask questions,
they know that their lifestylemay be threatened very quickly,
or it may take two or three years.
They may think back on,"Why didn't I go
to a doctor two years ago,when I had these symptoms?"
The incubation period has been knownto be as long as two years.
That's why I sayI believe we're really seeing
the very beginning.
When you see over 1,000 new casesin 1983 alone,
I think we're just seeing the beginning,we're going to see more and more patients.
They're going to have questions,
questions about what'sgoing on with them as individuals,
about their medical care,
about how to keep up with their lifestylethat they're accustomed to.
They're going to have questionsabout their home, their job,
are they going to be hired or fired.
They're going to have questionsabout the significant other
and the family.
You are treating not only the individual,but the entire family
and the significant other.
I'll speak to the emotional aspectsa little bit later,
when we get into the nursing care,because I think that's probably
the greatest thing we needto really focus on for these patients.
We know the physical care that is needed,pretty much,
but I think we needto be very aware of the emotional aspects.
Let me go into what is involvedin the immune system,
what is the defect, and then keep on goingand get into the nursing care.
The humoral immunity,as I said, is normal.
The cell-mediated immunity is impaired.
There's a difference in the balance.
The normal balance, like I said before,normally, you have two helper cells
to one suppressor cell,that may be totally reversed.
Normal number of suppressor cells
and normal function,and a decreased number of helper cells.
This was what was originally forecast.
Now we're seeing that any numberof combinations may happen
with the T-cell problems,
but usually, we havemore suppressor cells than helper cells,
and that's why you have a problem.
The infections associated with AIDS,
and this is by sight, I'll getinto the specific infections in a moment.
The lungs, the central nervous system,and the bloodstream,
are the usual areas that are affected.
In the lungs, you have pneumonia.
50-some percent of the patientshave pneumocystis pneumonia.
As I said, the mortality rateis tremendous.
It's the most frequently fatal problem,and it's the most common.
We had a patient who came in,
I believe it was June,
with the first symptoms.
The first time,he had been diagnosed as having AIDS.
He went through all of the testing,did well, and went home.
He came in three weeks ago,and within one week was sent
to the intensive care unit, intubated,and he died within 10 days of admission.
It can be very, very fast.
He had pneumocystis.
He was not diagnosedas having pneumocystis
until this past hospitalization,but within 10 days, he had died.
The other site isthe central nervous system.
Herpes meningitis is not unusual.
Cytomegalovirus in the bloodstreamfrom fungal infections,
candidiasis is not unusual.
Septicemia,
and of course, as you know,with all septic patients,
that carries a high mortality rate.
The difficulty with the patient with AIDSis that it is difficult
to diagnose and treat.
There are so many infectionsgoing on in this patient,
that it's hard to find outwhat is the real infection.
Often, the patientwill be asymptomatic as far as fever.
That will not bethe telltale sign all the time.
He may run a fever all the time,or he may be subnormal much of the time.
If you wait to find a high fever,you may be waiting too long to find
the diagnosis.
This is where our assessment skills comein to be so important.
We need to assessfor the occult signs of problems.
We need to do in-depth assessments dailyon these patients, and see if there
are changes eitherin the pulmonary status,
or the oxygenation,
look at the central nervous system,check mentation and changes there,
and look for any occult signsin the bloodstream that you might have
some problems.
Are they having any GI bleeding?
All sorts of occult signsthat we need to look for.
The specific infections,parasitic infections, pneumocystis, again,
the major culprit,
cryptosporidium, or Toxoplasma.
Toxoplasma gondii,to the central nervous system,
is especially devastating.
Fungal infections, Candida,
the cryptococcal, and histoplasmosis.
Candida,
often, the first thing that happenswith this patient is,
a patient will come in with a sore throat
and you find out that he has Candida.
What will ensue is the following workup,is the workup to find out where did
the Candida come from, why.
Normally,healthy people do not have Candida.
That may be one of the first signs.
Viral infections, we've spoken to thisin the parasitic and fungal.
You alsohave viral opportunistic infections.
The cytomegalovirus,the perineal herpes simplex.
That's another classic,that many of the patients--
I believe every patient we've hadwith AIDS has had herpes simplex,
at one time or another.
The other thing isthat 95% of gay males have
an antibody to the cytomegalovirus,
and we don't really know what that means.
We're not really sure what that's saying,but that's something to be aware of.
Bacterial infections,
not always opportunistic.
Some of these we may get,but the others, the ones
that are specifically opportunistic,are the mycobacterium, which is very,
very similar to the tuberculosis bacillus.
Miliary tuberculosis is rarely seenin the United States.
It's rarely seen amongst Americans,but it is seen amongst Haitians.
We're finding more and morethat some of the AIDS patients
have miliary tuberculosis,which is simply disseminated TB.
Symptoms.
As I said earlier,the symptoms may be very, very vague.
It's something that you don't frequentlyget treatment for.
General malaise and weakness,
he just doesn't feel good.
May have night sweats.
That's not unusual.
Fever at any time.
Diarrhea is oftena normal presenting symptom.
Again, frequently,they don't get treatment for it.
If you have diarrheaonce or twice a month,
you know it's rarethat you get treatment for it,
you live through it and go on.
Weight loss is often
a thing that peoplewill go get checked for,
but it's usually weight lossthat's fairly significant before
the going to the doctor.
A mild U.R.I.
is a cough, non-productive usually,at first, but it may increase.
Then dyspnea on exertion.
As I said,you've had a normally healthy person.
He may have some of these symptoms,but none of them fit.
They don't fit a symptomatic pattern.
They don't fit a systems pattern.
It's something that they just keep livingwith and go to the doctor late.
Other symptoms,
lymphadenopathy,
and then skin lesions.
The skin lesions are of two kinds.
The Kaposi's sarcoma
is like a raspberry.
It's been described like that.
It is non-painful.
It doesn't itch.
It's just like a bruise, really.
The patient may have one or two.
Kaposi's sarcoma has been known
to be endemic to some areas of Africa.
Usually, it affects males over 60,or tiny children.
That's why it's so unusualto have problems in this age group
with Kaposi's, and that's why peoplestarted really investigating
to see what was going on,that we've had that type of thing.
Then it starts spreading.
It's non-symptomatic, really.
It's just this bruise-like appearance,this raspberry-like.
Then it starts spreading,and the patient will have it all over.
The other kind of skin lesionthat I don't have mentioned up here,
are the lesions like from herpes
or mouth lesions.
Any mucosal lesion may be present,and that's something to be aware of.
The prognosis is not a nice one.
The prognosis for these patientsis repeated infection
with or without malignancies.
Progressive weight loss.
Eventually, multisystems failure,
and then death.
I've said that 41%of the patients thus far diagnosed
have died.
However,when you take away
the year of diagnosis,we find that there's a greater
than 70% mortality rate.
I also said that 48% of those diagnosishas been since 1983 alone.
The mortality rate is higherthan that first figure would indicate.
It's greater than 70%in within two years of diagnosis.
If they have the complicationsof the opportunistic infections,
then this is what you can anticipate.
There are some medications and CDCis working constantly to provide
more medications.
These change, they change all the time.
Bactrim is classically given
for the pneumocystis.
That'll probably be the first drugof choice that you'll see.
Septra is the other name.
Pentamidine is stillin the experimental stages,
and that can be given for the pneumocystisthat must be obtained from the CDC.
It is a very, very potent drug.
One of the concerns that you needto be very aware of with Pentamidine is
that there are anaphylactic reactionsto that,
and that they may not comewith the first dose.
We had a patientwho had been receiving Pentamidine
for about three or four days,and in the middle of the night,
suddenly developed respiratory distress.
He was intubated immediatelyand transferred to an intensive care area.
The next night, the same thing happened.
The Pentamidine was discontinued,and he went back to backroom
and did go home.
He has not been back in since then.
That was in January.
We're hoping that perhaps he has hadsome good effect from that drug.
It is something that you needto be very aware of, assessment-wise,
that the reaction doesn't always comeat the beginning of the dosage.
Amphotericin B
is given for any of the fungal infections.
Amphotericin alsohas an allergic-type reaction,
and it is wise to ask for prescriptionfor Benadryl and Tylenol
before giving this drug.
Most of our patients receivethat beforehand,
because if you've ever seena shaking chill,
after having given a patient Amphotericin,you'll never forget it.
The entire bed shakes.
Some of that can be preventedwith Benadryl and Tylenol.
Amphotericin B is frequently used.
ARA-A is the drug for herpes zoster,and it is used quite frequently.
They may receivesome of the other anti-cancer drugs,
such as bleomycin,vinblastine, or doxorubicin.
That depends on what's been diagnosed.
Then, interferonhas been used for Kaposi sarcoma.
I've not myself seen it.
I know that it is being used frequently,especially in California and in New York.
That's specific for Kaposi,the idea being
that it has antiviral activityand that it'll stop
the foreign body reproduction.
The thing to be aware of with these drugsis to realize that probably,
the patientwill not be receiving only Bactrim,
only Amphotericin,
or only Pentamidine,he will probably be receiving
a multitude of medications,
all of which have major side effects.
He's receivingsome of the anti-cancer drugs
and the Amphotericin, you're going to needto watch white cell activity
and all of that.
When he has a combination,there are all side effects that you have
to be very aware of.
Precautions.
I think with all of the media,we need to be especially careful.
When I say precautions,I'm not speaking only to the precautions
for the patient.
We need to be very cautious
that we don't isolatethis patient unnecessarily,
and that we don't isolatethe patient who comes in with an FUO.
One of the major thingsthat we might be doing
to these people is--
If you have a doctorwho normally admits patients with AIDS,
if another patient comes in with an FUO,it's very easy to immediately classify
that patient as having AIDS.
I think this has a very detrimental effecton the patient and the staff.
We must be able to wait
until we have significantdiagnostic material available
before that diagnosis is made.
Precautions speak not onlyto how to care for the patient,
but precautionas far as the emotional aspect
of that patient is concerned.
The other thing that's really importantwith precautions is that, as nurses,
we know what the precautions are.
We can look at them,we can understand why we're taking
those precautions.
We can be careful with when we use them,
but the other departments don't.
If you have somebody comingin to draw blood from a patient
and that patient has a note on the doorthat says blood precautions AIDS,
imagine what it does to the blood draw.
A lot of it is simply out of ignorance.
A lot of it is because they don't knowwhat that means,
because of a lot of the news media.
I probably shouldn't even say this,but I really get angry when I read a lot
of the reports and seesome of the things on television,
because I think only halfof the truth is given.
Unless we investigate,we can't find the final answers.
We're speaking to precautionsfor the patient and for us.
We need to be very awareof where we're coming
from and what we're thinking.
If you have somebody who's comingin to draw blood, yes, they do need
to have blood precautions,they need to wear gloves.
It's the same precaution they would takewith a patient with hepatitis B.
If you can let people know that,that the precautions for the patient
with AIDS are the same as thosefor the patient with hepatitis B,
I don't think the stigma will be as great.
I don't think it'd be as difficult.
The other department that you need to be--
Well, several, but be especially awareof housekeeping department.
Again, the only informationthe housekeeping folks have are
what they read in the papers.
We need to help them understandwhat's going on with this patient.
It is all right to go inand clean the room.
You can take the linen out of the room,
and there are some precautions tobe taken with that if the patient
has a lot of secretions.
If not, if the patient isin the diagnostic stages,
is getting up and walking around,and take caring for himself,
we don't need to gointo all of the detailed gowning
and gluing, and all of that.
We need to be aware that we can treat them
as we normally would.
Be aware of housekeeping,be aware of those
who are doing vena punctures.
Be aware of respiratory therapy personnel.
To this date, there is no evidencethat AIDS is transmitted
by an airborne cause.
Nobody believes that it's airborne.
The latest MMWR, which came out yesterday,states that it is not airborne.
The only reason we would needto wear masks, really, is if there is
a productive cough and there'sanother opportunistic infection going on.
We're protecting ourselvesfrom the infection.
We're also protecting the patient
from something else we may be carrying in.
It's a two-way deal.
Be aware of respiratory therapyand all the other departments
that might be coming in, and please,don't isolate this patient unnecessarily,
and don't frightenall the other departments unnecessarily.
Let me go back to this slide.
What you need to do, of course,to prevent any nosocomial infections?
Main thing is hand washingwith disinfectant before patient contact.
If you are having close patient contact,then you will wear gloves,
if you're handling blood specimens,body secretions, or excretions,
and if you're examiningand touching skin lesions.
Otherwise,it's really not necessary to wear gloves.
If you're going in to have a conversationwith this patient,
which I would really encourage to just goin intermittently and just talk,
you don't need to wear gloves,you don't need to isolate them
at that point.
If you do have gloves,certainly wash your hands after removing
the gloves and gown.
Hand washing, wearing gloveswhen you're handling the normal secretions
when you would wear gloves, certainly,if they're having diarrhea, wear gloves.
We would do that with any patient.
Gowns.
If the linen is soiled with bloodor other body fluids, then it's wise
to wear gowns.
Usually, this does not happenwith this patient until the patient
is very, very ill.
When the patient is on bedrest,then you may start having some trouble
with body secretions.
If they're in for diagnostic testing,
you probably won't have to useall of these great precautions.
Needles should be placedin a contaminated box.
You should have one boxin the room for that patient.
All the thing about needles is,you should not recap them.
The box should be so equipped
that you can just stick the needle in itwithout putting the top on.
The major thing, the major time
that nursing personnelget puncture wounds,
is when they recap the needles.
Don't recap them,just place them in the box.
They should be labeled contaminated.
I don't think we have to label themwith the patient's illness.
I think that segregatesthe patient even more.
Soil linen should be double-bagged.
These are the precautionsthat are stated by CDC.
We don't have to put this patientin the full regale of isolation.
Let me speak, just for a moment,to a personal experience
I had with isolation.
I was in Africa teaching nursingfor a while,
and I came back with encephalitis,and immediately was in isolation.
I was in a coma when I arrived.
When I woke from this coma,
I was in another country,and I was in isolation.
It was one of the mostdevastating feelings in my life.
I knew why, intellectually.
As a nurse,I understood all of the reasons,
but I felt so segregatedthat it made me feel like a non-person.
Everybody that came in would come inand stand like this,
and they'd washtheir hands real good beforehand,
my mother, my father,
my friends, everybody.
Then they'd walk out and be sure,"Have you washed your hands?
Have you washed your hands?"
[laughter]
Even though I knew why,and I certainly didn't want them
to get whatever I had,it made me feel terrible.
I've been ever conscious since then,of how we make our patients feel.
That's why I'm really speaking to this,especially with a disease
that can be so devastating.
Anyway, please be awareof how you're coming
across to that patient,and don't isolate them socially,
as well as isolating himfor his own protection
and for your own protection.
Much of the isolation for this patientis for the patient's protection
because of the problemwith the opportunistic infection.
Please be very aware of that.
The patient is goingto get progressively worse,
may come in with weaknessin all of these symptoms.
You may see the patientat different times during the illness,
and in different parts of the hospital.
You're going to see himduring different stages.
Certainly, if you work in intensive care,the patient is going to be much sicker
than on a general area.
One of the unique things that'll happenis the patient usually will come
in several times.
Hopefully, you can establisha really good rapport with this patient
so that when he comes back in,you'll be able to say,
"Well, hi, how have you been doing?
How did your--"
You can speak
to specific dischargeplanning you've done.
What is it that has broken down?
You can talk to themon an intellectual plane and they'll feel
a little bit more acceptedand more comfortable.
With the weakness, in general, malaise,frequently,
the patient has lost a lot of weight,and often, they should be immediately put
on a high-calorie dietwithin between meal feedings.
TPN has been considered.
It's something that often we wait to dountil a little bit later,
and it's something just to keep in mind,that you might want to put them
on total parenteral nutrition,but usually, the high-calorie diet
within between meal feedings suffices.
As far as the fever, certainly, your goalis to return to the afebrile state.
Another goal that isn't spoken to here,is that you want to realize that fever
is not the only indication of infection.
I am constantlymore and more impressed at how much
a hypothermic state indicates pre-sepsis.
Very frequently,just in the past two or three weeks,
we've had patients with hypothermia,who are suddenly agitated,
and the temp is 95.6 rectally,
and within 48 hours,that patient is septic.
Realize that, think about that.
If you have a patientwho is suddenly hypothermic,
start thinking of some other problem.
Again, with the patient with AIDS,if the immune system is malfunctioning,
you may not see a high fever.
The other time to assessfor that is during drug therapy.
You may have to really warm them upduring drug therapy.
If you give them Amphotericinand they've got a lot of chills,
or even if you're giving Amphotericinat all, be aware that they may chill
and become hypothermic.
Force fluid certainly,
we put juices at the bedside,so they're going out of style.
Just keep them there.
Something very simple,and also a very simple thing that can make
the patienthave increased confidence in you.
The other thing you need to watch for,as far as the fever is concerned,
is if they're not showing a febrile state,be sure you look at the white blood count
and the absolute granulocyte count,to see if there's something going on
with the immune system at that time.
Watch the white countand see what's happening there.
Most of this stuff is self-explanatory.
I'm not going to read over everything,but I did want to speak
to some of the specific things.
Certainly, you're goingto do chest auscultation,
even if the patient doesn't haveany problems respiratory-wise.
If you have a patient who's diagnosedas AIDS, you're going to want
to pick up any changesin the pulmonary status
before it's diagnosed as pneumocystis,
and avoid activitiesthat cause dyspnea on exertion.
The patient we had,who brought in his own running machine,
really got tired out,more tired than he anticipated,
and he kept trying.
He kept saying, "I'm goingto be able to keep up my body.
I'm going to maintain what I can do."
Once he got on treatment, it was hard.
He went home and was ableto pick up again.
We were able to say, "Hold off right now.
Let us slow you down,"
and you need to do that.
With skin lesions, certainly,you need to be aware of where they are.
Check the skin daily to see if thereare any new lesions open or not open.
See if there's more problem with Kaposi.
Another thing too,just an anecdotal thing,
the patients are certainly awareof when they have skin lesions.
We are aware when we scratch ourselves,but often,
they may not know exactly what'sthe best treatment for that.
We had a patient who came inwith a blister on his toe,
and he was going to lance it.
He said, "Well, my grandmother usedto do that and so I'm going to lance it,
and it'll be all better."
Of course, I was astounded and I said,"Please, let us take care of that."
Even though he knew a lot about AIDS,it never entered his mind that lancing
that blister would causeanother infection,
or could cause another infection.
How he was going to do it is,he was going to light a match and take
a pin, get the match sterilized,and lance his little blister on his foot.
These are things that you needto be aware of,
as far as patient teaching is concerned.
Just the little thingsthat may cause problems.
Just be very aware of other lesions.
After the patient goes for colonoscopy,be sure to see if they have any pain
or anything like that,there may be some occult lesions
that you need to be aware of.
Mouth lesions, again,watch the platelet count.
Be very aware of your platelet count,your white count,
and if the platelet count is down,put the patient on precautions
for low platelet activity.
Put them on precautions,not blood precautions, speaking of that,
as for drawing blood,but put them on precautions
so that you will avoidany undue problems with the bleeding.
Don't let them shavewith a straight razor.
The precautionsthat you would normally follow for that.
Let's see.
Let's get to the emotional state.
Certainly, we have spoken to preventionof infection and being aware
of the problems that can cause infection.
The emotions that this patientmay exhibit are amazing.
They go from anger, to frustration,to feelings of isolation and abandonment.
Frequently, the patients who have come inhave not told their families
of the alternative lifestyle.
We have had patients'family members come in
just screaming,
because they were unaware
that the patient was homosexual.
That does nothing
to get this patient better.
It does nothing for the family,except that they have these emotions
that they have to get out.
Be aware that those thingsmight come about,
and that perhapsyou may need to intercede.
That's hard.
You're a nursing personnel.
It's hard to knowwhen to intercede and when not to.
We have to be awareof the significant other
who may suddenly decidethat no longer is he interested.
He's scared to death.He's scared that he may get AIDS.
Of course, the fear of the unknown.
What's going to happen?
Everybody's read the newspapers.
The fear of death.
As I said before, frequently,when these patients get
to intensive care areas,they are alert and oriented.
Even though they're intubated,
they know what's going on.
They send messages even
while they have the tube,and even while they're tracked
or intubated.
What happens physiologically,or pathologically,
is that the lungs literally fillwith bacteria to the point
that the patient suffocates.
This is the type of thingthat they're looking forward to,
that they're afraid of,and we need to be aware of that fear.
What I would really encourageas far as emotions are concerned,
is to be honest,be very honest with the patients.
Answer the questions.
Be open with them.
You must get in touchwith your own feelings.
If you have some real feelingsabout the lifestyle,
you must get in touchwith those and decide
how you can approachthis patient and family.
Be very open and honest,but be in touch
with your own feelings before tryingto be real therapeutic for the patient.
Visit with nothing to do.
How often I'll go into a patient's roomand I have nothing in my hands,
and they'll say, "You're not goingto do anything to me?"
It's nice.
I happen to be in a positionas a coordinator that I can do that.
That I don't have to take an injectionevery time I go into a room.
It's a freeing experience for me.
It's very nice.
I would encourage all of youto do that same thing.
Just go in and contract with them.
Say, "I'm going to havesome free time at X hour.
Let's talk.
Let's plan to talk."
You can take five minutes
and you will have given themsomething that's
as valuable as a medication.
That will help them a lot.
I've had many patients saythat that does help.
The nurses who do that say,
"Wow, that makes me feelso much a part of the care.
I know more who they are,and they know who I am."
That helps tremendously.
Your goal for your discharge planning,and this is probably as important
as anything you do whilethe patient is hospitalized,
is prophylaxis.
Simply to prevent the spreadand to prevent rehospitalization.
We are hoping that we'll finda miracle drug that will prevent
that rehospitalization.
We haven't yet, but we can certainlytry healthcare measures
that will.
Limit the number of partners.
I've talked to some folkswho say they believe
that has already changed tremendously.
The statisticsabout how many partners patients with AIDS
may have had are absolutely astounding.
Some statistics say upto a thousand partners.
It's almost impossible to isolatethe other people that may be affected.
Again, I'm speaking to the 71% of patientswith aids who have been homosexual.
Know the partner's health status.
Certainly, be aware of that.
Use condoms, a simple request.
Eat a well-balanced diet.
Some folks suggest cooking meats,washing fruits
and vegetables very carefully.
It's a simple thing that we all think of,but it's good to tell the patients
that that's important too.
Minimize the use of recreational drugs.
Nitrous is one of the drugsthat has been implicated so frequently.
Then the other thingsthat you would teach them
have to do with the immune system.
Certainly, avoid contact with peoplewith colds and flu.
Something simple, a simple cold may bethe thing that puts them back
into the hospital.
Avoid contact with those folks.
Do not self-medicate.
It says here, with antibiotics,I would say with most anything,
even if they self-medicatewith Tylenol for a fever,
they may be decreasing the timethat they have to get to medical help.
Certainly, see the doctor for any changesin the medical condition.
If your partner develops symptoms,certainly,
the partner should seek medical help.
We're speaking to a large populationof people with many problems,
and I've spoken, like I said,primarily to the patient
who is homosexual, and there are others.
There are many others.
These are the peoplethat we are seeing most frequently,
so that's why I'm speakingto that population.
We have not seen it that muchin the population at large.
There have been a few isolated cases.
I know the fear is rampant,that AIDS will extend outside
of the populations at risk.
If we carry out the precautions,if we're wise in how we care
for the patients, we are not anymoreat risk with a patient with AIDS
than we are with a patientwith infectious hepatitis.
I think if we can look at it that way,
as hospital personnel,we won't have the fear of caring for them.
Another thing,for those of you who are staff nurse,
head nurse capacity, one good thingthat would help too is to pull aside
all the nursing assistants workingwith these patients and give them
a brief explanation.
They are frightened.
They're very frightened.
The only group that CDC recommendsnot care for patients
with AIDS is, the person who is pregnant
should not care for the patientwith pneumocystis.
The CDC recommends that.
No, it's not CDC,I think it's the National Health Center.
Other people should be able to.
If you can talkwith your nursing assistants
and just give them some information
so they feela little bit more comfortable,
they will not havethe fear that has been exposed
in many other parts of the United States.
One last slide.
Oops.
I said earlier and I didn't realizeI was coining a phrase
that many other people have used, also.
This is a CDC slide.
We are seeing probablythe very tip of the iceberg.
What we know isthat we have Kaposi sarcoma
and opportunistic infections.
What we anticipate may be possible arethe other sarcomas,
other thrombocytopenic problems,other immune effects, and then we may even
have some asymptomatic carriers.
Nobody has proved that yet,but I would expect and anticipate
that within the next year or so,we will see many,
many more people with AIDS.
What I would challenge you to do isto keep up to date,
and keep up to date not onlyfrom the newspaper articles
and stuff like that.
Try and keep up with someof the morbidity and mortality reports
and all of the other informationthat is available in medical journals.
Now, I don't knowif I've got time for questions.
I hope I do.
-Yes. I'm Tia Rileyand I work here with diabetics.
I'd like to compliment you
on an excellent presentation.-Thank you.
-I'd like to also know if therehas been seen in your investigations
a higher incidence of AIDSamong persons with diabetes
because of their increased susceptibilityto infections.
Also, question two,has there been any investigation
of other refugee groupssuch as the Cambodians or Laotians
as to the incidence of the disease AIDS?
-Good questions.I work a lot with diabetics too.
To my knowledge,I have never seen anything spoken to,
as far as diabetes is concerned,but I would expect that we might.
I've not seen any literatureat all that speaks to the diabetic.
I have seen literature that speaksto the hemophilia,
but not to the diabetic.
It would be somethingthat we should watch for
in our assessment.You're right.
The other patient that I'm thinkingthat we need to watch for,
and again, this is just me.
I've not seen any literature at all.
I would want to watchthe sickle cell patient too.
This is just somethingthat some of our nurses have talked about,
that we need to be aware of,maybe a problem with sickle cell.
No, I don't know of any investigationsof other refugee groups.
The Haitian government certainlyis very upset at being isolated.
I don't know of any other groupsthat have been isolated.
The reason they did is that there were5% of people in Miami who had AIDS,
who were Haitian immigrants.
I don't know of the other groups.
-I thoroughly enjoyed the lecture.
All through your lecture,you kept using the term he.
Have they ever been any women with AIDS?
-Yes, and I apologize.
Yes.
I think it's something like 3.2,but I'm not good on remembering numbers.
Yes, there have been some women with AIDSand they have been part of the risk groups
for the most part.
They have either been IV drug abusers,or they have had sexual contact
with AIDS patients.
I apologize.
Thank you.
Any other questions?
-At this point, do you know what stagethese lesions occur in the mouth,
and what they may look like?
I'm especially interested,since I work in oral surgery.
-Okay. If it's a Kaposi's lesion,it would be the raspberry-like lesion
that looks like a bruise.
If it's another kind of lesion,it would be the lesions that you see
with Candida,
or just with the mucosal breakdown.
If it's Kaposi's though,it is raspberry-like,
and pretty obviously differentfrom the other lesions.
If it's herpes,
what it is, is the lesion dependson the causative organism.
It varies with the cause.-Even in the mouth?
-Even in the mouth,it varies with the cause.
What you're going to have to dowith any problems
with the patient with AIDS is lookfor the cause before treating it.
Find out what the problem is.