n Assessment

Understand clearly why the product is being ordered and what the physician or other health care provider hopes to accomplish with the drug plan. Learn all about the patient’s history. Know the precautions or contraindications. What conditions exist that may help or hurt the patient’s ability to take antiviral medicines as prescribed?

n Diagnosis

Identify other problems this patient has that might limit the effectiveness of treatment. Because antivirals only lessen symptoms and cannot cure disease, the same viral infection often occurs many times, and patients may need education, comfort, and basic teaching about how to reduce pain, itching, or discharge. These patients often experience weakness and muscle wasting. Ask questions such as: Do they have adequate nutrition? Can they afford the medicine? Will they be compliant?

n Planning

More information about antiviral medications is available every day. Review the latest information from the package inserts before giving these products.

n Implementation

Several of these products have special storage requirements or instructions for mixing. Read the latest information to administer these products correctly.

n Evaluation

Watch the patient for signs of improvement in symptoms. Watch particularly for signs of toxicity or adverse effects that are specific to the medication taken.

n Patient and Family Teaching

n Assessment

Learn all about the history and course of the disease, the medications the patient has used, and past response to the medications. Most drugs used in the treatment of AIDS are toxic to the liver. Assess for past or present history of hepatitis or hepatomegaly (enlarged liver) plus current, as well as past, alcohol use or abuse. Assess for a history of pancreatitis and symptoms of peripheral neuropathy, because these are frequently caused by medications.

Ask about AIDS-related opportunistic infections—infections that develop because the damage to the body’s immune system leaves it unable to protect the patient against other infections. Opportunistic infections would not ordinarily be a problem to an individual, but because of reduced immunity, they may cause great pain and suffering in an AIDS patient. Ask the patient specifically about respiratory infections, skin lesions, and Candida infections.

Some of the specific questions the nurse might ask to explore related patient problems include: What are the patient’s beliefs and feelings about this illness? Does the patient have a support system? Does he or she have friends and family who can help the patient when he or she is most vulnerable to infection or having problems? Does the patient have health care insurance and the means to pay for medicines? Is the patient in need of financial assistance?

n Diagnosis

The medical diagnosis might be clear. In order to understand it, the nurse will want to understand what stage of disease the patient has (e.g., if the diagnosis is limited to exposure to HIV, or has exposure progressed to actual infection and symptoms). In addition to the medical diagnosis, the nurse will explore whether the patient has problems in the areas of hydration, nutrition, or hygiene? What are the financial needs, emotional concerns, and spiritual needs? Is there a support system in place, or is the patient going through this illness alone? Does the patient engage in unsafe sex or drug practices that put other individuals at risk? Are there knowledge deficits about HIV infection, prognosis, and treatment?

n Planning

Compliance is a big challenge for patients with HIV infection. They must return frequently to their health care providers for tests and examinations. Because they are at risk for developing opportunistic infections as a result of their damaged immune system, patients must be taught the signs of such infections. The patients must be willing to take all the medicines that are prescribed. Antiretroviral drugs are expensive and may have complicated directions for when they need to be taken. The drugs may cause side effects. For patients who are trying to slow or halt their HIV infection, it is important to provide individual teaching, encouragement and support and help with specific problems that present obstacles to treatment goals.

Before beginning drug therapy with antiretrovirals, the helper T lymphocyte (CD4) count must be measured, and plasma HIV RNA laboratory studies must be done. These results help assess a patient’s immunologic status and severity of infection. They also provide a means of measuring how well the treatment is working. A complete blood cell count (including a WBC count with differential), folate, vitamin B₁₂, ferritin, iron, and percentage of iron saturation, should also be obtained. Liver function tests and hepatitis B, C, and A serologies, as well as amylase, triglyceride, and lipase levels, will also be ordered. All of these laboratory studies are repeated during the treatment and help show treatment success or onset of adverse effects.

All of the protease inhibitors are potent inhibitors of the cytochrome P-450 enzyme system and have many contraindications to use of other drugs at the same time.

n Implementation

In working with HIV-infected patients, be certain to follow Standard Precautions. Wear gloves when necessary to avoid exposure to lesions or bodily fluids. Patients should be taught how to take care of minor problems and when they should return for care.

n Evaluation

Patients must see their health care provider on a frequent basis for further blood work that measures their WBC level and may indicate the presence of infection. Patients must also return to their health care provider sooner for evaluation than their regular schedule when they suspect the presence of opportunistic infections. Patients generally have fewer severe side effects with the protease inhibitors, although patients taking indinavir sulfate may develop “Crix belly.” This is a syndrome characterized by elevated levels of triglycerides, cholesterol, and plasma glucose, with a weight gain of 40 lb or greater. Fat accumulates in the lower abdomen and flanks, and tissue is often lost in the arms and legs.

n Patient and Family Teaching

n Assessment

Learn as much as possible about the patient’s health history, including any allergy, bone marrow depression, use of alcohol or other drugs that may produce drug interactions (particularly corticosteroids), and the possibility of pregnancy. Some antifungal drugs may be teratogenic (causing deformities in the fetus).

The patient may have a history of fever and chills at the onset of infection. Itching is a common finding. A history of recent antibiotic therapy is common. The nurse may observe the classic signs of white discharge and erythema (redness or irritation) associated with thrush (Candida infection). The patient may also have a history of multiple scaly or blistered red patches on the skin, itching and soreness of infected areas, and brittle nails with yellow discoloration and separation from the nail bed.

n Diagnosis

In addition to the medical diagnosis, what additional problems does the patient have? Are there difficulties in maintaining adequate nutrition or cleanliness or in paying for medications? Consider the need for education of the patient or family.

n Planning

Individuals allergic to penicillin may exhibit cross-sensitivity to antifungal agents, although this is rare. The patient may experience photosensitivity (abnormal response to exposure to sunlight) when taking these drugs.

Hepatotoxicity (usually reversible) and a few cases of hepatitis in children have been reported with ketoconazole. Liver function studies must be monitored so that any liver damage may be noted. The product should be discontinued if even a minor elevation in the liver function studies develops.

n Implementation

The absorption rate of griseofulvin is increased after the patient eats a fatty meal. Ketoconazole requires stomach acidity for dissolution and absorption. In patients with achlorhydria (lack of hydrochloric acid), tablets should be dissolved in several teaspoons of aqueous 0.2 NHCl solution. The patient should drink the solution with a straw to avoid staining the teeth and should follow the medication with a full glass of water. Explain to the patient how and why this is done.

Because griseofulvin is absorbed over a long period, single daily doses are often adequate. The patient must keep using the medication until the fungal infection is gone, as shown by both clinical and laboratory tests. This process may require several weeks or many months of therapy, depending on the organism responsible and the site of the infection. Use of both oral and topical antifungal agents may be required to treat some fungal infections, primarily tinea pedis (athlete’s foot).

n Evaluation

Observe the patient for therapeutic effects: chills or fever aqssociated with some infections should disappear; watch for signs of GI distress. The patient should continue to take the medication until the laboratory tests show that normal function has returned.

Nausea, vomiting, and diarrhea are symptoms of overdosage of most of the antifungal medications.

n Patient and Family Teaching