Chapter 4
Opportunistic Infections
Overview of the Home Care Plan for Opportunistic Infections
1. Understanding the Problem
Causes of opportunistic infections
Effects of opportunistic infections on the person with HIV/AIDS
Your goals
2. When To Get Professional Help
Symptoms that indicate that professional help is needed
Information to have ready when you call
What to say when you call
3. What You Can Do To Help
Supervise the use of antibiotics and medicines
Offer encouragement and reminders
5. Carrying Out and Adjusting Your Plan
Carrying out your plan
Checking on results
What to do if your plan does not work
Topics with an arrow (
) in front of them are actions you can take or symptoms you can look for.
Opportunistic infections occur when the immune system is not working properly. The infections occur in persons who have HIV/AIDS because they do not have the normal defenses to fight off organisms that cause infections. Opportunistic infections are more likely to occur when a special blood count, the CD4 or T4 count, is below 200. The CD4 count for normal healthy adults is between 700 and 1200. For the person with HIV/AIDS, the CD4 count usually decreases gradually over time.
The organisms that cause opportunistic infections are categorized as protozoa, fungi, viruses, and bacteria. These organisms are found widely in nature and often live in the human body. Persons with defective immune system are unable to fight off the growth and destructive action of these organisms within the body. Opportunistic infections are seldom spread to people who have normal immune systems and are healthy.
The information in this home care plan fits most situations, but yours may be different.
If the doctor or nurse tells you to do something else, follow what he or she says.
If you think there may be a medical emergency, see the section "When To Get Professional Help" on pp 42-44.
Your Goals
Know when to get professional help
Supervise the use of antibiotics and medicines
Offer encouragement and reminders
2. When To Get Professional Help
Call the doctor or nurse if any of the following occur:
Changes in the person's mental functioning.
This may or may not be accompanied by a stiff neck, a headache, or a fever. The person you are caring for will seem less alert, confused at times, forgetful, more irritable, or somewhat clumsy. These symptoms may point to an infection either within the brain or within the layers that cover the brain (called the meninges); the latter infection is called meningitis.
Coughing, difficulty breathing, or breathlessness, especially when moving.
Pneumonia is a very common infection for persons with HIV/AIDS. Pneumonia can be treated, but treatment must begin early. A delay will result in breathing problems that are frightening, incapacitating, and possibly life-threatening. The person with HIV/AIDS is also very susceptible to tuberculosis, a respiratory infection that is easily spread even to healthy adults and children.
A long siege of diarrhea, lasting for 5 days or more, with six or more stools a day.
Chronic diarrhea is often seen in persons with HIV/AIDS because the AIDS virus can affect the intestinal tract. Other organisms, such as salmonella, can also attack the digestive tract, causing symptoms such as abdominal cramping, uncontrolled diarrhea, and weakness. Although not all diarrhea is caused by opportunistic infections, it is important to report to health care professionals to determine the cause.
A painful rash, often seen on one side of the body, which seems to be spreading.
Chickenpox and shingles (a painful rash) are caused by the herpes zoster virus. People with HIV/AIDS are vulnerable to this virus, and caregivers can also become infected if they come into contact with the weeping blisters. Those who have not had chickenpox are susceptible to both chickenpox and shingles because the same virus causes both conditions. Those caregivers who have had chickenpox cannot get it again. As always, a caregiver should use precautions to prevent contact with body fluids. (See the home care plan "Preventing the Spread of HIV and Other Infections" [Chapter 3].)
Changes in vision.
Cytomegalovirus (CMV) infections, if left untreated, will result in blindness. The person with HIV/AIDS may complain of blurred vision, flashes of light, floating spots before the eyes, or blind areas within the visual field.
Severe pain in the chest with swallowing.
Candida albicans is the fungus that causes thrush infections in the mouth and throat. It can also infect the esophagus, causing inflammation and pain each time the person swallows.
Vaginal itching, irritation, and/or discharge develops.
Candida albicans often causes a yeast infection in the vagina of HIV-positive women that is difficult to get rid of.
When you call, have the answers ready to the following questions:
Problems involving the head
1. Has the behavior or alertness of the person you are caring for changed? When did this happen? Do either get worse at any particular time of the day?
2. Can the person tell you his or her name, the date, and where he or she is? Is he or she sleeping more?
3. Has he or she had any seizures?
4. Does he or she have any neck stiffness? If so, describe it.
5. Does he or she have headaches, and do they go away when treated with acetaminophen (e.g., Tylenol)?
6. Does a fever accompany any of the problems listed above?
Respiratory problems
7. Does the person you are caring for have a dry cough, or is he or she spitting up secretions? What color is the sputum?
8. Can he or she walk from one room to the next without feeling "breathless"?
9. How far (measured in feet) can he or she walk before feeling "breathless"?
10. Does he or she experience any chest pain when coughing, moving, or taking a deep breath?
11. Does a fever accompany the respiratory problems?
Gastrointestinal problems
12. Does the person you are caring for experience any nausea or vomiting?
13. Has he or she changed eating patterns or diet recently?
14. How does he or she feel after eating?
15. If he or she has diarrhea, when did it start? Describe the stool. How many stools are passed during a 24-hour period?
16. If he or she has diarrhea, what medicine is he or she taking to control it? Does it help? How often is it taken?
Skin problems
17. Does the person you are caring for have a new rash? Where is it located? How is this rash different from other rashes he or she has had in the past?
18. How does the rash feel (itches, burns, weeps, is hot)?
19. What medication is being applied to the rash? Does it help?
20. Does the person you are caring for experience any vaginal itching, irritation, or discharge?
Visual problems
21. How does the person you are caring for describe the eye problem?
22. Does he or she own prescription glasses, and if so, does he or she wear them? Does the vision improve when he or she wears the glasses?
23. Does the person complain of floating objects before the eyes? Can only one half of (actual) objects be seen?
It is important to know the person's CD4 count when describing symptoms. Symptoms become more of a concern when the CD4 count is low, for example, 20 as opposed to 500. Report the CD4 count along with the problems you are describing.
Here is an example of what you might say when calling for professional help:
"I am Rick Green, Bill Hoke's caregiver. Bill is a patient of Dr. Kroft. Bill says his eyes are blurry and he only sees half of what he's looking at. Bill's CD4 count, done 1 month ago, was 25."
Supervise the use of antibiotics and medicines
See that medications and antibiotics are taken at the prescribed times.
Because the person with HIV/AIDS often has many medications to take, some of which can cause nausea and other side effects, the person you are caring for may be tempted to omit medications or to stop taking them altogether. Help the person you are caring for to stick to medication schedules. Remind him that missing doses will make the medicines less effective.
Consider using medication boxes.
If the person you are caring for has difficulty remembering to take medicines, medication boxes (also called compliance packs) can be used. These plastic boxes, usually set up weekly, are divided into times of the day and days of the week. Using compliance packs is a way for the caregiver to verify whether the person has remembered to take medications at the prescribed times. If you can't find a plastic medicine box to suit your needs, an empty egg carton can work just as well; simply mark each slot with the name of the day of the week and the time that medicine is to be given that day.
Offer to assist with needed treatments.
Because certain treatments can be unpleasant (for example, pentamidine treatments administered monthly to prevent Pneumocystis carinii pneumonia), people with HIV/AIDS tend to omit them. Fatigue also interferes with how often the person with HIV/AIDS takes skin treatments and checks his or her temperature, and even how often he or she bathes and brushes teeth. Your assistance and encouragement are important. For example, you can put a checklist on the bathroom mirror or start a routine, such as brushing teeth after all meals.
Offer encouragement and reminders
Encourage but do not scold.
Avoid preaching or scolding. These techniques are discouraging and offensive. Again, offering assistance and providing gentle reminders about the purpose and importance of certain treatments or medications is always more effective. Be creative. Assist the person you are caring for to manage treatments and medications himself or herself.
Encourage a healthy lifestyle.
See that the immune system of the person you are caring for is supported through good nutrition, restful sleep, moderate exercise, good hygiene, stress management, and pleasurable experiences. Make sure that he or she avoids alcohol, "recreational drugs," tobacco, and "unsafe sex."
4. Possible Obstacles to Caregiving
Here are some attitudes or misconceptions that could prevent you from carrying out your plan:
"This cough and headache are just from a cold I've picked up (or from my smoking). It should clear up in a few days if I take things easy."
Response: For a person with HIV/AIDS, a cough is often the first sign of a serious respiratory infection. If it is not treated quickly, it may become a life-threatening pneumonia that is much harder to treat. Smoking makes the cough and respiratory distress worse. Also, smoking promotes the progression of AIDS. Call health professionals about colds and headaches early rather than later.
"Headaches are a regular part of my life. When I get upset they come more often. This one will pass as soon as I relax."
Response: With HIV/AIDS, headaches that are persistent or hard to control or that cause changes in the person's ability to think may be a sign of a more serious problem that should not be ignored. Report such headaches, especially if the CD4 count is low or has not been measured recently.
Think of other obstacles
Identify additional roadblocks that could keep you from following the recommendations of this home care plan.
Will the person I am caring for cooperate?
Will other people help?
How can I explain my needs to other people?
Do I have the time and energy to carry out my plan?
You need to develop plans for getting around these roadblocks. Use the four COPE ideas (Creativity, Optimism, Planning, and Expert information) in developing your plans. See pp 4-8 for a discussion on how to use the four COPE ideas in overcoming your obstacles.
5. Carrying Out and Adjusting Your Plan
Carrying out your plan
Infections must be treated as soon as possible. In order to deal with opportunistic infections early, you must be alert for any changes in normal patterns. The body will give alerting signs that all is not well and that an infection is in progress.
Checking on results
If the person you are caring for is feeling better, you are making progress. Pay attention to which recommendations are working, and keep a "diary" of your progress. Continue to encourage him or her to keep taking the medications and treatments that will prevent further opportunistic infections.
What to do if your plan does not work
1. Review this chapter.
2. If you find that you've skipped something, try it now.
3. If you find that you've done all that you can, call the doctor for further guidance.
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