Managing a Human Immunodeficiency Virus Positive Patient - Case Study Example

Nursing case study assignment- A 23 year old person with HIV infection Introduction: Statistics says by 2001, 40 million people were living with HIV /AIDS and more than 20 million had already died of AIDS, with above half of all new HIV infection was found to occur among young people, found to be increased from 3.9% in 1999 to 4.2 % in 2004. (Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2004; . http://www.cdc.gov/hiv/stats/hasrlink.htm. Accessed March 7, 2004.). Outline of the disease/ Health problem: The causative organism, Human immunodeficiency virus (HIV) , a retrovirus primarily infects and destroys primarily white blood cells, resulting in a breakdown of the immune system. The CD4+ T cells, that is crucial for the immune response and signaling is the main target of HIV , resulting ion a weakened immune system , rendering it for the body unfit to fight certain infections. With the depletion of these cells , the immunity decline and with opportunistic infections occurs, resulting in a infected patient ,described as having the acquired immune deficiency syndrome (AIDS). (Fred Hutchinson Cancer Research , Center,2007http://www.fhcrc.org/research/diseases/hiv_aids) .generally the common secondary infections seen in AIDS are, infections of the lungs, intestinal tract, brain, eyes and other organs, as well as debilitating weight loss, diarrhea, neurological conditions and cancers such as Kaposi's sarcoma and certain types of lymphomas. The causative agent of AIDS is human immunodeficiency virus (HIV) belongs to the family of human retrovirus and subfamily of lentiviruses.The HIV is spread most commonly by sexual contact ,infected blood, the sharing of needles or syringes , from mother to their fetuses during pregnancy or birth, or by breast milk that contains virus.. The best care setting for the patient would, If he is asymptomatic – palliative out patient care and home care If is symptomatic, palliative inpatient care followed by home based care. Palliative care‘s basic ideology is to both provide the care and comfort, which is best fitting in this stage. The decision as explained is based on the stage, the patient’s mentality and the reaction of society to the particular case. The team that would provide overall care in this would involve Physical practitioner, Nurse practitioner, Technical person, psychiatrist or social counselor and as a major force the patient’s friends and family. The nurse practitioner in this scenario has a range of activities from attending to the physical treatment and providing mental stability. (Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med. 1998; 339:33-39.) Pathophysiology and Sympathology: 1. HIV, a retrovirus primarily infects CD4+ lymphocytes and macrophages by attaching to the host cell by the association of a surface glycoprotein to the CD4 molecule. Thus on entrance, the virus core enters the cell cytoplasm of the host, and copies viral RNA to the DNA of the host by using viral reverse transcriptase. The newly produced viral DNA is then transported into the nucleus and is futher incorporated into the DNA of that cell. On activation , a new viral RNA and proteins are produced that induce budding, with additional cell infection. The ensuing reduction in cell-mediated immunity and secondary B-cell dysfunction leads to a immunologically suppressed state, resulting in proliferation of opportunistic infections and malignancies. ( McIntosh K. Human immunodeficiency virus: the virus and its pathogenicity. In: Yogev R, Connor E. Management of HIV Infection in Infants and Children. Mosby-Year Book; 1992::35-51.) 2. Most generally people newly infected with the HIV virus show fewer or no symptoms for a few years. Though asymptomatic , during this phase , HIV actively multiplies, infecting, and killing cells in the immune system, particularly CD4+ T cells, rendering people to be very infectious during this early phase. With the weakening of immune system , symptoms begin to emerge. Some of the early symptoms, flu-like illness with such symptoms as, Fever, Rash, Headache, Loss of appetite, swollen glands, and Achy muscles and joints .These early symptoms usually disappear within a week to a month. The Late Symptoms of HIV Infection occurs after about eight to nine years after the time of infection which can varies from person to person. Persistent, enlarged lymph nodes ,Excessive fatigue ,Weight loss ,Frequent fevers ,Night sweats ,Chronic or frequent diarrhea ,Genital sores, Thrush and mouth lesions ,Skin rash or flaky skin ,Joint stiffness and pain ,Bone pain ,Blurred vision ,Short-term memory loss ,Repeated bacterial, viral, or fungal infections. (Geleziunas R, Greene WC. Molecular insights into HIV-1 infection and pathogenesis. In: Sande MA, Volberding PA, eds. The Medical Management of AIDS, 6th ed. Philadelphia, PA: WB Saunders Co, 1999:23-39.) Developmental consideration: The developmental consideration of patient helps the Nurse practitioner to effectively formulate the type of management and care to be provided. Many theories are available, and one of the best theories available till date is Erickson’s model of psychosocial theory, describing their psychological – mind and social – relationship attributes.. He divided his stages as syntonic (trust) versus dystonic (mistrust). On reference to the Erickson’s psychosocial model the 23 years old patient falls in this stage 6, Intimacy Vs Isolation. The young adult life stage has relationships developed as lovers, friends, work connection, with a intimate and social and work based relationship. The basic power or good point is the love and affiliation they have whereas the malignancy or mistrust is the Promiscuity and exclusivity. To assess how the person would pass though each crisis successfully could be assessed by calculating the healthy ratio or balanced between to opposing disposition that represents each crisis. In this stage the patient goes through the opposing phase of intimacy and isolation in the young adult stage of 18 to 40 years of age with courting, and early parenthood features. The stage of intimacy, is marked by relationship with family and marital or mating partner(s). Erickson explained this stage as a phase of sexual mutuality -, where there is strong physical and emotional connection, support, love, comfort, trust, On the negative , the isolation side is picturised with feelings of feelings of loneliness, alienation, social withdrawal or non-participation. Thus by effectively interacting with the patient nurse practitioner can understand in what phase of psychosocial crises stage the patient is undergoing as either syntonic or dystonic. The duty of nurse practitioner would be strike at the right balance between the conflicting extremes and focusing on the idle or preferable situation. This is especially important in the present case study to do a stage analysis as the disease is said to spread potentially only in the age group of 14 to 40. So the proper knowledge becomes important to decide the course of action. (Erik and Joan Erickson psychosocial development theory 1950-97; Alan Chapman review and contextual material 2006-7 http://www.businessballs.com/erik_erikson_psychosocial_theory.htm ) Ongoing Nursing Care: According to John Demakis, Nurses are a vital part of any health care organization. the nursing staff dealing with HIV patient are expected to play multiple role as expert knowledge of nursing and HIV/AIDS care; caring; advocacy; effective communication skills; focus on their professional development; source of support; self-esteem building; role model; and, fostering independence. The Treatment modalities include antiretroviral, prophylaxis for opportunistic infections, prevention of vertical transmission, and counseling and testing. The first stage in management is to diagnose the patient to identify the stage of the disease through various Laboratory Diagnosis, that includes basic blood test as total lymphocyte count, complete blood count, ESR, Chest X-rays, could be done if necessary. The other specialized test as Antibody tests - ELISAs, immunofluorescence, Western blots and RIPA bioassays, Virus isolation , Demonstration of viral NA , Prognostic Tests a. HIV viral load , CD4 counts. Antiviral susceptibility assays (Mylonakis E, Paliou M, Lally M, Flanigan TP, Rich JD. Laboratory testing for infection with the human immunodeficiency virus: established and novel approaches. Am J Med. 2000; 109:568-576.) The second stage would be staging them based on the results and planning the management, in managing a physically fit, young adult with no symptoms and who is psychologically aware of the fact of carrying a dangerous virus which will cause disease and death in a few years, management priorities would be Psychological counseling Awareness about the diseases, cause and symptoms and transmission and safe methods. Insisting on regular visit. 1. If the patient is not seriously ill , then home care with regular hospital visits recommended, that are taken care by NP. 2. if the Patient is seriously ill hospitalization is recommended . Patient, referred to a hospital that provides specialist care where the role of NP is to provide medication as referred. 3. If patient refuses hospitalization NP can arrange for his/her care at home or if he/she so wishes to seek care from a practitioner of an alternative system of medicine. 4. Home care is advisable as a person with AIDS is in need of both psychological support and physical care. As there is no cure that the health services can provide, the best care can often be given by the relatives. At home she/he is in well-known social surroundings where she/he feels more secure. Before implementing, the relatives are to be informed about the disease, as how it spreads and how it does not spread and should be educated about the precautionary measures. They should be informed that the patient can become emotionally and mentally disturbed. The family and patient ,as they need support and should be visited, by NP whenever possible. The third stage would be deciding the medical care, usage of drugs, drugs that interfere with the activity of a retrovirus, the antiretroviral, that target two viral enzymes reverse transcriptase and protease. the nurses see to that the drug regimen is followed up to date. Nucleoside analog reverse transcriptase inhibitors, interferes with activity of reverse transcriptase eg AZT (zidovudine Non-nucleoside reverse transcriptase inhibitors hindering the action of reverse transcriptase eg delavirdine, nevirapine, and efavirenz. Protease inhibitors. Eg saquinavir Fusion inhibitors. Eg enfuvirtide. Usually combinations of antiretroviral drugs are more found to be more effective in suppressing HIV. Other drugs and therapies are aimed at preventing or treating opportunistic infections and other AIDS-related conditions. A major concern in the treatment of HIV infection is adherence to antiretroviral medications. Disenfranchised patients who face numerous social and economic hardships are particularly challenged with strict adherence programs. Individualized and intensive nursing-based interventions, provided by nurses enhance adherence by helping patients identify barriers and implement strategies to overcome these limitations. (Gortmaker SL, Hughes M, Cervia J, et al. Effect of combination therapy including protease inhibitors on mortality among children and adolescents infected with HIV-1. N Engl J Med. 2001;345:1522-1528). The next stage of management would the concern of biopsychosocial dimension. Many researches have proved that the psychological state of the patient highly affects the improvement. The individual with newly diagnosed HIV seropositivity commonly responds with shock and disbelief, followed by guilt, anger, and depression. In some instances, a symptom complex similar to posttraumatic stress disorder is common in the first few weeks after a person receives notification of his or her HIV positivity. The person may become extremely anxious and hyper vigilant about physical symptoms, exhibiting marked dependence on health care workers. Feelings of guilt prevail over previous life activities and self-blame for becoming infected. Depressive thoughts are common, and acute suicidal crises may occur. Some individuals may become socially isolated. They may fear that they will infect others or be rejected by others. Crisis intervention with newly diagnosed HIV-positive persons is aimed at restoring a positive psychological equilibrium and providing education for making the necessary lifestyle behavioral changes to protect self and others. Denial is a common defense mechanism among individuals with high-risk behaviors. Denial prevents individuals from undergoing HIV testing; it delays some HIV-positive individuals from seeking early medical care; and it prevents some HIV-positive individuals from changing their behavior to prevent HIV transmission. So it requires the entire care team to work together and by providing counseling and mental strength the issues could be solved. (Douzenis A, Brener N, Catalan J, Meadows J. Psychiatric disorder in HIV disease: description of 200 referrals to a liaison psychiatry service.Int Conf AIDS. 1991 Jun 16-21; 7: 215 (abstract no. M.B.2135) Unfortunately HIV/AIDS is an illness associated with cultural meanings that result in a "spoiled identity" and the stigmatization of afflicted individuals. It is identified with deviant behavior, it is classified as an STD, and it is viewed as the responsibility of the individual. The stigmatized identity has pervasive social consequences that threaten individuals' self-perception. The cultural barrier would be the greatest issue to be tackled that would need the counseling for patient and his family. Collaborative Care: The collaborative care would include a general practitioner, nurse practitioner – generic and social, social worker, psychosocial counselor, lab technicians and of course the affected persons family and friends.. Researches have proven that now a day’s specialist care is preferred over primary health acre doctors. (Guidelines for the clinical management of HIV infection in adults. WHO/GPAIDS/HCS 91.6 World Health Organisation.,2001) The HIV is a condition that needs both medical and emotional management of the patient to be managed. On medical front The physical practitioner- does the diagnosis and starts the pharmaco therapy, trying to keep the patient healthy. The nurse practitioner – has a role to play medically and psychologically, which is very crucial. The first concern would be to maintain the clinical safety nod comfort. This the achieve implementing precautionary sterilization method, monitoring blood count, protecting the patient from infection, administer drug as ordered, maintain diet and weight, etc. as a family nurse, create a comfortable environment for patient, educate patient and relatives, remove their stigma, make referral to community organization. As educator teach client and family the dos and don’ts and teach care giver the precautions to be taken. Psycho social Counselor or social worker: The case of adolescents and young adult’s requires a intervention of psychological treatment as it is very common among them to think that they are invincible, this belief may cause them to engage in risky behavior, delay HIV testing, and if they test positive, delay or refuse treatment. The lag in them to medical care can lead to increased transmission of HIV which is another grave issue. . from the reports of health care providers it could be understood that many young people, when they learn they are HIV-positive, take several months to accept their diagnosis and return for treatment. Health care providers, especially nurse practitioners may be able to help young people understand their situation during visits by Ensuring confidentiality Explaining the condition clearly Eliciting questions Emphasizing the success and effect of newly available treatments (Kirsch G, Moore H, Mayon-White R, Klimes I. Nursing in the community for people with HIV: description of a training/implementation programme.Int Conf AIDS. 1989 Jun 4-9; 5: 272 (abstract no. M.B.P.304). Conclusion: In nut shell the role of nurses in managing a HIV positive patient is Understanding of the social and political context of HIV disease and the impact of disclosure on stigma and discrimination. Enhancing models of nursing care and nursing service administration for different settings including health promotion and disease prevention in outpatient, hospital, home, and palliative care including hospice care settings. Supporting quality of life for people living with and affected by HIV/AIDS, including symptom management, adherence to treatment modalities, and prevention for positives. Modulating management as a psycho social counselor and educator. Read More