Client Profile: Mr. Thomas is a 42 year old man admitted to the hospital with complaints of shortness of breath, fever, fatigue and oral thrush. The health care provider reviews the laboratory and diagnostic tests with Mr. Thomas and informs him he has pneumonia and is HIV positive. Mr. Thomas believes that he contracted HIV while involved in an affair with another woman three years ago. He is afraid to tell his wife, knowing she will be angry and that she may leave him.
Case Study: The nurse assigned to care for Mr. Thomas reads in the medical record (chart) that he learned two days ago he was HIV positive. There is a note in the record that indicates that Mr. Thomas has not told his wife the diagnosis.
To complete a functional health pattern assessment, the nurse asks Mr. Thomas if he may ask him a few questions. Mr. Thomas is willing and in the course of their conversation shares with the nurse that he believes that he contracted the HIV during an affair with another woman.
He states, “How can I tell my wife about this? I am so ashamed. It is bad enough that I had an affair, but to have to tell her in this way – I just don’t think I can. She is not sick at all. I will just say I have pneumonia and take the medication my health care provider gave me. I do not want my wife of anyone else to know. If she begins to show signs of not feeling well, then I will tell her.
I just can’t tell anyone. What will people think of me if they know I have AIDS?”
1. Briefly discuss how the HIV is transmitted and how it is not. How can Mr. Thomas prevent the transmission of HIV to his wife and others?
In infected people, infectious HIV is present only in cells and in some bodily fluids. HIV can be isolated easily from blood, semen and vaginal/cervical secretions (including menstrual fluids). Blood and semen are the cells that are most likely to carry HIV. HIV has also been isolated from breast milk. With much greater difficulty, the virus has on occasion, been isolated from saliva, tears, and urine. It is has not been isolated from perspiration or feces. The current scientific view is that body fluids other than blood, semen, vaginal/cervical secretions, and breast milk, contain so little, if any, HIV that they are not of major importance in HIV transmission between individuals. HIV is very fragile outside of the body, so transmission requires direct contact of two substances, fluid containing the HIV from an infected person and susceptible cells (usually via the blood stream) of another person. Casual contact includes all types of ordinary every day, non-sexual contact between and among people. Shaking hands, hugging, kissing, sharing eating utensils, sharing towels or napkins, using the same phone and using a toilet seat are all examples of casual contact. Because HIV is quickly inactive outside the body, it cannot survive in open air or in water. (1) Methods that Mr. Thomas can transmit HIV to his wife and others would be any type of blood transmission or intimate sexual contact. Epidemiological data points to three modes of HIV transmission from person to person: from blood, from birth, and from sex. Since Mr. Thomas is male we can cross out birth. Mr. Thomas can prevent transmission of HIV to his wife and others by only engaging in sexual activity with a condom, and even then there is a risk of the condom breaking and then being careful with any types of cuts, open wounds, and contact with others and his own blood.
2. Mr. Thomas stated, “What will people think of me if they know I have AIDS?” How can the nurse explain the difference between being HIV positive and having AIDS?
The nurse can explain n that Mr. Thomas does not have AIDS. AIDs are a complication once the immune system can no longer handle fighting the HIV infection. HIV is the actual infection itself, AIDS is what happens once the immune system is compromised leading the way to other infections that may not affect a normal healthy adult or child, but become life threatening to a person with AID’s. This is caused by the weakened immune systems inability to fight off any infection.
3. Discuss the ethical dilemmas inherent in this case.
HIV disclosure is defined as a ‘complex and multifaceted process of making a voluntary or involuntary decision about whom to inform about one’s status, why, when, where and how’ . This is particularly challenging when it comes to informing patients’ sexual partners, also referred to as partner notification. The three approaches to partner notification include: i) source referral, whereby the health care provider encourages the patients to alert their partners themselves; ii) provider referral, whereby the health care provider notifies the partners with the consent of the patients while respecting the patients’ confidentiality; and iii) conditional referral, whereby the patients in agreement with the health care provider are supposed to inform their partners within a given time frame otherwise the health care provider will do so (but without revealing the patients’ identity)(2)
4. Does the health care provider have a legal obligation to tell anyone other than Mr. Thomas that he is HIV positive? If so, discuss.
Legally, the nurse can’t tell anyone. “In court notifying an HIV-positive patient’s partner can be argued in terms of breaching professional ethics because ethically it is wrong to disclose your patient’s result or diagnosis to third parties without that individual’s consent.”
5. Any loss, such as loss of one’s health, results in a grief response. Describe the stages of grief according to Kubler-Ross. Denial: “This cannot happen to me!”
Anger: “Why did this happen to me? Who’s to blame for this?”
Bargaining: “Just let me live, and I’ll do anything”
Depression: “I am too sad to do anything”
Acceptance: “I’m at peace with what is coming”.
6. Discuss which stage of grief Mr. Thomas is most likely experiencing. Provide examples of Mr. Thomas’s behavior that support your decision.
I believe that Mr. Thomas is experiencing both denial and anger. In denial, he recognizes that this is indeed happening to him but he does not want his wife to know and that is his refusal to accept what is going on. The anger portion comes from him blaming his affair for it happening in which sense he blames both himself and the woman he had the affair with.
7. What laboratory tests are used to confirm the diagnosis of HIV infection in an adult?
HIV is most commonly diagnosed by testing your blood or saliva for the presence of antibodies to the virus. A newer type of test checks for HIV antigen, a protein produced by the virus immediately after infection.
8. Discuss the function of CD4 T cells and provide an example of how the CD4 t cell count guides the management of HIV. CD4 cells are a type of white blood cell that’s specifically targeted and destroyed by HIV. A healthy person’s CD4 count can vary from 500 to more than 1,000. Even if a person has no symptoms, HIV infection progresses to AIDS when his or her CD4 count becomes less than 200. (3)
9. Briefly explain the purpose of viral load blood tests in monitoring the progression of HIV.
The viral load test measures the amount of virus in your blood. Studies have shown that people with higher viral loads generally fare more poorly than do those with a lower viral load.(3)
10. Mr. Thomas expresses a readiness to learn more about HIV. Discuss the nurse’s initial intervention when beginning client teaching and then discuss the progression of the HIV disease, including an explanation of primary infection, A, B, and C and four main types of opportunistic infections. There are different stages of HIV infection. Primary HIV infection can show symptoms that can be confused as the flu. These symptoms can last for a couple days to a few weeks and then disappear. Stage 2 is an asymptomatic stage meaning that the patient probably shows little to no symptoms. “This stage lasts for an average of ten years and, as its name suggests, is free from major symptoms, although there may be swollen glands. The level of HIV in the peripheral blood drops to very low levels but people remain infectious and HIV antibodies are detectable in the blood, so antibody tests will show a positive result. Research has shown that HIV is not dormant during this stage, but is very active in the lymph nodes. A test is available to measure the small amount of HIV that escapes the lymph nodes. This test which measures HIV RNA (HIV genetic material) is referred to as the viral load test, and it has an important role in the treatment of HIV infection.” (4) Stage 3 is symptomatic HIV characterized by lymph nodes and tissues becoming permanently damaged and the virus beginning to mutate to AIDs due to the inability of the body keeping up with helper T cell rebuilding as the HIV virus kills off the helper T cells. Stage 4 is progression of HIV to AIDS. AIDS is diagnosed when any condition listed in clinical stage 4 is diagnosed and/or the CD4 count is less than 200 cells/mm3 or a CD4 percentage less than 15. (4) The ABC’s of HIV are:
Abstinence for youth, including the delay of sexual debut and abstinence until marriage Being tested for HIV and being faithful in marriage and monogamous relationships Correct and consistent use of condoms for those who practice high-risk behaviours (4) The CDC has listed 24 types of opportunistic infections regarding HIV. As his nurse I would make sure Mr. Thomas had the information regarding all 24, but I would clarify on the 4 main ones since he is already exhibiting symptoms of those. Four main types of opportunistic infections in regards to HIV are: “Thrush: fungal infection of the mouth, throat, or vagina. Herpes simplex virus: can cause oral herpes (cold sores) or genital herpes. This is a fairly common infection but if you have HIV, the outbreaks can be much more frequent and more severe. Mycobacterium avium complex (MAC or MAI) – a bacterial infection that can cause recurring fevers, general sick feelings, problems with digestion, and serious weight loss Pneumocystis pneumonia (PCP) – a fungal infection that can cause a fatal pneumonia.” (6)
11. Following the nurse’s teaching, Mr. Thomas states, “How stupid I was to have that affair. Not only could it ruin my marriage, but it gave me a death sentence.” Share with Mr. Thomas what you know about long-term survivors, long-term non-progressors, and highly active antiretroviral therapy (HAART).
HIV carriers can carry the virus for a decade showing little to no symptoms.
There are many different types of maintenance drug therapies to alleviate symptoms, and reduce the rate of progression. Antiretroviral therapy can help stall the progression of the disease, however, discontinuation of antiretroviral therapy may result in viral rebound, immune decomposition, and clinical progression of HIV. Interruption of HAART is not recommended (7). With HAART, patients who have had a positive HIV test have gone as long as 30 years with little to no symptoms and no progression of AIDS (6). HAART is defined as a drug regimen to achieve sustained viral suppression. Simplified treatment regimens and decreasing the number of medications that patients have to take each day has proven effective in patient’s adherence to their treatment. Drug companies are constantly finding new ways to combine the inhibitors into 2-3 medications versus the extensive treatment regimens originally used. Overall adherence rates are still only 30-50% in the US, so I would recommend extensive follow up with Mr. Thomas and his health care providers to increase his adherence.
12. Discuss how the nurse should respond if Mr. Thomas’s wife approaches him in the hall and asks, “Did the test results come back yet? Do you know what is wrong with my husband?”
The nurse must tell Mr. Thomas’s wife that she cannot discuss Mr. Thomas’s medical condition with her and that she must ask Mr. Thomas himself. Legally and ethically, the nurse cannot give Mr. Thomas’s wife any information regarding his condition and diagnosis if Mr. Thomas has specifically asked for no information to be disclosed, which he has.
13. List five possible nursing diagnoses appropriate to consider for Mr. Thomas.
I chose these 5 for where Mr. Thomas is related to his disease at this time.
1. Deficient knowledge related to HIV infection, means of preventing HIV transmission, and self-care
2. Risk for infection related to immunodeficiency.
3. Activity intolerance related to weakness, fatigue, malnutrition, impaired
fluid and electrolyte balance and hypoxia associated with pulmonary infections.
4. Social isolation related to stigma of disease, withdrawal of support systems, isolation procedures, and fear of infecting others.
5. Anticipatory grieving related t changes in lifestyle and roles and unfavorable prognosis
1) Conner, Ross F., & Fan, Hung Y., & Vilarreal, Luis P. Aids, Science and Society, Sixth Edition, 2011, Jones and Bartlett Publishers, LLC 2) http://www.biomedcentral.com/1472-698X/11/6
7) Smeltzer, Suzanne C., & Hinkle, Janice L., & Bare, Brenda G., & Cheever, Kerry H. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, (2010), Wolters Kluwer Health/Lippincott Williams & Wilkins