HIV/AIDS attacks the innocent as well as those who place themselves in deliberately at-risk situations (AIDSInfo, 2016). The specific case study here relates to the situation in which a young 26-year-old woman, daughter of immigrant parents of east Asian descent, found herself. Ms Sara Lu lives at home with her parents and two female siblings, is an accountant preparing for graduate school. One of the requirements was a mandatory physical, her first since her open-heart surgery. Sara is also planning a wedding that is scheduled in 6 months. Her fiancé, 10 years her senior, would like to have children. He is the only individual with whom she has had any sexual contact since she was 18. Their sexual relations are persistently unprotected.
Sara’s Physical Assessment
Sara’s general symptoms are extreme fatigue, a sore throat, intermittent bouts of diarrhea, more sweating than usual, and mild shortness of breath for about a month. Her overall feeling of fatigue has prevented her from going to the gym where she normally works out three or four times every week. She complains that her symptoms remind her of the flu she had when she was 18 from which she did not easily recover which occurred at about the same time she became involved with her fiancé. At age 19 Sara had open heart surgery to correct a congenital heart valve defect. Sara experiences some atrial fibrillation when overly tired and stressed, but not enough to require medication. Ms. Lu’s physical examination reveals that she has enlarged lymph nodes in her neck and white patches on her oral mucosa. Her throat looks enflamed. Ms. Lu’s skin is warm to the touch and dry, and her vital signs are as follows: T 100.8°F, P 84, R 20, and BP 122/78 mm Hg. There are slight crackles in her left lower lung lobe.
In consultation with the physician, Sara’s nurse practitioner orders the following tests: a complete CBC, metabolic panel, urinalysis, throat culture, chest x-ray, TB testing, mononucleosis testing, a short-term antibiotic, and a gynecological visit. Ms. Lu is also asked for consent for HIV blood testing, which she reluctantly provides. A gynecological exam is also ordered; this will be the first time Sara has had a gynecological exam. During her follow-up visit, results show a clear chest x-ray, slight anemia, antibodies against HIV, ESR increased, CD4+ cell count 500, viral load 25,000, and thrush. Below are five nursing diagnoses for Sara based on Sara’s specific physical, psycho-social, cultural, and emotional needs.
Diagnosis 1
Fatigue that may be R/T increased demands for energy, i.e. graduate school preparation, upcoming wedding plans, overwhelming psychological worries R/T her family’s cultural background (AIDSInfo, 2016). Sara, a first-generation American, worries that her parents do not understand her physical changes, creating for Sara an additional psychological and emotional tension leading to increased energy requirements. These are evidence by continual lack of energy, inability to function normal ADLs, lack of concentration at work and on her upcoming studies and even wedding planning, overall feeling of exhaustion (UNKLab, 2012).
Outcome 1
Become more proactive in her wedding plans; make decisions about her graduate studies. Perform ADLs to the best of her ability on a daily level, and attempt to visit the gym for limited exercise to increase her metabolic output (Lodi, Philips, Logan, & et al., 2015).
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Intervention 1
Encourage Sara to: assess her sleeping habits, help her establish realistic activity goals, plan activities when she has higher energy levels, take periodic rest breaks to conserve energy, and keep track of her ADL functioning levels (CDC, 2016). Encourage Sara to discuss her situation with her family. They are close knit, but her parents’ cultural differences may be an added stressor to Sara since she is not certain how they will respond to her situation. Encourage Sara to visit the occupational therapist working in collaboration with her gym. If possible, cut down on her demanding work schedule (UNKlab, 2012).
Implementation 1
Encourage Sara to self-monitor her HR, BP, nutritional maintenance is necessary to meet body’s demands for increased energy to stimulate immune system in its fight against the HIV infection (AIDSInfo, 2016). Decrease her psychological energy demands by discussing her situation with her family to garner their support. Being forthright with her family will remove one of the emotional and psychological barriers to her fatigue (May, Gombels, Delpech, & et al., 2014). Visit the occupational therapist and go to the gym for limited periods of exercise.
Evaluation 1
Keep a daily diary about her implementation of the monitoring her HR, BP, breathing rate, daily nutritional intake. If Sara notices any increase in energy, her physical activity, report her progress (CDC, 2016). Ensure she plans activities when at highest energy level. Report her daily nutrition and liquid intake. Note her family’s reaction to her condition, supportive, non-supportive.
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Diagnosis 2
Imbalanced Nutrition: Less than Body Requirements R/T lack of interest in food, diarrhea, sore throat, inability to ingest food, chewing increasingly painful, inflamed buccal cavity, increased need of body for nutrition leading to weight loss from lack of intake (CDC, 2016; US Dept HHS, 2016).
Outcome 2
Maintain or increase weight gain through a more proactive positive attitude toward nutritional intake. Increased energy levels due to better dietary habits.
Intervention 2
Plan dietary scheduling with Sara. Encourage her to eat foods high in caloric and nutritional value. Decrease foods that create nausea or diarrhea, plan smaller meals, recommend foods that are easy to chew, swallow, and digest. Involve Sara in every step of the nutritional plans so that she will be proactively astute for the needs of her body now that she is certain of the HIV diagnosis (UNKlab, 2012).
Implementation 2
Sara needs to keep a daily record of her food intake, help plan meals with her mother who is the caretaker in the family, cooks all the meals, does the shopping. Sara needs to involve her parents in this part of her daily programming intervention. Sara should also record which foods are more attractive and easily digestible, eat larger meals when she is hungry. Keep small nutritional snacks with her so that she has no periods of hunger (AIDSInfo, 2016).
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Evaluation 2
Check with Sara on a weekly basis to see if she is maintaining her weight. Discuss her eating program, her parents’ and siblings’ reactions and assistance to her requirements for nutritional help.
Diagnosis 3
Anxiety/Fear – R/T change in circumstances, worry about parental attitude toward her illness, discussion with Sara’s fiancĂ© relating to his need for HIV testing. His desire for children from their marriage. Fear she will transmit disease to her family, that her fiancĂ© will break their relationship, that she will not be able to continue either her work or her studies and will become a social outcast as well as lose family support system (AIDSInfo, 2016; UNKlab, 2012).
Outcome 3
Be proactive with her family and fiancé, tell them exactly how she feels. Discuss the possibility of Sara’s having children, advise her to seek psychological counseling with a specific HIV/Aids trained counselor.
Intervention 3
Maintain stable and constant relationship with Sara. Ensure her of absolute confidentiality, keep track of any signs of withdrawal and/or anger in Sara’s demeanor, keep her apprised of all test results, and positive and/or negative changes in lab workups (UNKlab, 2012). Help Sara evaluate a new life-changing schedule that can include continued studies as well as her forthcoming marriage, but within the limitations of her energy levels.
Implementation 3
Schedule weekly or even bi-weekly appointments with Sara, even if they are only 10 or 15 minutes. Check on her diaried data, encourage Sara to openly discuss her anxieties, parents’ reactions to her daily struggle with life changes. Ensure that Sara has been in contact with a counselor, support group, or any other positive environment to help her through the various stages of her illness (May et al., 2014). The early stages will be the most difficult for Sara, she will need all the professional encouragement available (Lodi et al., 2015; May et al., 2014).
Evaluation 3
Chart Sara’s progress, see if her anxieties are lessening. Check with Sara about her family’s acceptance of her condition and the life-changes she has had to make. Ask Sara about her fiancé’s reaction to the need for HIV testing, if he has been to a doctor, what are his results, and the emotional situation incurred for them both.
Diagnosis 4
Social Isolation – R/T feelings of estrangement from friends and work colleagues, family members may also be a bit unwary of how to behave around Sara. Her fiancĂ© may reject Sara, which is also attuned with her fears and anxieties (May et al., 2014; UNKlab, 2012).
Outcome 4
Help Sara find support groups, whether in community or family members. Talk openly with Sara about how to locate external resources to help relieve her feelings of isolation.
Intervention 4
Discuss the feelings of isolation openly with Sara, limit the use of masks or protective gowns when talking with Sara. Be frank about her fiancé’s reaction to the situation. Ask if her wedding and educational plans have been revised, limited, or stopped, and discuss alternatives with Sara for any way to bring her back into the social sphere she once enjoyed.
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Implementation 4
Follow through with Sara, talk with her about the way she has approached any support group, her active involvement in any social engagements, within the limitations of her energy levels (UNKlab, 2012). Find out from Sara whether her wedding plans will go forward as planned. Discover whether she has the support of her fiancé since she has been with him for 8 years it has been a long-term relationship. He is essentially her SO, been her primary support in other aspects of her life even though she still lives at home with parents and siblings.
Evaluation 4
Evaluate Sara’s progress as she describes any social interaction, be attuned to any withdrawal from activities on Sara’s part, evident behavioral and attitudinal changes that can be addressed in their discussions or in group support meetings or with a one-on-one counselor.
Diagnosis 5
Powerlessness – may be R/T changes in circumstances, increased possibility of advancing CNS infections. Feelings of loss of control over own life (May et al., 2014). Sara may become more depressed over physical image, she took pride in her physicality prior to the illness, insufficient grieving time, feelings of anger, guilt, and displaced resentment at herself, increased dependence on others for her hitherto normal activities (UNKlab, 2012).
Outcome 5
Help Sara verbalize her attitudes, acknowledge her feelings rather than keeping them bottled up, help her to find positive ways of dealing with her situation, become proactive in making choices rather than allowing her feelings of anger and guilt create a lethargic reaction toward life.
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Intervention 5
Encourage Sara to be proactive in her situation. Assess when she feels the most powerless and help her deal with the actualities of the situation. Encourage her to understand all the ramifications of her condition (O’Connor et al., 2014). Powerlessness is a new sense of loss for Sara since she has been proactive all her life, she knew what she wanted to do in her career even in high school, now her condition has appeared to put a halt to these dreams. She feels virtually no control, so to help Sara take control, not delimit herself based on fear of the future. Also ensure Sara is continuing her ART treatments (Lodi et al., 2014; O’Connor, 2014).
Implementation 5
Talk with Sara regarding her activities, her anger, and guilt. See if she has taken as much control back in her life as possible with her education, her work schedule, physical activities, and wedding plans.
Evaluation 5
Evaluate Sara’s progress in dealing with her anger. Check on her progress – see if she is taking charge of her MA in accounting, even attending one class, if she is continuing her physical exercises at the gym, visiting with the occupational therapist, attending support group meetings. Be open with Sara regarding her future marriage. Sara feels powerless at not being able to have children, but this is not the case, ensure Sara that with correct precautions (HIV Ibase, 2016), Sara can have children if she continues with her antiretroviral therapy (ART), plans for a C-section birth, and continues her medication as prescribed (HIV Ibase, 2016; O’Connor et al., 2014).
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Evaluation of Sara – Post Diagnoses
Since the nursing diagnosis deals with the needs of the patient behind the medical diagnosis, dealing with Sara’s situation by discussing her family’s reaction, particularly in light of her family’s ethnicity is a necessary adjunct to a nursing diagnosis (UNKlab, 2012). How has this influenced their reaction to Sara’s condition? Are other family members involved in Sara’s changed circumstances? Nursing care and nursing extends beyond the medications, but embraces all components of a patient’s needs, whether in the clinical/hospital setting, in the home, at work, or in social reacclimatizing post diagnosis (UNKlab, 2012). A nursing diagnosis encompasses her continued care with the patient and helps her to understand all the risks involved in her condition, but also how Sara can remain proactive rather than withdrawn and lethargic (Lodi et al., 2015; May et al., 2014).
HIV Testing for Sara
According to the World Health Organization (WHO) for Sara’s initial visit to the clinic for testing, the results indicated that Sara is at Clinical Stage 3 of her disease (WHO, 2016) – R/T -unexplained weight loss, chronic diarrhea, prolonged fever, slight anemia, antibodies against HIV, ESR increased, CD4 cell count 500, viral load 25,000, and thrush. Sara’s CDR4+ (t-cells) count is at the lower level for HIV 1 stage (Lodi, et al. 2015; May et al., 2014). The objective is to increase her CDR4+ count since these fight infections, and stimulate her immune system against further infections (O’Connor, Smith, Lampe, & et al., 2014). In addition to the original tests, three tests are the most efficacious for HIV testing: “antibody tests, combination tests (antibody/antigen tests), and nucleic acid tests (NATs)” (US Dept HHS, 2016, sec HIV Testing). Due to the expense of the NATs, these are not routinely done in the first stages of testing. The antibody and combination antibody/antigen tests determine whether or not the patient is HIV positive due to the time it takes for the body to produce sufficient proteins for a result (3-12 weeks) (US Dept HHS, 2016, sec HIV Testing). Since Sara exhibits anemia, CBC testing is effective for this condition (UNKlab, 2012). Other types of infections are Opportunistic Infections (OIs) that arise when a person may not realize they have the HIV virus, or once diagnosed do not keep up with their prescribed therapy. OIs decrease the body’s immune system in warding off infections or keeping infections minimalized (CDC, 2016). Other testing related to OIs are annual TB screening, PAP smear for cervical cancer screen, monitor for other sexually transmitted diseases, CBC screening for blood disorders seen with blood cancer and also for infections, and ass for lymphadenopathy (swollen lymph nodes in CA or infection) (CDC, 2016).
Most Likely Source of Sara’s Infection
The most likely source of Sara’s infection is her prolonged (8 years) unprotected sexual relations with her fiancé. At her insistence, he was tested positive for HIV/Aids and since Sara has had no other sexual contact since she was 18, then it is apparent that he transmitted the disease to her (AIDSInfo, 2016). Another possibility would be needle exchange in drug use, but since Sara has never used recreational drugs of any kind, this is highly unlikely. Her open heart surgery at the age of 19, which involved blood transfusions, may be a contributor, but since the percentage of infected blood being used in a US hospital are virtually non-existent, this too is another negated possibility (AIDSInfo, 2016). Although the initial damage is done, and Sara is HIV positive, further sexual contact with her fiancé should be through protected sex rather than unprotected helping to reduce further advances with the disease counter intuitive to her ART therapy and other prescribed medications (May et al., 2015; O’Connor et al., 2014).
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Can an HIV Positive Woman Have a Baby?
In the event that Sara’s marriage takes place and that both she and her fiancé are HIV positive, he would still like to have a child. Sara is afraid this is not possible, but according to the statistics on HIV positive mothers giving birth to a non-HIV baby (AIDSInfo, 2016; HIV Ibase, 2016, sec 6.3). The factors involved in this situation are quite good (CDC, 2016). Sara can become pregnant with minimal risk to the baby if she continues her ART during and after the pregnancy. Her future husband’s HIV positive status will have no impact on the baby’s HIV status (HIV Ibase, 2016, sec 6.3). Birthing through the birth canal is most dangerous since the baby’s eyes and other mucous membranes would be in contact with the mother’s mucosa (HIV IBase, 2016, sec 6.3). A C-Section is the only recommendation for an HIV positive mother to give birth. Breastfeeding or even using breast milk is another situation to avoid. The infection can be transmitted through breast milk (CDC, 2016; HIV IBase, 2016, sec 6.3).
References
AIDSInfo. (2016). HIV testing. US Department of Health and Human Services. Retrieved from https://AIDSInfo.nih.gov/understanding-hiv-aids/fact-sheets/19/47/hiv-testing
CDC. (2016). Opportunistic infections. Center for Disease Control and Prevention. Retrieved from https://www.cdc.gov/hiv/basics/livingwithhiv/opportunisticinfections.html
HIV Ibase. (2016). Pregnancy and HIV, sec. 6.3. Retrieved from http://i-base.info/ttfa/6-hiv-and-pregnancy/3-hiv-and-pregnancy-overview/
Lodi, S., Phillips, A., Logan, R., Olson, A., Costagliola, D., Abgrall, S., van Sighem, A., Reiss, P., MirĂł, J., Ferrer, E., & et al. (2015). Comparative effectiveness of immediate antiretroviral therapy versus CD4-based initiation in HIV-positive individuals in high-income countries: observational cohort study. Lancet HIV, 2(8), 335-343. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26423376
May, M., Gompels, M., Delpech, V. & et al. (2014). Impact on life expectancy of HIV-1 positive individuals of CD4+ cell count and viral load response to antiretroviral therapy. AIDS, 28(8), 1193–1202. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004637/
O’Connor, J., Smith, C., Lampe, F. & et al. (2014), Failure to achieve a CD4+ cell count response on combination antiretroviral therapy despite consistent viral load suppression. AIDS, 28(6), 919-924. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24335482
US Dept of Health and Human Services. (2016). Laboratory testing for initial assessment and monitoring of hiv-infected patients on antiretroviral therapy. Aids Info.com. Retrieved from https://AIDSInfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/3/tests-for-initial-assessment-and-follow-up
WHO. (2016). WHO classification for HIV/AIDS infection. IBASE. Retrieved from http://i-base.info/ttfa/learning-resources/who-classification-system-for-hiv-infection/
