Nursing Care of Acquired Immune Deficiency Syndrome
University of Jamestown
N 331: Medical-Surgical Nursing
November 1st, 2018
Acquired immunodeficiency syndrome (AIDS) is an infectious disease marked by severe immunodeficiency, resulting in the patient becoming increasingly susceptible to various opportunistic infections and cancer. It is the third and final stage of human immunodeficiency virus infection (HIV). According to Shannon (2018), the prevalence of human immunodeficiency virus infection in the United States is approximately 1 million cases with an annual incidence of about 40,000 cases. The Center for Disease Control (CDC) reported an estimate of 18,160 people diagnosed with HIV/AIDS in alone 2016 while a whooping 1,232,346 people have received an AIDS diagnosis since the inception of the epidemic in the early 1980s (Cdc.gov, 2018). It is caused by human immunodeficiency virus, an RNA classified as retrovirus. The virus targets CD4 cells receptors. Following primary infection, the HIV viral envelope fuses with the cellular membrane of the CD4 cells, thereby enabling the virus to incorporate its RNA into the host cells (Shannon, 2018). This results in viral replication and dissemination as well as the destruction of CD4 cells with a drop in CD4 T-cell count, normal being 500-1500 cells/ cubic milliliters. The CD4 count is used to stage HIV infection; when the cell count falls below 200 cells/cubic millimeters, the patient is in the third stage of infection and receives a diagnosis of AIDS. The nurse has a very important role to play in delaying the progression of the disease to the terminal stages and to ensure the patient lives a quality life. The CD4 cell count is utilized in staging HIV infection.
90-90-90 is a global treatment program initiative of the Joint United Nations Programme on HIV/AIDS with a directed goal that by 2020, among the people living with HIV, 90% will be aware that they are infected, 90% will be on sustained antiretroviral therapy, and 90% of everyone on antiretroviral therapy will be virally suppressed. The ultimate goal being to end the epidemic by 2020 (Unaids.org, 2018). However, according to (Bradley-Springer, 2018)), in spite of the advances made already, problems still exist that militate against realizing the desired goal by the year 2020. One of the problems that plague HIV treatment is the issue of non-adherence or non-compliance with the medication regimen. This leads to the development of drug resistance in which the virus fail to respond to treatment (Shannon, 2018)). Most of the HIV/AIDS patients are managed through home-care. Therefore, the home-care nurse has a very critical role to play in ensuring medication compliance and eventual prevention of the development of AIDS or delayed progression and improved quality of life for the AIDS patient.
Patient profile: Ken Dunn is a 42years old with symptomatic human immunodeficiency virus (HIV) disease. He lives with his partner and caregiver, Joe. Ken is a writer who works from home. The home health nurse visits twice weekly to assess Ken’s physical status and help with his numerous medications. In addition, to antiretroviral, drugs, Ken takes herbal supplements. He asks the nurse whether he should start smoking marijuana as he heard it might help his appetite. His CD4 T cell count recently dropped from 500 to 420cells/cubic mm. He says he knew he was sick but did not call the doctor or home health nurse. He also asks about hospice.
Home health nurse notes-objective data:
Dry cough, crackles in bilateral lung bases. Wrapped in blanket and states that he is still cold. Room temperature is normal. Ken admits mild dyspnea for the last two days. B/p 150/90, pulse 106/minute, and regular, respiration 28/minute and regular, oral temperature 101.8 degrees F. Purplish spots on his neck and arms.
The CD4 T cell count is one of the two laboratory tests that are used to monitor the progression and prognosis of human immunodeficiency virus infection; the other being the viral load (Lewis et al., 2017). In this particular patient, the CD4 T cell count recently dropped from 500 to 420cells/cubic mm. This significant change in the CD4 count indicates the entry of the patient into Stage 2 when count is between 200 and 499cells/cubic mm (Shannon, 2018). However, with the presence of certain AIDS-defining conditions (and/or CD4 T cell count of less than 200), the patient is classified as stage 3 (AIDS) of HIV disease. The Center for Disease Control has a comprehensive list of AIDS-defining conditions (Cdc.gov, 2018). In this case, going by the objective data of dry cough, crackles, dyspnea, temperature 106/min and purplish spots on the arm and neck, the patient may likely have an opportunistic infection of Pneumocystis pneumonia as well as Kaposi sarcoma, which are subject to confirmation. This indicates, considering the recent CD4 T cell count that the patient has progressed to stage 3 of HIV infection, which is the acquired immune deficiency syndrome.
The home health nurse plays a pivotal role in ensuring adherence to medication regimen and also in monitoring the physical status of the patient. In this case study, the three nursing diagnosis that are of priority for the patient are:
Imbalanced nutrition: less than body requirements. This occurs when the intake of nutrients becomes inadequate to meet the body’s metabolic needs (Matt, 2018). It is related to the patient’s lowered nutritional intake (possibly as a result poor appetite as patient indicated by desire to find help in marijuana) and increasing metabolic demands as a result of ongoing infection. An evidence of this is patient’s is inability to keep warm in spite of being wrapped up in blanket.
Powerlessness: this describes the experience of inability to exert control or influence over one’s situation (Matt, 2018). The patient often feels that one’s actions do not affect the outcome of the disease. In this case, this is related to the patient’s recent significant drop in the CD4 T cell count and worsening physical state. It is evidenced by the patient’s failure to call and inform the doctor or the home health nurse of new and worsening symptoms.
Knowledge deficit in the medication management of human immunodeficiency virus infection: this is related to lack of exposure to information or misinterpretation, as evidenced by the patient asking the home health nurse if he should start smoking marijuana to help improve his appetite (Matt, 2018). It is also evidenced by the patient’s use of herbal supplement, not considering the fact that they may have drug interaction with the antiretroviral medication thereby reduce the efficacy.
Considering Ken’s imbalanced nutrition (less than body requirement), the following nursing interventions will be of immense benefit:
To assess how much patient is able to chew, taste and swallow by examining the oral cavity for lesions of the mouth, throat and esophagus. HIV/AIDS patients are often susceptible to candidiasis, herpes simplex, hairy leukoplakia which may significantly lower the patient’s ability to swallow and even lead to poor appetite (Matt, 2018).
To weigh patient serially and evaluate with reference to the premorbid weight. Weight loss is a reliable, objective indicator of nutritional deficiency (Matt, 2018).
To encourage ambulation and increased physical activity as much tolerated. This may improve the patient’s craving for food and as well as the physical well-being (Matt, 2018).
To plan diet with patient and encourage high-caloric, nutritionally rich foods. Patient should be encouraged to eat frequent but small meals and to eat at times of the day when the appetite is appreciable (Matt, 2018).
To encourage patient to call the doctor for medication prescription that stimulate the appetite. Medications such as dronabinol, megestrol, and oxandrolone are known to serve as appetite stimulant in patients living with AIDS (Matt, 2018).
One of the symptoms highly recommended to be reported immediately include dyspnea, especially when related to activity and not relieved by rest (Lewis et al., 2017). This is because it is one of the respiratory manifestations of opportunistic infections such as Pneumocystis pneumonia, Mycobacterium avium-intercellulare, Legionella, and cytomegalovirus. Ken Dunn admitted to mild dyspnea and feeling of unwell but failed to report this either to the doctor or home health nurse. This is not uncommon in people living with HIV/AIDS. According to (Steward, Koester and Fuller, 2018), stigmatization constitutes a significant barrier to patient reporting symptoms or seeking care. HIV/AIDS patients experience similar health problems as others with chronic conditions but then, these problems are said to be worsened by societal negative beliefs and attitudes (Lewis et al., 2017)). The stigma, according to (Shannon, 2018), can lead to the isolation, negative coping, and inadequate social support. As a consequence, they tend to internalize problems unless it is an environment or health care worker they can trust. Another significant reason the patient did not report his infection may be the feeling of helplessness or worthlessness. People living with HIV/AIDS have a higher rate of depression than the healthy population and these symptoms may serve as early indicators (Shannon, 2018).
Individuals living with HIV/AIDS rely mostly on the home health nurse (and caregivers) in coping with the disease condition and treatment burden (Lewis et al., 2017). Therefore, one of the duties of the nurse is to identify areas where the patient has knowledge deficit and then teaching on such topics on a regular basis. Considering Mr. Dunn’s health status and questions, the following topics should be included in teachings during visits:
Signs and symptoms the patient needs to report to the doctor or the home health nurse immediately or within 24hours, (Lewis et al., 2017). This is important because of the failure of Mr. Dunn to notify of his worsening illness.
The importance of adherence to medication regimen and avoiding drug interactions by informing the primary care physician before commencing over-the-counter or herbal medication (Lewis et al., 2017). This teaching is necessary due to the fact that the patient is on herbal supplements of which it was not stated whether the doctor is aware or not. Apart from this, he also wanted to know if he should start taking marijuana with the hope of tackling poor appetite.
The importance of planning the diet to include high-caloric foods that tends to stimulate the appetite. The patient should also be taught to eat small but frequent meals and also to identify the time of the day his appetite is highest. He should be taught to eat around such time (Matt, 2018) This teaching is necessary because of Mr. Dunn concern about his appetite.
The signs and symptoms of infection. This is most likely a reinforcement of knowledge as Mr. Dunn was fully aware of his symptoms but chose to not report it for reasons best known to him.
End of life care. In spite of advances in the management of HIV/AIDS, most patients end up becoming disabled and succumbing to death. It is the duty of the nurse to help the patient cope with the new reality. It is especially important to include this teaching because the patient asked specifically about hospice care.
There are numerous reasons why the 90-90-90 global treatment goal may not be realized by the year 2020. One of such reasons is patient’s non-adherence to medication regimen which engenders drug resistance and a rapid progression of the disease. There is evidence to support the fact the home health nurse plays a pivotal role in identifying barriers and teaching patients on the importance of adherence with the treatment regimen and providing necessary support. In their research article, Wood et al. (2018) concluded that the nurse-led home-based approach has the potential of helping ensure adherence to antiretroviral drug therapy. The review evaluated the correlation of home-based nursing care and morbidity in patients living with HIV/AIDS. Seven studies were conducted; four were focused on the effect of nursing-led home-based adherence support. Results indicated that there was improvement in adherence to antiretroviral drugs with nurse-led home-based care. In order to ensure medication compliance, the home health nurse should incorporate home care education related to antiretroviral medication as part of the care plan, with the patient being made to verbalize the following elements of the teaching instructions:
Knowledge of the names of each medication,
Actions of each medication,
Dose and frequency of each medication
How to take medication (for example, whether with meals or before meals),
Possible side-effects of each medication,
The importance of adhering to medication regimen,
The need to inform health care provider of any side effects of new symptoms,
The importance of keeping track of medication and setting medication reminders.
Matt, V. (2018). 13 AIDS (HIV Positive) Nursing Care Plans. online Nurseslabs. Available at: https://nurseslabs.com/13-aids-hiv-positive-nursing-care-plan/
Steward, W., Koester, K. and Fuller, S. (2018). online Nursesinaidscarejournal.org. Available at: https://www.nursesinaidscarejournal.org/article/S1055-3290(18)30136-5/pdf
Shannon, M. (2018). HIV update. Nursing Made Incredibly Easy!, 16(5), pp.34-41.Wood, E., Zani, B., Esterhuizen, T. and Young, T. (2018). Nurse-led home-based care for people with HIV/AIDS. online Bmchealthservres.biomedcentral.com. Available at: https://bmchealthservres.biomedcentral.com/track/pdf/10.1186/s12913-018-3002-4
Lewis, S., Bucher, L., Heitkemper, M., Harding, M., Kwong, J. and Roberts, D. (2017). Medical- Surgical Nursing:Assessment and management of clinical problems. 10th ed. St. Louis, MO: Mosby, pp.222, 228, 229.
Bradley-Springer, L. (2018). AIDS 2018 and One More Thing. online Nursesinaidscarejournal.org. Available at: https://www.nursesinaidscarejournal.org/article/S1055-3290(18)30176-6/pdfUnaids.org. (2018). 90–90–90 – An ambitious treatment target to help end the AIDS epidemic. online Available at: http://www.unaids.org/en/resources/documents/2017/90-90-90 Accessed 16 Nov. 2018.
Cdc.gov. (2018). HIV in the United States | Statistics Overview | Statistics Center | HIV/AIDS | CDC. online Available at: https://www.cdc.gov/hiv/statistics/overview/ataglance.html Accessed 16 Nov. 2018.
Cdc.gov. (2018). Appendix AAIDS-Defining Conditions. online Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5710a2.htm Accessed 16 Nov. 2018.