Case Study 103 – Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome
Scenario
K.D. is a 56-year-old man who has been living with human immunodeficiency virus (HIV) infection for 6 years. He had been on antiretroviral therapy (ART) with a regimen of tenofovir and emtricitabine (Truvada), with darunavir and cobicistat (Prezcobix). He stopped taking his medications 4 months ago because of depression. The appearance of purplish spots on his neck and arms persuaded him to make an appointment with his provider. At the provider’s office, K.D. stated he was feeling fatigued and having occasional night sweats. He said he had been working long hours and skipping meals. Other than the purplish spots, the remainder of K.D.’s physical examination findings was within normal limits. The doctor took 3 skin biopsy specimens and obtained a chest x-ray examination, tuberculin test, and laboratory studies, including a CBC, CD4 T-cell count, and viral load.
Over the next week, K.D. developed a nonproductive cough and increasing dyspnea. Last night, he developed a fever of 102° F (38.9°C) and was acutely short of breath, so his partner brought him to the emergency department. He was admitted with probable Pneumocystis jiroveci pneumonia (PJP), which was confirmed with bronchoalveolar lavage examination under light microscopy. K.D.’s CD4 T-cell count is 175 cells/μL and viral load 35,230 copies/μL. K.D. is on nasal oxygen, IV fluids, and IV trimethoprim-sulfamethoxazole. His current VS are 138/86, 100, 30, 100.8° F (38.2° C) and SpO2 92%.
1. What is the importance of CD4 T-cell and viral load counts?
2. What is PJP? Pneumocystitis jiroveci Pneumonia. Most common opportunistic infection in persons with HIV>
3. The skin biopsies return a diagnosis of Kaposi sarcoma (KS). What is KS?
4. What is the significance of K.D. developing KS and PJP in light of the CD4 count?
5. K.D. has been seropositive for several years. What factors might have influenced his development of PJP and KS?
6. Name 4 problems you must manage at this time with K.D.
7. What type of isolation precautions do you need to use when caring for K.D.?
- Droplet- pneumonia
- Contact
- Standard
- Airborne
Correct answer is: A
8. What immediate complication is K.D. at risk for experiencing? Acute respiratory failure
9. To detect this complication, what will be the focus of your ongoing assessment?
10. Why was K.D. placed on trimethoprim-sulfamethoxazole? What major side effects do you need to monitor for in K.D.?
11. What aspects of K.D.’s care can you delegate to the licensed practical nurse (LPN)? Select all that apply.
- Providing instructions about a high-calorie, high-protein diet
- Administering first dose of IV trimethoprim-sulfamethoxazole
- Repositioning K.D. and having him deep breathe every 2 hours
- Developing a plan of care to improve K.D.’s oxygenation status
- Reinforcing teaching with K.D. about good hand washing techniques
- Monitoring K.D.’s pulse oximetry readings and reporting values under 95%
12. K.D. has 20 KS lesions on his neck, upper chest, and both upper arms, all of which are closed and painless. How will you care for these lesions?
- Keep each lesion covered with a clear, transparent dressing.
- Place sterile, saline-soaked gauze over each lesion twice daily.
- Keep the lesions dry, cleaning the affected areas gently as needed.
- Apply topical antibiotic ointment twice daily to the affected areas.
.
13. Because of compromised immune function, K.D. is at risk for developing other opportunistic infections. List 5 infections.
14. Outline the assessment you need to perform to determine whether these problems are present.
We need to get labs, full skin assessment, vitals, respiratory, cardiac assess.
15. What interventions can you use to help K.D. in managing his depression?
Support groups, allow for expressing of fears/feelings, psychologist, exercise, sleep schedule.
16. Recognizing that K.D. has multiple posthospital needs, you begin discharge planning. What type of assessment do you need to complete as part of K.D.’s discharge planning?
17. What other health care team members might you involve in K.D.’s discharge planning?
RD, respiratory, home health, counselor or psychologist.
CASE STUDY PROGRESS
K.D. is responding well to treatment for PJP and plans are being made for discharge. He will receive follow-up care at the outpatient clinic and soon begin radiation treatments for the KS. His ART regimen is changed to a fixed-dose combination regimen with emtricitabine-tenofovir-efavirenz (Atripla).
18. K.D. is kept on trimethoprim-sulfamethoxazole (Bactrim) 2 tablets once daily. He asks why he has to keep taking Bactrim “since the pneumonia is gone.” How would you respond?
Full dose as prescribed to make sure it doesn’t return and that its fully working.
19. What is the reason that K.D. receives combination ART therapy with emtricitabine-tenofovir-efavirenz (Atripla)?
- Combination ART is only effective when CD4-positive T-cell counts are below 200/μL
- Giving the drugs in a single pill reduces the incidence of cross-resistance between drugs
- Using smaller doses of three different drugs reduces the incidence of side effects of each drug
- Combination ART inhibits viral replication in different ways and decreases the chance of drug resistance
20 How can you help K.D. take Atripla as prescribed?
21. What ongoing laboratory monitoring will K.D. need?
22. K.D. was taught about disease transmission and safer sex and encouraged to maintain moderate exercise, rest, and dietary habits when he was first diagnosed with HIV infection. Give at least 3 additional topics to stress with K.D. before he goes home.
CASE STUDY OUTCOME
K.D. took the Atripla as prescribed and was happy that after 3 months of therapy, his CD4 T-cell count was up to 403 cells/μL. The KS lesions have declined in number and size with the ART and radiation therapy. He says his partner and he are dealing with his fatigue., Overall, he says he feels better and taking the diagnosis of HIV “more seriously” by doing more to stay healthy.
Difficulty: Advanced
Setting: Outpatient clinic, hospital
Index Words: systemic lupus erythematosus (SLE), lupus nephritis, lupus cerebritis, plasmapheresis
Giddens Concepts: Immunity, Elimination, Perfusion, Safety
HESI Concepts: Immunity, Elimination, Perfusion, Safety
Name _________________________________ Class/Group _______________ Date _______________
Scenario
D.W. is a 29-year-old married woman with three children under 5 years of age. She saw her provider 7 months ago with intermittent fatigue, joint pain, low-grade fever, and unintentional weight loss. Her provider noted small, patchy areas of vitiligo and a scaly rash across her nose, cheeks, back, and chest at that time. Laboratory studies showed D.W. had a positive antinuclear antibody (ANA) titer, positive anti-dsDNA test, positive anti-Sm test, elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and decreased C3 and C4 serum complement. Joint x-ray films showed joint swelling without joint erosion. D.W. was diagnosed with systemic lupus erythematosus (SLE). Initial treatment consisted of hydroxychloroquine (Plaquenil), prednisone, and naproxen sodium, and ice packs. D.W. responded well and the steroid was tapered and stopped. She was told she could follow up every 6 months unless her symptoms became acute. D.W. resumed her job in medical billing at a large geriatric facility.
1. What is the significance of each of D.W.’s laboratory findings?
2. Using the mnemonic SOAP BRAIN MD, how is SLE diagnosed?
3. What priority problems would be addressed in D.W.’s care plan at the time of diagnosis?
Respiratory care, pain management, skin care, infection control.
CASE STUDY PROGRESS
Twenty-eight months after diagnosis, D.W. seeks out her provider, saying that she has increased fatigue and puffy hands and feet. D.W. reports that she has been working longer hours because of the absence of two co-workers who are on maternity leave.
Chart View
Laboratory Test Results
| Sodium | 129 meq/L (129 mmol/L) low |
| Potassium | 4.2 meq/L (4.2 mmol/L) normal |
| Chloride | 119 meq/L (119 mmol/L) slightly elevated |
| Total CO2 | 21 meq/L (21 mmol/L) low (alkalotic) |
| Blood urea nitrogen (BUN) | 34 mg/dL (12.1 mmol/L) high |
| Creatinine | 2.6 mg/dL (230 mcmol/L) high |
| Glucose | 123 mg/dL (6.8 mmol/L) slightly elevated |
| Urinalysis | 2+ protein, 2+ hematuria abnormal |
4. Which laboratory findings concern you, and why?
5. The goal of therapy in lupus nephritis is to normalize or prevent the loss of renal function. To reach this goal, what additions to D.W.’s care can you anticipate?
6. The provider orders cyclophosphamide 100 mg/m2/day orally in two divided doses. D.W. weighs 140 pounds (63.5 kg) and is 5 feet, 4 inches (163 cm) tall. How much will she receive with each dose? 100/101.7= 10,170/2= 5085mg each dose.
7. What key points should you include in a teaching plan about cyclophosphamide therapy?
CASE STUDY PROGRESS
D.W. is seen in the immunology clinic twice monthly during the next 3 months. Although her condition does not worsen, her BUN and creatinine remain elevated. While at work one afternoon, D.W. begins to feel dizzy and develops a severe headache. She reports to her supervisor, who has her lie down. When D.W. starts to become disoriented, her supervisor calls 911, and D.W. is taken to the hospital. D.W. is admitted for probable lupus cerebritis related to acute exacerbation of her disease.
8. What other findings indicative of central nervous system involvement should you assess for in D.W.?
9. What protective measures need to be instituted at this time?
10. In caring for D.W., which care activities can be delegated to the UAP? Select all that apply.
- Monitoring D.W.’s BUN and creatinine levels
- Counseling D.W. on seizure safety precautions
- Assisting D.W. with personal hygiene measures
- Assessing D.W.’s neurologic status every 2 hours
- Measuring D.W.’s blood pressure (BP) every 2 hours
- Emptying the urine collection device and measuring the output
Correct answers are:
CASE STUDY PROGRESS
The provider orders pulse therapy with methylprednisolone 125 mg IV every 6 hours and plasmapheresis once daily.
11. What major complications associated with immunosuppression therapy will D.W. have to be monitored for?
12. D.W. asks about what plasmapheresis does and why it might help her feel better. How you would respond?
Chart View
Vital Signs
13. D.W. returns to the floor after the plasmapheresis. The UAP reports D.W.’s vital signs to you. Based solely on her vital signs, what could be happening with D.W. and why?
14. You go to assess D.W. What do you need to include in your assessment?
15. D.W. is complaining of dizziness and is slightly diaphoretic but denies any headache, nausea, or paresthesia. What do you immediately suspect is occurring and why?
16. You need to call the provider regarding D.W.’s status. Using SBAR, what would you report to the provider?
17. What do you expect your care of D.W. will include over the next 2 to 3 hours?
Iv fluids, bed rest, fall precautions. I&O, assess, weight.
18. What outcome criteria would support that D.W.’s condition is stabilizing?
ADEQUATE Urine output, increase in blood pressure, normal skin turgor, decrease in HR.
19. You note that D.W.’s husband is visiting her. You enter the room to ask whether they have any questions. D.W.’s husband states, “I have tried to tell her that she cannot go back to work. Sure, we need the money, but the kids and I need her more. I’m afraid that this lupus has weakened her whole body and it will kill her if she goes back to work. Is that right?” How should you respond to his concerns?
Work will not kill her but stress can worsen the symptoms. Maybe they can compromise a work schedule depending on how she feels.
CASE STUDY OUTCOME
D.W.’s condition stabilizes with fluids and plasmapheresis and she can be discharged 6 days later. With the addition of cyclophosphamide to her regimen, her condition improves and she experiences no further episodes of cerebritis. Her husband and she decide that she is not going to return to work so she can focus on her health and family.
