Answer KEY-HIV-AIDS- Unfolding Reasoning PDF

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Human Immunodeficiency Virus UNFOLDING Reasoning

Michelle Johnson, 36-years old

Primary Concept Immunity Interrelated Concepts (In order of emphasis) • Gas Exchange • Infection • Stress • Coping • Clinical Judgment • Patient Education • Communication • Collaboration NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Safe and Effective Care Environment 17-23% • Management of Care 9-15% • Safety and Infection Control Health Promotion and Maintenance 6-12% Psychosocial Integrity 6-12% Physiological Integrity 6-12% • Basic Care and Comfort 12-18% • Pharmacological and Parenteral Therapies 9-15% • Reduction of Risk Potential 11-17% • Physiological Adaptation © 2018 Keith Rischer/www.KeithRN.com

Covered in Case Study ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓

UNFOLDING Clinical Reasoning Case Study:

History of Present Problem: Michelle Johnson is a 36-year-old African American female with no prior medical history who presents to the emergency department complaining of extreme fatigue for the past several months and experiencing occasional night sweats. During the past week, she has developed a sore throat, dry, nonproductive cough, fever at night with increasing shortness of breath. Michelle embarrassingly admits that she has had a vaginal yeast infection that she has tried to treat with over the counter medications with no success. Michelle states to the triage nurse, “I came in today because I am worried something is wrong with me, I hope it’s nothing serious!”

Personal/Social History: Michelle has been divorced for five years and has two daughters (ages 14 and 16) who works full time as a legal secretary. She has recently been working longer hours, skipping meals, and stressed over the possibility of not being able to provide for her two daughters. She has been involved in only one relationship since her divorce. She is engaged to Ken, who has hemophilia and plan to get married next year. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Data from Present Problem: Clinical Significance: All of these problems can be caused by exposure to almost any virus Extreme fatigue for the past several months (e.g., influenza)—not just to HIV, BUT, these may be the first indications and experiencing occasional night sweats. of the acute HIV infection several months ago. About 50% to 90% of people who are first infected with HIV develop an acute infection within four weeks. Manifestations of this acute HIV infection can be fever, night sweats, chills, headache, and muscle aches. During the past week, she has developed a sore throat, dry, nonproductive cough, fever at night with increasing shortness of breath.

Potential respiratory infection with a dry cough and exertional dyspnea in the weeks before the development of other symptoms, fever plus a headache, malaise, night sweats, general fatigue, weight loss, and chest pain are among the clinical manifestations typically seen with HIV.

Vaginal yeast infection that she has tried to treat with over the counter medications with no success.

Vaginal infection that has not been able to be corrected by treatment is a clinical RED FLAG for HIV. Women often have gynecological conditions as a result of HIV infection. These can include persistent, reoccurring and difficult-to-treat vaginal yeast infections. Immunizations are also difficult as these patients can develop the condition you are trying to prevent: AKA chicken pox. Clinical Significance: Sole provider for her daughters, difficult financial burden. Is experiencing significant situational stress working long hours and intimate relationship with an individual with a significant chronic illness.

RELEVANT Data from Social History: Working longer hours, skipping meals, and stressed over the possibility of not being able to provide for her two daughters.

Patient Care Begins: Current VS: T: 99.6 F/37.6 C (oral) P: 108 (regular) R: 24 (regular) BP: 110/75 O2 sat: 91% RA

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Denies Quality: Region/Radiation: Severity: Timing:

© 2018 Keith Rischer/www.KeithRN.com

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT VS Data: Clinical Significance: Low-grade temperature may be due to infectious process such as pneumonia, but needs to be T: 99.6 trended and closely monitored P: 108

Tachycardia likely indicates increased metabolism due to elevated temperature and infection, but could also be compensatory response due to dehydration or sepsis. More clinical data needs to be collected.

R: 24

Too high and is a clinical RED FLAG. Tachypnea needs to be investigated d/t potential respiratory infection and respiratory distress. Sepsis should also be considered as tachypnea may be compensatory mechanism due to sepsis.

BP: 110/75

Trend BP closely to determine patient ambiguity or softening of BP related to sepsis. TREND closely to determine if sepsis is developing!

O2 sat: 91% RA

Clinical RED FLAG. This is too low for a healthy woman and needs to correlate with HR of 108 or so to ensure accuracy.

Current Assessment: GENERAL APPEARANCE: ORAL & NECK: RESP: CARDIAC: NEURO: GI: GU: SKIN:

Average built female with a worried expression on her face. Appears pale and tired. Calm, body relaxed, no grimacing, appears to be resting comfortably Oral mucous moist and intact. Cervical lymph nodes enlarged bilaterally Slight SOB with exertion and crackles heard bilaterally in lower lobes posteriorly Tachycardia, pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, equal to palpation at radial/pedal/post-tibial landmarks, brisk cap refill Alert & oriented to person, place, time, and situation (x4) Abdomen flat, soft/nontender, bowel sounds audible per auscultation in all four quadrants Voiding without difficulty, urine clear/yellow Skin integrity intact, skin turgor elastic, no tenting present

What assessment data is RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Assessment Data: Clinical Significance: Pale color could be due to lack of RBC/anemia, immune system suppressed, Appears pale and tired. infection. General finding. Cervical lymph nodes enlarged bilaterally

Indicates an infectious process that is present in her body that may be systemic

Slight SOB with exertion and crackles heard bilaterally in lower lobes posteriorly

Respiratory problem is likely consistent with pneumonia. Crackles are present as a result of fluid in the alveoli due to pneumonia or atelectasis. Also, respiratory sat that is low supports this concern.

Cardiac Telemetry Strip:

© 2018 Keith Rischer/www.KeithRN.com

Interpretation: Sinus tachycardia-rate 110 Clinical Significance: Tachycardia likely indicates increased metabolism due to elevated temperature and infection, but could also be compensatory response due to dehydration or sepsis. More clinical data needs to be collected. Sinus tachycardia is not normal and must be investigated – It is a symptom of a more significant problem.

The care provider orders the following based on the clinical data that the nurse has collected: Collaborative Care: Medical Management Care Provider Orders: Complete blood count (CBC)

Rationale: Has signs of obvious infection. Need to determine WBC and neutrophil, lymphocyte differential is relevant in this scenario.

Basic metabolic panel (BMP)

Determine chemistries of sodium and potassium as well as renal function/fluid balance once creatinine is known.

Rapid HIV

Determine if HIV is the primary source of infection in this scenario

Chest x-ray

Determine if pneumonia or another resp. Infection/problem is present that is causing her symptoms.

Radiology Reports: Chest x-ray What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse? RELEVANT Results: Clinical Significance: Represents the accumulation of intra-alveolar fibrin, debris, and organisms as a Diffuse ground-glass result consistent with pneumocystis pneumonia (PCP) opacity present bilaterally

Lab Results: Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Neutrophil % (42–72) Lymphocyte % (2-10) Hgb (12–16 g/dL) Platelets (150-450 x103/µl)

Current: 3.0 88 6 9.8 208

High/Low/WNL? LOW HIGH WNL LOW WNL

Most Recent: 8.5 70 4 10.5 225

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable: These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! WBC: 3.0

• ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection • Viral infections, overwhelming bacterial infections, and bone marrow disorders can all cause leukopenia. Patients with severe leukopenia should be protected from anything that interrupts skin integrity, placing them at

© 2018 Keith Rischer/www.KeithRN.com

Worsening TREND-is a clinical RED FLAG

risk for an infection that they do not have enough white blood cells to fight. Neutrophil %: 88

• ALWAYS RELEVANT for same reason as WBCs • Most common leukocyte • FIRST RESPONDER to any bacterial infection within several hours or when the inflammatory response is activated

Worsening TREND-is a clinical RED FLAG. Elevated in response to bacterial infection

• Normal finding. Elevated with viral infection, but not always elevated in the presence of HIV

Stable

Lymphocyte %: 6 Hgb: 9.8

• ALWAYS RELEVANT to determine anemia or acute/chronic blood loss. • Level supports chronic anemia

Stable. Though LOW, it is not a recent trend

• If platelets are low, it will obviously be significant and must be noted • Any patient on heparin products must also have this noted because of the clinical possibility of heparininduced thrombocytopenia (HIT) • Develops when immune system forms antibodies against heparin that cause small clots and lower platelet levels

Stable

Platelets: 208

Basic Metabolic Panel (BMP:) Sodium (135–145 mEq/L) Potassium (3.5–5.0 mEq/L) Glucose (70–110 mg/dL) Creatinine (0.6–1.2 mg/dL)

Current: 148 3.5 90 0.8

High/Low/WNL? HIGH WNL WNL WNL

Most Recent: 142 3.8 101 0.9

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

These labs are ALWAYS RELEVANT, therefore they must be intentionally noted by the nurse! Sodium: 148

• Is hypernatremic most likely because of dehydration • I consider Na+ the “Crystal-Light” electrolyte. Though this is simplistic, it does help to understand in principle how basic Na+ is to fluid balance • When you add one small packet of Crystal Light to your 16-ounce bottle of water, the concentration is just right. This is where a normal Na+ will be (135-145) • Where free water goes, sodium will follow to a degree. Therefore if there is a fluid volume deficit due to dehydration, Na+ will typically be elevated because it’s concentrated (less water) • If there is fluid volume excess, Na+ will be diluted and will likely be low. It is the “foundational” fluid balance electrolyte!

© 2018 Keith Rischer/www.KeithRN.com

Worsening

Potassium: 3.5

• Essential to normal cardiac electrical conduction, as is Mg+ • f too high or low can predispose to rhythm changes that can be life-threatening! • K+ tends to deplete more quickly with loop diuretic usage than Mg+

Stable

Glucose: 90

• Required fuel for metabolism for every cell in the human body, especially the brain • Relevant with history of diabetes or stress hyperglycemia due to illness • Elevated levels post-op can increase risk of infection/sepsis.

Stable

Creatinine: 0.8

• GOLD STANDARD for kidney function and adequacy of renal perfusion • The functioning of the renal system affects every body system; therefore, it is ALWAYS relevant!

Misc. Labs: CD 4 count (>500 cells HIV RNA level, (40-75 copies/mL)

Current: 189 60,000

Stable

High/Low/WNL? LOW HIGH

What lab results are RELEVANT and must be recognized as clinically significant by the nurse?

RELEVANT Lab(s):

Clinical Significance:

CD4: 189...