Human_Immunodeficiency_Virus__HIV__and_Tuberculosis__TB_.docx

Section 1 Nursing Process: Assessment The nurse admits Raymond to a private room at the end of the hall. According to hospital protocol, the nurse puts on a mask before starting the admission process. Raymond tells the nurse that his significant other is downstairs and that he would like for him to stay in the room with him. How should the nurse respond? "Your healthcare provider (HCP) wants you to get some rest." Raymond is requesting an opportunity for psychosocial support, which should be honored by the nurse. "He may stay, but only after we have the results of his tuberculin skin test." Significant others may stay with appropriate protective equipment. "He may stay, but he needs to wear a mask." Raymond's significant other may stay in the room, but he should wear a mask to help decrease the possibility of contracting the TB organism. "You don't want to risk infecting your significant other with TB, do you?" Raymond's partner has already been exposed. In addition, this response denies Raymond the support he is requesting. Section 2 Raymond's significant other, Brandon, arrives. Raymond wants to know why a mask is necessary for people entering his room. What teaching should the nurse implement? Explain the use of a private room and mobile high-efficiency particle filters placed in the room. These are necessary precautions against infectious, airborne diseases such as tuberculosis (TB). However, providing this information does not answer Raymond's question. Explain that the tuberculosis (TB) organism is most often spread through the air. When an infected person coughs or sneezes, they produce infectious droplets that can be breathed in by another person. This answer provides Raymond with the scientific rationale for wearing a mask. Tell Raymond that tuberculosis (TB) will not be spread to others, and everything will be okay if the mask is worn. This is false information. Wearing a mask will not prevent the contraction of tuberculosis (TB), but it will reduce the risk of contracting the disease. Tell Raymond that masks are required for those persons who do not agree to be vaccinated with BCG vaccine. The BCG (Bacille Calmette-Guerin) vaccine is not generally recommended for use in the United States. It is only used for very select persons who meet specific criteria. Section 3 Safety and Infection Control The unlicensed assistive personnel (UAP) asks why Raymond could not be in an empty semiprivate room closer to the nurse's station so the staff would not have to walk so far to provide care. What information should the nurse provide to the UAP on infection control practices? The client needs to be at the end of the hall because he requires privacy. This is not the reason for the location of Raymond's room. The implementation of airborne precautions for possible TB requires a private, negative pressure room assignment. According to the Centers for Disease Control (CDC), in addition to isolating Raymond by using a private room, engineering controls can help to prevent the spread of TB. Controlling the direction of the airflow can prevent contamination of air in adjacent areas. A private room is required to implement contact precautions for possible TB. Airborne precautions, rather than contact precautions, are required to prevent the spread of TB. The client needs to be at the end of the hall for confidentiality. Confidentiality is provided for every client, regardless of the client’s room location. Submit The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide to the UAP? A mask is required for healthcare workers entering the room of someone suspected of having active TB. TB is spread by airborne transmission of droplet nuclei. A specific fit tested, high-efficiency particulate air (HEPA) mask is necessary to filter the mycobacterium tuberculosis bacillus. Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond’s room for any reason. The only protective apparel required when entering the room is a HEPA mask. The UAP will only be in the room for a brief moment to deliver the tray, so no intervention is needed by the nurse. Since TB is spread by airborne transmission of droplet nuclei, a HEPA mask is necessary for the UAP to wear. The nurse needs to inform the UAP of this and ensure that appropriate personal protective equipment is worn in Raymond’s room. Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB. Gloves do not prevent the transmission of an airborne organism. Submit Previous Section Section 4 Nursing Process: Intervention An acid-fast bacilli (AFB) stain is part of the initial admission prescriptions. Early morning sputum specimens will be collected for 3 consecutive days and sent to the lab. Which tasks may the nurse delegate to the UAP? Select all that apply Have the UAP tell Raymond that the specimen must be collected in the early morning. This task may be delegated. Provide Raymond with three sterile specimen cups at his bedside. This task may be delegated. Allow the UAP to teach the client how to cough to obtain sputum from deep in the bronchi. Teaching is a responsibility of the nurse that cannot be delegated. Raymond needs to be taught to cough deeply, using the diaphragm to produce sputum from the bronchi instead of saliva from the oral cavity. Document the time and date that each sputum specimen was collected. This task may be safely delegated. However, it is the nurse’s responsibility to ensure that the documentation is completed and sent with the specimen to the lab. Instruct the UAP to assess Raymond’s ability to expectorate a sputum specimen. This task may not be delegated. Section 5 Raymond is scheduled for several activities the following morning. Which activity should Raymond perform first upon awakening? Eat a nutritionally dense, early morning snack sent from the food services department. While small, nutritionally dense meals and snacks are necessary for clients with HIV and/or TB, another action is of greater priority. Obtain the first of three sputum specimens for laboratory testing. Secretions collecting during the night provide the opportunity for the client to cough and expectorate upon awakening before performing other morning activities. Take a shower and get ready to go to radiology for a chest X-ray. Another action is of greater priority. Weigh to determine if weight loss from the disease is continuing. Although daily weight monitoring may be done, another action is of greater priority. Section 6 Safe and Effective Care Environment: Management of Care A licensed vocation nurse (LVN) says to the nurse who is making assignments, "I do not want to be assigned to care for Raymond. I have never cared for a client with HIV and do not want to start now. I have a family at home that needs me." Which information should the nurse base a response about the LVN’s right to refuse care for a client with HIV? The LVN does not have enough experience to care for a client who is on isolation and may therefore refuse to care for clients with a contagious disease. This answer does not meet the professional guidelines set forth by the ANA Code for RNs or LVNs that guide ethical nursing practice. The LVN may refuse to care for a client in circumstances in which risk to the nurse outweighs the nurse's responsibility to care for a client, or if the assignment conflicts with the nurse's ethical standards. According to the ANA Code for Nurses, a nurse may morally refuse to participate in care, but only on the grounds of either client advocacy or moral objection to a specific type of intervention. Exceptions may be made when risk of harm outweighs the nurse's responsibility to care for a given client. For example, an immunosuppressed nurse may refuse to care for clients with certain infectious processes. The pregnant nurse may refuse to care for the client with HIV who has secondary infections such as toxoplasmosis or cytomegalovirus, both of which can cause severe damage or death to the fetus. Refusal to treat or care for a person based on race, gender, or age is discrimination, which the federal government prohibits. The LVN in this case is not refusing to care for the client based on these parameters. If the nurse did refuse, it would be illegal. The required staffing ratio of licensed personnel to client population does not allow for professional nurses to refuse to care for a client. Staffing ratio is a budgeting issue. Nurses in many states may claim "safe harbor" if they feel staffing is unsafe, but this is not the reason given for refusal in this case. Submit How should the nursing supervisor respond to the staff LVN who does not want to care for Raymond? "I understand. I will assign you to a different client and give Raymond to one of the other LVNs." This response does not provide an opportunity to assess if something else is needed. "I understand you are concerned, but I am concerned about you losing your job over this." Not only is addressing possible dismissal of the LVN premature, this response does not provide an opportunity to assess whether something else is needed. "I understand your fears, but do you realize this will cause a hardship on your fellow staff members?" This response does not help develop the LVN as a team member, nor does it provide an opportunity to assess if something else is needed. "I understand you want to protect your children. Please tell me your concerns regarding caring for a client with HIV." This response by the nurse supervisor demonstrates compassion and provides an opportunity to discover if education of the staff LVN is needed. Section 7 Nursing Process: Plan of Care The nurse creates a plan of care for Raymond. The nursing diagnosis of Knowledge Deficit is used to describe what is needed during client education sessions with Raymond. Which statements by Raymond indicates that he understands why he is at risk for TB? Select all that apply "I realize my helper T cells are diminished from HIV. Those are the cells needed to fight TB." HIV attacks the CD4 receptors on the helper T cells that help the body fight off diseases such as TB. "I may get TB because my viral load count is diminished." An increased HIV viral load indicates disease progression and puts the client at risk for opportunistic infections. A decreased viral load count is desirable. It is a goal of anti-HIV therapy. "I am at risk for developing TB because I was born with a low number of helper T cells." This may indicate Raymond is in denial or lacks correct information. HIV is acquired rather than genetic in origin. "I realize I am at risk for acquiring TB because I used intravenous drugs in the past." Raymond could have been exposed to HIV and hepatitis virus from a contaminated needle. However, the mode of transmission of the Mycobacterium tuberculosis bacilli is through respiratory secretions, not blood-borne routes. “I guess living in that homeless shelter increased my chances of getting TB.” The risks of acquiring the infection and of developing clinical disease depends on the infection's existence in the population, especially among persons residing in high-risk environments for the transmission of TB, such as correctional facilities, homeless shelters, hospitals, and nursing homes. Submit After 3 days, the nurse receives the results from Raymond's tuberculin skin test that was administered at his HCP's office. Even though Raymond's reaction to the tuberculin skin test measures only 5 mm in diameter, the HCP documents a positive test result. A new graduate nurse finds this confusing. The new graduate nurse thought that a 10 mm induration was the minimum size for a positive reading and asks the nurse preceptor for clarification. How should the nurse preceptor respond? "This confuses me, too. I think we need to consult with the HCP." The nurse preceptor should be able to explain the tuberculin skin test result. "That is not always true. A 5 mm induration is considered positive for TB in a person with HIV." The person with HIV has diminished T cell immunity, which compromises their ability to react to skin tests. Therefore, an induration of 5 mm is considered a positive reaction, rather than the standard of 10 to 15 mm for other groups. "It may be that you are confusing induration with inflammation in skin testing results." The hardened, raised area of induration at the site of the skin test is measured. Any flat, reddened area of inflammation is not measured. The graduate nurse did not indicate confusion between the two. "Let's ask the nurse practitioner who specializes in caring for clients who are HIV positive." Although the nurse practitioner is an excellent resource, the nurse preceptor should be able to explain the tuberculin skin test result. Section 8 Pharmacologic and Parenteral Therapies Before breakfast, the nurse brings Raymond the HIV medicines that are due. Raymond inquires about his other medications, stating, "I take all my HIV pills at once before breakfast. I don't want to bother with taking medication all day long!" How should the nurse reply? "To be most effective, HIV medications are prescribed on different schedules." Some HIV inhibitors need to be given on an empty stomach and some need to be given with food for best effectiveness. Many need to be taken around the clock, even if sleep is disrupted, to ensure drug efficacy. "Okay. I will give the rest to the UAP to bring in as soon as possible." This is not the correct way for Raymond to take his medication, nor is it within the UAP's scope of practice to give medications. "We are just trying to provide you with the best nursing care possible on this unit." That is a defensive reply, which does not contribute to educating Raymond. "We need your cooperation to help fight this disease." This reply is judgmental and implies that Raymond is uncooperative, which he is not. Submit Raymond responds by agreeing to take his medications as prescribed. He then states, "However, I don't know what good they will do. Do you?" How should the nurse respond? "I honestly do not know, but I would give it a try. What is there to lose?" This response does not educate Raymond about the purpose of the HIV medications. "The main purpose of these medicines is to block the replication of the HIV virus." The purpose of the antiretroviral and inhibitor medicines is to block the replication of the HIV virus and prevent opportunistic diseases. "You should talk to your HCP about your medications." The nurse should be able to answer Raymond's question about his medications. "Tell me about the experiences your friends have had with these medicines." Exploration of how Raymond formed his opinion would be better left until after the nurse answers Raymond's question. Submit Raymond’s HCP has also prescribes the anti-tuberlosis regimen of rifabutin/isoniazid/pyrazinamide/ethambutol. What information is important to teach Raymond about the use of rifabutin/isoniazid/pyrazinamide/ethambutol? Select all that apply Rifabutin stains urine, stool, saliva, sweat, and tears reddish-orange. This teaching can help Raymond prepare for this side effect without anxiety. Liver function tests should be routinely conducted and monitored. The major side effect of isoniazid, rifabutin, and pyrazinamide is drug-induced hepatitis. Therefore, Raymond must be taught the importance of having blood samples drawn to monitor his liver function. There is no need to wear sunscreen when exposed to sunlight while taking rifabutin/isoniazid/pyrazinamide. Pyrazinamide may make the skin sensitive to sunlight, and this should be taught to the client. Visual disturbances related to ethambutol therapy may develop during therapy, but may resolve once treatment is discontinued. Ethambutol is generally well tolerated. The most significant adverse effect is optic neuritis. Rifampin/isoniazid/pyrazinamide has been known to cure HIV within a few months of taking it. Rifampin/isoniazid/pyrazinamide is a first-line anti-tubeculin drug Section 9 What is the priority nursing diagnosis for Raymond at this time? Risk for new opportunistic infections related to decreased immune function. Since Raymond's immune system is no longer competent, he is at risk for additional opportunistic infections. Immune problems start when the CD4 cell count drops below 500 cells/mm3. Preventing infections is a basic need and is a high priority in the immunocompromised client. Social isolation related to worsening of condition. Social isolation should be addressed, but there is a higher priority nursing diagnosis. Imbalanced nutrition, less than body requirements related to medication side effects. Although this is frequently a side effect of HIV and TB medications, there is a higher priority nursing diagnosis. Fatigue related to altered body chemistry. Although the client initially complained of fatigue, there is a nursing diagnosis with a higher priority. Submit Nursing Process: Planning Raymond has been diagnosed with the opportunistic disease TB. He has experienced weight loss and has a CD4 cell count of 240 cells/mm3 . The HCP moves Raymond from the HIV asymptomatic stage (CDC HIV Infection Stage 1) to the HIV Infection Stage 3 (AIDS). Previous Section Section 10 Safety and Infection Control A UAP says, "Now that Raymond's condition has worsened and he has been moved to the HIV Symptomatic stage, shouldn't added precautions be posted on Raymond's door to protect staff members?" What information should the nurse give the UAP? Following standard precautions will minimize the exposure to blood and body fluids. Standard precautions are designed to prevent contact with blood or body fluids, which are the mode of transmission for HIV, and are used regardless of the stage classification of the disease. Reverse isolation procedures should be implemented to protect the staff. Reverse isolation protects the immune-compromised client, not the staff. Respiratory precautions are all that are needed, and those are already posted on the door. This does not address the UAP's concerns about prevention of HIV transmission from client to staff. Staff members caring for Raymond should begin prophylaxis medications. Unless HIV exposure occurs, staff should not begin the postexposure prophylaxis regimen. Submit Previous Section Section 11 Reduction of Risk Potential The nurse notices that Raymond has left most of his dinner untouched. The nurse offers to order something different for Raymond, but he replies that his mouth is sore and he just doesn't feel like eating. Which assessment finding by the nurse would be indicative of oral candidiasis, a common secondary infection in persons with compromised immune systems? Blisters on the tongue or oral mucosa. This is a sign of herpes simplex virus type 1 (HSV-1) infection. Inflammation of the gums. This is a symptom of gingivitis. Painless white lesions on the lateral surface of the tongue. This is a description of leukoplakia. White-yellow patches on the tongue or oral mucosa. This sign is indicative of a Candida albicans infection. It is a common finding in people with HIV, and it frequently occurs with a falling CD4 cell count. Submit The nurse notifies the HCP, who prescribes nystatin (Nyamyc) 6 mL PO 4 times per day. What instruction should the nurse give Raymond about the use of liquid nystatin (Nyamyc)? Place all of the suspension in the mouth, then swish and swallow immediately. This is not the proper way to take liquid nystatin (Nyamyc). Sip the suspension over 5 minutes, swishing and swallowing after each sip. This is not the proper way to take liquid nystatin (Nyamyc). Place the suspension in the mouth, then swish for several minutes before swallowing. This "swish and swallow" technique is the proper way to take liquid nystatin (Nyamyc). HCPs also recommend gargling, as well as swishing, prior to swallowing. Use the applicator to paint the medication on the infected sites and swallow the remaining dose. This describes the recommended procedure for young children or infants taking nystatin (Nyamyc). Section 12 Nursing Process: Intervention Raymond Malone is 5' 11" (180.3 cm) tall. He has a large frame and weighs 152 lbs (68.9 kg). His current body mass index (BMI) is 17.4. Raymond says he realizes he should eat, but he does not have the energy or the appetite, even when he has no oral pain. The nurse identifies the nursing diagnosis of, "Imbalanced Nutrition: less than body requirements." To achieve the goal of improving Raymond's nutrition, the nurse should preform which nursing intervention? Select all that apply Request a dietary consultation for Raymond to better assess Raymond’s nutritional status and food preferences. Determining Raymond's food preferences is a good first step. It is essential that Raymond be an active participant in his care so he has some control. If a favorite food is not on the menu, it can be requested. Request a prescription for total parenteral nutrition. While this may eventually be needed, it is not the best intervention at this point. Monitor for oral thrush and diarrhea. HIV can cause profuse diarrhea, night sweats and decreased appetite due to yeast. Instruct Raymond to focus on breakfast, the most important meal of the day. It is not necessary to focus on breakfast. Adequate nutrition can be achieved from meals eaten throughout the day. Weigh daily and record signs of wasting syndrome. Clients with HIV/AIDS or TB can lose weight. Wasting syndrome or cachexia can include redistribution of fat (lipodystrophy), hollow cheeks, or buffalo hump. Submit Since Raymond now has thrush, in addition to fatigue and anorexia, which food best contributes to improving Raymond’s nutrition? Broiled steak. Although steak is a good source of protein, it requires energy to chew, and it may be irritating to Raymond's mouth. Milk shake. A milk shake is a nutrient-dense food. It provides needed calories, calcium, and protein. Raymond can drink the nutritious snack without using the energy it would take to eat a full meal. Raymond may find that the cool liquid is soothing to his sore mouth. Tomato soup. Although liquid soup is not difficult to eat(and the warmth could be soothing), the acidity of the tomato soup may be irritating to Raymond’s mouth. Lettuce salad with raw vegetables. Although a salad with raw vegetables is a good source of vitamins, it requires energy to chew, and it may be irritating to Raymond’s mouth. Section 13 Risk Potential Raymond develops severe diarrhea with occasional incontinence that could be caused by an opportunistic gastrointestinal infection or by one of his medications. While stool cultures are pending, other interventions can be initiated. Which tasks should be delegated to the UAP? Select all that apply Weigh Raymond each morning before breakfast. Weights can be obtained by the UAP. Measure the urine output. Measurement of the urine output can be delegated to the UAP, who can then report to the nurse. Count and record the number of watery stools. The UAP can legally count and record the number of watery stools. However, it is the nurse's responsibility to be aware of the client's condition and promptly report any significant changes to the HCP. Assess Raymond’s peri-rectal skin during incontinent care. The nurse must always assess and evaluate nursing care. This task requires judgment and expertise beyond the scope of practice of the UAP. Check Raymond’s skin turgor to determine if he is dehydrated. The nurse conducts physical exam procedures, including assessing for alterations in skin turgor, to determine hydration status. This expertise is not within the scope of practice for the UAP. Submit Previous Section Section 14 When performing Raymond's morning physical assessment, the nurse discovers that he has a weak, rapid pulse, decreased skin turgor, and dry, sticky, oral mucous membranes. His weight is 2 lbs (0.91 kg) less than it was yesterday morning. What is the highest priority nursing diagnosis for Raymond? Fatigue. Fatigue may be present with diarrhea, but it is not the priority nursing diagnosis. Disturbed sleep pattern. While diarrhea may certainly disrupt sleep, this is not the priority diagnosis. Deficit fluid volume. A weak, rapid pulse; decreased skin turgor; dry, sticky, oral mucous membranes; and weight loss are signs of dehydration. Situational low self-esteem. Incontinence of stool may lead to low self-esteem, but this is not the priority diagnosis. Submit Which action should the nurse take first? Hold Raymond's breakfast tray to provide bowel rest. While clear liquids or another diet that promotes bowel rest may be prescribed, another action should be performed first. Perform oral care and moisten mucous membranes. Another action should be performed first. Take Raymond's blood pressure to assess for postural hypotension. Postural hypotension can result from dehydration. Therefore, it is important for the nurse to obtain this vital information because it directly impacts Raymond's safety. Notify the HCP of Raymond's weak, rapid pulse. Another action should be performed before notifying the HCP. Section 15 Raymond's stool cultures are negative. After treatment with fluids and diet modification, his diarrhea resolves in 24 hours. Raymond's fluid balance is restored, and his oral candidiasis is resolving. Fill in the blankThe HCP is notified of Raymond’s physical exam findings indicating possible dehydration and vital signs, including a blood pressure of 100/50. It is determined that Raymond could use a bolus of IV fluids. The HCP prescribes 1000 mL of normal saline to run over 6 hours. The drop factor tubing set is 15 drops/mL. How many drops/minute will the IV run? (Enter the numeric value only. If rounding is required, round to the whole number.) 1000/360 X 15 = 41.66 = 42 gtts/minute Section 16 Nursing Process: Evaluation Before Raymond is discharged home, it is important that he understands how to prevent the spread of HIV. When discussing infection control practices with the nurse, Raymond says, "I have heard that condoms don't always prevent HIV." How should the nurse respond? "If used correctly and consistently, latex condoms are highly effective in preventing the transmission of HIV." Raymond’s misinformation and misunderstanding is a common myth regarding the effectiveness of latex condoms. Studies prove that condoms work. "I know you would feel terrible if you passed HIV to someone because you did not use a condom." Not only is this statement judgmental, the nurse also presumes to know how Raymond will feel. "I will have an AIDS educator discuss condom use with you." The nurse has the knowledge to respond to Raymond's question. "What is your source of information about condom failure?" While it may be helpful to know where Raymond got his information, this response does not answer Raymond's question. Submit Raymond assures the nurse that he will use a condom with each sexual encounter. He also expresses concern that he may become dehydrated again. What resource can be provided for Raymond in the event this complication occurs? Meals on Wheels. Meals on Wheels is a national nonprofit organization that delivers food to the elderly, the disabled, and the homebound. Raymond would not be a candidate to receive help from Meals on Wheels. HIV/AIDS support group. Although an HIV/AIDS support group can be a valuable resource, it cannot prevent Raymond from getting diarrhea or becoming dehydrated. Access to the services of a registered dietitian. It is essential that the nurse arrange a consult for Raymond with a registered dietitian before Raymond is discharged home. The dietitian will give Raymond specific information on suggested foods and liquids to include in his diet to help prevent dehydration if diarrhea occurs at home. The registered dietitian will provide Raymond with resources, such as a phone number, that will give him access to the dietitian on an outpatient basis. Access to a nurse on hospital unit. The nurse is not the most important resource for Raymond after he is discharged from the hospital. The nurse’s primary responsibility is to the clients on the hospital unit. Section 17 Case Outcome Prior to discharge, Raymond demonstrates that he has the correct knowledge of management of the TB and HIV infections. He replies that he feels more secure with the community resources available to him. He is discharged home, and he leaves the hospital with his partner.