HIV/AIDS

Case Study:
Amy Grimes, a 37-year-old female, came to the local mental health hospital complaining of
impaired concentration, withdrawal from family and friends, mood swings, difficulty with her
memory, fatigue, and suicidal ideation. Two months before coming to the hospital, she had
moved to the area to be with her family.
On admission, Ms. Grimes assessment revealed she had lost 4.5 to 7 kg (10 to 15 lb) since
coming to live with her parents. She has not been able to read or concentrate. Her suicidal ideas
involve harming herself but no specific plan. Ms. Grimes psychosocial history revealed that she
was an IV drug abuser in the mid-1980s. Ms. Grimes stated she had returned home to tell her
family that her test for human immunodeficiency virus (HIV) was positive. Her family told her
they would stand by her. Her medical history included having had diarrhea for the past 3 weeks,
nights sweats, and enlarged glands in her neck and under her arms. Two of her friends recently
had been told that they were HIV positive, and two other friends died from acquired
immunodeficiency syndrome (AIDS). She fears she has become depressed, believes she is
losing her mind, and is becoming more confused. She told the nurse she was having difficulty
with tremors in her legs, which occasionally have given her problems with walking.
Her admitting diagnosis was major depression single episode; rule out AIDS dementia complex
(ADC).
After Ms. Grimes psychiatrist was informed of her history, medication orders were given for
fluoxetine (Prozac) and nortriptyline (Pamelor).
Current vital signs and laboratory results are as follows:
BP 134/88 mmHg
HR 90 bpm
Respirations 20 breaths/min
Temperature 37.2 C (98.9 F) orally
ELISA Positive for HIV antigens (confirmed by Western blot test)
Chest x-Ray Film Within normal limits
RBC 3.5 x 106/mm
WBC 6.6 x 10/mm
Hgb 12.9 g/dl
Hct 36.8%
Lymphocytes 13%

After 1 week of psychotherapy and medication therapy, Ms. Grimes did not show any
improvement in mood, affect, or neurologic deficits. She began falling when attempting to walk,
had difficulty with the Mini-Mental State Examination, and became more confused. The
psychiatrist made a medical referral. Two physicians refused to accept the referral. Finally an
oncologist accepted Ms. Grimes case. Two days later Ms. Grimes was transferred to the
oncology unit. More tests were ordered.
Results for a CBC with differential were the following:
RBC 5.5 x 106/mm
WBC 4.4 x 10/mm
Hgb 12.7 g/dl
Hct 38.9%
Lymphocytes 11%
Monocytes 3%
The lymphocyte subset results were the following:
Total lymphocyte Count 411/mm
Absolute B-cell Count 99/mm
Absolute T-cell Count 206/mm
Helper : Supporter Ration (CD4 : CD8) 0.07
Routine chemistry results were the following:
Na 137 mmol/L
Glucose 120 mg/dl
Creatinine 0.8 mg/dl
Albumin 2.6 mg/dl
BUN 9 mg/dl
Total protein 6.3 g/dl
K 3.7 mmol/L
Cl 100 mmol/L
CO2 26 mmol/L

Results of other tests were the following:

VDRL Negative
Hepatitis B serology Negative
Viral Load 230,000 copies/ml
Stool Culture Salmonella
CT Scan Mild brain atrophy and white matter changes

Once Ms. Grimes was transferred to a medical floor, treatment with

abacavir/zidovudine/lamivudine (Trizivir) and ampicillin (Ampicin) for Salmonella infection
was begun. During Ms. Grimess hospitalization, her assessment revealed no previous
opportunistic diseases. She reported that her first symptoms were night sweats, diarrhea, and
difficulty with her memory. Difficulty walking began shortly thereafter. Her respiratory status
began to change. On day 9, she developed a nonproductive cough, dyspnea, cills, and a few
crackles in the base of her lungs. The physician was informed of changes, and orders included
oxygen via mask at 40%, a chest x-Ray film, and a second CD4 count. The chest x-Ray
examination revealed bilateral infiltrates. A flexible fiberoptic bronchoscopy revealed
Pneumocystis carinii pneumonia (PCP). Ms. Grimes was treated with IV pentamidine. On day
13, her respiratory status worsened. There were indications of respiratory failure, and a decision
had to be made about intubation and mechanical ventilation. Ms. Grimes had difficulty with
decision making and exhibited some psychomotor slowing. Her family was kept informed of her
physical condition. Ms. Grimes wanted her family to help her make this difficult decision.
Considering the quick onset of her symptoms and change in condition, the family chose
admission to the intensive care unit (ICU) and mechanical ventilation. She was admitted to the
ICU. Treatment with IV ampicillin and IV hydrocortisone was initiated.
Within 2 days, Ms. Grimes was afebrile and was weaned from the ventilator. Her respiratory rate
had fallen from 40 to 25 breaths/min, and her respiratory distress had lessened. Ms. Grimes was
then transferred back to the medical unit, receiving oxygen via nasal cannula. A thid CD4 cell
count was 190/mm. Tables 28-1 and 28-2 show diagnostic data at Ms. Grimess return to the
medical unit.
After her return to the medical unit, Ms. Grimes was treated for oral candidiasis with nystatin
(Nyaderm) and ketoconazole (Nizoral). Her skin tests indicated complete failure of delayed
hypersensitivity reactions, and AIDS was diagnosed. After 1.5 weeks of IV trimethoprimsulfamethoxazole (TMP-SMZ; Bactrim), Ms. Gimes was weaned from oxygen and discharged.
After discharge from the hospital, Ms. Grimes was treated with Retrovir (zidovudine) 300 mg;
abacavir 300 mg; lamivudine 150 mg; and oral TMP-SMZ.

Table 28-1

Vital Signs

Day

13

14

15

BP

112/72

154/82

132/84

132/62

112/72

130/84

HR

112

112

112

120

112

90

RR

20

22

26

36

40

35

Temp. (F)

98-99

98-99

99-100

100-102

102-103

98-99

Table 28-2

Laboratory Results / ABG Findings / Ventilator Settings

Day

7 (room air)

9 (40% O2)

13 (100% O2)

14 (40% O2)

15 (room air)

pH

7.48

7.49

7.45

7.48

7.46

PCO2

36

32

35

28

32

PaO2

49

44

104

93

85

SaO2

89

83

97

97

96

HCO3

27

25

24

20

23

Vent. Mode

A/C

A/C

Vent. Rate

17

17

Tidal Vol.

900

900

PEEP

14

12

Answer the following questions in full sentences, utilizing proper APA format and typed.

1. What is the difference between HIV infection and AIDS?

2. What clinical indicators confirmed that Ms. Grimess HIV infection had progressed to
AIDS?

3. What symptoms and pulmonary diagnostic findings in Ms. Grimess case indicated the
need for transfer to the ICU?

4. What treatments did Ms. Grimes receive in the ICU to ensure a successful outcome?
Include medications for HIV infection such as highly active antiretroviral therapy
(HAART) and PCP prophylaxis and discuss their action.

5. What are some of the nursing interventions with rationales that will help Ms. Grimes
with her psychosocial and physiologic needs?

HESI REVIEW QUESTIONS

Please select the best answer for the following questions.
1. A nursing student approaches an instructor following a needlestick to the finger from a needle
used for an injection with a known HIV-positive client. Which instructor statement is most
accurate?
____A. Postexposure prophylaxis will need to be started within 1 to 2 hours.
____B. HIV antibody testin will need to be done in 6 weeks and then again in 3 months.
____C. At the end of the clinical shift, you should make an appointment to see your health-care
provider.
____D. Flush immediately with water for 10 minutes and cover with a bandage and glove.

2. A client diagnosed with HIV, has a CD4-positive T-lymphocyte count of 160 mcg/L. A nurse
evaluates that interventions have been most effective when which outcome is achieved?
____A. Soft formed stools daily
____B. Skin integrity nonintact
____C. Free of opportunistic diseases
____D. Current weight maintained or gaining weight

3. A client is diagnosed with Pneumoncystis carinii pneumonia (PCP) secondary to AIDS. Upon
assessment for the specific symptoms of PCP, the nurse should expect to find:
____A. dyspnea, fever, nonproductive cough, and fatigue.
____B. weight loss, night sweats, persistent diarrhea, and hypothermia.
____C. dysphagia, yellow-white plaques in the mouth, and sore throat.
____D. lung crackles, chest pain, and small, painless purple-blue skin lesions.

4. A nurse planning care for a client being admitted with newly diagnosed active tuberculosis
(TB) secondary to AIDS. Which intervention is most important for the nurse to plan?
____A. Monitor for signs of bleeding.
____B. Teach strategies for skin care.
____C. Institute airborne precautions.
____D. Assess CD4 and T-lymphocyte counts.

5. A nurse is teaching a client and the family members about protection measures when the
client, diagnosed with AIDS, returns home. Which instruction indicates that the nurse is unclear
about the disease transmission?
____A. Disinfect items in your home, using a bleach solution of 1 part bleach to 10 parts of
water.
____B. Dispose of contaminated items, except sharps, by placing them in a plastic bag then in
the garbage.
____C. Use separate dishes and silverware and wash them with soap and water or place them
in the dishwasher.
____D. Wearing gloves, clean body fluid spills with soap and water, and then disinfect the area
with bleach solution.

6. The white blood cell (WBC) count of a client with systemic lupus erythematosus (SLE)
shows a shift to the left. Which nursing diagnosis reflects the highest priority for this client?
____A. Ineffective health maintenance
____B. Impaired skin integrity
____C. Ineffective individual coping
____D. Ineffective protection

7. A client is to start taking prednisone for the treatment of rheumatoid arthritis (RA). Which
client statement indicates that medication teaching was successful?
____A. I will take the medication on an empty stomach to maximize absorption.
____B. I will take the specific dose ordered at the same time every day.
____C. I will not have to limit my sodium intake.
____D. I will not have to adjust my insulin regimen.

8. The nurse assesses the client with rheumatoid arthritis for which of the following
characteristic joint changes?
____A. Swan-neck deformity and ulnar deviation
____B. Heberdens and Bouchards nodes
____C. Tophi
____D. Charcots joints

9. Which one of the following suggestions by the nurse would be most helpful to an human
immunodeficiency virus (HIV) positive client who has altered taste perception?
____A. Drink plenty of salty broths and other fluids to stimulate taste buds.
____B. Try zinc supplementation to improve taste perception.
____C. Increase intake of meat to at least one serving per day.
____D. Avoid using plastic eating utensils.

10. A client returns to a clinic for a follow-up visit and is diagnosed as positive for HIV. The
client expresses fear related to lack of finances, fear of social avoidance, and hopelessness.
Which action by the nurse should provide the most client support?
____A. Referral to a physician infectious disease specialist.
____B. Referral to a community-based HIV clinic.
____C. Referral to the local public health department.
____D. Recommendation to disclose the diagnosis to family.