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Nursing Acute Care Rotation

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Presentation of the Client

The patient was a 30 year old woman who presented with persistent cough. It had been two months since the persistent cough started. In addition, the patient had witnessed significant reduction in her body weight, and was beginning to get worried about her condition. As she was examined, it was evident that episodes of coughing kept interrupting her speech. She also kept complaining of severe fever that kept relapsing after very few hours. At night, she would experience several episodes of sweating, sometimes finding her bedding completely drenched in fluids. She was beginning to think that she was infected with HIV, especially considering that they recently disagreed with her husband over an extramarital affair. However, her husband was not as ill as herself. As a matter of fact, the young woman was looking disturbed as though she had never suffered from a major disease. However, it was understandable due to the pace at which she was losing weight and the amount of energy she had to use in coughing. It was a productive cough, meaning that she would have to excuse herself to spit the sputum in a container she had carried. It was a situation that no one would want for a lady of such a bright future. Worse still, she looked pregnant from the protrusion that on her belly. According to her, she had been diagnosed with tuberculosis a few years before but got treated. She was put in a regimen which, in her opinion, she got well before she cleared. The drugs were supposed to have been taken for up to six months. Initially, she went for the first bunch of drugs that was to last her for the first four months. In this first section, she took all the drugs as recommended as she was feeling very ill at the time. However, the second batch was given at a time when she was beginning to feel well. And so, when she was certain that her condition was much better, she decided to stop taking the drugs. After all, the drugs caused her a lot of side effects, including nausea. Asked if her doctor had told hr anything about compliance to the drugs, she maintained that they did not talk to her personally, but explained it to her husband who failed to inform her. The patient was not on any drugs at the time, but was contemplating starting herself on the previous drugs again. This was due to the fact that the current condition presented in the similar way as the first. She had thought that she could use the drugs to treat her condition like they had helped her get better earlier on. At this point, the patient was taken to the laboratory where her sputum was taken for testing. In addition, the laboratory personnel also took a sample of her blood. The results were to be ready in as soon as possible. It was hard to wait for her diagnosis to be made because the way she coughed gave an impression she was going to die the next minute. In addition, she was taken to a spirometer where her breathing was assessed by special respiratory apparatus. Meanwhile, she was given antitussives to help her control her coughing as she literally lacked the energy to cough for too long. Contacted, the laboratory personnel insisted that they would test her to tuberculosis as well as HIV given that the two are quite related. It was a tense moment as it was hard to imagine myself handling a patient with HIV.

Primary and Secondary Infection

The laboratory findings indicated that the patient was suffering from tuberculosis that had relapsed. It was clear that she had not cleared her drugs for the initial infection, and therefore did not get healed completely. For one to get well completely, he or she must take all the drugs as recommended by the doctor. In fact, one is supposed to start afresh in case a dose or two are missed. This is something that physicians really emphasize on to their patients considering that non-compliance will essentially mean no therapy at all. It is the reason she ought to have listened to the doctor’s instructions very keenly. Unfortunately, the physician had given instructions to her husband who apparently did not understand anything. He did not explain anything to her wife concerning her drugs. And so, while the doctors thought she was being healed, nothing was really happening. The results indicated positive for tuberculosis as well as for HIV/AIDS. It was difficult to imagine how this information would be given to her in a manner that would not break her heart. However, that fact that she had been suspicious of the same infection provided the confidence to face the challenge. And so, the patient was called to a solitary room where a short session of counseling was organized. This was to prepare her psychologically for the unfortunate information that had found her family. It was certain that she would die together with her family in a matter of years. She also had to be told that her infection with tuberculosis was related to the HIV infection. This was a sign that her immunity was already running low and that something drastic had to be done.

The primary infection was related to the secondary infection in that tuberculosis presents easily in people with suppressed immunity. The HIV infection was already causing her immune-suppression to the extent that the body was already vulnerable to most infections. According to literature, one can stay with tuberculosis infection for a very long time if they have a functional immune system. However, the moment immunity starts to go down it presents as a major disease. Notably, a third of the global population has tuberculosis infection that does not present as a disease because they have functional immune system. Indeed, it was difficult to tell how she had contracted HIV infection given that she was not certain about her husband’s infidelity. However, it was decided that her husband had to be tested as well in order to prevent her from infecting other people or avert a possible re-infection of her wife. In fact, it was possible that the tremendous weight loss must have been due to the effects of HIV infection as well. This combination of infections is quite popular given that tuberculosis has been globally associated with tuberculosis. It goes without saying that her husband’s negligence had also cost her because she was not fully healed of her initial tuberculosis. Had she been told how important compliance was with regards to the drugs for tuberculosis, she would have been more cautious with her medication and succeeded in treating her condition. In addition, he doctor should have informed her instead of her husband considering that she was mature and of sound mind. It was more probable for the husband to ignore the instructions because he was not the one suffering. However, it had happened and a solution had to be sought. The relapse of hr tuberculosis had been caused by the infection with HIV.  

Holistic Assessment of Client

It was important that contact tracing be done in order to ascertain the number of people who might have been infected as well. In this regard, she was asked if she could provide information regarding any person she had had a sexual intercourse with a part from her husband. In her response, she insisted that there wasn’t any, but noted that her husband must have been seeing someone at the moment. She resolved to talk to him about it first before they both came back to the hospital for psychotherapy. As for her personal health, her sputum was taken for further testing in case she could be developing opportunistic infections. Although these later turned negative, it was clear that she had to be put on drugs as soon as her tuberculosis was healed. The fact that she was pregnant had complicated her choice of drug regimen, making it hard to put her in one. The only viable option at the moment was either change her tuberculosis regimen or wait until her tuberculosis was cured. After all, she still had a CD4 count of 400. This was only slightly above the mark, but could certainly keep her going for some time.

The doctors also tested her for problems associated with the respiratory tract. It was possible that the tuberculosis infection had caused serious complications to her lungs, portending a serious trouble for her future. However, it turned out that her lungs were alright and still functioned properly. The only problem was that she could not be promised that she would be alright. The fact that she had HIV infection implied that she could fall ill at any time. Thus, she had to keep a close tie with her doctors in order to provide her with the right advice on what to do. In addition, her viral load had to be assessed often in order to know when to institute antiretroviral therapy. This is because giving her too early would predispose her to the severe side effects that some of the drugs cause. In addition, she could exhaust all the therapeutic regimens available before these drugs could help her prolong her life. It should b noted that antiviral drugs are used for the entire lifetime once started. Thus, starting her too early would limit hr choice of drugs in case she became resistant to a particular regimen. On the other hand, she could not be started on these drugs too late because they would be too weak to experience immune reconstitution.   

Present Stressors

The major concern to this woman was psychological stressors considering that she was still keen on pursuing her career as well as building her family. She looked particularly worried about her little baby and what would become of it. It was uncertain if she would also end up getting infected at birth given that they shared a circulatory system. However, she was assured that there were safe methods of delivery that will ensure that her baby remained safe even after delivery. She was also told that if she undertook to comply with her medications, she would stay long enough of take care of her little angel. At some point, the doctor’s invited another woman who was also infected with HIV and equally had a child. She was surprised to see the child quite healthy and uninfected. However, she did not want to be sure that her case would turn out the same way. And so, she crossed her lips and prayed that things happened in her favor. It was the beginning of a new life for her.

The other thing that seemed to trouble her was her job as well as education. For one, she did not know how she would approach her colleagues at work with such kind of news. It was a great challenge given that some of her colleagues could use this as a reason to avoid her company. Although stigma against HIV victims is currently low, it is a possibility that she could not wish away. Indeed, it was even possible that she could have been paid less money given that her condition would not allow her to work as hard as she used to. However, it was her master’s degree that was significantly affected. She had invested so much of her savings to pay for her fees. She expected that she would get a better job as soon as she finished so that she could get back her money. This was now threatened given that she was not even sure of securing a new job with her medical condition. As a matter of fact, very few employees would be willing to employ a person who would only stay shortly in employment. This bothered her so much, and it was evident in her face.

Client’s Strengths and Needs

The client needed a lot of counseling in order to come to terms with her new condition. It was an accident that had struck at a time she had not expected. Left alone, she could easily decide to commit suicide or harm herself. This made it important to put her close to members of her family as well as trusted friends. In addition, the nurses encouraged her to join buddy groups constituting women who were facing the same situation. According to them, this would help her to solve the emotional baggage that had resulted from her condition. In addition, it would help her in taking her drugs by ensuring that she remained compliant to the regimen. Although she was yet to be started on antiretroviral, it was advisable to get her into a group to start familiarizing with the women. These regimens are so delicate such that noncompliance can easily result in treatment failure or even resistance to the drugs. This is why she had to be cautious if she really wanted to live. it would also help her take care of her baby till she was old enough. For example, they would tell her how to treat her baby such that she never gets infected.

The patient was strong in the sense that she was on good diet all that time. Although she only had a CD4 count of 400, she was still very strong, and there were no signs that she would fall ill soon. She did not really have to be told what to eat considering that she was a professional in nutrition. In fact, her combination of foods was later adopted by most of the women she had joined in the group. They believed that she had chosen the right foods that will enable them live healthy lives for much longer time. The lady also had a supportive family that kept comforting her. As she stayed behind in the hospital to be treated of her tuberculosis, they would come every day to pray and sing with her. At times, they would invite their pastor to come over for a prayer session. In fact, most patients found this important and would occasionally. It was clear that her commitment to religion was helping her out. She would have been more stressed up if not for these people who kept consoling her. At some point, even her husband came to terms with the new reality and would occasionally come.

Plan of Care

The plan of care for the lady is to treat her tuberculosis first and then embark on treating her for HIV. This is due to the fact that HIV is not an infection and is only a manifestation of immune failure. Thus, by treating her of tuberculosis the doctors were ensuring that these bacteria would not take advantage of her low immunity to invade various parts of her body. According to literature, extra pulmonary tuberculosis can be more dangerous that pulmonary tuberculosis because it can be misdiagnosed. In addition, this will ensure that her condition did not deteriorate further before the disease got to stage three where opportunistic infections became more obvious. Tuberculosis, if left untreated, will serve as an example of early opportunistic infection and may be difficult to treat if her immunity became lower than it was at the moment. It was important that she was freed of any possible diseases so that her immune system is not put under the strain of having to fight these infections. It was basically a strategy to preserve her immune system and await the onset of opportunistic infections that was equally fatal.

Later on, she would be managed for opportunistic infections when they began to appear. However, this was subject to their emergence given that they usually emerge at different times for different people. It goes without saying that the doctors had to keep checking her level of CD4 count as well as hr viral load. This would help determine when to start her on the required drugs. In addition, she would also have to be monitored for opportunistic infections. The most lethal one is usually diarrhea that is caused with certain species of fungi. The knowledge of these symptoms will help the doctors to effectively manage her condition in a manner that will ensure that it does not affect her life or the life of her baby significantly. This made it necessary to monitor her constantly and record her progress.

In conclusion, the 30 year old lady had been diagnosed with tuberculosis as well as HIV/AIDS. She had been diagnosed with tuberculosis a few years before but got treated. At that time, she was put in a regimen which, in her opinion, she got well before she cleared. The drugs were supposed to have been taken for up to six months. However, she did not finish her drugs causing the disease to relapse. This is a common phenomenon in the treatment of tuberculosis and is indeed the reason why people are encouraged to complete their drugs. The major concern to this woman was psychological stressors considering that she was still keen on pursuing her career as well as building her family. She looked particularly worried about her little baby and what would become of it. The other thing that seemed to trouble her was her job as well as education. For one, she did not know how she would approach her colleagues at work with such kind of news. It was a great challenge given that some of her colleagues could use this as a reason to avoid her company. However, she had a supportive family that kept comforting her. As she stayed behind in the hospital to be treated of her tuberculosis, they would come every day to pray and sing with her. At times, they would invite their pastor to come over for a prayer session. These certainly kept her going even though she was only a young lady who had not seen much about HIV infections. 

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