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Case Study 86

Name: Arnela Suhopoljac


12/12/15

Class/Group: RNSG-2363-51218

Date:

INSTRUCTIONS: All questions apply to this case study. Your responses should be
brief and to the point. When asked to provide several answers, list them in order of
priority or significance. Do not assume information that is not provided. Please print
or write clearly. If your response is not legible, it will be marked as ? and you will
need to rewrite it.

Scenario:
K.D. is a 36-year-old gay professional man who has been human immunodeficiency
virus (HIV) infected for 6 years. He had been on antiretroviral therapy (ART) with
Combivir (zidovudine and lamivudine) and nelfinavir (Viracept). He self-discontinued
his medications 6 months ago because of depression. The appearance of purplish
spots on his neck and arms persuaded him to make an appointment with his
physician. When he arrived at the physician's office, the nurse performed a brief
assessment. His vital signs (VS) were 138/86, 100, 30, 100.8 F (38.2 C). K.D.
stated that he had been feeling fatigued for several months and was experiencing
occasional night sweats, but he also had been working long hours, skipped meals,
and had been particularly stressed over a project at work. The remainder of K.D.'s
physical examination was within normal limits. The doctor ordered a chest x-ray,
CBC, lymphocyte studies, including CD4 T-cell count, ultra sensitive viral load,
cytomegalovirus assay, and a tuberculin test.
Over the next week, K.D. developed a nonproductive cough and increasing
shortness of breath (SOB). Last night, he developed a fever of 102 F and was
acutely short of breath, so his roommate, J.F., 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 admission WBC and lymphocyte studies demonstrate an
increased pattern of immunodeficiency compared with earlier studies. K.D. is
admitted to your medical unit and placed on nasal oxygen, IV fluids, and IV
trimethoprim-sulfamethoxazole (Bactrim).

1.What is PJP?

This type of pneumonia is caused by the fungus Pneumocystis jiroveci.


This fungus is common in the environment and rarely causes illness in
healthy people. However, it can cause a lung infection in people with a
weakened immune system like K.D. who has HIV.

2.What is the significance of the purplish spots over K.D.'s neck and arms?
Black, purple or dark brown spots on the skin can be a sign of the
AIDS-defining cancer Kaposis sarcoma
It can also affect the lungs and intestines and cause swelling in the
legs. Sometimes there is tooth pain or tooth loss, weight loss, night
sweats, or fever for longer than 2 weeks.
3.Differentiate between HIV-positive status and AIDS.
One can have HIV without having AIDS.
HIV is a virus that has no symptoms. A person who has HIV who does
not have AIDS may have an active and effective immune system.
AIDS is a disease, and may have symptoms of various diseases such as
TB, meningitis, and cancer. Their immune system is rapidly growing
and less and less effective at protecting their body.
4.Why is K.D.'s development of KS and PJP of particular importance in
light of his HIV status?
It is important because getting KS is a sign that his HIV is leading to
AIDS.
After years of living normally with HIV, a person will start developing
AIDS, as the immune system begins to weaken. At this stage, the
person will become vulnerable to various Opportunistic Infections,
which can attack any part of the body. Such infections could range
from fungal infections and colds to diseases like TB or cancer.

5.K.D. has been seropositive for several years, yet he has been
asymptomatic for AIDS. What factors might have influenced K.D.'s
development of PJP and KS?
Firstly he discontinued his ART medication.
Secondly, he has been skipping meals. His nutrition was not up to par,
leaving his body open for damage.
He might be malnourished, which makes his susceptible to get sick
more often which can lead to AIDS quicker.

6.Identify four problems you must manage regarding K.D.

Nutrition
Hand washing and not making him more sick
Treating his JPJ
Managing his fever and keeping him from getting worse

7.What precautions will you need to use when caring K.D.?


Hand washing, and making sure everything is clean to not make his
susceptible to get worse.
8.What is the focus of your ongoing assessment?
Monitor his pulse ox
Monitor his breathing and respiratory status
Monitor his temperature
9.What major side effects of his antibiotic should you monitor K.D. for?

Sore throat or cough


Trouble breathing
Secer cramps or diarrhea
Unusual bleeding

10.What aspects of K.D.'s care can you delegate to the LPN? (Select all
that apply.)
a.
Administering first dose of IV trimethoprim-sulfamethoxazole
(Bactrim)
b.
Monitoring K.D.'s pulse oximeter readings, reporting values under
95%
c.

Developing a plan of care to improve K.D.'s oxygenation status

d.

Providing instructions about a high-calorie, high-protein diet

e.

Reinforcing teaching with K.D. regarding good handwashing techniques

f.

Repositioning K.D. and having him deep breathe every 2 hours

Case Study Progress:

K.D. is responding well to treatment for PJP, and plans are being made for discharge.
His ART regimen will be restarted, and he will be starting radiation treatments for
Kaposi's sarcoma. He will receive follow-up care at the outpatient clinic.
11.K.D. is kept on trimethoprim/sulfamethoxazole (Bactrim) two tablets
once daily. He asks why he has to keep taking the drug since the
pneumonia is gone. How would you respond?
The pneumonia might not be fully gone and can reoccur, we want to
start you on your ART therapy first prior to discontinuing it
12.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 as HIV positive. Give at least four additional topics
that should be discussed with K.D. before he goes home.

Side effects of his medications


What to look for if new infection
Optimize immune system
Consequences of stopping ART or his medications again

13.What laboratory data will most likely be monitored in K.D. in the


future?

CBC
Basic chemistry
CD4-T cell count
HIV viral load

14.List at least five other opportunistic infections that K.D. is at risk for
developing.

Gastroenteritis
Encephalitis
Menengitis
Pneumonia
Tuberculosis

(Harding, 2013, pp. 383-387)


Harding, M., Snyder, J., Preusser, B. (2013). Winningham's Critical Thinking Cases in
Nursing: Medical-Surgical, Pediatric, Maternity, and Psychiatric, 5th Edition

[VitalSource Bookshelf version]. Retrieved from


https://bookshelf.vitalsource.com/books/978-0-323-08325-6