Clinical Map up activity

Preparation guideline
 Pneumocystis pneumonia
o https://www.cdc.gov/fungal/diseases/pneumocystis-pneumonia/index.html
 Suwanwongse, K. & Shabarek, N. (2020). Tension Pneumothorax following Pneumocystis
jirovecii pneumonia. Cureus 12(1)
 Concept based curriculum vol. 1 p. 487-509

Assignment

 Complete the system disorder worksheet

 Complete both case studies

HIV/AIDS case study 1

K.D. is a 56 year-old man who has been living with human immunodeficiency virus (HIV)
infection for 6 years. He had been on antiretroviral therapy (ART) with a regimen of tenofovir
and emtricitabine (Truvada), with darunavir and cobicistat (Prezcobix). He stopped taking his
medication 4 months ago because of depression. The appearance of purplish spots on his neck
and arms persuaded him to make an appointment with his provider. At the provider’s office,
K.D. stated he was feeling fatigued and having occasional night sweats. He said he had been
working long hours and skipped meals. Other than the purplish spots, the remainder of K. D.
physical examination findings was within normal limits. The doctor took 3 skin biopsy
specimens and obtained a chest X-ray examination, tuberculin test, and lab studies, including a
CBC, CD4 T-cell count, and viral load.
Over the next week, K. D. developed a nonproductive cough and increasing dyspnea. Last night,
he developed a fever of 102 F (38.9 C) and was acutely short of breath, so his partner 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 CD4 T-cell count was 175 cells/ul and viral load 35,230 copies/ uL. K. D. is on
nasal oxygen, IV fluids and IV trimethoprim-sulfamethoxazole. His current VS are 138/86, 100,
30, 100.8 F (38.2 C) and SpO2 92% on room air.

1. What is the importance of CD4 T cell and viral load counts?

2. What is PJP?
3. The skin biopsies return a diagnosis of Kaposi Sarcoma (KS). What is KS?
4. What is the significance of K.D. developing KS and PJP in light of the CD4 count?
5. K. D. had been seropositive for several years. What factors might have influence this
development of PJP and KS?
6. Name 4 problems you must manage at this time with K. D.
7. What type of isolation precautions do you need to use when caring for K. D.?
a. Droplet
b. Contact
 c. Standard
d. Airborne
8. What immediate complication is K.D. at risk of experiencing?
9. To detect his complication, what will be the focus of your assessment?
10. Why was K. D. placed on trimethoprim-sulfa methoxazole? What major side effects do
you need to monitor for K.D.?
11. What aspects of K. D. ‘s care can you delegate to the licensed practical nurse (LPN)?
Select all that apply
a. Providing instructions about a high calorie, high protein diet
b. Administering first does of IV trimethoprim-sulfamethozazole
c. Repositioning K.D. and having him deep breathe every 2 hours
d. Developing a plan of care to improve K. D.’s oxygenation status
e. Reinforcing teaching with K.D. about good hand washing techniques
f. Monitoring K. D.’s pulse oximetry readings and reporting values under 95%

12. K.D. has 20 KS lesions on his neck, upper chest and both upper arms, all of which are
closed and painless. How will you care for these lesions?

13. Because of compromised immune function, K. D. is at risk for developing other

opportunistic infections. List 5 infections

14. Outline the assessment you need to perform to determine whether these problems are
present.

15. What interventions can you use to help K. D. in managing his depressions?

16. Recognizing that K.D. has multiple posthospital needs, you begin discharge planning.
What type of assessment do you need to complete as part of K. D.’ discharge planning?

17. What other health care team members might you involve in K, D.’s discharge planning?

Case study progress

K. D. is responding well to treatment for PJP and plans are being made for discharge. He will
receive follow-up care at the outpatient clinic and soon begin radiation treatments for the KS.
His ART regimen is changed to a fixed-dose combination regimen with emtricitabine-tenofovir-
efavirenz (Atripla).

18. K. D. is kept on trimethoprim-sulfamethoxazole (Bactrim) 2 tablets once daily. He asks

why he had the keep taking Bactrim “Since the pneumonia is gone.” How would you
respond?

19. What is the reason that K.D. receives combination ART therapy with emtricitabine-
tenofovir-efavirenz (Atripla)?
20. How can you help K.D. take Atripla as prescribed?

21. What ongoing lab monitoring will K. D. need?

Scenario 2
You are working in a community health clinic and you have just taken C. Q., a 38 year-year-old
woman, into the consultation room. C. Q. has been divorced for 5 years, has two daughters
(ages 14 and 16), and works full time as a legal secretary. She is here for her yearly routine
physical examination. C. Q. states she is in a serious relationship, is contemplating marriage,
and just wants to make certain she is “okay.” No abnormalities were noted during C.Q. physical
examination. Blood was drawn for routine blood chemistries and hematology studies; since she
has never been tested, C. Q. agrees to a human immunodeficiency virus (HIV) test. The provider
requests you perform a rapid HIV test, which is an antibody test. Within 20 minutes, the results
are available and are positive.

1. Does a positive rapid HIV test mean that C. Q. has HIV? If it is negative, does it mean
she does not have HIV?
2. What counseling do you need to offer to C. Q. ?

C. Q. returns to the clinic 2 days later. The provider informs you that C. Q.’s Western blot test
results confirm that she has HIV infection; he requests you be present when he talks to her.
Before leaving C. Q.’s room, the provider requests that you give C. Q. verbal and written
information about local support groups and help her call a friend to accompany her home this
evening. She looks at you through her tears and states, “I can’t believe it. J. is the only man I’ve
had sex with since my divorce. He told me I had nothing to worry about. I can’t believe he
would do this to me.”
3. C. Q.’s statement is based on 3 assumptions: 1) J. is HIV positive; 2) he intentionally
withheld the information from her; and 3) he intentionally transmitted the HIV to her through
unprotected sex. Based on your knowledge of HIV infection, how would you counsel C. Q.?

4. In addition to offering alternative explanations and exploring options, what is your

most important role right now?
5. C. Q. asks you whether she has AIDS. What do you tell her?
6. Why is it a good idea for C.Q. to have someone she trusts take her home this
evening?
7. C.Q. gives you the name and phone number of someone she wants you to call. You
stay with her until she leaves with her friend. Has C.Q.’s right to privacy been
violated? Explain why or why not?

C. Q. returns to the clinic 4 days later to discuss her diagnosis.

8. What are your goals for C. Q. at this time?

9. What additional lab tests would you anticipate for C. Q. and Why?
10. C. Q. asks whether there is any treatment available. How would you respond?
11. The provider starts C. Q. on a regimen of tenofovir-emtricitabine (Truvada),
darunavir (Prezista) and ritonavir (Norvir). What general information will you give C.
Q. about antiretroviral therapy (ART)?
 12. C. Q. asks why she has to take so many drugs instead of a “big dose” of one drug.
What would you tell her?
13. What other issues will you discuss with C. Q. at this visit?
14. Review the general measures you will discuss with C. Q. to promote her overall
health.
15. C. Q. asks if she must tell J. of her HIV status. Does she have a legal responsibility to
inform him?
16. What reporting obligation does the clinic have?
17. Before C. Q. leaves the clinic, you recognize the need for further teaching when she
says:
a. “Joining a support group can help me deal with my HIV diagnosis.”
b. “I will not use any other medication without checking with my health care
provider.”
c. “If my viral load becomes undetectable, I will not have to worry about
transmitting HIV to someone else.”
d. “If my skin turns yellow, I have unusual muscle pain or feel dizzy or weak, I
will call the provider immediately.”
Two weeks later, C. Q. visits the office and asks to speak to you in private. She thanks you for
talking to her the day she received the news of her diagnosis. She tells you that J. confessed to
her that he has hemophilia and tested positive for HIV after having been infected through
contaminated recombinant factor VIII products. He was afraid to tell her about his diagnosis
because she might leave him. C. Q. tells you that she is angry with J. They are going through
counseling and the wedding is “off” at the moment.