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The definition and classification system for HIV infection was revised and
published in December 18, 1992, by the Centers for Disease Control and Prevention
(CDC). The CDC classifiy HIV infection according to CD4 + T-lymphocyte count and
clinical conditions associated with HIV infection (CDC, 1992). The CD4+ Tlymphocyte cell is affected by the HIV virus. The CD4 + T-lymphocyte (helper) cell
are often called the quarterback of the immune system. The destruction of Cd4 + Tcells creates an imbalance in the ratio of T4 to T8 (suppresor) cells; suppresor cell
turn off the immune response when it is no longer needed (Alspach, 1991). The
reduction of the CD4+ T-cell count compromisses the immune system. The
compromised immune system allows opportunistic organisms to invade the body,
which normally would be able te defend itself from the invaders.
The HIV/AIDS classfications system emphasizes the clinical importance of
the CD4+ lymphocyte count in the categorization of HIV refected clinical conditions
(CDC, 1992). The definition includes all infected persons with CD4 + counts of less
than 200/mm3 and patients diagnosed with three additional apportunistic infections:
pulmonary tuberculosis, invasive cervical cancer, and reccurent bacterial penumonia
(Thompson et al., 1993).
According to the CDC (1992) Revised Classification System, CD4 + T
lymphocytes are placed in three categories.
Category 1: 500/l
Category 2: 200 to 499/l
Category 3: 200/l
fundamental issues determining ICU eligibility for patients with AIDS; the patients
prognosis and the patients whises regarding life support (Hall et al., 1992). Hall et all
(1992) also suggest a prognostic staging system for patients with AIDS. They suggest
the peresence of each of the following abnormalities be scored as one point :
Severe diarrhea or serum albumin < 2 g/dl
Any neurologic deficit
PaO2 < 50 mmHg
Hematocrit < 30%
Lymphocyte count < 2500/mm3
WBC count < 2500/mm3
Platelet count < 140,000/ mm3
Patients are devided into stages I to III according to their score (0 points, 1 points, and
2 to 7 points, respectively). In the original study 1 years survivals were 50%, 30%, 8%
for stage I to III, respectively (Hall et al., 1992).
In addition to assessment based on a staging system, the patient and family
must be involved in the decision process, and their whises taken into consideration. It
is important that the patient make his or her whises known to the nurse, physician, and
significant others. Rigid policies regarding ICU admission are undesirable, and it is
necessary to make a detailed evaluation of each situation on a case by case basis (Hall
et al., 1992).
9. What treatments were done for Mr. Michael to ensure a succesful outcome from
the ICU ?
The results from the flexible fiberoptic bronchoscopy indicate PCP. This is
turn alerted the physician to begin IV pentamidine. When Mr. Michaels status did
not improve, additional medications were used; ampicillin and hydrocortisone. His
oral candidiasis was treated with ketoconazole.
10. Are the ICU nurses at an increased risk of acquiring AIDS from patients who
receive mechanical ventilation ?
The statistic of medical personnel contracting AIDS from patients are quite
low. The use of universal precautions by all medical personnel lessens the risk of
infection. It is important to handle blood and body fluids properly. It is important to
follow the CDG recommendations for prevention of HIV transmission in health care
settings and to follow the Occupational Safety and Health Administrations (OSHAs)
blood and body fluid precautions.
The risk of acquiring HIV infection from patients in health care settings is less
than 1% at 95% confidance level (Oskins, 1990). From a recent study over a 6 year
periode, 76 ICU employes were exposed to 56 mucosal splashes and 25 needle-sticks.
None of the health care personal seroconverted for HIV (Hall et al., 1992). It is
important that ICU staff take precautions to avoid blood and body fluids from all
patients. In a survey published in an article Scherer, Haughey, Wu, and Kuhn (1992),
59% of nurses were fearful of contracting AIDS from patients; 67% stated a major
concern was not knowing a patients HIV status.
11. What are some of the nursing intervension that will help Mr. Michael with his
psychosocial and psychologic needs ?
Mr. Michaels initial admission assesment demonstrated several psychosocial
needs. It is important to asses his safety both through necessary suicidal precautions
and asistance with ambulation. Mr. Michaels safety should be a priority. It also very
important to maintain the patients support systems.
Potential nursing diagnoses for ADC include the following :
Anxiety related to unknown progession of HIV/AIDS
Ineffective coping related to depression and AIDS dementia
ADC related to unknown progession of HIV/AIDS
Fear related to the unknown progession of HIV/AIDS
It is necessary to design a plan of care according to assesment data and expected
outcames. For example, since Mr. Michael will have preceptual alterations, including
diminishing memory, it is important to have him keep a calender to help him follow
treatment regimens. Instructions should be simple and concise.
During the time that mr. Michael has PCP, it is important to follow care
according to developed nursing diagnoses and expected outcomes.
Nursing diagnoses developed by Henry and Holzemer (1992, pp. 247-248)
include the following :
Hyperthermia related to human responses to the disease responses to
PCP
Impaired gas exchange related to the disease proces PCP
High risk for altered respiratory function: dyspnea related to the disease
process of PCP
Alteration in comfort: nausea or vomiting related to administration of
pontamidine or sulfamethoxazole-trimethoprim
The nursing care of a patient with ADC and PCP in the critical care unit
depends not only on the nurses knowledge of the physiology of the disease process
but also on the physiology of the disease process but alsoon the psychosocial needs of
the criitically ill patient (Henry & Holzemer, 1992).
12. What assigned to an HIV infected patient, what personal feelings or concerns
should be acknowledge ?
According to Bradley-Springer, Schwanberg, and Frank (1994), in
aquantitative study assessing nurses reactions to the possibility of caring for HIV
infected patients, nurses held a wide variety of oponions and concerns. In the area of
caring, the nurses expressed sadness, empathy, and compassion. They wanted to give
the best care possible, would trust precautions, and would not refuse to care for HIV
positive patients. In the area of avoidance, the authors found that nurses were
concerned for themselves and their families. Forty two percent of the nurses felt trhat
they were not properly prepared to care fot HIV infected patients.