Friday, March 31, 2006

Care Plan Two...DiVa style

I didn't think I did very well on this care plan because my goals are actually interventions, but my prof liked it so well that she is encouraging me to expand my research and have it submitted for publication in a scholarly journal. Whoa! I was not expecting that, nor was I expecting two extra credit points in addition to a perfect score. Check it out...

Admission information

AP, is a 42 year old African American male, was admitted to the hospital for sepsis/pneumonia, rule out tuberculosis. His stage of growth and development is somewhere between stage 5 (intimacy vs. isolation and) stage 6 (generativity vs. stagnation). The patient was brought to the emergency room by his sister with an episode of respiratory distress. Although the patient has a history of HIV, this diagnosis was not the focus of his treatment. The priority at the time of his hospitalization was the resolution of his respiratory issues, pneumonia and ruling out tuberculosis. Additional notes: This patient was being treated primarily for the pneumonia, but actually was experiencing what is known as full blown AIDS.

Medical history Includes

Genital herpes, hair follicle disease, Hepatitis B, HIV, colon cancer, tuberculosis, colostomy and rectal prolapse.

Advance Directives

The patient is a full code. The house officers explained the prognosis of the patient and the family had a meeting. They came to the conclusion that it would be his wish to live despite the odds.

Psychosocial and Cultural Assessment

The patient’s spiritual preference is Southern Baptist. AP is a single man and the hospital staff was under the impression that AP lived an alternative lifestyle. He is currently disabled and relies on Medicaid/Medicare for insurance coverage. AP had only informed his family that he suffered from colon cancer. That was only part of the diagnosis. AP was also HIV+ and had not disclosed his HIV status to the family. This caused him a bit of anxiety because he was concerned that his family would find out from medical staff. To address the anxiety the patient was sedated and the RIKER scale was used to assess his level of anxiety. He made it clear during his primary assessment that he did not want anyone to know. As a result, it is believed that AP lived out the remaining days of his life in secrecy and withdrawn from the people that he could rely on for support.

Nursing Diagnosis and Evidenced-Based Nursing Interventions

Social Isolation and inadequate support related to stigmatization of HIV/AIDS as evidenced by failure to disclose complete information regarding his health status to the family.

Ineffective coping related to HIV/AIDS status and alternative lifestyle as evidenced by medication non-compliance, substance abuse and high levels of anxiety.


1. Meet psychological/emotional needs by expressing feelings and utilizing his family as a means of support.

2. Identify ineffective coping behaviors and consequences

3. Take action to correct isolation and participate in support groups once a week designed for members of the community who are a part of the same peer group, and that suffer the same ailment. (AIDS support group)

4. Learn about the importance of treatment compliance and develop a schedule to manage his medications.

5. Develop a relaxation program or tap into spirituality to help develop healthy coping mechanisms to deal with the stress and anxiety associated with HIV/AIDS

Interventions and Scientific Rationales

- Establish a therapeutic relationship with the patient

Rationale: promotes trust and enables the patient to discuss sensitive matters without fear of judgment. Once this type of relationship has been developed, it will be easier to encourage the patient as he comes to grips with the seriousness of his condition and to support the patient when he decides to disclose his illness to the family.

- Encourage the patient to express his feelings through journaling about his feelings of stigmatization.

Rationale: Many people find journaling to be a non-threatening way to share feelings about various life situations without fear. A group of professional nurses from the University of Texas at Austin performed a study on the benefits of writing and discussing the trauma of having HIV/AIDS, which enabled the subjects to think about and reorganize their feelings about their condition. As a result the patients were able to overcome the stigmatization and improve their quality of life. “Psychological benefits include a decrease in depressive symptoms, anxiety, and negative emotion, and higher self-esteem (Esterling et al. 1999).”

Evidenced- Based Support
“Stigma is a real or perceived fear of discrimination (related to the diagnosis of HIV/AIDS). Individuals with HIV/AIDS fear negative responses from others (Bigner & Bozett 1989, Doll et al. 1994, Moneyham et al. 1996). Social isolation and loss of supportive relationships, imposed by others who fear contagion (Muma et al. 1995) are major stressors for individuals with HIV/AIDS (Lippmann et al. 1993). Stigma associated with having HIV causes clients to be concerned about disclosure to family, friends, and co-workers, especially when they are taking multiple medications (Campbell 1990, Weiner 1991, Moneyham et al. 1996).”

“Given the complexity and burdens of HIV/AIDS, there is a need for an effective, easy, low cost intervention that integrates health care services and improves outcomes for patients with HIV/AIDS. When individuals experience stressful events, such as living with HIV/AIDS, and are unable to share their thoughts and feelings with others, they are at an increased risk for physical and mental health problems (Petrie et al. 1998).

“…emotional disclosure through a writing intervention would result in cognitive reorganization and a reduction in perceptions of stigmatization. In turn this would improve the psychological and physical health and health-related behaviours of persons with HIV/AIDS. This hypothesis stems from previous findings that both cognitive reorganization (e.g. Pennebaker 1997b, Pennebaker et al. 1997) and reduced perception of stigmatization (Pennebaker & Seagal 1999) were linked to improved psychological and health outcomes.”
(Pgs. 511-513, Abel, E., Rew L., Gortner E., and Deville, C. L. (2004).

-Plan a family meeting to support the patient as he makes his disclosure to the family. Be available to help educate the family, answer any questions and provide community resources.

Rationales: It is clear that AP felt that his family would abandon him if they were aware of his HIV+ status. His family is a close knit, spiritual family. During his time in the Medical Intensive Care Unit, his entire family stood at the bedside and prayed for him and talked to him, even though he was unable to respond. At the time of this exacerbation of illness, the patient’s sister was the primary caregiver. If the family has support and are well educated about the course of illness, the patient should be able to experience a good quality of life.

Evidenced- Based Support

“Beliefs about illness Studies of low-income and minority populations indicate that many persons have inadequate and incorrect information about HIV and its transmission (Mays & Cochran 1987, Flaskerud & Thompson 1991, Stewart 1993). Individuals may view ART as harmful and doubt its effectiveness, based on their experiences, or be influenced by what others say (Misener & Sowell 1998, Roberts & Mann 2000, Catz et al. 2001, Ammassari et al. 2002).”
(Pgs. 511-513, Abel, E., Rew L., Gortner E., and Deville, C. L. (2004).

A study of patients with AIDS in Thailand performed by nurses at the University of Manchester England revealed the following evidence:
Anxiety, reluctance and stigmatization have often been seen within some families of PWAs due to lack of knowledge and the people with AIDS (PWA) less acceptable behaviors in the past. PWA’s have been left alone in hospitals or temples, increasing their psychological problems (Polmuk, 1996). The acceptance from the family may encourage PWAs to cope better with their illness. Thus, preparing PWAs, family and community to live together well is a crucial health care policy to be considered that should include community and home care programs, (Molassiotis and Maneesakorn, 2004 ).

- Perform regular screenings for depression and medicate accordingly. In addition to pharmacological treatment, the patient will need to develop a network of support within the community.

Evidenced- Based Support

“Patients at all stages of HIV infection need psychosocial support to deal with depression, anxiety, and other emotional problems that can develop as the patient’s condition changes. At each visit, screen your patient for depression and refer her for further treatment if indicated. The health care provider may prescribe a selective serotonin reuptake inhibitor (SSRI), which is considered a first-line therapy for depression. In general, general, SSRIs are well tolerated and relatively safe to use, especially for patients with hepatitis or other hepatic impairment. Any antidepressant should be prescribed in conjunction with counseling, talk therapy, or support groups.” (Pg. 62, Kenny, 2004)

-Develop a relaxation program or tap into his spirituality to help develop healthy coping mechanisms to deal with the stress and anxiety associated with HIV/AIDS
Rationale: The patient history revealed that the patient had a past problem with alcohol and possibly drugs. The use of controlled substances is an unhealthy coping mechanism or means of dealing with stress associated with illness. Additionally, some of the anti-viral medications are incompatible with the use of controlled substances. The history of African Americans includes a rich spiritual component, which was evidenced in this patient’s treatment by the visit, prayers/blessings and anointments received from religious clergy. Since this proves to be a part of the patient’s life, it could be incorporated into his plan of care to help alleviate stress and anxiety.
Evidenced- Based Support
“exploring the contribution of spirituality to health functioning have reported that spirituality did provide some empirical benefit for health status (Levin & Schiller 1987, Levin & Vanderpool 1989, Idler & Kasi 1992, Dein & Stygall 1997, Mathews et al. 1998). Their findings suggested that individuals who reported overall improved health status identified themselves as being spiritual. Additionally, spirituality was found to provide a buffer against illnesses and allow quicker recovery from general illnesses. Although these populations were not HIV infected, they were living with some form of a chronic illness, which HIV has clearly become.”
(Pg. 462 Coleman, 2003)

- Address medication non-compliance and the consequences

Rationale: One of the reasons why the patient experienced this period of exacerbation was because he wasn’t taking his medications properly. Mainly, because he didn’t want his sister to figure out his HIV status by the plethora of medications that he was prescribed, but it could be secondary to the fact that he was not sufficiently educated about the importance of medication compliance.
The following list of interventions and rationales are from a nurse at Florida International University who developed a program of care to address medication non-compliance, patient education and treatments for emotional problems that regularly occur with patients that suffer with HIV/AIDS.

(Pgs 9-10. Jones, 2004)

•” Establish a trusting relationship with your patient. If you’re nonjudgmental when he says he’s missed a few doses, he’ll be more likely to continue being honest with you about his behavior. By understanding why and when he may be missing doses, you can work with him to improve his adherence to the regimen.”
• “Be an educator. For example, teach the patient how the virus invades the body, why the drugs work, what adverse drug reactions to expect, and why he must adhere to the treatment regimen. Encourage him to ask questions and provide other details that he needs or wants to know.”

• “Provide ongoing support. Ask the patient about adverse reactions and other concerns he has and help him address them. Advise him to discuss concerns with the prescriber, in case his regimen can be modified. Encourage adherence by graphing his viral load and CD4+ cell count before and throughout treatment, so he can see the benefits of adhering to treatment.”

•” Find creative ways to help the patient stick to his therapy. For example, help him devise a dosing schedule that fits his daily habits as closely as possible. Suggest the use of devices, such as beepers on watches and medication boxes, to keep him on track. Enlist relatives and close friends to remind him to stick to his schedule.”

•” Tailor adherence strategies in view of any concurrent mental or behavioral conditions. A patient with a co-diagnosis, such as depression or substance abuse, may need additional help and referrals. For example, depression can be treated with the use of antidepressants and counseling or a patient may request placement in a drug rehabilitation program to help him overcome substance abuse.”

Abel,E., Rew L., Gortner E., and Deville, C. L. (2004). Cognitive reorganization and stigmatization among persons with HIV. Journal of Advanced Nursing, 47 (5). Retrieved Mar 20, 2006, from EBSCO Host.

Coleman, C. L. (2003). Spirituality and sexual orientation: relationship to mental well-being and functional health status. Journal of Advanced nursing, 43(5). Retrieved Mar 20, 2006, from EBSCO HOST.

Jones, S. G. (2004). Taking HAART: how to support a patient with HIV/AIDS. TravelNursing2004, Retrieved Mar 20, 2006, from EBSCO Host.

Kenny, P. E. (2004). The changing face of aids. Nursing2004. Retrieved Mar 20, 2006, from EBSCO Host.

Molassiotis, A. and Maneesakorn S.,(2004). Quality of life, coping and psychological status of thai people living with AIDS. Psychology, Health & Medicine, 9(3). Retrieved Mar 20, 2006, from EBSCO Host.

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