3. What clinical indicators would classify Mr.

Michael as having major depression

or ACD ?
A patient with major depression usually complains of depressed mood,
diminished interest or pleasure in activities, appetite change with weight change (up
or down), insomnia or hypersomnia, fatigue or loss of energy, inability to concentrate,
feelings of worthlessness guilt, psychomotor agitation or retardation, and thoughts of
death or suicide. Any five of these symptoms lasting for at least 2 weeks are clinically
significant for a major affective disorder requiring intervention (Thompson, Novak,
Pursell, & Swift, 1993). It is important to take a careful history to determine
symptoms and situational crises that could precipitate the symptoms. Assessment of
suicidal ideation is important at the tine of the initial interview. Any precipitating
factors such as bereavement, medication reaction, or thyroid problems should be ruled
out. Nurses in acute care or mental health settings must be aware of the psychosocial
and neuropsychiatric aspects of HIV disease. It may be necessary to manage the case
of a patient who has anxiety or depression associated with a new diagnosis of HIV
infection or AIDS or a patient who may be manifesting dementia associated with
AIDS (Flaskerud & Ungvarski, 1992).
The HIV virus is capable of invading brain tissue. Neurologic symptoms have
been reported in approximately 40% to 70% off all AIDS patients, with 10% of these
patients having demonstrated neurologic involvement at the time of diagnosis
(Beckman, 1990, Flaskerud & ungvarski, 1992). According to Thompson et al (1993),
the early manifestations of ADC are memory loss, impaired concentration, apathy,
depressed mood, agitation, unsteady gait, tremor, kekakuan, motor weakness, and
psychotic features. HIV positive patients are often aware of the changes in their
neurologic well-being, which may lead to an adjustment disorder with fear, anxiety, or
depression.
Mr. Michael presented with symptoms that fit both categories. The most
significant symptoms the precipitated the transfer to a medical unit was the cange in
his walking abilities. It is important to avoid medications that have anticholinergic
side affects because these can cause delirium, including hallucinations, confusion,
and sometimes agitation. The medication of choice include zidovudine,
psychostimulants, and antidepressants (Thompson et al., 1993). ADC is considered a
fatal illness. It has been difficult to find a proven treatment for HIV encephalopaty,
which has a survival time reported of 90 days from diagnosis to death (Beckman,
1990). Cognitive and motor faculties decline further in people with CD4+ cell count
bellow 200/mm3 (Scherer, 1990). Clinical symptoms have improved with
combinations of zidovudine and psychostimulants (Clochesy, Breu, Cardin, Rudy, &
Whittaker, 1993).
4. What is the difference between HIV infection and AIDS ?
The terms HIV infection I and AIDS are not synonymous. AIDS is used to
indicate only the most severe diseases or clinical conditions observed in the
continuum of illness related to infection with the retrovirus human immunodeficiency
virus type I (HIV-1) (Flaskerud & Ungvarski, 1995).

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

These categories guide clinical and therapeutic management of HIV infection, an

asymptomatic condition, or persistent generalized lymphadenopathy (PGL) (CDC,
1992). As many as 90% of HIV infected persons have severe flulike symtomps 1 to 3
weeks after infection. These symptoms may last 1 to 2 weeks. During this time their
HIV antybody test results are usually negative, althought they do have a steady
decline in their CD4+ T-lymphocyte count (Flaskerud & Ungvarski, 1995). The HIV
antobody test results usually become positive 2 to 18 weeks after infection.
The early symptomatic stage develops when CD4 + T-cell counts drop to
around 500/l (Flaskerud & Ungvarski, 1995). Clinical conditions that could occur at
this stage included candidiasis, herpes zozter, pelvic inflammatory disease, and
peripheral neurophaty (CDC, 1992).
The late symptomatic stage begins when a patients CD4 + T-lymphocyte cell
count drops below 200/l (Flaskerud & Ungvarski, 1995). A patients may develop
life-threatening infections and cancers. The infections usually remain tretable. At this
point the stage of infections reflects the CDC criteria for AIDS. The last stage of HIV
infection is the advanced HIV disease stage. The patients CD4 + T-cells have dropped
to less than 50/l (Flaskerud & Ungvarski, 1995). Once this level has been reached,
death is likely within 1 year.
5. What clinical indicators classified Mr. Michael as having AIDS rather than as as
being HIV positive ?

Laboratoty findings in the diagnosis of AIDS include a positive HIV antibody

test, decreased white blood cell (WBC) and lymphocyte counts, depressed CD4+ Tcell count, and an abnormal CD4-CD8 ratio (Jone, 1993). According to the CDCs
definition and classification of the the diaseas, Mr. Michael converted for, being HIV
positive to having AIDS when his CD4 count went below 200/l. Mr. Michael also
had three opportunistic diseases. He was diagnoses with PCP, Candida of the oral
mucosa, and Salmonella of the gastrointestinal tract.
6. Describe the symptoms of PCP
Individuals infected with HIV eventually have at least one episode of PCP.
The statistic are as high as 75% to 80% of patients diagnosed with AIDS will have
PCP. PCP as simple fungus and is found in the lungs of humans, rats, cats, dogs, and
several other animal (Flaskerud & Ungvarski, 1992). Most children by age 4 years
have developed antibodies to Pneumocytis carinii (Thompson et al., 1993). PCP is not
considered a serious pathogenic organism unless a person is severely
immunocompromised. In PCP the alveoli fill with ptoteinaceous material that contains
cysts and trophozoites. Air distribution into alveoli filled with PCP is impaired.
Symtomps associated with PCP include fever, high respiratory rate (>30/min)
usually dyspnea on exertion then at rest, normal or abnormal chest examination
results, normal breath sounds or minimal rales, cyanosis around the mouth, nailbeds,
and mucous membranes, non productive cough (unless patient is a smoker) and
thrush, which indicates immunosuppression. (Flaskerud & Ungvarski, 1992;
Thompson et al., 1993).
7. What symtomps and pulmonary diagnostic in Mr. Michaels case indicated the
need for transfer to the ICU ?
Mr. Michaels symptoms following his transfer to the medical unit included
dyspnea, fever, and nonproductive cough. His chest x-ray showed minimal infiltrates
in both lobes. Oxygen was necessary for his hypoxia. His vital signs were within
normal limits except for his temperature. He required admission to the ICU whwn his
respiratory status became life threatening. Because of his diminished respiratory
status, Mr. Michael required intubation and mechanical ventilation.
8. Mechanical ventilation and ICU admission for a person with AIDS is
controversial. Why was Mr. Michael admitted to the ICU ?
The primary reason for patients with PCP to be admitted to the ICU is for
mechanical ventilation related to respiratory failure. Early studies indicated an 87% to
100% mortality rate for patients with PCP requiring mechanical ventilation (Henry &
Holzemer, 1992). Later studies indicate survival rate is better for a first episode of
PCP than for subsequent episodes. PCP is being diagnosed earlier and is being treated
more effectively (Singer, Askanazi, Akiva, Bursztein, & Kvetan, 1990). With this
early treatment, 72% of patients with AIDS and PCP survive their first bout.
(Clochesy et al., 1992).
The episode of PCP for Mr. Michael was his first . His CD4 count was below 200/l
but not significantly. Accroding to hall, Schmidt, and Wood (1992), there are two

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.