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The health management system encompasses the individual's motivation to manage personal health-related activities. The health management system includes a person's perception of his or her own health status and a person's motivation to strive for an optimal level of wellness as demonstrated by follow through with the therapeutic treatment plan. The patient's choices related to compliance are stressed in this parameter for the ED patient. As with patients who have inadequate support systems, these patient's social support and health maintenance needs are less acute than their physical needs in most instances. Nonetheless, the patient should not be discharged without some determination of ability or willingness to comply with the treatment plan, including an assessment of financial, intellectual, emotional, and social resources.
Two case studies selected for demonstration of patient care needs and nursing interventions within this health system address the issues of compliance and motivation.
| COMPLIANCE | MOTIVATION |
| health maintenance | congruence with life- |
| health practices | style |
| life-style | health perception |
| self-care | incentive |
| smoking | needs assessment |
| substance use or
abuse |
personal goals |
impaired home maintenance management
altered health maintenance
noncompliance (specify)
health-seeking behaviors (specify)
| Health Management System | |||
| Level I | Level II | Level III | Level IV |
| Noncompliance with Rx regimen (meds, appts., diet) reveled on routine interview; nonsymptomatic | Noncompliance with Rx regimen is precipitating factor in this episode, e.g. wound infection, hypertension | Continued lack of compliance (deliberate or unintentional) would pose life-threatening situation, e.g. , DKA , CHF, recurrent GI bleeds | |
| Does not use safety devices in hazardous environment – current visit is a product of this behavior | Repeatedly treated as a result of poor safety practices current pattern is potentially self destructive | ||
| Identifies deficiencies in ADL; able to follow instructions and cooperate with intervention plan | Identifies problem with self –care but is unable or unwilling to cooperate in planned intervention | Presents with significant illness or injury secondary to self –care deficit, e.g. hypothermic, untreated ulcers | |
| Presents unclean and unkempt, with infestation; inadequate clothing | Homeless, indigent, unable to access social service or health care system – refer to social worker | ||
| Homeless, indigent, unable to access social service or health care system – refer to social worker | |||
| Preexisting condition requires more in-depth care than patient or support system is able to mobilize | |||
| Presents because not accepted at other health program i.e. substance abuse; unable to get shelter; detox | |||
Debra Kosko, MN, CRNP
Mr. Scott is a 51-year-old black male who arrived ambulatory into the ED triage area. He states that 20 min ago he picked up a drinking glass and it broke, lacerating his finger. A 1-cm superficial laceration of the patient's right fifth digit is noted by the triage nurse. The laceration area is cleansed and dressed, while the patient waits to be sutured. Mr. Scott's vital signs at triage are BP 174/114, pulse "6 and regular, respirations 20 and easy. Mr. Scott states he has had high blood pressure (HBP) for 15 years but that he has no other medical problems. He states he was taking 50 mg hydrochlorothiazide (HCTZ) and 50 mg Tenormin, each twice a day. Mr. Scott admits that 1 month ago he had stopped taking his medication/or weeks while he had a cold, but he has been back on his medicine since. Mr. Scott slates he last saw his doctor 10 months ago at which time his BP was above normal. At his last visit his doctor had said if the BP remained high, he would change Mr. Scott 's medication at the next visit. Mr. Scott did not keep his follow-up appointment and stales. "I do not like to go to the doctor." At triage Mr. Scott denies any headache, chest pain, shortness of breath, peripheral edema, extremity weakness, paresthesia. or visual changes.
Triage Assessment, Acuity Level II: high blood pressure, in no acute distress. BP systolic<200, diastolic< 115: laceration with distal circulation, motor ability, and sensation (CMS) intact, hemostasis achieved by direct pressure.
In the treatment area Mr. Scott's repeat BP sitting is right arm 186/124. left arm 182/120, with a regular pulse of 76 beats/min. Mr. Scott's previous medical record reveals four ED visits over the past 2 years, all for miscellaneous chief complaints not related to high BP. During each visit his BP was elevated and he had been advised to continue his medications and keep his follow-up appointment to maintain BP control. Mr. Scott's funduscopic exam reveals arterial-venous (A- V) nicking bi-laterally with sharp discs. His heart sounds are normal S1. S2; no S3. S4. or murmur: point of maximal impulse (PMI) is non displaced. His lungs are clear, his peripheral pulses are 4+, and there are no carotid, femoral, or renal bruits. There is no evidence of peripheral or sacral edema. A 12-lead ECG shows normal sinus rhythm without signs of myocardial ischemia or hypertrophy. A urinalysis shows /-protein and a specific gravity of 1.021. Chest x-ray reveals mild left ventricular hypertrophy. The electrolytes and CBC are normal.
Mr. Scott discussed his efforts at BP control over the years. He has decreased his cigarette smoking from three packs a day to three cigarettes a day. He denies the use of alcohol or illegal drugs. He says he eats in fast-food restaurants every day. though he understands that salt could increase his BP.
Mr. Scott was given 10 mg nifedipine sublingual. Within 30 min his BP decreased to 152/98 and was maintained at the lower level for over 1 hour. He was instructed at discharge to continue his 50 mg HCTZ twice a day, to discontinue the Tenormin. and begin enalapril 5 mg, 1/2 tablet each morning. Follow-up care was established using the departmental guidelines (Table 10.1). Mr. Scott was instructed to call his doctor and make an appointment to be seen within a week.
Stressors such as a visit to the ED or finger trauma can cause increased sympathetic nervous system activity. Such activity may result in labile BP changes in which there is a diastolic BP greater than 90 mm Hg in an individual who usually has a diastolic BP less than 90 mm He (1). Mr. Scott, who has a documented 15-year history of HBP is not having labile BP changes. Of those patients with labile BP. it is estimated that 10 to 25% will progress to conditions of chronic HBP (1).
There are two pathophysiological processes which occur during the asymptomatic or silent years of HBP. Trauma to the vessels in the arterial circulation occurs, causing accelerated atherosclerosis in large vessels and thinning and possible rupture of small vessels (1). In addition, HBP causes increased peripheral vascular resistance and increased work load on the heart (2). Patients can remain asymptomatic for years while target organ damage is occurring, primarily in the heart, kidneys, and cerebellum. Left ventricular hypertrophy can develop from cardiac adaptation to the increased pressure and after load caused by the elevated BP (3,4). This was evident on Mr. Scott's chest x-ray. Enlargement of the left ventricle can produce myocardial ischemia, angina pectoris, congestive heart failure, and myocardial infarction. Arteriosclerosis of renal vessels can occur causing renal insufficiency and ultimately renal failure. Mr. Scott could be show ing early renal disease, evidenced by the 1+ protein found on urinalysis. His long-standing HBP has caused the small vessels of the kidney. particularly the basement membrane of the glomerulus, to become thick and fibrotic, preventing effective filtration of metabolic wastes. resulting in proteinuria (3).
Plaques and emboli can lead to hypertensive encephalopathy. cerebral hemorrhage, and stroke (2,5). The vascular changes from HBP within the eye result in retinopathy. As the pressure rises, the arterioles in the retina constrict and leak. Leaking can cause the formation of cotton wool spots, hemorrhages, and papilledema (3). Mr. Scott's funduscopic exam revealed early retinal changes associated with a history of long-standing elevated BP.
The dilemma of treatment compliance in HBP is that the majority of people who have the disease are symptom-free. It is estimated that 50% of patients with HBP drop out of their treatment program within the first year, and 75% within 5 years (6). Numerous socioeconomic factors can determine a person's ability to follow an HBP treatment program such as income, education, occupation, and race (7). Complexity of regimen has also been identified as a cofactor for noncompliance. Single-dose therapy has been found to have a greater influence on drug adherence than multiple dose therapies (8.9).
However, even before therapy can be established, the patient needs to have access into care, and once referred, appointment-keeping compliance. A needs assessment of both the patient and the system can identify factors that either enhance or impede a particular patient's compliance with treatment (10). The individual patient's coping skills and attitude toward himself and HBP have an obvious impact on subsequent behavior. The patient's social support system of family or friends is of value as is his ability to pay for care and medication (11). Lack of transportation to and from appointments may also influence appointment-keeping behavior. Pre appointment reminders, in the form of phone calls or mailings, have been shown to enhance appointment-keeping behavior significantly (11.12.13). The greatest impact on patient compliance has been identified as the provider-patient relationship (14,15,16). Factors that have a positive influence on this relationship are that the patient see the same provider each visit, and that the provider convey a sense of having time for the patient, including the family, when possible. Discussion and instructions should be presented in language the patient can understand with opportunity for questions. In addition, the patient needs to know what the treatment program is as well as its purpose (17). Direct verbal communication of the information by the provider can usually produce greater compliance than written material (10). Mr. Scott displays some knowledge of HBP and the cardiovascular risk factors (i.e., smoking) but has not been compliant with follow-up care resulting in poorly controlled BP and early signs of target-organ damage.
Mr. Scott is a middle-aged black male with a 15-year history of HBP, poorly controlled for at least 5 years, and showing evidence of early target-organ damage. In the United States HBP is more prevalent among blacks compared with whites and starts at an earlier age and has a higher incidence and mortality rate in blacks (3.18). In fact, the highest incidence of HBP is among middle-aged black males. The disease is more severe in blacks and causes more end-organ damage. This leads to a higher case fatality rate. Though mortality from HBP has been declining since 1950, it continues to show higher prevalence in the middle-aged black male population.
Mr. Scott, though asymptomatic, has a sustained diastolic BP of around 115. He requires prompt evaluation and care. His management will focus on pharmacological intervention to decrease the BP without cardiovascular compromise. However, the greatest challenge lies in the education of the patient about this disease with appropriate referral for continuing care. The appropriate nursing diagnoses for this patient's care are (19):
Diagnosis: Potential for alteration in cardiac output related to increased systemic vascular resistance from vasoconstriction
Desired patient outcome: The patient's diastolic BP will be less than or equal to 80 to 100 mm Hg.
Diagnosis: Knowledge deficit related to HBP treatment and its asymptomatic target-organ damage.
Desired patient outcome: The patient will describe the relationship between elevated BP and damage to other body systems and will be symptom-free.
Diagnosis: Knowledge deficit related to HBP and its implications for life-style change.
Desired patient outcome: The patient will describe the relationship between his uncontrolled BP and poor compliance with medication and follow-up care, smoking, and dietary habits. The patient will stop smoking and describe measures to reduce salt intake.
Diagnosis: Noncompliance related to lack of understanding of benefits of maintaining treatment program.
Desired patient outcome: The patient will identify reason(s) for noncompliant behavior: the patient will acknowledge consequences of continued noncompliant behavior: the patient will participate in agreed-on plan of care.
Nursing interventions for Mr. Scott have both a clinical and educational focus. The clinical goal is an acute and efficacious reduction in BP. The nurse should repeat the triage BP in both arms. establishing a baseline. Pertinent questions should be asked targeted at acute symptomatology related to increased BP such as chest pain. shortness of breath, peripheral edema. visual changes, and paresthesia. The nurse should perform a physical exam related to target-organ systems including the heart, lungs, and peripheral extremities. The physician will order a baseline ECG to evaluate the patient for ischemia and left ventricular hypertrophy that would influence choice of pharmacological intervention. The doctor ordered 10mg nifedipine sublingual because of Mr. Scott's target-organ damage and elevated repeat BP. Nifedipine is a calcium-channel-blocking agent that produces prompt reduction of both systolic and diastolic BP, mean arterial pressure. and systemic vascular resistance (20,21). Onset of action of sublingual nifedipine is 55 to l0 min after administration. Maximal effect is achieved within 30 min, with a mean duration of action of 4 to 6 hr (20).
TIP: A reflex increase in heart rate occurs in most patients receiving sublingual nifedipine. Therefore, the nurse must closely monitor Mr. Scott's BP and pulse particularly for the first 15 min, and thereafter every half hour.
Possible adverse effects in the use of nifedipine include dizziness. headache, palpitation, premature ventricular beats, and hypotension (20). Mr. Scott's BP following treatment with nifedipine was I 52/98. and he experienced no adverse effects. His stay in the ED was extended an additional hour to monitor his vital signs for any prolonged adverse effects of nifedipine.
The second area of importance for nursing intervention involves patient education. While Mr. Scott is having his vital signs monitored, the nurse can enhance a positive patient provider relationship. This relationship is vital to Mr. Scott's compliance outcome (22). The nurse should close the door if possible, creating a few quiet moments to discuss BP in clear language appropriate for Mr. Scott. The nurse should recognize that the most vital area of noncompliance for Mr. Scott is his follow-up with a primary provider. The nurse should explore some of the factors specific to Mr. Scott's reasons for noncompliance and identify potential areas for assistance and improvement. Potential barriers to compliance such as cost, transportation, and scheduling conflicts with work or other responsibilities should be explored. The nurse should discuss reasons why Mr. Scott stopped taking his BP medication. The nurse should also review Mr. Scott's understanding of the role sodium intake plays in BP control. The nurse should review what foods Mr. Scott eats followed by what foods should be avoided. Since processed foods are consumed daily by Mr. Scott and are very high in sodium, they are of particular concern. Recipes that make food without salt appealing would be valuable. A referral to the dietician may be indicated.
Mr. Scott will need follow-up within a few weeks of discharge from the ED following pharmacological intervention. The nurse should refer Mr. Scott back to his usual source of care. Table 10.1.1 provides a guideline on HBP referral.
The nurse will provide Mr. Scott with needed information about the medications that were prescribed by the physician as well as about side effects. The nurse will describe the appropriate actions to take if unusual changes occur, such as chest pain or paresthesia. With the appropriate nurse-patient relationship the nurse should try to influence Mr. Scott to maintain his relationship with his primary doctor. All these aspects of patient education along with Mr. Scott's desire to change poor health behaviors will ultimately reduce his potential for mortality and morbidity.
Table 10.1.1 High Blood Pressure Referral Guidelinesa
| Diastolic Blood Pressure | Follow-up within | Systolic Blood Pressure When DBP < 90 | Follow-up within |
|
History of HBP |
|||
| <90 | 2 months | <140 | 2 months |
| 90-104 | 2 months | 140-199 | 2months |
| > 105 | 1 week | > 200 | 1 week |
| > 115 | 48 hr | > 200 | |
|
No history of HBP |
|||
| < 90 | 1 year | 1 year | |
| 90 to 104 | 2 months | 1 year | |
| > 105 | 1 week | 1 week | |
| > 115 | 48 hr | ||
| “Any HBP medication prescribed, modified, or given during ED visit, follow-up as per physician instructions (but not longer than 1 week) | |||
| Adapted from Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure: approved by The East Baltimore High Blood Pressure Control Program and The Johns Hopkins Hospital Department of Emergency Medicine, with permission. Baltimore, The Johns Hopkins Hospital, 1988. | |||
Ronald Nichols, RN
Tom is a 37-year-old, divorced, white male who is brought to the ED by a concerned friend. Tom's friend states that Tom has been drinking heavily for weeks and has started to act strangely. He has locked himself in his apartment and has not gone outside for days. When the nurse speaks to Tom, he is alert and oriented to person and place. He does not know the day or date. Tom smells of ethanol (ETOH) and his affect is mildly restricted. His behavior in general is appropriate for an individual mildly intoxicated. Tom's triage vital signs are BP 134/84, pulse 88 and res-ular, respirations 18 and regular, temperature 98° F. Tom's pupils are equal and reactive to light. He has positive bilateral nystagmus. His physical exam is otherwise negative.
Tom denies any history of medical problems, takes no medications, and has no drug allergies. Tom states he has never before been treated for chemical dependency He acknowledges that he has used cocaine intranasally on weekends since age 32. He initially was using $80 a weekend and now is up to $240 "or so" for the last 6 months. He states he steals and sells drugs to support his habit. Tom stales that fie has thought about "mainlining'' recently as he continues to crave cocaine more and feels "depressed" the day after using it. Drinking helps him feel better. Tom's usual ETOH intake is 2 six-packs of beer and a pint of whiskey daily. Tom stales he has been drinking since he was 13 years old, became a weekend binger at age 18, and a daily drinker after his marriage failed. He has been drinking at his current rate for 1˝ years.
Tom acknowledges that his father was an alcoholic and physically abused Tom as a child. Tom states he is "not like" his father and does not have a problem. Tom says he has stopped drinking on his own many times in the past. He just “likes to drink”. Tom is able to share that, on occasion, when he slops drinking, he feels "ill,” with shaking, sweating, nervousness, anorexia, nausea, vomiting, sleeping difficulties and feeling paranoid. He denies seizures or hallucinations. He always feels much, better "within a day or two" when he resumes drinking.
Tom's pattern of drinking includes a beer for breakfast, one or two beers for lunch "just lo get by" and "no real heavy" drinking unfit he gets home from work. Tom admits that he was fired from his job 2 weeks ago and is about to be evicted from his apartment. He states his family "hates" him and will not speak to him when he calls. He has been arrested once for driving while intoxicated (DW1). Tom admits that he has recently thought of killing himself but has made no specific plans or attempts. Tom states he drank a pint of whiskey and ' 'snorted coke'' late last night. He only came to the ED today because his friend asked him to.
Triage Assessment. Acuity Level ///.' alcohol and drug dependence: potential for acute withdrawal.
Tom is taken to the treatment area to begin medical management for alcohol and cocaine withdrawal and lo initiate a referral for detoxification.
Patients who abuse alcohol and other drugs need to be assessed for their degree of dependence and the physical compromises that may have occurred with chronic abuse. Tom relates a typical case history of chronic abuse for many years. He clearly has had problems with serious withdrawal symptoms when he has attempted to stop drinking in the past.
The focus of nursing and medical therapy should be to help Tom through the initial withdrawal phase of chemical dependency with particular attention to preventing injury. Acute alcohol withdrawal can lead to death. Lab tests will usually indicate serious chemical imbalances including glucose, magnesium, calcium, and liver enzymes. Tom should initially be treated with fluids, magnesium sulfate. Folvite, and other electrolytes as needed. He should also be provided with PO sedation to aid in the control of tremors, nervousness, and hallucinations, all hallmarks of acute withdrawal syndrome.
The benzodiazepines seem to be the safest and most effective chemical agents for reducing alcohol withdrawal symptoms.
Tom has expressed some concern about feelings of suicide, which is not unusual during acute alcohol intoxication. Therefore, he should be managed in a highly visible, well lighted area. Restraint as an initial intervention is discouraged but may become necessary. if in the course of withdrawal, Tom threatens harm to himself or others.
TIP: In some instances patients do not require direct medical management for acute detoxification.-If the home situation is supportive, a family member can help the patient with medications, fluids, and diet. A social worker may be needed to help assess the home environment or to help place the patient in an appropriate shelter.
As Tom completes this initial phase of withdrawal, which may last for several hours, a complete medical exam is indicated. Particular attention should be paid to the neurological exam to rule out head trauma or other pathologies that may be contributing to Tom's altered mental state and psychiatric symptoms.
A caring, nonjudgmental, nonconfronting attitude by the nurse while carrying out nursing activities is the first step to establishing a trusting, therapeutic relationship. Patients with problems related to substance abuse are used to being told they are "hopeless." "have no motivation." "going to die." They are used to being mistreated. The substance abuser usually has a "crisis" orientation to life situations and is seen in the ED secondary to some other real or perceived crisis. not usually for their substance-abuse problem. Even if the person is able to ask for help for their abuse problem, they are not always able to move beyond recognition of need.
Chemical dependency is a disease and must be approached as such by everyone involved in the patient's care. Chemical dependence should not be approached as a "moral weakness." "lack of will power," or even "desired" life-style. The substance abuser did not take his first drink or injection with the intent of addiction. Addiction results from a combination of genetics and environment. Cocaine. nicotine, and heroin seem to be the most addictive drugs used today. with relapse rates approaching 100%. Most often, relapse can be traced to the environment and cues which set off internal stimuli for drug craving, such as pictures, talk of "using" or drinking, and physical and psychological distress.
For many people substance abuse has become such a way of life that they do not know how to quit. Most substance-abuse patients have not been drug-free since adolescence. Many substance-abuse patients cannot say why they started, why they have problems with relapse, or why they want to quit. Motivation for treatment is very hard to establish and is frequently associated with the most recent crisis that brought the individual to the ED. Even if motivation is established. success is not guaranteed. Relapse should be considered a normal, expected part of the disease, much like hypoglycemia is a common recurrence with a patient with diabetes mellitus.
Denial is a natural part of being human: the patient with chest pain who refuses to be evaluated, the hypertensive patient with headaches who does not take his medication, the young executive with a family history of colorectal cancer who cannot find time for an annual physical. All these people believe that "I" am not sick: it is always "the other" person.
In many instances, the substance abuser in the ED cannot remember why he came to the ED (blackouts) or may have cognitive or learning disabilities that are genetic or the result of many years of substance abuse. The patient's ability to acknowledge that there is a problem is very limited under these circumstances. In many instances. acknowledgment of a problem occurs only gradually.
The ability to rationally accept that there is a problem and effectively do something about it may take even longer. This slow realization process is one reason why there is a high level of recidivism from 5- to 7-day treatment programs. However, each time the patient returns for help there may be a new level of appreciation by the patient for his problem that may enhance his motivation for the next time.
Besides the nursing problems related to his physiological needs, the patient with a substance-abuse problem has many psychosocial needs. These are usually specific to the patient and his constellation of support persons. For Tom who has not had family support for some time, the nursing diagnoses may be made as follows:
Diagnose: Self-esteem disturbance related to history of poor outcomes in social interactions evidenced by suicidal feelings; lack of social supports.
Desired patient outcome: The patient will identify internal and external stimuli that contribute to feelings of unworthiness: the patient will identify internal and external resources that will assist him to develop more positive feelings about himself: the patient will describe the role alcohol and cocaine play in enhancing feelings of depression and poor self-esteem.
Diagnosis: Potential for self-directed violence related to stated feelings of depression enhanced by chronic substance abuse
Desired patient outcome: The patient will describe improved mood. increased hopefulness, and decreased suicidal ideation or intent: the patient will identify internal or external resources that he can use when these feelings occur; the patient will describe the role alcohol and cocaine play in enhancing these feelings.
Diagnosis: Ineffective individual coping related to inability to make appropriate decisions in health care enhanced by chronic substance abuse
Desired patient outcome: The patient will identify internal and environmental stressors which impair his ability to make appropriate health care decisions; the patient will verbalize an understanding of how alcohol and cocaine interfere with his ability to make appropriate decisions; the patient will identify personal strengths that may promote effective coping and decision making in a situational crisis.
Diagnosis: Social isolation related to self-imposed withdrawal enhanced by chronic alcohol and drug use
Desired patient outcome: The patient will not isolate himself from friends and relatives; the patient will state why social interaction is necessary; the patient will identify one person he will call when he feels the need to lock himself in his apartment.
The nurse working with the substance-abuse patient in the acute-care setting should work with the counselors and other health care providers to help the patient accept treatment, regardless of his willingness to agree that there is a problem. The patient should be told that he is not responsible for his disease but that he is responsible for his recovery. The nurse should support his family and friends to take on a "tough love" attitude toward the patient. The feeling conveyed should be that "I will help you to work on solutions to the problem; I will not help you to find excuses or help you to die." The nurse in the ED should not fight the patient's denial. The nurse should provide nonreactive emotional support to the patient and make the patient aware of available treatment. The patient will decide when he is ready to help himself.
Aderhold RN, Mooring RA: Alcoholism. In: Dornbrand L, Hooli AJ, Fletcher RH, and Picard Jr GG. eds. Manual of clinical problems in adult ambulatory care. Boston Little, Brown, 1985:456.
Clark WD: Alcoholism: Blocks to diagnosis and treatment. Am J Med 1981:71:275-286.
Finley B: Counseling the alcoholic client. J Psychiat Nurs 1981: 19:32-34.
Svitlik B: Helping the alcoholic patient on the road to recovery. J Emerg Nurs 1980: dark 7(8): 119-203.
Karla Alwood, MS, CRNP
Joann is a 2 7-year-old black female who presents to the triage nurse of the Emergency Department complaining of a sore throat progressively worsening over the past 2 weeks. She reports that the throat pain is now so severe that she is unable to eat solid food and is even having difficulty swallowing fluids. Joann describes some mild upper respiratory symptoms that include congestion, rhinitis, and a loose. mildly productive cough of clear to white sputum. She has also noted slight dyspnea on exertion. She denies any nausea, vomiting, or diarrhea but complains of occasional chills and sweats at night. In addition, Joann describes a history of fatigue that has persisted and gradually worsened over the past 3 to 4 months.
Joann's report of her past medical history is vague. She denies any major medical problems or hospitalizations. She states that she was treated for a rash on her hack approximately I year ago and has a history of a "low blood count. "She admits to previous intravenous drug use and sharing needles but states she has been relatively drug free for the past month. She occasionally drinks alcohol but denies recent ingestion because it burns her throat. She has no regular medical provider and seeks episodic health care through the emergency department.
On brief examination, the triage nurse notes a thin black female, mildly ill appearing. Her BP is 94/60, HR 110, temperature J00.6°F. Her respirations are 20 and easy. She has tender, enlarged cervical lymph nodes bilaterally. Her tonsils are not swollen, but the pharynx is red and covered with a white exudate. There is no trismus and, despite her pain with swallowing, she has no difficulty handling her secretions. She has scarred tract marks on both arms and mildly dry scaling areas on her face and hairline.
Triage Assessment, Acuity Level I: Sore throat, upper respiratory infection (URI) symptoms, RR < 32, fever < 102.
The patient is referred to the "non-urgent" clinic for further care. There, a more detailed history is taken. Joann describes a burning sensation with swallowing that travels all the way down to her stomach. The night sweats she had related earlier have been occurring off and on for over a year, but have recently worsened with the onset of her current symptoms. She has not taken her temperature but reports that the sweats have been occurring 4 to 5 nights of the week to the extent that she has to get up and change her night clothes and bed linen. Her dyspnea has also been gradually worsening over the past few months, and some days she feels too tired even to get out of bed. Her UR1 symptoms started about 2 months ago but have not worsened, and her cough, although mildly productive, remains clear. Of additional concern to her is a progressive, unexplained weight loss that started about 6 months ago and now totals approximately 20 Ib.
Joann states that her dry, scaling skin rashes have persisted despite the use of emollients. She states that she has been taking over-the-counter (OTCj iron pills for her low blood count. Her last menstrural period was approximately 1 month ago and she notes occasional menstrural irregularities that are not new. She denies a history of sexually transmitted diseases but reports frequent vaginal yeast infections over the past year. She has a steady sexual partner who also uses intravenous drugs. and she uses no regular form of contraception. She denies drug allergies or use of prescription medications. She smokes 1 pack of cigarettes per day and drinks alcohol occasionally. She has a 5-year history of intravenous drug use (IVDU) and last used intravenous drugs approximately 2 to 3 weeks ago. She shares needles only with her sex partner. A n old chart reveals that the rash she described a year ago was diagnosed as shingles (herpes zoster). At that lime, due to her presenting history and diagnoses, she was counseled and tested for human immunodeficiency virus (HI 1',. She failed to keep her follow-up appointment despite numerous attempts made to contact her. Joann is currently unaware that her enzyme-linked immunosorbent assay (ELISA) and Western blot tests were positive.
When Joann presented with herpes zoster a year ago she was experiencing symptoms of immune suppression. Depressed cellular immunity in conjunction with her history of intravenous drug use and sharing of needles is a predictor for HIV and acquired immune deficiency syndrome (AIDS) (1).
The etiologic agent of AIDS is HIV. This virus induces a progressive. time-dependent destruction ofT4 lymphocytes. which are key components to the integrity of the cellular immune system (2). In addition, the virus has been found to invade other classes of immune cells such as cells of the nervous system, intestine, kidney, and bone marrow. This, in part, accounts for the widespread and complex nature of an HIV infection. With progressive viral invasion and destruction of lymphocytes, cellular immunity declines, and the opportunistic infections that characterize this disease begin to emerge.
The HIV-infected patient often presents with symptoms that indicate a predictable, progressive derangement of immune function. with AIDS being a late manifestation of that process. The specific stages of HIV infection may be viewed on a continuum that chart the decline of the immune system. Initially, the majority of individuals infected with HIV are asymptomatic, although some may experience a mononucleosis-like illness that will completely resolve, persist, or evolve into one of the other HIV-associated syndromes. Throughout the course of HIV infection, various constitutional symptoms or the so-called AIDS related complex (ARC) may develop. These symptoms are characterized by persistent generalized lymphadenopathy, unexplained fevers, persistent night sweats. chronic diarrhea, and weight loss. Additional manifestations with a somewhat poorer prognosis include oral candidiasis hairy leukoplakia, immune thrombocytopenia, and multidermatomal herpes zoster (3).
This disease has a long latency or subclinical phase that. according to recent reports, may persist up to 10 years (3). However, as T4 cell counts decline, infected persons exhibit increasingly more overt symptomatology indicative of immune dysfunction. End-stage disease or AIDS is usually seen when the T4 cell count falls below 200 (400 to 1600 is normal) and opportunistic infections emerge. Some of the more common or virulent forms of infection found in the United States include
Pneumocystis carinii pneumonia, parasitic infections such as toxoplasmosis and cryptosporidiosis, fungal infections such as cryptococcosis and histoplasmosis, and viruses such as cytomegalovirus and chronic mucocutaneous herpes simplex. Other AIDS-de-fining illnesses include Kaposi's sarcoma, some forms of lymphoma. wasting syndrome, and AIDS encephalopathy (3).
The ELISA test identifies HIV antibodies. In the asymptomatic patient, a positive ELISA test is an indication of exposure and infection with HIV, but is not diagnostic for AIDS. The Western blot analysis uses electrophoretically marked proteins to differentiate antibodies and is used in conjunction with the ELISA test to confirm a diagnosis of HIV. AIDS is defined when an opportunistic infection or cancer presents in the HIV-infected individual.
TIP: A patient with a positive HIV test does not necessary have AIDS. This distinction is important when providing counseling and making patient referrals. However, it is important to note that patients may be severely immunocompromised and still remain asymptomatic, emphasizing the need for prompt medical follow-up.
Transmission of HIV occurs primarily through three known routes:
(a) inoculation of blood by transfusion of blood or blood products. needle sharing among intravenous drug users, and needle stick, open wound, and mucous membrane exposure in health care workers: (b) sexual activity with known HIV-infected or high-risk partners; and (c) perinatal, intrauterine, or peripartum exposure (4). Joann has two of these risk factors (sexual partner and IVDU) and poses a potential threat to future offspring since she is not currently using any regular form of contraception.
Transmission of the HIV virus may be easily prevented in all three of these situations. First, needle sharing among intravenous drug users should be avoided in all instances. If this is not possible, all needle works should be cleaned in bleach prior to each use. Safer sex practices using latex condoms with nonoxynol 9 spermicidal foam or jelly should prevent both pregnancy and sexual transmission of disease. In addition, condoms and foam prevent transmission of other sexually transmitted diseases (5, 6).
Nursing diagnoses for Joann are multiple and complex. First there are the problems related to her current physical needs. In addition. the actual and potential problems related to her HIV status combined with the psychological impact of receiving this information will require immediate and supportive attention. Although many of these problems cannot be solved during this visit, the nurse should enumerate primary concerns on the care plan and begin to systematically approach those that are of highest priority during this visit.
Diagnosis: Fluid volume deficit related to decreased fluid intake because of dysphagia, odynophagia, and repeated episodes of night sweats and fever.
Desired patient outcome: The patient will have improved skin turgor, moist mucous membranes, alert mental status, and BP systolic > 90 mm Hg and HR < 100.
Diagnosis: Altered nutrition, less than body requirements, related to the constitutional symptoms of HIV infection including anorexia, di-arrhea, and decreased nutrient absorption.
Desired patient outcome: The patient will maintain her weight and develop strategies aimed at increasing her calorie intake. The patient will state ways to prepare high-calorie, high-protein foods or use supplements; prepare food so that it is visually appealing and provide herself with small, frequent, nutritional meals.
Diagnosis: Impaired swallowing related to irritation, pain, and swelling of esophagus and pharynx from presumed esophageal infection.
Desired patient outcome: The patient will have reduction in pain and improved ability to swallow. The patient will describe strategies for preparing very cold or warm fluids that will be more comfortable to swallow.
Diagnosis: Activity intolerance related to anemia and imbalance between oxygen supply and demand from opportunistic infection.
Desired patient outcome: The patient will describe strategies for conserving energy and provide the time and setting for adequate rest and sleep periods.
Diagnosis: Knowledge deficit related to HIV and AIDS and implications for health, health management, and prognosis.
Desired patient outcome: The patient will be able to describe what an HIV infection is, how to recognize worrisome signs and symptoms, and how to prevent transmission to others by using safe sex practices and by not sharing needles.
Diagnosis: Potential for impaired adjustment related to required changes in life-style to maintain wellness.
Desired patient outcome: The patient will acknowledge the importance of life-style changes; the patient will state ways to remove barriers that impede change; the patient will identify personal strengths that will aid her in making life-style changes: and the patient will follow-up on her care.
Diagnosis: Potential for anticipatory grieving related to poor prognosis associated with AIDS.
Desired patient outcome: The patient will be able to discuss her potential loss and will begin the experience of grieving in a supportive environment. The patient will verbalize that grief is "normal" secondary to loss. The patient will identify grieving behavior, such as variability in mood and preoccupation, as normal and will develop strategies to accept and modify these.
Diagnosis: Potential for body image disturbance related to body changes that occur with AIDS complications such as continued weight loss, hair loss, development of skin lesions, and so on.
Desired patient outcome: The patient will describe strategies to visually enhance body image through use of dress, hair covering. and covering of wounds. The patient will describe coping mechanisms and social supports for this process.
Diagnosis: Potential for impaired social interaction related to behavior of social supports and others that may fear infection from social contact or criticize social behavior of intravenous drug use.
Desired patient outcome: The patient will demonstrate behavior that may maintain or improve social interactions: the patient will practice "safe" behavior that will communicate to others that she is being responsible (i.e., safe sex, use of disposable tissues when coughing, no needle sharing, contraception, etc.).
Other diagnoses that may be considered are:
Anxiety
Potential for chronic pain
Sleep pattern disturbance
Potential for new infections
Altered wake-sleep patterns
Self-esteem disturbancePotential family problems include:
Ineffective family coping: disabling or compromised
Potential for altered role performance
One of the more difficult aspects of Joann's care is providing support when she is informed of her HIV test results. Since Joann was tested a year ago, she must have considered the possibility of AIDS diagnosis. Her reasons for not following through are unknown: however, denial is often a normal reaction to a potentially unpleasant outcome. The supportive relationship that is established at the time she is told other diagnosis should help her to move toward acknowledgment other problem and the need for follow-up care. She should be encouraged that patients receiving appropriate medical care have a better long-term prognosis.
A "lifeline" should be provided to the patient including telephone numbers of HIV clinics and community agencies concerned with HIV patients. The reactions of family members and friends may be unpredictable, and the patient's permission to include them in the counseling and support role is required. For Joann, her boyfriend is an important link. He too may be infected and may require the same help and support as Joann. A patient such as Joann should be assisted to recognize and cope with the emotional feelings that accompany the diagnosis of AIDS. These feelings may include shock or disbelief: fear and anxiety related to prognosis and potential disability and abandonment; depression over the absence of a cure and inevitable physical decline; anger and concern over needed life-style changes: guilt related to possibly spreading the infection to others and acknowledgment of high-risk behavior such as intravenous drug use (7).
Joann needs regular follow-up care. Given her poor compliance in the past, the nurse should stress to Joann the need for regular medical follow-up. Many times, transportation and financial constraints are barriers to treatment that can be minimized through social work support. If at all possible the emergency department nurse can help the patient make the follow-up appointment with the AIDS counseling center. The nurse can help initiate a plan of care for the patient by providing the intake counselor at the follow-up center with the nursing diagnosis list already prepared and provide the counselor with a telephone number or significant other that can help to ensure follow-up compliance by the patient.
Joann should recover from her current illness and return to most of her normal activities. However, she must be committed to stopping her intravenous drug use and beginning a treatment program to maximize her long-term survival.