Case study of a patient who has been diagnosed HIV positive

14 Case study of a patient who has been diagnosed HIV positive







Assessment on admission


When greeting and introducing yourself to Ms Chitalwa, you notice she is very anxious and visibly upset. Her vital signs are: pulse 118 regular, respiratory rate 28, temperature 37.3°C tympanic, oxygen saturation 94% (receiving 2-L oxygen via nasal specs). She is in a bay with five other patients on your medical ward.


During your assessment discussion with Ms Chitalwa, using the Roper, Logan and Tierney (Roper et al 2000) model of activities of daily living, you note that she is normally totally independent in all activities of daily living (see Table 14.1).


Table 14.1 Assessment of Ms Chitalwa using the Roper, Logan and Tierney model







































Maintaining a safe environment She requires assistance due to reduced mobility and lethargy. Local hazards include the oxygen tubing for her nasal specs and the drip stand and tubes for her intravenous co-trimoxazole
Communicating She is fluent in English, which is her second language. Shortness of breath is reducing her sentence length. Recent HIV diagnosis has been a shock to her and she appears to be upset and withdrawn. She is very worried that her HIV status will be discovered by the other patients in her bay, as well as by her flatmates when they come to visit her. She seems reluctant to communicate about her HIV diagnosis. She has spent a lot of her time reading her bible. She is happy to be called Jessie
Breathing Jessie becomes short of breath easily. She is receiving oxygen therapy via a humidification system and nasal specs. She finds it difficult to have a deep breath, and starts coughing
Eating and drinking Her appetite has been reduced for the last week. She is a vegetarian. She feels nauseous when she tries to eat
Eliminating She is too weak to walk to the bathroom, even with assistance
Personal cleansing and dressing She is able to wash herself with a bowl at the bedside. She has been unable to bathe or shower for the last 3 days due to her lethargy and shortness of breath
Controlling body temperature Currently no problems
Mobility Severely reduced. Can barely manage five steps without becoming distressed. Oxygen and IV therapy are continuous so her range is already restricted due to the length of the tubes and IV lines
Working and playing Does not want to discuss this right now
Expressing sexuality Does not want to discuss this right now
Sleeping Feels tired but has had a very unsettled night. Has not slept properly for several days, cannot remember how long
Dying She is convinced that she is dying. The recent HIV diagnosis has made her resign herself to this fact. She has seen people die of HIV in Nigeria when she was younger and remembers the pain and suffering they went through, as well as the stigma for them and their families



Jessie’s nursing care plans




Jessie’s environment remained safe throughout her hospital stay and recovery.


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Feb 25, 2017 | Posted by in NURSING | Comments Off on Case study of a patient who has been diagnosed HIV positive

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