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Immunologic Disorders

Case Study 82

Name______________________ Class/Group_________________ Date____________________

Group Members__________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

You are a nurse at a university student health clinic. T.Q. comes in to your clinic and informs you of his immunodeficiency problem. He has just moved here to go to school. He gives you a letter from his attending physician, hands you a vial of gamma globulin, and asks you to give him his “shot.” The letter from T.Q.’s physician states that he was diagnosed with primary immunodeficiency disease 18 years ago. He has an adequate number of B cells, but they fail to mature properly and become plasma cells or immunoglobulin. T.Q. states he has a history of chronic respiratory and gastrointestinal infections. He is maintained on 0.66 mL/kg gamma globulin IM every 3 weeks and has tolerated this well. He has no known drug allergies. His vital signs are stable.

1. Can you honor this patient’s prescription? Why or why not? How could you provide him with his injection?

2. What should you do while the physician is verifying information?

3. You note on T.Q.’s health record that he has not received his polio, measles, mumps, or rubella vaccines. What explanation can be given for the lack of these vaccinations?

4. The clinic physician receives confirmation from T.Q.’s physician and orders the gamma globulin. What questions would you ask T.Q. that would reassure you that the medication he brought was safe to administer?

5. Briefly describe the maturation cycle of the B cell.

6. Compare how primary immunodeficiencies differ from secondary immunodeficiencies.

7. What is the most common primary immunodeficiency?

8. How do you know what type of immunoglobulin deficiency T.Q. has?

9. Explain why T.Q. is at greater risk for developing infections than his classmates.

10. Before T.Q. leaves, you assess his knowledge and give specific precautions. What will you assess, and what precautions will you give?

Case Study Progress

T.Q. returns in 3 weeks with complaints of a stuffy nose. He is also due for his next injection of gamma globulin.

11. What will you assess to further evaluate his stuffy nose?

12. If T.Q. is developing a sinus infection, what signs are you likely to encounter on examining him?

13. T.Q.’s nares do not appear swollen or red, although he does have some clear mucus drainage. His temperature is normal at 98.4° F (36.9° C). Should you give the medication or ask him to return when he is no longer having nasal stuffiness? Why or why not?

14. What do you need to teach T.Q. before leaving the clinic?

Case Study 83

Name______________________ Class/Group_________________ Date____________________

Group Members__________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

You are working at a physician’s office, and you have just taken C.Q., a 38-year-old woman, into the consultation room. C.Q. has been divorced for 5 years, has two daughters (ages 14 and 16), and works full time as a legal secretary. She is here for a routine physical examination and requested that a human immunodeficiency virus (HIV) test be performed. C.Q. stated that she is in a serious relationship, is contemplating marriage, and just wants to make certain she is “okay.” No abnormalities were noted during C.Q.’s physical examination, and blood was drawn for routine blood chemistries and hematology studies. The physician requests you perform a rapid HIV test, which is an antibody test. Within 20 minutes, the results are available and are positive.

1. Does a positive rapid HIV test mean that C.Q. definitely has HIV? If it is negative, does it mean she definitely doesn’t have HIV?

2. What counseling do you need to provide to C.Q.?

Case Study Progress

The physician informs you that C.Q.’s Western blot test results confirm that she is HIV positive; he requests that you be present when he talks to her. Before leaving C.Q.’s room, the physician requests that you give C.Q. verbal and written information about local HIV support groups and help C.Q. call a friend to accompany her home this evening. She looks at you through her tears and states, “I can’t believe it. J. is the only man I’ve had sex with since my divorce. He told me I had nothing to worry about. I can’t believe he would do this to me.”

3. C.Q.’s statement is based on three assumptions: (1) J. is HIV positive; (2) he intentionally withheld the information from her; and (3) he intentionally transmitted the HIV to her through unprotected sex. Based on your knowledge of HIV infection, how would you counsel C.Q.?

4. In addition to offering alternative explanations and exploring options, what is your most important role at this time?

5. C.Q. asks you whether she has AIDS. What do you tell her?

6. Why is it a good idea for C.Q. to have someone she trusts transport her home this evening?

7. C.Q. gives you the name and phone number of a relative she wants you to call. You remain with her until she leaves with her relative. Has C.Q.’s right to privacy been violated? Explain why or why not.

Case Study Progress

C.Q. returns to the office 4 days later to discuss her diagnosis.

8. What are your goals for C.Q. at this time?

9. What additional laboratory tests would you anticipate for C.Q.?

10. C.Q. asks whether there is any treatment available. How would you respond?

11. C.Q. asks why she has to take so many drugs instead of a “big dose” of one drug. What would you tell her?

12. The physician starts C.Q. on a regimen of Truvada (tenofovir and emtricitabine), Reyataz (atazanavir), and Norvir (ritonavir). What general information will you give C.Q. about ART therapy?

13. What other issues will you discuss with C.Q. at this visit?

14. Does C.Q. have a legal responsibility to inform J. of her HIV status?

Case Study Progress

Two weeks later, C.Q. visits the office and asks to speak to you in private. She thanks you for talking to her the day she received the news of her diagnosis. She tells you that J. confessed to her that he was afraid to tell her about his hemophilia because she might leave him. J. tested positive in the 1980s after being infected through contaminated recombinant factor VIII products. C.Q. tells you that they are going to get married and invites you to the wedding.

Case Study 84

Name______________________ Class/Group_________________ Date____________________

Group Members__________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

J.P., a 56-year-old man, developed a severe viral infection and suffered fatigue, fever, and myalgia. Although he recovered from the acute episode, J.P. never quite regained his normal activity level. Six months later, J.P. continues to find it difficult to work a 10-hour day as a brick mason, so he returns to his physician. Diagnostic studies reveal heart failure (HF) related to postviral cardiomyopathy.

Following medical management with metoprolol (Toprol XL) and furosemide (Lasix), his condition stabilizes and he returns to work, but his attendance is erratic. J.P.’s condition gradually deteriorates. Sixteen months later he is readmitted to the hospital complaining of dyspnea with minimal exertion, fatigue, orthopnea, chest pain, anorexia, and feelings of abdominal fullness. He has 1 + peripheral edema and is diaphoretic. Further studies reveal that J.P. has cardiac dilation, moderate to gross ventricular hypertrophy, and a systolic ejection fraction of 17%, consistent with severe congestive cardiomyopathy. Because J.P.’s only other health problem is mild hypertension, a heart transplant evaluation is recommended. J.P. and his wife discuss his prognosis, and he agrees to an evaluation for possible heart transplantation.

1. If J.P. is accepted for cardiac transplantation, what data will be collected in addition to his past medical history, current diagnostic findings, and cardiac evaluation?

2. What criteria does J.P. meet that will make him eligible for cardiac transplantation?

3. Identify five contraindications for cardiac transplant.

4. J.P. is accepted for cardiac transplant and placed on the waiting list. What fears or concerns might J.P. experience during this waiting period?

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