Human Immunodeficiency Virus

This assignment will revolve around a single episode of care provided to Mr. A, a recently diagnosed Human Immunodeficiency Virus (HIV) positive gentleman. As part of his ongoing care, he attends a Genito-Urinary Medicine department as an outpatient every 3 months in order to ascertain the progression of his disease. As part of this assessment, he undergoes a series of blood tests, including a count of his T-helper cells (colloquially known as a “CD4 count”).

At the time, Mr. A was a Clinical Stage 1 asymptomatic patient, according to the World Health Organisation (WHO) HIV staging criteria (WHO, 2005), meaning that he was not currently receiving Highly Active Antiretroviral Therapy (HAART). The assignment will cover the pathophysiology of HIV, focusing specifically on the relationship of the CD4 count to disease progression. Communication strategies relating specifically to the short-term professional and therapeutic relationships developed with Mr. A will also be discussed.

In line with guidelines published by the Nursing and Midwifery Council (NMC), specific names and places have been amended to retain anonymity for all concerned, and consent has been obtained from the patient (NMC, 2008). The HIV organism belongs to a family of viruses known as retroviruses, meaning that their genetic information is carried as ribonucleic acid (RNA) rather than deoxyribonucleic acid (DNA). The virus itself favours the T-Helper cell of the body’s immune system, but must first gain entry to the cell. Within the immune system, the T-helper cell acts as a director: it has no ability to directly fight infection.

Rather, antigens from antigen-presenting cells are presented to it, which then bind to the CD4 receptor. This in turn causes the Helper T-Cell to begin producing cytokines. The cytokines then go on to stimulate and activate several different types of cell more active in the fight against disease, such as macrophages and Killer T-Cells (Tortora and Derrickson, 2008). In order for it to deliver its genetic information and take over the replication equipment of the targeted cell, the HIV virus attaches itself to the CD4 receptor on the surface of the T-Helper cell.

In the normal immune response, binding to the CD4 receptor causes a chain reaction, resulting in release of cytokines, but the HIV virus uses this receptor to activate another receptor known as CCR5 to change the shape of the T-Helper cell and the virus, allowing the virus to penetrate the outer membrane of the cell and release its RNA into the host cells cytoplasm (Levy, 2007). In turn, the virus’s RNA takes over the cell replication equipment and makes copies of itself, eventually causing cellular lysis and the release of many copies of itself.

The cycle then repeats, causing an exponential drop in the number of T-helper cells in the blood stream (Marieb and Hoehn. 2007) The drop in the number of T-Helper cells has an exponential effect. Initially, patients may present to their local General Practitioner (GP) with ‘flu-like symptoms, or a mononucleosis-type illness. This represents Primary HIV infection, where the levels of HIV virus are at their highest and the T-Helper cell count is at its lowest (Pratt, 2003). Eventually, the immune system begins responding to the overwhelming number of HIV viruses, and the infection enters its latent stage (Smeltzer et al. 008).

During this time, the HIV virus is ‘burying’ itself inside deep tissues, making it more difficult for the immune system to find and destroy it (Pratt, 2003). As previously stated, as the HIV virus proliferates, the number of T-helper cells the patient has declines. Without any T-Helper cells, the body would be unable to identify pathogens and therefore activate more aggressive immune cells responsible for the proliferation of the full immune response (Smeltzer et al. 2008).

As HIV almost exclusively attacks T-Helper cells, a ‘count’ of such cells is a useful indicator of disease progression as well as the current state of the immune system (Lima et al. 2009). The count itself consists of a venous blood sample, which is then examined by a computer, which gives an estimation of the number of CD4+ T-Cells in the body. The normal range for T-Helper cells is approximately 400-1600 cells per cubic millimetre of blood (Terrence Higgins Trust, 2008). However, an HIV positive patient may have a count below 350/mm3.

This is the point at which treatment with Highly Active Antiretroviral Therapy (HAART) will normally begin (WHO, 2005). In the case of Mr. A, his T-Helper cell count was a routine check: ensuring that his count had not fallen below the threshold to being treatment and that other factors, such as his viral load, were still within ‘safe’ limits. Although once considered a rapidly -developing terminal disease, advances in treatment have made HIV more of a long-term condition rather than a death sentence (Centres for Disease Control and Prevention, 2002). In 1997, approximately 4. % of patients with AIDS died, compared to less than 1. 0% in 2007 (National AIDS Trust, 2009): 3. 7% decease in less than a decade. In fact, with access to appropriate treatments and regular monitoring, it is estimated that HIV infection will not significantly reduce life expectancy of the average male (National AIDS Trust, 2009). Patient communication within an outpatients setting can be especially difficult. For example, in a genitourinary setting, most care consists of single incidents, unlike on an acute surgical unit, where the nurse may have several days to build up a relationship of mutual trust.

Since 1996, the Department of Health (DOH) has advocated a shift away from inpatient care towards the ambulatory and primary care settings (DOH, 1996). Unfortunately, this can result in Lloyd (2003, pp. 100) refers to as the ‘ambulatory paradox’: health care professionals have a desire to get patients through the system and out again as fast as possible. This can leave patients confused and disillusioned with the ambulatory service, as they feel ignored, undervalued and powerless. In the case of Mr. A, the communication employed seemed appropriate at the time.

On his arrival at the clinic, I greeted Mr. A and introduced myself, as I was waiting for him to arrive. Nolan and Ellis (2008) advocate that the therapeutic relationship begins as soon as the patient and practitioner meet: thus the adage about first impressions being everything. Smiling and offering my hand to Mr. A seemed to relax considerably: he had seemed initially quite lost and tense. This initial introduction already seemed to soften the perceptions that most have of the Genitourinary setting.

In fact, Bilney and D’Ardenne (2001) found that patients visiting GU clinics can have a decidedly ‘warped’ view, mainly relating to confidentiality and shame issues, and can therefore be quite hostile and withdrawn: thoroughly non-productive within any healthcare setting. In this particular outpatient setting, the power balance between patient and nurse can be difficult to maintain. From the patient’s perspective, the nurse holds most of the power: patients are asked to divulge deeply personal information to a complete stranger and then potentially undress and submit to an extremely intimate examination.

With Mr. A, the nursing staff were possibly the only people aware of is HIV diagnosis, and because of this, could have held all of the perceived power. Egan (2002) proposes that power is inherently shifted away from the client in such settings. Grasha (1995) takes this thought further and identifies six types of power: expert, information, referrant, legitimate, reward and coercive. In this case for example, the nursing staff had information power: we help privileged information relating to the patient, as well as expert power: we know more information relating to Mr. A’s condition than Mr. A.

This power balance is potentially unknown to us as healthcare professionals, as we encounter such situations every day. The Johari window (Luft, 1969) explores how we and others view ourselves and names this part of ourselves the ‘blind area’: the area of our personality that others can see, but we cannot, perhaps through habitual action or maybe through a lack of introspection and reflection (Benner, 1984). It is therefore important that as nurses we are self-critical and self aware, thus allowing us to be truly empathic when dealing with patients. Having gotten past the introduction stage, Mr. A was then accompanied to a consultation room where he was again greeted by another nurse.

Fortunately, this was a nurse that he had previously met and experienced, and therefore the difficulties in presenting and forming an initial relationship were already overcome. The consultation process then began. In order to put the patient at ease, my mentor and I employed a variety of different techniques. For example, non-verbal communication strategies were employed, specifically the SOLER technique (Egan, 2002): sitting Squarely on to the patient, Open posture, Listening, Eye contact and Relaxing.

This body language technique has a variety of benefits: the open posture, for example, shows attentiveness, while the eye contact engages with the patient, and by extension the patient should engage with the healthcare professional (Egan, 2002). The very layout of the consultation room was also beneficial to communication: the way that the seats and the desk are positioned removes any physical barrier between the patient and the nurse, an aspect that Nelson-Jones (1990) feel can be detrimental to nurse-client communication.

When the actual discourse began, several different verbal communication techniques were used to enhance and promote communication. For example, my mentor and I when discussing his feelings since his last visit used a combination of open questions and probing questions: initially, “how have you been since we last saw you? ” (Open question) followed by some specific probing questions: “how often are you experiencing diarrhoea? “.

Open questions allow the patient to discourse over a wide area of topics without much depth, allowing the skilled listener to then direct and by extension glean appropriate information through the use of probing questions (Nolan and Ellis, 2008). Advocacy, from a nursing perspective, can be defined as “… the process whereby a nurse provides a patient… with information to enable them to make informed decisions… “(Weller, 2005). In the case of Mr. A, advocacy involved specifically providing information relating to his symptom control options: giving him the control over this aspect of his care.

Mr. A was suffering from acute bouts of diarrhoea that could have been attributed to a medication he had been prescribed by a consultant, co-trimoxazole, as prophylaxis measure against pneumocystis pneumonia (British National Formulary, 2007), a potentially life-threatening disease for immune-compromised people. Mr. A was concerned that the diarrhoea was affecting his quality of life and wished to stop. In this case, he was provided with the ramifications of his decision, and decided to continue treatment, but with loperamide (a common anti-motility drug) added in to help control the diarrhoea.

By providing appropriate and timely information, Mr. A was able to make an informed choice concerning his healthcare. According to Benner (2000) the act of simply offering choice to a patient is a major act of advocacy: allowing the patient to take ownership of their condition, and from that move towards self management. Concurrently, Honey (1988) advocates being open-minded to the feelings of others, and from there negotiating a successful solution for all involved. Assertiveness skills are vital within any aspect of nursing care, not only between the nurse and other professionals, but also have a place within the nurse-patient relationship.

During the consultation, Mr. A mentioned that since his diagnosis, he had not worked and felt quite depressed, feeling that he may need to change direction and start anew. On further probing, he was discussing his desire to maybe retrain as a hair dresser, although did not know how to move forward. Most, if not all, patients diagnosed with HIV develop depression of some kind, with as many as 1 in 10 developing a significant mood disorder (Perry, 1994). Coupled with the increased stress caused by his unemployment (Royal College of Psychiatrists, 2008), it appeared that Mr. A was indeed depressed. In this case, it seemed appropriate to form a contract of sorts with him. My mentor set a clear goal, to enquire at a local college with relation to hairdressing courses, and to report back on his progress at his next check up.

This was handled in an informal manner: a jovial suggestion rather than an edict. Culley (1991) suggests that such behaviour can help to empower patients: getting them to share responsibility and progress, rather than being static. Through this means, not only could Mr. A progress personally, but he could also feel better connected to the service, and by extension more comfortable. In conclusion, it appears that developing a genuine therapeutic relationship is not only vital to the success of outpatient care, but also a cornerstone of good nursing practice. Although many outpatient encounters are single episodes of care with sometimes no follow up, it is still vital the strategies such as those outlined above are employed to ensure that patients receive the best possible care.

With respect to GU medicine, it is intrinsic to the nature of the work that a trusting, productive relationship is built with patients: due to the intimate nature of the exchange, trust is vital to provide an accurate and useful service to patients. I feel that in this circumstance, I displayed and employed several effective strategies to build the initial patient relationship, but with the benefit of hindsight, I think that there is still more work that I can do to develop my practice and ensure that patients feel comfortable and by extension engaged with the service that I am offering.

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