Question

You are a nurse at a university health clinic. Twenty-year-old T.Q. comes in and informs you he is a new student
and he has an immunodeficiency problem. 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
T.Q. was diagnosed with primary immunodeficiency disease (PIDD) at age 2. 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 0.66mL/kg of gamma
globulin (GamaSTAN) given intramuscularly every 3 weeks and has tolerated this well. He has no known
drug allergies (NKDA). His vital signs are stable.
1. Can you honor T.Q.'s prescription? Why or why not? How could you provide him with his injection?

2. While the provider is verifying the information, you place T.Q. in a treatment room and
obtain his permission to perform a history and physical assessment so the clinic has baseline
information. What essential components do you need to include and why?
3. You note on T.Q.'s health record that he has not received an MMR (measles, mumps, rubella)
vaccine. Why?
4. The provider receives confirmation from T.Q.'s physician that T.Q. has a PIDD and
orders the gamma globulin (GamaSTAN). Differentiate between primary and secondary
immunodeficiency.
5. . Explain why T.Q. is at greater risk for developing infections than his classmates.
6. What role does gamma globulin play in managing PIDD?

7. What questions would you ask T.Q. that would assure you the medication itself is safe to
administer?
8. Your assessment of T.Q. is unremarkable. After you administer the gamma globulin, you
assess T.Q.'s knowledge and give specific precaution instructions. What will you assess and
what precautions will you review?
9. Write a sample SOAP note documenting T.Q.'s visit to the clinic.

CASE STUDY PROGRESS
Several weeks later, on T.Q.'s return visit for an injection, he complains of a stuffy nose.

10. What is your immediate concern?

11. What assessment do you need to perform to evaluate his stuffy nose?

12. If T.Q. were developing a sinus infection, what manifestations would you likely see when
examining him?
13. 3. T.Q. denies any cough, headache, sore throat, fatigue, or muscle ache. T.Q.'s nares do not
appear swollen or red, although he does have some clear mucous drainage. External auditory
canals and tympanic membranes clear. There is no adenopathy or sinus tenderness, and
his lung sounds are clear to auscultation. Oral cavity and pharynx normal; there is no
inflammation, swelling, exudate, or lesions. Vital signs are 110/60, 76, 18, 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 he leaves the clinic?

15. Write a sample SOAP note documenting T.Q.'s visit to the clinic

Case Study #2

Scenario
You are working in a community health clinic 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 her yearly routine physical examination C.Q. states 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. Blood was drawn for routine blood chemistries
and hematology studies; since she has never been tested, C.Q. agrees to a human immunodeficiency
virus (HIV) test. 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 does not have HIV?

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

CASE STUDY PROGRESS
C.Q. returns to the clinic two days later. 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 clinic 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. and why?

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) and
efavirenz (Sustiva). What general information will you give C.Q. about ART therapy?

13. C.Q. asks if she has to tell J. of her HIV status. Does she have a legal responsibility to inform
him?
14. C.Q. asks if she has to tell J. of her HIV status. Does she have a legal responsibility to inform
him?

15. What reporting obligations does the clinic have?

16. . Before C.Q. leaves the clinic, you recognize the need for further teaching when she says:
a. "Joining a support group can help me deal with my HIV diagnosis."
b. "I will not use any other medications without checking with my health care provider."
c. "If my viral load becomes undetectable, I will not have to worry about transmitting HIV to
someone else."
d. "If my skin turns yellow, I have unusual muscle pain or feel dizzy or weak, I will call the
provider immediately."
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 has hemophilia
and tested positive for HIV after having been infected through contaminated recombinant factor
VIII products. He was afraid to tell her about his diagnosis because she might leave him. C.Q. tells you that
she is angry with J. They are going through counseling and the wedding is "off" at the moment.

Answer 1

1. Yes the drug can be given if the protocol of the clinic allows to. Secondly , before administering his physician needs to be consulted regarding his last dose of injection , due injection and any other specific details which needs to be known . Would take help of the on call doctor if required.

2. Assessment for any past medical history, illnesses and vaccinations or any other issues.

3.As he is suffering from PIDD , it is important to understand that vaccinations can cause diseases which they are supposed to make antibodies as they are immune compromised. MMR are live vaccines so they can cause harm and moreover vaccines and gamma globulins should not be given together as its globulins efficacy can be affected.

4.Primary immunodeficiency is inherited or genetic where as secondary is due to external cause which compromises the immunity for example: AIDS/HIV, burns or malnutrition.

5.He is more prone to infection as he is lacking natural defense mechanism .

6. We can assure by asking about previous shots, any discomfort or any problems during last shots.

Case scenario 2#

1.A positive rapid test indicates that HIV antibodies are present but it needs to be confirmed with other tests like ELISA whereas a negative may not always be negative as it can take from months to years to develop HIV antibodies.

2. It is very important to do counseling on Anti Retroviral Therapy and the need for adherence .It is also important to tell her about home care and side effects of drugs, clinical manifestation of the disease so that she can seek medical treatment as early as possible . she should be counselled regarding preventing the transmission of disease ,avoiding unsafe sexual practices. She can be encouraged to take support from family and friends.

3.As CQ s nurse I would explain her what might have happened a) J might have been unaware of his condition. b) he might have not told her as she was working and did not want her to be in trouble as she was also supporting her daughters. c) it can be checked if we do a blood test for her daughters to detect any deviation so that they too can be started on treatment.

4.It is extremely important to understand the patient's current mental situation ,she is in a shock and she needs utmost care and support from us without being judgemental.

5.It would be better to explain about the importance of counts in the blood or markers like CD4 <200 and symptoms of AIDS like extreme wasting, diarrhea, dementia and opportunistic infections.

6.It is not violation of her privacy as she wants us to help her. She needs support and expects understanding and care from her loved ones. As she might go through a series of anxieties and frustration it would be better to have someone from the family to be by her side if only she is willing to share.Therefore permission must be sought.