A situation occurred recently that I would love to get your opinion on regarding ethical and appropriate disclosure related to a HIV+ patient in active AIDS.
A 'brand new' group of pre-nursing students completed two weeks of basic care workshops i.e. bedmaking, ambulation, bedbath, oral & peri care etc. The third week consisted of 3 clinical days (from 7:30am to 12pm) on a med/surg floor. Students were paired and assigned a patient. Students were to provide bathing, bedmaking, vs, etc for that patient. Apparently, two students found out after the fact that their patient was HIV+. They did wear gowns because this patient had C.diff in addition to everything else. However, they didn't know about the AIDS. When I heard about this, I couldn't believe that their instructor didn't give them a heads-up on this situation. These were new students--and this was their very first time giving patient care. How can you not tell students--who are still getting the hang of handwashing, gloving, universal precautions etc--that their patient has the HIV+ virus and is experiencing active AIDS? I believe the instructor had a responsibility to inform these students so they could be extra careful, take a little extra time etc when dealing with this patient. What do you think? Thanks, Steph
Barfing, most likely not. Coughing, quite possibly.
As a student, I'd like to better understand the several different lines of logic that have shown up in this thread. I haven't taken care of a pt. w/advanced HIV but in my limited experience it seems like when there is evidence of a pt. being immuno-compromised (for whatever reason - and that could include everything from HIV+ status to CA-related pan-cytopenia) they are placed in reverse isolation. Is an immuno-compromised pt. at a much higher risk of carrying other secondary infections, which also are an issue both for the pt. and the staff?
Everyone in the hospital is immuno-compromised. That's why nurses aren't supposed to come in sick. Most illnesses you are worried about spreading to the patient are not airborne (and I commend you for caring about your patient's safety, that is a good thing). Very few illnesses are actually airborne, that's why very few require reverse isolation/negative pressure rooms. The ones you are probably worried about are spread by droplet. So, simply washing your hands before going in the room and not coughing all over the HIV patient is keeping them safe. If we were really that concerned about someone breathing on the HIV patient, they wouldn't be able to have visitors. As far as them giving you some secondary infection, they are no different from any other patient in that regard and no more likely to give you something. You avoid getting coughed on, and wash your hands after patient care. Nurses don't need to don a space suit to care for HIV patients for our safety or theirs.
This is the voice of reason. Any patient can have HIV, so no, you don't need to be told. You should assume they all do.
Personally, I have seen enough bigotry and outright ignorance from healthcare workers towards HIV+ patients to believe that it should be a secret and nurses don't have the right to know (plus, it isn't like HIV is easy to transmit in the healthcare setting doing CNA work
I totally agree. One of my very first patients was HIV+. It was a big secret. His family even thought he was dying of leukemia. My instructor did not tell me, the other nurses did not tell me, the patient did not tell me. I read it in his chart. Everyone is to be treated as if they are HIV+. That is the whole point of Universal Precautions. If you work in say the ED and you have a bad trauma come in, they may have HIV, Hepatitis, or TB. You just never know.
It's called Universal Precautions because....IT'S FOR EVERYONE.
Would it be nice if they knew about the patient's status...certainly.
But necessary to give the patient appropriate care, given their tasks??? Not really.
I have worked in hospitals that will not give HIV in report or write it in the chart, unless the diagnosis is HIV specific.
Consider this ...out of all the people that we know have HIV, probably about as many in the hospital have it and we do not know, because they have never been tested for it. And many will die of many other things completely unrelated, and never ever show any sign.
Do you wear gloves on the subway, or a condom over your body when you go to the Beach...You know a lot of gay men like tans. Do you wash off every hospital chair with bleach prior to sitting in it...Ohhh the Germs.
The point is you cannot get AIDs from casual contact. Parents of AIDs patients frequently bathe them gloveless,. I have sat on the patient's bed to comfort them and brush their hair. Putting on gloves is not rocket science and if you dont know how to to put on nonsterile gloves as a starting nursing student...you probably need to rethink your choice of profession.
AIDs patients walk among us in daily life, looking as healthy or healthier than us. They are not neutropenic, unless the CD4 or Tcell counts are excessively compromised...and no more fragile than anyone with a chronic disease state...some doing better and others doing worse.
These days HIV does not even rate a private room in most places...in many neutropenics don't even get a private room, but get placed with a"clean" patient.
And, yes, all people working closely with the patient deserve a thorough report. However, in many places that will not necessarily include HIV status. For example radiology, respiratory and phlebotomy routinely do not receive that info and are substantially more at medical risk.
I can also say that while I have been injured by patients, none of those injuries occurred while working two years on an HIV unit.
A situation occurred recently that I would love to get your opinion on regarding ethical and appropriate disclosure related to a HIV+ patient in active AIDS.
A 'brand new' group of pre-nursing students completed two weeks of basic care workshops i.e. bedmaking, ambulation, bedbath, oral & peri care etc. The third week consisted of 3 clinical days (from 7:30am to 12pm) on a med/surg floor. Students were paired and assigned a patient. Students were to provide bathing, bedmaking, vs, etc for that patient. Apparently, two students found out after the fact that their patient was HIV+. They did wear gowns because this patient had C.diff in addition to everything else. However, they didn't know about the AIDS. When I heard about this, I couldn't believe that their instructor didn't give them a heads-up on this situation. These were new students--and this was their very first time giving patient care. How can you not tell students--who are still getting the hang of handwashing, gloving, universal precautions etc--that their patient has the HIV+ virus and is experiencing active AIDS? I believe the instructor had a responsibility to inform these students so they could be extra careful, take a little extra time etc when dealing with this patient. What do you think? Thanks, Steph
I know a lot of people have responded to this but I did want to add something.
I work in a hospital now as a nurse tech and have had HIV+ patients to take care of before. One time it was not mentioned in report or to me by other nurses. It wasn't written on the Kardex either. Tech's don't routinely get out patient charts and read them. We don't have time to sit and do this. It was a PCA (similar to CNA) who told me this particular person was HIV+. There were no contact precautions listed on the door, no reverse ventilation in the room. Nothing to let anyone know or give any clues about this situation.
BUT.... this was not my first dealing in clinicals either. I am well versed in universal precautions. For the two very new students......well, I believe the clinical instructor should have pulled them aside, told them about their client and how to act appropriately in the room.
That is a big thing to deal with for the first time. I know I had to go talk to one of my co-workers for a few minutes after I found out.
Contact precautions and reverse ventilation are NOT necessary for HIV postive patients. You don't need to do anything to protect yourself from them that you don't do with every other patient.
Thanks Fergus. After 7 years providing care to HIV patients I can affirm that they are in need of the same universal precautions as anyone else. Period. It makes me sad that there are students going into clinical situations without adequate knowledge and training.
I cannot understand why a patient with HIV causes so much consternation and need to debrief. They are just people with a disease that is much more of a chronic condition than ever before. And one can just read the CDC statistics to realize there are many people we are in contact with every day that have HIV, HepB, etc - and neither they nor we know of it.
We need to continue this dialogue, of affirming what HIV is/is not, how it is/is not transmitted etc - hopefully if we cut down on some of the stigma associated with HIV, we'll have a chance of identifying who does have it and providing them with resources for treatment, social support etc.
Contact precautions and reverse ventilation are NOT necessary for HIV postive patients. You don't need to do anything to protect yourself from them that you don't do with every other patient.
It would be so nice if more people (nursing students included) understood that persons with HIV, ARC and AIDS are so much more at risk from us than we are from them.
In fact they need more human contact because of their disease and the depression and ostracizing that goes along with it, than the "usual" patient would.
Maybe that's where I want to work. (I still don't have the short answer to that question.)
A situation occurred recently that I would love to get your opinion on regarding ethical and appropriate disclosure related to a HIV+ patient in active AIDS.
A 'brand new' group of pre-nursing students completed two weeks of basic care workshops i.e. bedmaking, ambulation, bedbath, oral & peri care etc. The third week consisted of 3 clinical days (from 7:30am to 12pm) on a med/surg floor. Students were paired and assigned a patient. Students were to provide bathing, bedmaking, vs, etc for that patient. Apparently, two students found out after the fact that their patient was HIV+. They did wear gowns because this patient had C.diff in addition to everything else. However, they didn't know about the AIDS. When I heard about this, I couldn't believe that their instructor didn't give them a heads-up on this situation. These were new students--and this was their very first time giving patient care. How can you not tell students--who are still getting the hang of handwashing, gloving, universal precautions etc--that their patient has the HIV+ virus and is experiencing active AIDS? I believe the instructor had a responsibility to inform these students so they could be extra careful, take a little extra time etc when dealing with this patient. What do you think? Thanks, Steph
When I was a student, we were told to assume that ALL pts are HIV+. In reality, we do not always know if our pts are infected or not. Hopefully a student would know how to put on gloves & not touch their own mucous membranes before going into clinicals!
Surely they have been told about universal precautions. That should cover risks, regardless of what other info they have. Not all pts with bloodborne pathogens are diagnosed or treated before we care for them, so we need to assume that every patient has the potential to be contagious. But politically speaking, I agree that AIDs should not have special secretive measures.
Barfing, most likely not. Coughing, quite possibly.
As a student, I'd like to better understand the several different lines of logic that have shown up in this thread. I haven't taken care of a pt. w/advanced HIV but in my limited experience it seems like when there is evidence of a pt. being immuno-compromised (for whatever reason - and that could include everything from HIV+ status to CA-related pan-cytopenia) they are placed in reverse isolation. Is an immuno-compromised pt. at a much higher risk of carrying other secondary infections, which also are an issue both for the pt. and the staff?
Nope, you are incorrect. There are HIV+ pts on every kind of floor, and only universal precautions are used. Both HIV and C-diff can be contracted by the staff if exposed to body fluids, though C-diff needs even greater contact precautions b/c it can reside on skin and surfaces. An advanced AIDS case is susceptible to pathogens that are normally carried in their own bodies & commonly in the environment -- things we carry with us & do not react to, they no longer have the immune systems to fight -- many of their secondary infections are from pathogens they (like the rest of the population) already carry.
An advanced AIDS case is susceptible to pathogens that are normally carried in their own bodies & commonly in the environment -- things we carry with us & do not react to, they no longer have the immune systems to fight -- many of their secondary infections are from pathogens they (like the rest of the population) already carry.
Yes, this was my point exactly -- instead of shrouding HIV in secrecy, supposedly to preserve the pt.'s privacy, how about we recognize their special degree of susceptibility to garden-variety organisms that are present nearly everywhere and allow their caregivers to act accordingly. And yes, I have seen an HIV+ pt. in reverse isolation due to their HIV+ status.
Fergus' point about all hospital pts. being immuno-compromised due to impaired health status (the reason for their hospitalization) is well taken.
Another question has occurred to me - hope an experienced nurse can answer. In those hospitals which specifically do not disclose a person's HIV+ status to staff -- if they've been diagnosed as HIV+, and are taking meds, realistically wouldn't the nurses know anyway, just by looking at the MAR? It's not like protease inhibitors are in the top 5 prescribed meds ...
MLOS just because someone was in reverse isolation does not mean it was needed or that it is needed in general (caroladybelle's post adressed this, few HIV patients are compromised in the way someone in for a bone marrow transplant is). I have worked with nurses in a unit who instituted contact precautions on a baby with questionable HIV status. They were gowning and gloving before they would touch the baby for EVERYTHING even when they would have no contact with fluids. It was embarassing to me that nurses would do this and I was even more embarassed when it took our hospital infection control doc to convince them to stop.
fergus51
6,620 Posts
Everyone in the hospital is immuno-compromised. That's why nurses aren't supposed to come in sick. Most illnesses you are worried about spreading to the patient are not airborne (and I commend you for caring about your patient's safety, that is a good thing). Very few illnesses are actually airborne, that's why very few require reverse isolation/negative pressure rooms. The ones you are probably worried about are spread by droplet. So, simply washing your hands before going in the room and not coughing all over the HIV patient is keeping them safe. If we were really that concerned about someone breathing on the HIV patient, they wouldn't be able to have visitors. As far as them giving you some secondary infection, they are no different from any other patient in that regard and no more likely to give you something. You avoid getting coughed on, and wash your hands after patient care. Nurses don't need to don a space suit to care for HIV patients for our safety or theirs.