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
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 ...
Yes, the MAR is a good clue. For me, if I was on a nononco or hem floor, a diagnosis of Pneumonia with IV Highdose Bactrim/ Septra was always a clue. Use of Pentamidine on noncancer or nontransplant pts. The HAART meds, labs for viral load, CD4 or Tcells. Use Ganglicyclovir. (Yes, my age shows, these were the predominant clues about 10 years ago, with the exception of the HAART med).
But remember, that techs (which were issue) do not usually see these and students may not be as clued in on Septra, Pentam, etc.
And remember Phlebotomy routinely draws blood on HIV+ patients, yet rarely knows the status. They are in more "danger" than the average student/tech.
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.
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No, you're missing the point. They are susceptible to pathogens ALREADY within their own bodies. For example, if they carry the herpes virus, their body will no longer be able to suppress it & they will have horrible breakouts from the virus. You can't protect them from things they already carry, baseline pathogens.
It is very rare to place an HIV pt in "reverse isolation". Most HIV+ pts are not in full-blown AIDS, and they are placed on normal wards. They are not required to announce their HIV status -- it is a pt confidentiality issue. Healthcare workers do not have the "right" to know, and often times we don't know. Often times the pt himself/herself doesn't know! But regardless, UNIVERSAL PRECAUTIONS work for the vast majority of HIV+ pts.
By the way, this will probably be on your NCLEX: Universal precautions are the standard of practice for HIV+ patient.
Also from the site, see below. "Standard isolation" is used to protect the rest of the floor in the last example described below, when an HIV+ pt has active TB. Isolation is used for some TB cases in order to prevent the room's circulating air from flowing into the hallway & in other pt's rooms. Additionally, other precautions are taken with the opportunistic infections in order to protect the RN & other patients.
I could also see where "reverse isolation" would be needed in very extreme cases, when a pt has full-blown AIDS & no immune system to speak of. I have had pts die of AIDS on my regular med-surg floor, but generally they already have so many complications from the opportunistic infections (esp. cancers) that they no longer are placed in isolation -- instead, they are allowed full contact with family/friends & staff in order to "die with dignity" rather than isolated & alone.
Excerpt:
"There are rarely any extra precautions to be taken by carers and health care workers looking after people with HIV with specific opportunistic infections.
This is because, by the nature of the disease, the organisms that cause opportunistic infections such as candida, PCP, toxoplasmosis, MAI, CMV are prevalent everywhere and standard universal precautions are adequate to deal with them.
Some specific extra precautions for immunocompetent carers are probably only required in a few situations:
Herpes zoster (shingles)
If there's an attack, until the blisters or lesions settle down and dry out, people who have never had chicken pox (and especially pregnant women) should keep away. If contact has taken place protection is available in the form of immunoglobulin.
Herpes simplex
If there's an attack around the mouth kissing would be infectious at the time; if round the genitals touching could be infective, so wear gloves.
Salmonella
In people with HIV this may be long drawn out, and they may excrete salmonella for a longer time in faeces despite the antibiotic therapy, so extra hygiene and disinfection precautions are advised. Salmonella infection is notifiable and standard hospital and community guidelines exist.
Cryptosporidiosis
The epidemiology isn't wholly understood: it could cause an acute diarrhoea-type illness in people with a normal immune system, or much more severe life-threatening illness in people with immune deficiency. The same precautions as for salmonella are advised.
`Active TB'
i.e. when coughing up TB organisms.
The chance of becoming infected with m.TB if you have been in prolonged contact with someone who has active TB is approximately 50%. Prolonged contact means sharing a home, a ward or being in other close proximity for many hours. In other circumstances the chances of infection are very much lower - probably around 8-10% if you encounter TB organisms in the air. It is important to note that these risk estimates are derived from the USA, where the BCG vaccination is not given routinely at puberty, so the chances of infection in the UK are much lower for individuals who have received the BCG vaccination (it is believed to provide approximately 70% protection in immunocompetent people). M.TB can linger on droplets in the air for several hours, so if you are caring for someone with TB and you haven't received the BCG vaccination, it is best to wear a mask. Once treatment has begun, TB ceases to become infectious within a few weeks, and individuals can often be treated at home provided they can be relied upon to take the full course of medication. If the full course of medication is not taken the TB may relapse, with the additional danger that it will be multi-drug resistant : that is, insensitive to the commonly used cocktail of anti-TB drugs. If multi-drug resistant TB emerges it is frequently lethal, but it is not any more infectious than other strains of TB. Unfortunately, active multi-drug resistant TB can persist for many months, and it is often difficult to determine if a patient has ceased to be infectious. For this reason people with MDR-TB are usually isolated in hospital until they are pronounced non-infectious, and the hospital will have infection control procedures to protect visitors."
I think I deserve to know if a patient has HIV or Hep B,C. I think all healthcare workers deserve to take that little bit of 'extra' precaution when their patient has an infectious disease. Individual behavioral and medical problems can make it more or less risky for healthcare workers, depending on the patient.
I totally resent the fact that someone doesn't think I have a right to this information because if I have this info, I 'might' hurt their feelings by wearing goggles, masks or stay out of the reach of their bloody spit or flying body fluids. I have become very angry to find this info was withheld from me and this put me at risk.
So...I have learned the hard way to be cautious and alert to any situation involving blood and body fluids, PARTICULARLY with uncooperative patients. There ARE passive aggressive folks out there who withhold info, and someone also may not have had time to read the chart for the DX, so we can't trust word of mouth. I'm the kind of nurse that tends to jump in and help. I've had to retrain myself to use caution in today's politically correct climate.
I don't think the issue is trying to prevent nurses from using precautions with HIV+ patients in order to be pc. No one wants you to go into a room without a faceshield and be splattered with blood. I think the issue is making them use precautions with all their patients and not relying on a known diagnosis, because as many have already pointed out HALF of the people with HIV don't know they have it. That means we have ALL looked after HIV patients without knowing it. Makes those precautions seem important ALL the time and if we are using them ALL the time by definition we aren't relying on a known diagnosis anyways, making it superfluous info....
It's awful, but believe it or not, we are told that a person can keep it a secret and as far as being the healthcare professional, we are expected to use universal precautions, and as long as we do, there is nothing to worry about.
I think we should be told. Universal precautions or not. I have taken care of a gentleman with AIDS before until he passed away, and wasn't afraid of him, so where to the "higher ups" get off acting like we have no need to know? That really peeves me..... :angryfire
I hear ya!!! We have a nondisclosure type facility. The assumption that universal precautions are supposed to be followed routinely and will provide adequate protection is kind of a mantra around here. I believe that UP's are essential, however -- it does seem like it is wrong to withhold such a major piece of information from the people who are caring for the patient!!!
I have had both extremes as far as HIV patients -- one guy was very hostile and angry -- attempting to bite the home care nurses -- one saintly woman said that she would take his case as her primary assignment -- she walked in to his room on day 1 and said -- I am here to give you the best care that I can -- I know that you are hurting and angry, that you -- for some reason-- feel the need to lash out at us. I have raised my 4 children, have grandbabies and have accomplished all the major goals that I have set for myself. I am going to be the best D*&^ nurse you have ever had -- if you bite me or spit on me and I get aides and die -- it won't be any skin off my nose -- you'll have to live with the consequences -- I'm not afraid of you. The guy was sweet as heck with her and even ended up being a favorite patient among our gang.
The other guy got his HIV from a tainted transfusion he received while in a foreign country serving in the military He would remind every nurse that was going to do anything for him to wera gloves or double glove -- just to be safe. He was such a dear man!!!
I think of it this way: what if they were caring for this patient the day or the week BEFORE he tested positive. Another reminder that we need to keep our own interests in mind and protect ourselves with every patient during every encounter; not rely on our instructors, supervisors, managers, etc. to inform us.
I think of it this way: what if they were caring for this patient the day or the week BEFORE he tested positive. Another reminder that we need to keep our own interests in mind and protect ourselves with every patient during every encounter; not rely on our instructors, supervisors, managers, etc. to inform us.
So very very true. We must look our for ourselves first and foremost.
I think I deserve to know if a patient has HIV or Hep B,C. I think all healthcare workers deserve to take that little bit of 'extra' precaution when their patient has an infectious disease.
I totally resent the fact that someone doesn't think I have a right to this information because if I have this info, I 'might' hurt their feelings by wearing goggles, masks or stay out of the reach of their bloody spit or flying body fluids. I have become very angry to find this info was withheld from me and this put me at risk.
I've had to retrain myself to use caution in today's politically correct climate.
It is not a matter of "I deserve to know".
It has nothing to do with "Politically Correct".
It has nothing to do with "Hurting Feelings".
It has to do with what is necessary to take care of ALL PATIENTS and ALL HEALTHCARE WORKERS.
I worked an Infectious Disease unit for two years and Oncology for nine years. Both units had a great number of HIV+. I have NEVER had an HIV patient put me in danger of contracting the disease.
I have been strangled by Alzeheimers patients. I have had meningitis patients attack and break my pregnant coworkers fingers. I have been hit by MDs that threw charts, had a glass thrown at me by VIP patient, had an ortho patient bite me and cause a serious infection. And I have the usual sprains/muscle injuries, by AOx3 patients that were fully explained how to move and chose to put me in danger by grabbing my neck, or moving wrong during transfers. I have had two respiratory infections acquired from working with highly infectious patients that the MDs (THE REAL DANGER TO STAFF) "didn't want to embarass" by putting putting on respiratory precautions. One took 8 weeks of antibiotics to clear up...over 8 staff members got infected.
And I repeat, I HAVE NEVER HAD AN HIV PATIENT ENDANGER ME.
If they are spitting, vomiting or bleeding, YOU NEED TO BE USING PRECAUTIONS REGARDLESS OF THEIR HIV STATUS.....and you don't need to know their status to have the common sense to know that. No one is "withholding info from you". And you need to be using that "extra" precaution with everyone....in your hospital ...in your school....in your work...and in your life.
caroladybelle, BSN, RN
5,486 Posts
Yes, the MAR is a good clue. For me, if I was on a nononco or hem floor, a diagnosis of Pneumonia with IV Highdose Bactrim/ Septra was always a clue. Use of Pentamidine on noncancer or nontransplant pts. The HAART meds, labs for viral load, CD4 or Tcells. Use Ganglicyclovir. (Yes, my age shows, these were the predominant clues about 10 years ago, with the exception of the HAART med).
But remember, that techs (which were issue) do not usually see these and students may not be as clued in on Septra, Pentam, etc.
And remember Phlebotomy routinely draws blood on HIV+ patients, yet rarely knows the status. They are in more "danger" than the average student/tech.