The paper deals with the case study of Justin. On placement in a student’s health clinic at a local university, a 24 year old male student, named Justin is presented. He notices some worrying symptoms including blisters on his penis. The patient has not experienced these symptoms in the past. Upon investigation, the client revealed that the he had sex – including oral sex three times in last 24 hours. The patient reported that he had not used condoms as his partner informed him that the STD screen was clean for everything. In response to the case study, the assignment discusses the sexually transmitted infection (STI) that Justin is highly likely to suffer. In the context of the STI chosen the assignment will address the pathophysiology of this STI, the assessment and management of this STI, ethico-legal issues that may arise with the diagnosis of an STI. Further, the assignment will discuss the role of the sexual health team members involved in the management of Justin. Lastly, the education needs for Justin to prevent further STIs are outlined.
Justin has been practicing unsafe sex and is experimenting with his sexuality. Because of his unsafe sex practices, he is at risk of developing Genital herpes. It is one of the most common STIs.
Genital herpes is caused by the Herpes simplex virus (HSV) and in most cases HSV type 2 is responsible for the disease. HSV-1 is often the cause of fever blisters or cold sores (Garland & Steben, 2014). However, the patient denies the history of cold sores on his mouth or sore around his genitals before. His case history highlights that he rarely practices the safe sex, thus the blisters on penis in such situations is mainly caused by the genital herpes. Genital herpes is easily transmitted through sexual contact and may happen even if the concerned person is containing virus without exhibiting the related signs or symptoms (Schiffer & Corey,2014). As the virus enters the skin it travels along the nerve path, where it can become dormant and persist there indefinitely. Both HSV 1 and HSV 2 infections occur by contacting the infectitious secretions on oral, anal and genital mucosal surfaces. Contacting other anatomical site such as eyes, non-mucosal surfaces, such as lesions on the buttocks and trunk can also cause genital herpes. In this type of viral infection, the symptoms may appear months after the initial exposure. The mucous membrane lines the opening of the body, which is the door to the viruses. The primary infection is characterised with the small blisters on genital areas that may burst to leave open sores. Genital herpes mainly affect genitals, mouth, and anal region (Johnston & Corey, 2016).
Diagnosis of genital herpes includes several tests. PCR blood tests are used to look for pieces of viral DNA. This is most common test and is accurate. The health care providers may collect sample from sores for cell culture and can be observed under microscope for HSV (Liu et al., 2015). Both the tests have a chance of giving false results, if the patient has started to recover recently. Antibodies against HSV do not show up until several weeks and it is difficult to identify the time of exposure or noticeable exposure. With the help of the direct fluorescent antibody testing, it is easy to detect the glowing antibodies that stick to the viral antigens in the sample. This testing is useful to differentiate between the HSV 1 and HSV 2. Overall, the clinical diagnosis has low sensitivity and specificity (LeGoff et al. 2014).
Nurses can asses for impaired skin integrity that is related to skin inflammation, vesicles and crusting. Further assessments include hyperthermia indicating increased hypothalamic set point, fatigue due to decrease in energy source and risk of imbalanced nutrition pertaining to appetite down and lastly acute pain that may be caused by the infection in pain neurons. Based on the assessment HSV is diagnosed (Posavad e al., 2017).
According to Fife et al. (2015), daily suppressive treatment with valaciclovir can reduce HSV-2 transmission. This drug was investigated among HSV-2 discordant heterosexual couples. The infection was reduced by 75%, for clinical disease and reduces the acquisition (measured by serology) by 48%. Development of vaccine effective against this disease is not been found. Antiviral treatment is helpful and commonly prescribed medication include- Zovirax, Famvir, Valtrex, which are known to prevent outbreak. Antiviral medicine should be taken daily and it makes the living easier. These medicines can be taken as pill. According to the guidelines of WHO for adolescents with a first clinical episode of genital HSV infection, a standard dose of aciclovir over valaciclovir or famciclovir is recommended (Sands-Lincoln & Goldmann, 2016). The dosages are as follows-
Intermittent therapy can consist of antiviral therapy for five or ten days. Suppressive treatment for recurrent infections includes taking the antiviral drugs everyday and is given for six outbreaks a year (Bibbins-Domingo et al., 2016). Therefore, the dosage may be like-
Diagnosing and management of HSV involves use of several medical equipments and processes. The circumstances under which it is conducted may raise ethical or legal concerns. The ethical issues that may arise in this case are the patient safety, informed consent, and confidentiality. The care providers must strictly follow the four principles of ethics such as beneficence, maleficence, social justice and respect for autonomy (Scott, 2014).
Administering the patients with medicines that are not examined may lead to adverse outcomes and may be as fatal as death. Breaking the protocol of patient safety may cause ethical issues particularly in Expedited Partner Therapy. This act may cause legal consequences on the ground of professional negligence. It may lead to legal lawsuit against the hospital, claiming for compensation for heath loss. If the patient fails to provide informed consent regarding the choice of the treatment then the care provider fails to make clinical decision. Initiating treatment without taking informed consent may have adverse complications. It is considered the breach of patent’s autonomy, respect and dignity. Patients should be informed about availability of testing of HSV, treatment and lack of sensitivity and specificity of antiviral drugs. In Australia, federal government sets regulations on use of blood tests and genetic tests using human subjects (Todres, 2017).
In case one the partners visits the clinic together and the infection of one of them is revealed, the relationship may be compromised. If the partner hides the information, it may lead to ethical and legal issues. Lawsuits are obvious when the potential partner allegedly gives them the herpes. Leaking the patient’s health information to third party may involve legal consequences as it may involve defamation and social stigmatisation. In case one partner does not want the information to be shared by the other partner, and if the request is denied it may lead to compromising of confidentiality and the patient may resort to legal help. Partners can also file lawsuits that their opposite consorts have given them herpes (Caulfield & Willis, 2016)).
Nursing management include keeping the affected area clean and dry to keep away other infections. Sexual contact must be avoided until the sores are gone. Home care for management for Justin includes bathing in warm water, keep the area clean and wear comfortable clothing (Whitehead, 2017).
Counselling the infected patients is best way to manage the disease. Justin must be counselled along with his potential partner to cope up with the infection. It will help prevent the sexual and perinatal transmission. Counselling is based on the natural sources of disease and asymptomatic shedding, first episode and recent infection, information pertaining to antiretroviral therapy and its impacts, successive therapy with recurrent infections. The patient should be educated about the side effects of the medicines. The rationale for counselling is to break the cycle of recurrent infections. It can be possible only if the patient has knowledge of the infection, and daily antiviral therapy (Davis et al., 2016).
Management of the genital herpes not only involves dealing with the physical symptoms but also the psychological concerns. Patients often feel anxiety due to uncertainty related to disease and its curability. Anxiety related to denial and refusal from potential partners is the main cause of concern. Therefore, the sexual health team members should address the psychological concerns in this manner. Intervention for mental distress, anxiety and depression due to STI may include patient centered care and therapies such as “Acceptance and commitment therapy” or psychodynamic therapy. Justin can be engaged in relaxing or recreational activities such as exercise, sports or anything that can calm his mind (Jayasuriya et al., 2015).
The patient must be educated about safe sex and severe disorders associated with the genital herpes. The rationale for the education is to prevent the recurrent infections. The consequences are worst when the infection is spread to mouth, eye and central nervous system. Justin must be aware of the fact that the risk of HIV infection is doubled in the people diagnosed with genital herpes (HSV 2). The use of condoms can prevent the herpes virus infection. Justin must be informed to use condoms when meeting new partners. The patient should be instructed to avoid sex during the lesions or prodromal symptoms. Most people are unaware of the HSV infection and those with history of STDs are highly likely to have genital herpes. It is because genital herpes are hard to spot. Therefore, Justin must learn to communicate with his partner about history of STDs and sexual history. Limiting the sexual partners is advisable for Justin, as it will reduce the risk of exposure to HSV and other STIs. As the patient has multiple sex partners, he should ensure that she is tested for genital herpes (Davis et al., 2016).
Justin should be aware of consequences of sexual contact with partner who has genital sores. Oral sex is risky as the oral herpes may pass to the genitals through the process. Oral herpes causes sores are known to cause cold sores of fever blisters. Since, Justin frequently engages in orals sex he may be at high risk of future infection and he should be advised to receive oral sex from partners with cold sores. The patient may never have an outbreak but may be highly contagious to the sexual partner. Therefore, Justin should be advised to educate the same to his partners (Davis et al., 2016). According to McGregor et al. (2014) illicit drugs impairs judgment and lower inhibitions. During intoxication, people are less careful to practice safe sex, which may lead to adverse outcomes. Since, Justin is the regular, binge drinker he must be educated about adverse consequences of sex while intoxication.
Genital herpes is the significant public health issue as it can cause substantial morbidity if it is left untreated and undiagnosed. It is one of the most common STIs and is highly likely to occur in the people with unsafe sex practices. All the patients with ulcers in the genital area are suspected to have HSV. Overall, the clinical diagnosis has low sensitivity and specificity. Nursing assessment includes physical examination for the related symptoms. Although there is no exact cure for the illness, it can be effectively managed. The health care team must help the patient to cope up with the illness by education, counselling, medication and home care. In addition to the physical problems, the health care team must also deal with the psychological issues of the patient. Education and counselling will prevent of recurrent infections as well as risk of HIV.
Bibbins-Domingo, K., Grossman, D. C., Curry, S. J., Davidson, K. W., Epling, J. W., García, F. A., ... & Mangione, C. M. (2016). Serologic screening for genital herpes infection: US preventive services task force recommendation statement. Jama, 316(23), 2525-2530.
Caulfield, P., & Willis, D. (2016). Herpes simplex virus:‘to disclose or not to disclose.’An exploration of the multi-disciplinary team’s role in advising patients about disclosure when diagnosed with genital herpes simplex virus. International journal of STD & AIDS, 0956462416665730.
Davis, A., Roth, A., Brand, J. E., Zimet, G. D., & Van Der Pol, B. (2016). Coping strategies and behavioural changes following a genital herpes diagnosis among an urban sample of underserved Midwestern women. International journal of STD & AIDS, 27(3), 207-212.
Fife, K. H., Mugwanya, K., Thomas, K. K., Baeten, J. M., Celum, C., Bukusi, E., ... & Lingappa, J. R. (2015). Transient Increase in Herpes Simplex Virus Type 2 (HSV-2)–Associated Genital Ulcers Following Initiation of Antiretroviral Therapy in HIV/HSV-2–Coinfected Individuals. The Journal of infectious diseases, 213(10), 1573-1578.
Garland, S. M., & Steben, M. (2014). Genital herpes. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(7), 1098-1110.
Jayasuriya, N. D. V., Sivayogan, S., & Buddhakorale, K. (2015). Psychological impact due to genital herpes among Central STD Clinic attendees in Sri Lanka. Sri Lanka Journal of Venereology, 5(1).
Johnston, C., & Corey, L. (2016). Current concepts for genital herpes simplex virus infection: diagnostics and pathogenesis of genital tract shedding. Clinical microbiology reviews, 29(1), 149-161.
LeGoff, J., Péré, H., & Bélec, L. (2014). Diagnosis of genital herpes simplex virus infection in the clinical laboratory. Virology journal, 11(1), 83.
Liu, J., Yi, Y., Chen, W., Si, S., Yin, M., Jin, H., ... & Zhang, J. (2015). Development and evaluation of the quantitative real-time PCR assay in detection and typing of herpes simplex virus in swab specimens from patients with genital herpes. International journal of clinical and experimental medicine, 8(10), 18758.
McGregor, J. A., French, J. I., Jones, J., & Perhach, M. (2014, June).crowdsourced analysis of gbs perinatal disease as a sexually transmissible infection (sti) underscores need for gbs vaccine and patient education regarding gbs as an sti to be able to make well-informed sexual practice choices. in sexually transmitted diseases (vol. 41, pp. s147-s147). two commerce sq, 2001 market st, philadelphia, pa 19103 usa: lippincott williams & wilkins.
Posavad, C. M., Zhao, L., Dong, L., Jin, L., Stevens, C. E., Magaret, A. S., ... & Koelle, D. M. (2017). Enrichment of herpes simplex virus type 2 (HSV-2) reactive mucosal T cells in the human female genital tract. Mucosal immunology.
Sands-Lincoln, M., & Goldmann, D. R. (2016). Antiviral Drugs to Prevent Clinical Recurrence in Patients with Genital Herpes. The American Journal of Medicine, 129(12), 1264-1266.
Schiffer, J. T., & Corey, L. (2014). Herpes simplex virus. In Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier Inc..
Scott, P. A. (2014). Unsupervised self-testing as part public health screening for HIV in resource-poor environments: some ethical considerations. AIDS and Behavior, 18(4), 438-444.
Todres, J. (2017). Physician encounters with human trafficking: legal consequences and ethical considerations.
Whitehead, L. (2017). First-episode genital herpes: interventions for men and women. Nursing Standard, 31(22), 40-41.
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