Tuberculosis (TB) - Roxborough School of Nursing - Nursing 200 PDF

TUBERCULOSIS (TB) Roxborough School of Nursing Nursing 200 Learning Outcomes Delineate the pathogenesis of tuberculosis (TB) Categorize adults at risk for tuberculosis Differentiate the various diagnostic studies used for the detection and diagnosis of tuberculosis...

TUBERCULOSIS (TB) Roxborough School of Nursing Nursing 200 Learning Outcomes Delineate the pathogenesis of tuberculosis (TB) Categorize adults at risk for tuberculosis Differentiate the various diagnostic studies used for the detection and diagnosis of tuberculosis Categorize the mechanism of action, side effects, and nursing implications of drug therapy for tuberculosis Categorize teaching needed for the patient diagnosed with tuberculosis Organize care based on the nursing process for a patient diagnosed with tuberculosis. Tuberculosis Caused by Mycobacterium tuberculosis Slow-growing slender, rod-shaped acid-fast organism with a waxy outer capsule Pulmonary Tuberculosis Pathophysiology Gram-positive, acid-fast bacillus Spread from person to person via aerosolization Transmission usually requires close, frequent or prolonged exposure When inhaled, lodge in alveoli in the small distal airways Local inflammatory response occurs A granuloma forms from alveolar macrophages and contains the bacteria surrounded by collagen, fibroblasts and lymphocytes TB infection can be detected by skin test Center of the lesion contains necrotic tissue, becomes a granular mass Cavities are formed, calcify, seen on chest x-ray Pulmonary Tuberculosis Infection Pathophysiology Latent Tuberculosis Infection If infected but not exhibiting active disease it can not be spread Reactivation Tuberculosis is reactivation of the disease in a previously infected person Occurs in persons who have chronic diseases or are immunosuppressed Who is at risk??? Pulmonary Tuberculosis Disease Pathophysiology Initial immune response is inadequate, organism is not contained, active primary disease occurs TB Disease or Primary Tuberculosis Infection Bacteria can be spread Tuberculosis Resurgence caused by: 1. High rates of TB in those with HIV infection 2. Emergence of multidrug-resistant (MDR) strains Disproportionately seen in the poor, underserved, and minorities Drug Resistance Multidrug resistance (MDR TB): resistance to first line drugs used to treat the disease pre-extensively drug-resistant TB (pre-XDR TB) Extensively drug resistant (XDR TB): Resistance to first line TB Drugs, at least one second line TB drug and at least one drug in the quinilone antibiotic sub-class At Risk Close contact w/active TB patient Immunocompromised patient Substance abuse Inadequate health care resources Preexisting medical conditions Immigration: countries w/high prevalence of TB Living in overcrowded or substandard housing Health care worker performing high risk activities Manifestations Fatigue Weight loss Anorexia Low-grade fever Night sweats Cough Other Complications Miliary Tuberculosis Pleural Effusion and Empyema Genitourinary Tuberculosis Tuberculosis Meningitis Skeletal Tuberculosis Focus of Interprofessional Care Early detection Accurate diagnosis Effective disease treatment Preventing TB spread to others Diagnostic Studies Intradermal PPD (Mantoux) test Chest x-ray Acid-fast bacillus smear (AFB) Interferon Gamma Release Assay blood test Sputum Culture Tuberculin Skin Test (Mantoux) Most commonly used reliable test for TB O.1 ml purified protein derivative (PPD) given intradermally Read after 48-72 hours Annual for health care workers 10 mm induration/redness = exposure & infection w/TB (5-9 mm for immunocompromised) Chest x ray after + PPD Diagnostic Studies Chest X-Ray Used to evaluate pulmonary tuberculosis findings Dense lesions in apical and posterior segments of upper lobe with cavity formation may be noted Acid Fast Bacillus smear Determines tubercle bacilli Not specific for tuberculosis Interferon-gamma release assays (IGRAs) Indicates TB infection – does not distinguish active vs latent QuantiFERON – TB Gold T-SPOT TB test Sputum culture (sample) of M. tuberculosis = definitive diagnosis  Classification Class 0: No exposure; not infected Class 1: Exposure; no evidence of infection Class 2: Latent infection; no disease (e.g., positive PPD reaction but no clinical evidence of active TB) Class 3: Disease; clinically active Class 4: Previous disease; not clinically active Class 5: Suspected disease; diagnosis pending Prior to Initiating Treatment Baseline Data Required Based on medication utilized Liver function tests and renal function studies Vision examination Audiometric testing Medication Management Goals of therapy include: Make disease noncommunicable to others Reduce symptoms of the disease Effect a cure in the shortest possible time Collaborative Care Medical Management of TB Bacillus Calmette-Guerin (BCG) vaccine Widely used in developing countries In United States: recommended for use in infants, children and healthcare workers who are repeatedly exposed to untreated or ineffectively treated people with active disease  Collaborative Care Medical Management of TB Chemotherapeutic agents (antituberculosis agents) 6 to 12 months Prophylactic Treatment: used to prevent active disease Single drug given for 6-12 months Initial Phase (first 2 months daily therapy) Continuation Phase (remaining 4+ months of therapy) Collaborative Care Medical Management of TB Resistant strains may require more than 4 medications Acute adherence to therapy is critical for survival Directly Observed Therapy (DOT) Collaborative Care Drug Therapy for TB Due to resistance the current four medication first-line (initial phase) regimen includes: Isoniazid (INH) Rifampin (RIF)(Rifadin) Pyrazinamide (PZA) Ethambutol (EMB)(Myambutol) Collaborative Care Drug Therapy for TB If no drug resistance is demonstrated in the cultures after the first 2 months of therapy, four + months of therapy will continue with isoniazid and rifampin (continuation phase) Collaborative Care Medical Management of TB Effective treatment should show negative cultures within 2-3 months of therapy Patient is no longer infectious to others If cultures remain positive, consider drug resistance 2-3 other medications will be added to the regimen Collaborative Care Drug Therapy for TB First-line: Isoniazid (INH) Rifampin Pyrazinamide (PZA) Ethambutol *Vitamin B6 (pyridoxine): prevents isoniazid associated peripheral neuropathy Collaborative Care Drug Therapy for TB Compliance (adherence) issues with patient: combination meds Isoniazid & rifampin (Rifamate) Isoniazid, pyrazinamide, and rifampin (Rifater) Collaborative Care Drug Therapy for TB Second-line Capreomycin, ethionamide, para-aminosalicylate sodium, cycloserine  Collaborative Care Isoniazid (INH) Monitor for hepatotoxicity and neurotoxicity Give Vitamin B6 (pyridoxine) to prevent neurotoxicity Avoid alcohol Take on empty stomach or at least 1 hour before meals because food interferes with medication absorption avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts) result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Notify HCP of changes in vision Collaborative Care Rifampin (Rifadin) Monitor for hepatotoxicity, anemia or thrombocytopenia Inform the patient that urine and other secretions will be orange May interfere with efficacy of oral contraceptives Teach patient to report: yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise Avoid alcohol Collaborative Care Pyrazinamide (Tebrazid) Monitor for hepatotoxicity, anemia or hyperuricemia Drink a glass of water with each dose, increase fluid during the day Teach patient to report: yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately Wear sunscreen or protective clothing to prevent photosensitivity reactions Avoid alcohol Collaborative Care Ethambutol (Myambutol) Obtain baseline visual acuity tests Determine color discrimination ability Teach to report changes in vision immediately Hyperuricemia Collaborative Care Streptomycin Sulfate (Streptomycin) Should be used only in multi-drug resistance TB (MDR-TB) Ototoxicity Monitor renal function studies and urine output (nephrotoxic) Consume at least 2-3L of fluid daily Collaborative Care Medication Management Monitor during medication therapy LFTs, BUN, creatinine, sputum culture, auditory and vision tests  Nursing Assessment / Analyze/Recognize Cues History Patient’s exposure to TB Country of Origin Previous results of TB tests Bacillus Calmette-Guerin (BCG) vaccine given? Nursing Assessment / Analyze/Recognize Cues Clinical Manifestations Temperature Sputum Breath Sounds Oxygen Saturation Nursing Assessment / Analyze/Recognize Cues Clinical Manifestations Symptom free in early stages * Latent TB infection have positive skin test but symptom free Active TB disease Initial: fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, night sweats, cough with white frothy sputum Nursing Assessment / Analyze/Recognize Cues Clinical Manifestations Active TB disease advanced: Rust colored sputum / Hemoptysis HIV-infected patients: atypical physical exam and chest x-ray findings. Classic s/s may be attributed to other HIV-opportunistic infections Nursing Assessment / Analyze Cues Diagnostic Tests Results of: Tuberculin skin test or Interferon-gamma release assay Acid-fast bacilli in sputum Chest x-ray Sputum culture  Nursing Diagnosis / Client Problems Ineffective airway clearance Alteration in gas exchange related to necrosis of lung tissue Alteration in comfort: pain related to pleurisy Ineffective coping related to isolation and long-term therapy Planning / Generate Solutions Goals: Pt will Have functional pulmonary function Comply with therapeutic regimen Have no recurrence of disease Take appropriate measures to prevent the spread of the disease Nursing Implementation / Take Actions 1. Health Promotion 2. Acute Intervention 3. Ambulatory and Home Care Nursing Implementation / Take Actions Health Promotion Selective screening in high risk groups Identify contacts of positive TB patients to be screened and treated if necessary Positive skin test must receive a chest x-ray for further workup Nursing Implementation / Take Actions Acute Intervention Place the patient on __________ precautions Use _________oxygen Ensure adequate _____________ Administer _____________ Nursing Implementation / Take Actions Acute Intervention For patients suspected of having TB: Airborne isolation Start appropriate drug therapy Receive immediate medical workup Nursing Implementation / Take Actions Acute Interventions What do you teach patients on Airborne isolation? Nursing Implementation / Take Actions Acute Interventions Teach patients on isolation: Cough or sneeze into a tissue Use a tissue when sputum is produced from coughing Careful hand-washing after handling sputum or soiled tissues Keep door to room closed Wear a regular surgical mask when leaving room  Nursing Implementation / Take Actions Acute Interventions Promote airway clearance Humidified oxygen Advocating adherence to treatment regimen Administer Antibiotics as Ordered Promote activity and ensure adequate nutrition Nursing Implementation / Take Actions Acute Interventions Teach about TB and prescribed treatment Avoid alcohol or substances which can damage liver Stress importance of skin testing for persons living with infected person Assess support system and personal resources Nursing Implementation / Take Actions Ambulatory and Home Care Educate patient about TB while at home Sputum specimens every 2-4 weeks Avoid inhalants/aerosols Medication adherence Side effects of therapy  Nursing Implementation / Take Actions Ambulatory and Home Care Low cost community clinics for treatment Home care RN Follow-up care at least for one year during treatment Nursing Evaluation References Honan, L. (2024) Medical –Surgical Nursing (3rd ed.) Focus on Clinical Judgement Philadelphia, PA:Wolters Kluwer