Focus on Tuberculosis Relates to Chapter 28 Nursing

Focus on Tuberculosis (Relates to Chapter 28, “Nursing Management: Lower Respiratory Problems, ” in the textbook” Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tuberculosis (TB) • Infectious disease caused by Mycobacterium tuberculosis • Most often involves the lungs Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

TB Involves • • Lungs Larynx Kidneys Meninges • Bones • Adrenal glands • Lymph nodes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tuberculosis • Second most common cause of death from infectious disease worldwide • 2 billion of world’s population estimated to be infected (one third of population) Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tuberculosis • Prevalence • 8 to 9 million new cases and 2 million deaths each year • 14, 000 new cases in the United States per year Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tuberculosis • Resurgence • High rates of TB with HIV infection • Multidrug-resistant strains of M. tuberculosis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Tuberculosis • Disproportionate in • Poor • Underserved • Minorities • Other risk factors Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Spread via airborne droplets when infected person • • Coughs Speaks Sneezes Sings Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Spread • Not by hands or objects • Brief exposure rarely causes infection • Transmission usually requires close, frequent, or prolonged exposure Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Spread • Inhaled bacilli pass down bronchial system and implant themselves on bronchioles or alveoli • Multiply with no initial resistance • Replicates slowly and spreads via the lymphatic system Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Favorable environments for growth • • • Upper lobes of lungs Kidneys Epiphyses of bone Cerebral cortex Adrenal glands Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • If cellular immune system is activated • Tissue granuloma forms • Contains the bacteria and prevents replication and spread of disease • Most of the time infection remains contained and active disease does not develop Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Without sufficient immune response • Organism is not contained • Active primary disease results • Immunosuppressed and diabetic patients are at higher risk for disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • TB infection • “latent TB infection” (LTBI) • Not a ‘case’of TB • TB disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Etiology and Pathophysiology • Dormant TB organisms persist for years • Few ever develop TB • Reasons for reactivation are not well understood Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Classification • Classes • • • 0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, no disease 3 = TB, not clinically active 4 = TB suspected Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Clinical Manifestations • Fatigue • Malaise • Anorexia • Weight loss • Low-grade fevers • Night sweats • LTBI - asymptomatic Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Clinical Manifestations • Cough becomes frequent • Produces white, frothy sputum • Hemoptysis is not common and is usually associated with advanced disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Clinical Manifestations • Acute symptoms (generalized flu symptoms) • • High fever Chills Pleuritic pain Productive cough Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications • Miliary TB • Large numbers of organisms invade the bloodstream and spread to all organs • Acute or chronic symptoms Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications • Pleural effusion and empyema • Caused by bacteria in pleural space • Inflammatory reaction with plural exudates of protein-rich fluid • TB pneumonia • Large amounts of bacilli discharging from granulomas into lung or lymph nodes Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Complications • Other organ involvement • • • CNS—meninges Bone and joint tissue Kidneys Adrenal glands Lymph nodes Genital tracts Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Skin testing • Intradermal administration of tuberculin (Mantoux - PPD) • Induration at injection site indicates exposure • Sensitivity remains for life and individual should not be tested again • 10 mm is positive for immunocompetent individuals Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Skin testing • Response ↓ in immunocompromised patients • Reactions ≥ 5 mm considered positive Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Chest x-ray • Cannot make diagnosis solely on x-ray • Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Bacteriologic studies • Stained sputum smears examined for acid-fast bacilli • Required for diagnosis Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Bacteriologic studies • On different days three consecutive sputum samples are collected from • Gastric washings • CSF • Fluid from an abscess or effusion Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Diagnostic Studies • Quanti. FERON-TB (QFT) • New test • Rapid blood test (few hours) • Does not replace cultures Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Collaborative Care • Hospitalization not necessary for most patients • Drug therapy used to prevent or treat active disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • Active disease • Four drugs are used in initial phase for maximum effectiveness • Treatment is aggressive to combat resistant strains of TB Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • First-Line Drugs (table 28 -9) • • • Isoniazid (INH) Rifampin Ethambutol Rifabutin Pyranzinamide Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • Directly observed therapy (DOT) • Noncompliance is major factor in multidrug resistance and treatment failures • Requires watching patient swallow drugs • Preferred to ensure adherence Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • Active disease • Patients should be taught about side effects and when to seek medical attention • Liver function • Renal function • Vision screening Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • Latent TB infection • Individual is infected with M. tuberculosis, but is not acutely ill • Usually treated with INH for 6 to 9 months • HIV patients should take INH for 9 months Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Drug Therapy • Vaccine • Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world • Efficacy not clear • Results in positive PPD reaction Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Assessment • Assess for • • • Productive cough Night sweats Afternoon temperature elevation Weight loss Respiratory status Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Diagnoses • Ineffective breathing pattern • Imbalanced nutrition: Less than body requirements • Noncompliance • Ineffective health maintenance • Activity intolerance Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Planning • Goals • • Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation • Ultimate goal in the United States is eradication • Selective screening programs in high-risk groups to detect TB • Identify contacts of patient with TB Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation • Acute intervention • Airborne isolation • Until patient is considered noninfectious • 3 negative smears • HEPA mask • Appropriate drug therapy • Immediate medical workup Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation • Teach patient • Cover nose and mouth with tissue when coughing, sneezing, or producing sputum • Hand washing after handling sputum-soiled tissues • Drug education Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Nursing Implementation • Ambulatory and home care • Ensure patient can adhere to treatment • Teach symptoms of recurrence Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Evaluation • Expected outcomes • • Complete resolution of disease Normal pulmonary function Absence of any complications No transmission of TB Copyright © 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.