Med-Surg: Chapter 24: Tuberculosis Flashcards
What is Tuberculosis (TB)
life-threatening respiratory infection caused by the organism Mycobacterium tuberculosis
- can affect any body system if not treated promptly
- highly contagious
Who is at risk?
- populations living outside the U.S.
- low socioeconomic groups
- homeless
- incarcerated populations
- persons infected with HIV or who have AIDS
How is TB transmitted?
aerosolized droplets inhaled from the coughing or sneezing of an infected individual
- droplets of M. tuberculosis are tiny and can remain suspended in the air for several hours
- those whose sputum is infected with active TB are most likely to transmit the infection
- droplets dry quickly and can remain suspended in the air for hours
- if not isolated immediately, TB can spread
Tuberculosis Classifications
- Latent Tuberculosis Infection (LTBI)
- Primary Tuberculosis Infection (PTBI)
- Primary Progressive TB Infection (PPRBI)
- Drug-resistant M. tuberculosis (MDR TB)
Latent Tuberculosis Infection (LTBI)
- classic sign: calcified granuloma evident on chest x-
- the inactive bacilli remain dormant within the healed granuloma (bacteria lie dormant within calcified granuloma that can be see on chest x-ray)
- have no symptoms, usually asymptomatic
- not contagious
- as long as immune system remains intact, the bacilli remain in the healed tissue of the granuloma for the individuals lifetime and do not progress to TB infection
- disease reactivated if immune system becomes compromised; HIV infection, long-term diabetes, chronic renal disease, long-term steroid administration, sepsis, malnutrition
Primary Tuberculosis Infection (PTBI)
granuloma formation is initiated but is unable to progress to calcification leading to PTBI
- individuals with a weakened immune response are unable to control the multiplication of Mycobacterium
- asymptomatic
- confirmed by positive sputum cultures and positive skin test
- not infectious
Primary Progressive TB Infection (PPTBI)
aka symptomatic TB infection
- nonspecific symptoms: fatigue, weight loss, and night sweats
- cough with rusty-colored or blood streaked sputum
- as disease progresses, dyspnea, orthopnea (SOB when lying flat), and rales evident
Drug-resistant Mycobacterium Tuberculosis (MDR TB)
can be mono-drug or poly-drug resistant (one or more of the first-line medications used for treatment of TB are not effective)
- caused by primary or secondary means
- Primary resistance: caused by person-to-person transmission
- Secondary (acquired): develops during treatment and results from an ineffective treatment regimen or incomplete treatment regimen
How is Diagnosing Done?
- laboratory testing
- skin test
- chest x-ray
Diagnosing: Laboratory Testing
-Sputum test for culture and acid-fast staining
Diagnosing: Chest x-ray
suspicious cavitating lesions (resulting from pathologic processes leading to necrosis and formation of a “gas-filled” space within the lung tissue) are seen on chest x-rays
Diagnosing: Skin Test
Mantoux Test
- positive purified protein derivative (PPD)
- standard method
- injection of 01. mL of PPD intradermally into forearm; within 48 to 72 hours after injection, administration site should be observed for a reaction
Goals of Treatment of TB
- cure the patient
- minimize the transmission of M. tuberculosis to other persons
Treatment: Medications
four-drug combination: Antibiotics -isoniazid (INH) -rifampin (RIF) -ethambutol (EMB) -pyrazinamide (PZA) >treatment should continue for 9 to 12 months
The person with TB should be placed on what, when admitted to the hospital?
airborne isolation precautions
-immediate isolation of the patient with suspected or confirmed TB infection in a private room with negative airflow capabilities is a priority
Airborne Precautions
- use of a N95 mask respirator for healthcare personnel (requires fit-testing)
- snug-fitting surgical mask for visitors
- patient’s movement and transportation to other departments should be limited to essential needs only
- if leaving the negative-pressure room, patient must wear a surgical mask
Complications of TB
> extensive respiratory tissue destruction by M. tuberculosis can lead to:
- Respiratory failure
- Bronchopleural fistula formation (abnormal pathway or sinus tract that develops between the bronchus and pleural space)
- Pleural effusions (collections of fluid in pleural space)
> untreated active TB can spread to parts of the body outside the respiratory system via the bloodstream and lymph circulation
-extrapulmonary TB can present as meningitis, lymphadenopathy, bone disease, and liver and kidney failure
Clinical Manifestations of TB
-unexplained weight loss
-night sweats
-fever
-chills
(seen as a result of the inflammatory response to Mycobacterium)
-Rusty-colored sputum (result of destruction of lung tissue during granuloma formation)
-Collection of WBCs presents in an attempt to wall off infection, resulting in production of sputum
-Pleuritic chest pain r/t chronic coughing
Nursing Assessments
> Oxygen Saturation
-decreased O2 Sat occurs with destruction of lung tissue, lessening the available surface area for air exchange
> Temperature
-fever is a result from inflammatory process
> Sputum
-blood-tinged or rusty-colored sputum is present as a result of the destruction of lung parenchyma tissue
> Breath Sounds
-wheezing from irritated airways; rales/rhonchi from fluid/exudates
When dealing with the medications modifications may be necessary in what special circumtances?
- HIV +
- pregnancy
- drug resistance
- in children
Nursing Actions
> Humidified O2
-helps ensure adequate oxygen delivery to the tissues and maintains integrity of the mucous membranes
> Institute airborne isolation
-TB is extremely contagious; care must be taken to avoid transmission to other individuals, especially ones with increased risk for infection
> Administer antibiotics as ordered
-antibiotics are the definitive treatment for TB and are essential in controlling the spread of the disease
> Adequate Nutrition
-adequate caloric intake to maintain optimal body weight for recovery (symptom of TB report of weight loss)
Teachings
> Stress importance of skin/blood testing for individuals living with or exposed to the infected person
- helps monitor the spread of TB and ensures prompt treatment if necessary
- TB is a reportable disease and is tracked by local, state, and federal health authorities; healthcare providers are obligated to notify local health departments of an identified TB infection so that an investigation of contacts can be initiated and any positive TB infections can be identified and treated
> Complete all medications
-incomplete treatment or interruptions can cause the emergence of drug-resistant forms of the bacterium
> Assess patient support systems and community resources that will ensure successful adherence to the treatment plan after discharge
Evaluating Care Outcomes
successful treatment of TB requires early detection and a comprehensive, interprofessional structure that addresses the clinical, psychosocial, environmental, and financial issues
-b/c of long-treatment period, patients need to be encouraged to follow the prescribed plan of care after discharge
> resolving TB:
- ability of the patient to gain and maintain a stable body weight
- improved skin turgor and muscle tone
- absence of cough and sputum production
- even and unlabored breathing
- cessation of fevers and night sweats
Medication: Isoniazid
others: Pyrazinamide, Ethambutol
antimycobacterial (selective anti-tuberculosis)
- highly specific for mycobacteria
- inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall
- for active and latent TB
- orally or IM
- when given IM, warm to room temperature to ensure that solution is free of crystals, and inject deeply into large muscle
- for active TB, direct observation therapy to ensure adherence
> can cause Peripheral Neuropathy: numbness, burning, and pain resulting from deficiency of pyridoxine, vitamin B6
- administer 50 to 200 mg vitamin B6 daily
- prophylactic use of pyridoxine at 25 to 50 mg/day can decrease risk of acquiring peripheral neuropathy
- if peripheral neuropathy develops, can be reversed by administering pyridoxine
- notify provider if manifestations occur
> can cause Hepatotoxicity: anorexia, malaise, fatigue, nausea, and yellowish discoloration of skin and eyes
- monitor liver function tests
- elevated liver function tests can result in the need to d/c the medication
- avoid alcohol
- contact provider if manifestations occur
> can cause Hyperglycemia and decreased glucose control (in patients with diabetes mellitus)
- monitor blood glucose
- clients with diabetes might require additional antidiabetic medication
> isoniazid contraindicated in patients who have liver disease
use cautiously in older adults, those who have diabetes mellitus or alcohol use disorder
isoniazid, pyrazinamide, ethambutol, are pregnancy risk category C
consider using a second form of birth control (condom) if taking a hormonal contraceptive as various antibiotics decrease their effectiveness
take isoniazid 1 hour before meals or 2 hours after meals with a full glass of water
If GI discomfort, take with meals
avoid foods with high levels of tyramine (aged cheeses, cured meats)
