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Tuberculosis
What is
Tuberculosis?
Prevalence
Tuberculosis is a bacterial infection that
causes more deaths in the world than any
other disease.
About 2 billion people are infected with the
bacilli and about 2 million people die
annually.
8 to 9 million deaths occur d/t TB
14,000 new cases in the U.S. each year
Tuberculosis (TB)
Caused by:
Mycobacterium tuberculosis
In the United States:
Rates declining
Incidence decreased with:
Improved sanitation
Surveillance
Treatment of people with active disease
Rates still high in selected populations
The Disease Process:
Chronic and recurrent
Affects the lungs
Can invade any organ
Resurgence of Tuberculosis!!
1980s and 1990s
Causes
HIV AIDS
Multiple drug resistant strains
Social Factors
Immigration
Poverty
Homelessness
Drug Use
Continues to decline
TB-control programs
Initiation and completion of appropriate medications
Worldwide TB
Countries that account for 90% of world cases of
TB
Countries of Asia
Africa
Middle East
Latin America
In Austin, Texas
Large number of immigrants, college students, and
visitors from:
India
Middle East
Latin America
Other Risk Factors for TB
Overcrowded Conditions
Nursing homes, rehabilitation facilities and
hospitals
Homeless shelters
Drug treatment centers and prisons
People with Altered Immune Functions
Older adults
People with AIDS
People on chemotherapy
Spreading the Disease
Mycobacterium tuberculosis
Slow-growing, rod shaped, acid fast bacillus
***Waxy outer capsule which makes it resistant to destruction
Transmission
Infectious person
Coughs, sneezes, sings, or talks
Airborne droplets
Remain suspended in the air for several hours
Susceptible Host
Breaths in microorganism
Normal defenses of the upper respiratory system do not protect.
Ask Yourself?
Can the disease be spread by:
Hands
Books
Glasses
Dishes
Clothing
Bedding
Risk For Infection
Characteristics of the Infected Person
TB is active
How much of the lung is involved
Coughing
Extent of Contamination of the Air
Overcrowded conditions
Air circulation
Susceptibility of the Host
Immuno-compromised
Nutrition
Health
Infection Takes Hold
Minute droplet nuclei inhaled
Upper lobe
Lodges in alveolus or bronchiole
Leads to inflammation
Neutrophils and macrophages isolate seal
off but cannot destroy
Sealed off colony of bacilli (tubercle)
Inside infected tissue dies
Creating a cheese-like center
The Immune Response
Adequate
– Scar tissue encapsulates the bacilli
Inadequate
– Tuberculosis develops
– Extensive lung destruction can occur
– Spread by the blood to other organs
• Genitourinary tract
• Brain (meningitis)
• Skeletal
Common Sites of TB Disease
Lungs – most common
Pleura
Bones and joints
Lymphatic system
Genitourinary systems
Central nervous system
Disseminated (miliary TB)
Tuberculosis Can Spread within
the Body
Tuberculosis Infection
The bacteria is inhaled but the immune system
encapsulates the bacteria preventing it from
becoming active and progressing to a disease.
TB infection that does not have an active case is
not considered a case of TB, but referred to as
latent TB.
TB tubercle usually stays inactive for life, a small
percent converts to active disease
Tuberculosis Disease
• The immune system is not
sufficient to stop the disease so
active bacteria multiply and
cause clinically active disease.
Signs & Symptoms
Fatigue, malaise (late afternoon)
Low grade fever, night sweats
Anorexia, weight loss
Hemoptysis
Frequent productive cough
mucoid or mucopurulent
Tight, dull chest
Joint pain
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
Skin Testing
Tuberculin Skin Test (Mantoux)
positive test does not signify active disease
0.1 ml PPD intradermally
Read in 48-72 hours
Administering the Tuberculin Skin Test
Inject intradermally 0.1 ml of 5
TU PPD tuberculin
Produce wheal 6 mm to 10 mm
in diameter
Do not recap, bend, or break
needles, or remove needles from syringes
Follow universal precautions for infection control
Results
• Measure induration
– Positive 10 mm
– Possible 5-9 mm
– Negative 0-4
• Repeat x2 or x3 if any clinical signs
25% false negative
Diagnosing
• Skin test positive 3-12 weeks after
exposure
• Chest x-ray
• Sputum - Acid Fast Bacillus (AFB)
– Smear not definitive
– Culture is only definitive diagnosis
• May need up to 8 weeks to grow
Chest X-Ray
•
Abnormalities often seen in apical
or posterior segments of upper
lobe or superior segments of
lower lobe
•
May have unusual appearance in
HIV-positive persons
Arrow points to cavity in
patient's right upper lobe.
•
Cannot confirm diagnosis of TB
Cultures
Use to confirm diagnosis of TB
•
Culture all specimens, even if smear negative
•
Results in 4 to 14 days when liquid medium
systems used
Colonies of M. tuberculosis growing on media
Newly converted to positive
PPD
• Isoniazid 300 mg X 6-9 months
prophylactive prevents active Tb
Drug Therapy
• Active disease
– Patients should be taught about side effects and
when to seek medical attention (see Lewis p.573)
– Liver function should be monitored
• Latent TB infection
– Individual is infected with M. tuberculosis, but is not
acutely ill
– Usually treated with INH for 6 to 9 months
– Patients with HIV should take INH for 9 months
Medications
• Newly diagnosed clients with active disease
typical treated with four medications
– isoniazid (INH) oral 300 mg daily or 900 mg twice a
week.
– rifampin oral 600 mg daily or twice a week
– pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G per
day or 30 to 70 mg/kg once a week
• minimum 9 months
• take in AM
• 90% have negative sputum in 3 months
– ethambutal oral 15 mg/kg daily
• Other medications
– rifabutin
– rifapentine
Drug
Isoniazid (INH)
Side effects
Noninfections hepatitis
Peripheral neuropathy
Hypersensitivity
Nursing Implications
Give B6 pyridoxine as
prophylactic against
peripheral neuropathy
Assess for S&S of
hepatitis (jaundice, yellow
skin, dark urine, clay
colored stools, pruritis)
Rifampin (Rifadin)
GI disturbances
Orange discoloration of
body fluids (sputum, urine,
Inform patient about
orange discoloration of
fluids/ urine
sweat, tears)
Ethambutol
Retrobulbar neuritis
(decreased red-green color
discrimination)
Get a baseline Snellen
vision test and color
discrimination and
monthly when on high
doses
Pyrazinamide
(PZA)
Hepatoxicity, polyarthritis,
Skin rash, hyperuricemia
Assess for S&S of
hepatitis (jaundice, yellow
skin, dark urine, clay
colored stools, pruritis)
Isoniazid
•
•
•
•
Most effective TB drug
Take in AM with food
Continue until sputum negative 6 months
Adverse Effects:
– peripheral neuropathy
– hepatitis
• Monitor
– Liver Functions Studies (AST and ALT)
– Avoid hepatotoxins (ETOH, acetaminophen)
Rifampin
• Take on empty stomach
• Monitor liver function tests
• Can cause:
– Hepatitis
– Suppression of oral contraceptives
– Do not stop medication
• Will cause flu-like syndrome and fever when resumed
• Colors body fluids
– Sweat urine saliva tears: turn orange-red
Pyrazinamide
• Increase fluids
• Take with food
• Adverse Effects
– Hepatotoxicity
– Hyperuricemia
• Monitor
– Uric acid levels
– AST and ALT
– Avoid hepatotoxins (ETOH; Tylenol)
Ethambutol
• Protect from light
• Adverse effects: retrobulbar neuritis, skin
rash, reversible with discontinuation of the
drug
• Monitor color vision and acuity
Symptoms of Liver Toxicity
loss of appetite
N/V
dark urine
jaundice
malaise
unexplained elevated temperature for
longer than 3 days
abdominal tenderness
Close Monitoring While Taking
Antituberculosis Medications
Monitor liver functions
Regular office visits
Check for compliance
Rifampin
Check color of urine
INH
Check urine for metabolites
Give medication
Twice week in the office if compliance is a problem
Monitoring Response to Treatment
Monitor patients bacteriologically monthly until
cultures convert to negative
After 3 months of therapy, if cultures are positive
or symptoms do not resolve, reevaluate for
Potential drug-resistant disease
Nonadherence to drug regimen
If cultures do not convert to negative despite 3
months of therapy, consider initiating DOT
Monitoring Response to
Treatment
• The patient asks how long
before he can be considered
non-contagious?
• Answer:
The patient is considered
infectious until three sputum smears are
negative for acid-fast bacilli.
When can a TB patient be
considered noninfectious?
When they meet all three criteria (CDC)
• Received adequate TB treatment for a
minimum of two weeks
• Symptoms have improved
• Has three consecutive negative sputum
smears from sputum collected in an 8-24
hr interval (one being early morning
specimen)
Answer this
How would the nurse assess if
the patient has been
compliant with taking their medications?
Urine would be orange
Cultures would be negative for
AFB
Drug Therapy
Directly observed therapy (DOT)
– Used with those clients who are noncompliant
and do not show signs of improvement after
treatment. Noncompliance is major factor in
multidrug resistance and treatment failures
– Provide drugs directly to the client and watch
client swallow drugs
– Costly, but preferred to ensure adherence
Drug Therapy
Vaccine
– Bacille Calmette-Guérin (BCG) vaccine to
prevent TB is currently in use in many parts of
the world
- once person receives this vaccine, will have a false
testing with the TST (TB Skin Test). For assessment,
must have chest x-ray.
Nursing Diagnosis labels
appropriate for the client with
tuberculosis
Ineffective airway clearance
Impaired gas exchange
Nutrition, less than body requirements
Activity intolerance
Risk for noncompliance
Knowledge deficit
Ineffective health maintenance
Nursing Assessment
• Assess for:
– Productive cough
– Night sweats
– Afternoon temperature elevation
– Weight loss
Isolation
• negative flow room
• vent to outside
• masks, not ordinary
– molded to fit face
– patient wears a standard mask when outside
room
• ultraviolet light
General Teaching
•
•
•
•
cover mouth and nose to cough
dispose of tissues
hand washing
take meds as prescribed
– 35% noncompliant
• monitor side effects
Criteria for Patient to return
home (CDC)
• Follow up plan with local TB program
• Patient on treatment with DOT arranged
• No infants or children under 4 years old or
persons with immunocompromised
condition at home
• All household members have already been
exposed
• Pt willing to not travel outside home until
sputum smear are (-)
Patient returning home
Should be instructed to:
• Cover mouth and nose with tissues when
coughing or sneezing
• Sleep alone
• No visitors until non-infectious
Chronic Management
•
•
•
•
Follow up in 12 months
5% recurrence, relapse
Test frequent contacts
Factors which can cause relapse
– immunosuppression
– HIV/AIDS
– prolonged debilitating illness
Compliance
•
•
•
•
•
Therapeutic, consistent relationship
Understand lifestyle flexibility
Education
Reassurance, reduce social stigma
Take meds at clinic
The End