Download Core Curriculum Slides - Austin Community College

Tuberculosis
Causative Organism
Mycobacterium
Tuberculosis
Gram-positive, acid-fast bacillus
(AFB)
Etiology and Pathophysiology
 Brief exposure rarely causes infection
 Transmission requires close, frequent, or
prolonged exposure
 Inhaled bacilli pass down and lodge in the
alveoli
 Replicates slowly and spreads via the lymphatic
system
 Body immune system responds by initiating the
inflammatory response.
Transmission of Tuberculosis
 How is Tuberculosis transmitted?
Transmission of Disease
 Spread via airborne droplets when infected
person
 Coughs
 Speaks
 Sneezes
 Sings
Ask Yourself?
Can the disease be spread by:
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Hands
Books
Glasses
Dishes
Clothing
Bedding
Individuals at Risk
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Poor, underserved
Homeless persons
Residents of inner-city neighborhoods
Foreign-born person
Older adults
Those in institutions (long-term care facilities, prisons)
Injection drug users
Immunosuppressed
Asian, native Hawaiian have highest reported cases
Classification System for TB
Class
Type
Description
0
No TB exposure
Not infected
No history of exposure
Negative reaction to tuberculin skin test
1
TB exposure
No evidence of infection
History of exposure
Negative reaction to tuberculin skin test
2
TB infection
No disease
Positive reaction to tuberculin skin test
Negative bacteriologic studies (if done)
No clinical, bacteriological, or radiographic
evidence of active TB
3
TB, clinically active
M. tuberculosis cultured (if done)
Clinical, bacteriological, or radiographic
evidence of current disease
4
TB
Not clinically active
History of episode(s) of TB
or
Abnormal but stable radiographic findings
Positive reaction to the tuberculin skin test
Negative bacteriologic studies (if done)
and
No clinical or radiographic evidence of
current disease
5
TB suspected
Diagnosis pending
What can trigger
reactivation of latent
TB infection (LTBI)
Answer:
Host’s defenses become impaired
Which of the following
are Signs and Symptoms?
Select all that apply
a. Fatigue
b. Non-productive cough
c. Weight loss
d. Sudden onset of high fever >1020
e. Night sweats
f. Anorexia
g. Decreased movement of chest wall
Signs and Symptoms
Cough becomes frequent
Produces white, frothy sputum
Hemoptysis is not common and is
usually associated with advanced
disease
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
TB Skin Test (Mantoux)
Uses purified protein derivative (PPD)
intradermal
Administering the Tuberculin Skin Test
• Inject intradermally
• 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
Reading the Tuberculin Skin Test
 Read reaction 48-72 hours after
injection
 Measure only induration
 Record reaction in millimeters
 Positive reaction
=> 5 mm induration – high risk persons
=> 10 mm induration – moderate risk persons
=> 15 mm induration – low risk persons
Means that the person has been exposed to Tb and
developed antibodies, does not differentiate between
active and dormant Tb infection.
Factors that May Affect the
Skin Test Reaction
Type of Reaction
Possible Cause
False-positive
Nontuberculous mycobacteria
BCG vaccination
Anergy
False-negative
Recent TB infection
Very young age (< 6 months old)
Live-virus vaccination
Overwhelming TB disease
 If a person has other symptoms and has a
negative skin test, then the HCP would
likely order a __________ ________?
Chest X-Ray
•
Does this chest x-ray confirm
the diagnosis of Tb?
•
Abnormalities often seen in apical
or posterior segments of upper
lobe or superior segments of
lower lobe
Arrow points to cavity in
patient's right upper lobe.
Bacteriologic Studies
 Sputum for AFB
AFB (shown in
red) are tubercle
bacilli
 QuantiFERON-TB
 Blood is obtained from patient and placed in container with
mycobacterial antigens. If the patient is infected with TB, the
lympocytes in the blood will recognize these antigens and
secrete interferon, a cytokine produced by lymphocytes. Test
results are available in a few hours.
Sputum 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
Goals of Nursing Care
 Goals:
 Comply with therapeutic regimen
 Have no recurrence of disease
 Have normal pulmonary function
 Take appropriate measures to prevent
spread of disease
Four Drug Regimen
 isoniazid [INH]
 rifampin [Rifadin]
 pyrazinamide [PZA]
 ethambutol
Drug Therapy
 Active disease
 Patients should be taught about side
effects and when to seek medical
attention
 Liver function should be monitored
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, pruritus)
Take on empty stomach
Avoid foods that contain tyramine
and histamine (tuna, aged cheese,
red wine, soy sauce, yeast extracts)
Check liver enzymes, BUN,
Creatinine levels monthly
Rifampin (Rifadin) GI disturbances
Orange discoloration of body fluids
(sputum, urine, sweat, tears)
Inform patient about orange
discoloration of fluids/ urine
Discolor contact lenses
 Metabolism of other meds and
makes them ineffective such as
cardiac meds and steroids.
Drug
Side effects
Nursing Implications
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,
pruritus)
Monitor uric acid levels
Have newer drugs with combinations of these
Treatment Guidelines
 Initiation Phase of Treatment
 Multiple-medication regimen of all 4 meds
 Administered daily for 8 weeks
 Continuation Phase of Treatment
 d/c ethambutol and continue other 3 meds
 Administered for 4-7 months
 Patient begins to feel better in this phase
Drug Therapy
 Latent TB infection
 Individual is infected with
M. tuberculosis, but
does not have the disease. Usually has been
exposed to someone with tuberculosis.
 Usually treated with INH for 6 to 9 months
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?
What is the appropriate response?
Answer this
How would the nurse assess
if the patient has been
compliant with taking their
medications?
Direct Observation Therapy
 Used with those patients 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 patient and watch patient
swallow drugs
 Costly, but preferred to ensure adherence
 If refuses DOT then may have to put involuntarily in
treatment facility to protect the community.
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 Interventions
 What type of isolation is typically ordered?
 What PPE is worn? Who wears this equipment?
 What type of room are they in?
 Patient Teaching
 Cover nose and mouth with tissue when
coughing, sneezing, or producing sputum
 Hand washing after handling sputum-soiled
tissues
 Ambulatory and home care
Fungal Infections - Who is at Risk
 Seriously ill patients being treated with
 Corticosteroids
 Antineoplastic drugs
 Immunosuppressive drugs
 Patients with AIDS
 Patients with Cystic Fibrosis
Fungal Infections
 Histoplasmosis
 Pneumocystis pneumonia
 Cocciidiodomycosis
 Nocardiosis
 Blastomycosis
 Actinomycosis
 Cryptococcosis
 Aspreigillosis
 Candidiasis
Diagnosis
Skin
Serology
Biopsy
Drug therapy
Amphotericin B
 Intravenous
 Side effects
Hypersensitivity reactions
 Fever and chills
 Malaise
 Nausea and vomiting
 Thrombophlebitis at injection site
 Pre-medicate with Benadryl to increase tolerance and
decrease hypersensitivity
 Monitor renal function
 Ensure adequate hydration

Drug Therapy
 Oral Antifungal agents
 ketoconazole (Nizoral)
 fluconazole (Sporanox; Difulcan)
 Flucytosine (Anobon)
 Monitor effectiveness with serology testing
 Side Effects
 N/V
  liver enzymes
 Bone marrow depression – monitor WBC, platelets
Lung Abscess
Pus-containing lesion of the lung
Formed by necrosis of lung tissue
Lung Abscess
 Causes
 Aspiration of material from GI tract into
lungs
 Lung cancer
 Tuberculosis
Signs and Symptoms
 Productive cough of purulent foul smelling
and foul tasting sputum
 Fever and chills
 Pleuritic pain
 Dyspnea
 Weight loss
Diagnosis
 Sputum cultures – obtained first so can confirm
treatment modalities
 Chest x-ray
 Bronchoscopy
Treatment and Nursing Care
Drug Therapy- Antibiotics
 Penicillin
 Clindamycin
**Large doses of IV are required because the
antibiotic must penetrate the necrotic tissue and
fluid in the abscess.
**May need to make home health referral for IV to
be given at home
 Antipyretics
 Chest physiotherapy and postural drainage
Treatment and Nursing Care
Drug Therapy
 Increase fluid intake
 Rest
 Good nutrition
Nursing Care
 How do you know if the treatment is
effective?