Focus on Tuberculosis

Tuberculosis (TB) Infectious disease caused by Mycobacterium tuberculosis

TB Involves Lungs Larynx Kidneys Meninges Bones Adrenal glands Lymph nodes

Tuberculosis Second most common cause of death from infectious disease 2 billion of world’s population estimated to be infected (one third of population)

Tuberculosis Prevalence 8 to 9 million new cases and 2 million deaths each year 14,000 new cases in the United States per year

Tuberculosis Resurgence High rates of TB with HIV infection Multidrug-resistant strains of M. tuberculosis

Tuberculosis Disproportionate in Poor Underserved Minorities

Etiology and Pathophysiology Spread via airborne droplets when infected person Coughs Speaks Sneezes Sings

Etiology and Pathophysiology Spread Not by hands or objects Brief exposure rarely causes infection Transmission requires close, frequent, or prolonged exposure

Etiology and Pathophysiology Spread Inhaled bacilli pass down bronchial system and implant themselves on bronchioles or alveoli Multiply with no initial resistance

Etiology and Pathophysiology Replicates slowly and spreads via the lymphatic system

Etiology and Pathophysiology Favorable environments for growth Upper lobes of lungs Kidneys Epiphyses of bone Cerebral cortex Adrenal glands

Etiology and Pathophysiology If cellular immune system is activated Tissue granuloma forms Contains the bacteria and prevents replication and spread of disease

Etiology and Pathophysiology Without sufficient immune response Organism is not maintained Active primary disease results Immunosuppressed and diabetic patients are at higher risk for disease

Etiology and Pathophysiology Dormant TB organisms persist for years Few ever develop TB Reasons for reactivation are not well understood

Classification Classes 0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, no disease 3 = TB, not clinically active 4 = TB suspected

Clinical Manifestations Early stages are usually free of symptoms

Clinical Manifestations Fatigue Malaise Anorexia Weight loss Low-grade fevers Night sweats

Clinical Manifestations Cough becomes frequent Produces white, frothy sputum Hemoptysis is not common and is usually associated with advanced disease

Clinical Manifestations Acute symptoms (generalized flu symptoms) High fever Chills Pleuritic pain Productive cough

Complications Miliary TB Large numbers of organisms invade the bloodstream and spread to all organs Acute or chronic symptoms

Complications Pleural effusion and empyema Caused by bacteria in pleural space Inflammatory reaction with plural exudates of protein-rich fluid

Complications TB pneumonia Large amounts of bacilli discharging from granulomas into lung or lymph nodes

Complications TB pneumonia manifestations Fever Chills Productive cough Pleuritic pain Leukocytosis

Complications Other organ involvement CNS—meninges Bone and joint tissue Kidneys

Complications Other organ involvement Adrenal glands Lymph nodes Genital tracts

Diagnostic Studies Skin testing Intradermal administration of tuberculin Induration at injection site indicates exposure Sensitivity remains for life and individual should not be tested again

Diagnostic Studies Skin testing Response ↓ in immunocompromised patients Reactions ≥ 5 mm considered positive

Diagnostic Studies Skin testing Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens

Diagnostic Studies Chest x-ray Cannot make diagnosis solely on x-ray Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB

Diagnostic Studies Bacteriologic studies Stained sputum smears examined for acid-fast bacilli Required for diagnosis

Diagnostic Studies Bacteriologic studies On different days three consecutive sputum samples are collected from Gastric washings CSF Fluid from an abscess or effusion

Diagnostic Studies QuantiFERON-TB (QFT) New test Rapid blood test (few hours) Does not replace cultures

Collaborative Care Hospitalization not necessary for most patients Drug therapy used to prevent or treat active disease

Drug Therapy Active disease Four drugs are used in initial phase for maximum effectiveness Treatment is aggressive to combat resistant strains of TB

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

Drug Therapy Active disease Patients should be taught about side effects and when to seek medical attention Liver function should be monitored

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

Drug Therapy Vaccine Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world Efficacy not clear Can result in positive PPD reaction

Nursing Assessment Assess for Productive cough Night sweats Afternoon temperature elevation Weight loss

Nursing Diagnoses Ineffective breathing pattern Imbalanced nutrition: Less than body requirements Noncompliance

Nursing Diagnoses Ineffective health maintenance Activity intolerance

Planning Goals Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease

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

Nursing Implementation Acute intervention Airborne isolation Appropriate drug therapy Immediate medical workup

Nursing Implementation Teach patient Cover nose and mouth with tissue when coughing, sneezing, or producing sputum Hand washing after handling sputum-soiled tissues

Nursing Implementation Ambulatory and home care Ensure patient can adhere to treatment Teach symptoms of recurrence

Evaluation Expected outcomes Complete resolution of disease Normal pulmonary function Absence of any complications No transmission of TB