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

2. 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

3. 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

4. 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)

5. 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

6. 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

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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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 10mm is positive for immunocompetent individuals

24. 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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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