1. Tuberculosis
Chapter 28
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

2. Tuberculosis (TB)
Infectious disease caused by Mycobacterium tuberculosis
Lungs most commonly infected
Primary cause of death worldwide
Leading cause of death in patients with HIV/AIDs
Greater than 2 billion people infected worldwide
Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis.
It usually involves the lungs, but any organ can be infected.
TB is a primary cause of death worldwide from a potentially curable infectious disease.
It is the leading cause of mortality in patients with HIV/acquired immunodeficiency syndrome (AIDS).
The incidence of TB worldwide declined until the mid-1980s when HIV disease emerged. The major factors that contributed to the resurgence of TB were (1) high rates of TB among patients with HIV infection and (2) the emergence of multidrug-resistant (MDR) strains of M. tuberculosis.
Worldwide, more than two billion people (one third of the population) are currently infected with TB.
Although the prevalence of TB has increased in Europe, in the United States it has steadily declined since reaching a resurgence peak in 1992.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

3. Case Study
iStockphoto/Thinkstock
S.C. is a 57-year-old Chinese man who was transported from a homeless shelter for having respiratory symptoms.
He has a history of IV drug use and is HIV positive.
He has been coughing regularly and producing mucopurulent sputum.
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4. Case Study What risk factors does S.C. have for TB?
iStockphoto/Thinkstock
What risk factors does S.C. have for TB?
What diagnostic tests would you expect the HCP to order for S.C.?
Homeless, IV-drug user, resident of shelter, poverty, Asian descent, immunosuppression (HIV)
Tuberculin skin-test (TST), interferon-γ release assay (IGRA), chest x-ray, sputum c&s, sputum for AFB
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5. Risk Factors Homeless Residents of inner-city neighborhoods
Foreign-born persons
Living or working in institutions (includes health care workers)
IV injecting drug users
Poverty, poor access to health care
Immunosuppression
Asian descent
TB occurs disproportionately in the poor, the underserved, and minorities.
In the United States, persons at risk include the homeless, residents of inner-city neighborhoods, foreign-born persons, those living or working in institutions (long-term care facilities, prisons, shelters, hospitals), IV injecting drug users, persons at poverty level, and those with poor access to health care.
Immunosuppression from any etiology (e.g., HIV infection, malignancy, long-term corticosteroid use) increases the risk of active TB infection.
The prevalence of TB in the United States is highest in those of Asian descent.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

6. Multidrug-Resistant Tuberculosis (MDR-TB)
Occurs when a strain develops resistance to two of the most potent first-line anti-TB drugs
Extensively drug-resistant TB (XDR-TB) resistant to any fluoroquinolone plus any injectable antibiotic
Several causes for resistance occur.
Once a strain of M. tuberculosis develops resistance to two of the most potent first-line antituberculosis drugs (e.g., isoniazid [INH], rifampin [Rifadin]), it is defined as multidrug-resistant tuberculosis (MDR-TB).
Extensively drug-resistant TB (XDR-TB) occurs when the organism is also resistant to any of the fluoroquinolones plus any injectable antibiotic agent.
Resistance results from several problems, including incorrect prescribing, lack of public health case management, and patient nonadherence to the prescribed regimen.
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7. Etiology and Pathophysiology
Spread via airborne droplets
Can be suspended in air for minutes to hours
Transmission requires close, frequent, or prolonged exposure.
NOT spread by touching, sharing food utensils, kissing, or other physical contact
M. tuberculosis is a gram-positive, acid-fast bacillus that is usually spread from person to person via airborne droplets produced by breathing, talking, singing, sneezing, and coughing.
A process of evaporation leaves small droplet nuclei, 1 to 5 μm in size. These droplets contain M. tuberculosis.
Because they are so small, the particles remain suspended in the air for minutes to hours and are transmitted via inhalation to another person.
TB is not highly infectious, and transmission usually requires close, frequent, or prolonged exposure.
Brief exposure to a few tubercle bacilli rarely causes an infection. Factors that influence the likelihood of transmission include the (1) number of organisms expelled into the air, (2) concentration of organisms (small spaces with limited ventilation would mean higher concentration), (3) length of time of exposure, and (4) immune system of the exposed person.
The disease cannot be spread by touching, sharing food utensils, kissing, or any other type of physical contact.
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8. Etiology and Pathophysiology
Once inhaled, particles lodge in bronchiole and alveolus.
Local inflammatory reaction occurs.
Ghon focus – develops into granuloma
Infection walled off and further spread stopped
Only 5-10% will develop active TB.
Once inhaled, these small particles lodge in the bronchiole and alveolus.
A local inflammatory reaction occurs, and the focus of infection is established. This is called the Ghon focus, which develops into a granuloma, the hallmark of TB.
The formation of a granuloma is a defense mechanism aimed at walling off the infection and preventing further spread. Replication of the bacillus is inhibited, and the infection is stopped.
Seventy percent of immunocompetent adults infected with TB are able to completely kill the mycobacteria.
The remainder will contain the mycobacteria in a nonreplicating dormant state.
Of these individuals, 5-10% will go on to develop active TB infection when the bacteria begin to multiply months or years later.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

9. Etiology and Pathophysiology
Aerophilic (oxygen-loving) – causes affinity for lungs
Infection can spread via lymphatics and grow in other organs as well:
Kidneys
Bones
Brain
Adrenal glands
M. tuberculosis is aerophilic (oxygen-loving) and thus has an affinity for the lungs.
However, the infection can spread via the lymphatic system and find favorable environments for growth in other organs, including the kidneys, epiphyses of the bone, cerebral cortex, and adrenal glands.
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10. Classification Classes 0 = No TB exposure 1 = Exposure, no infection
2 = Latent TB, no disease
3 = TB, clinically active
4 = TB, not clinically active
5 = TB suspected
Several systems can be used to classify TB. The American Thoracic Society classifies TB based on development of the disease:
Class 0
No TB exposure, not infected (no history of exposure, negative tuberculin skin test)
Class 1
TB exposure, no evidence of infection (history of exposure, negative tuberculin skin test)
Class 2
Latent TB infection –
TB infection without disease (significant reaction to tuberculin skin test, negative bacteriologic studies, no x-ray findings compatible with TB, no clinical evidence of TB)
Class 3
TB infection with clinically active disease (positive bacteriologic studies or both a significant reaction to tuberculin skin test and clinical or x-ray evidence of current disease)
Class 4
TB, but not clinically active
No current disease (history of previous episode of TB or abnormal, stable x-ray findings in a person with a significant reaction to tuberculin skin test; negative bacteriologic studies if done; no clinical or x-ray evidence of current disease)
Class 5
TB suspect (diagnosis pending); person should not be in this classification for more than 3 months
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11. Classification Primary infection Latent TB infection (LTBI)
When bacteria are inhaled
Latent TB infection (LTBI)
Infected but no active disease
Active TB disease
Primary TB
Reactivation TB (post-primary)
TB can also be classified according to its presentation – primary, latent, or reactivated and whether it is pulmonary or extrapulmonary.
Primary infection occurs when the bacteria are inhaled and initiate an inflammatory reaction. The majority of people mount effective immune responses to encapsulate these organisms for the rest of their lives, preventing primary infection from progressing to disease.
Latent TB infection (LTBI) is a TB infection in a person who does not have active TB disease. These individuals are asymptomatic and cannot transmit the TB bacteria to others. An estimated 10 to 15 million Americans have LTBI, of which 5-10% will develop active TB disease at some point. Therefore treatment of LTBI is important.
If the initial immune response is not adequate, the body cannot contain the organisms, the bacteria replicate, and active TB disease results.
When active disease develops within the first 2 years of infection, it is termed primary TB.
Post-primary, or reactivation TB, is defined as TB disease occurring 2 or more years after the initial infection. Individuals co-infected with HIV are at greatest risk for developing active TB.
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12. Clinical Manifestations
LTBI – asymptomatic
Pulmonary TB
Takes 2-3 weeks to develop symptoms.
Initial dry cough that becomes productive
Constitutional symptoms (fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats)
Dyspnea and hemoptysis late symptoms
People with LTBI have a positive skin test but are asymptomatic.
Symptoms of pulmonary TB usually do not develop until 2 to 3 weeks after infection or reactivation.
The characteristic pulmonary manifestation is an initial dry cough that frequently becomes productive with mucoid or mucopurulent sputum.
Active TB disease may initially manifest with constitutional symptoms such as fatigue, malaise, anorexia, unexplained weight loss, low-grade fevers, and night sweats.
Dyspnea is a late symptom that may signify considerable pulmonary disease or a pleural effusion.
Hemoptysis, which occurs in less than 10% of patients with TB, is also a late symptom.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

13. Clinical Manifestations
Cough becomes frequent.
Hemoptysis is not common and is usually associated with advanced disease.
Dyspnea is unusual.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

14. Clinical Manifestations
Can also present more acutely
High fever
Chills, generalized flulike symptoms
Pleuritic pain
Productive cough
Adventitious breath sounds
Extrapulmonary TB manifestations dependent on organs infected
Sometimes TB has a more acute, sudden presentation. The patient may have a high fever, chills, generalized flulike symptoms, pleuritic pain, and a productive cough. Auscultation of the lungs may be normal or reveal crackles, rhonchi, and/or bronchial breath sounds.
The clinical manifestations of extrapulmonary TB are dependent on the organs infected.
For example, renal TB can cause dysuria and hematuria. Bone and joint TB may cause severe pain. Headaches, vomiting, and lympadenopathy may be present with TB meningitis.
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15. Complications Miliary TB
Large numbers of organisms spread via the bloodstream to distant organs.
Fatal if untreated
Manifestations progress slowly and vary depending on which organs are infected.
Can include hepatomegaly, splenomegaly, and generalized lymphadenopathy
Appropriately treated pulmonary TB typically heals without complications except for a scar and residual cavitation within the lung. Significant pulmonary damage, although rare, can occur in patients who are poorly treated or who do not respond to anti-TB treatment.
Miliary TB is the widespread dissemination of the mycobacterium. The bacteria are spread via the bloodstream to distant organs. The infection is characterized by a large amount of TB bacilli and may be fatal if left untreated.
It can occur as a result of primary disease or reactivation of latent infection.
Clinical manifestations of miliary TB slowly progress over a period of days, weeks, or even months.
Symptoms vary depending on which organs are infected.
Hepatomegaly, splenomegaly, and generalized lymphadenopathy may be present.
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16. Complications Pleural TB Pleural effusion Empyema
Bacteria in pleural space cause inflammation.
Pleural exudates of protein-rich fluid
Empyema
Large numbers of tubercular organisms in pleural space
Pleural TB can result from either primary disease or reactivation of a latent infection.
A pleural effusion is caused by bacteria in the pleural space, which trigger an inflammatory reaction and a pleural exudate of protein-rich fluid.
Empyema is less common than effusion but may occur from large numbers of tubercular organisms in the pleural space.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

17. Complications TB pneumonia Other organ development
Large amounts of bacilli discharged from granulomas into lung or lymph nodes
Manifests as bacterial pneumonia
Other organ development
Spinal destruction
Bacterial meningitis
Peritonitis
Acute pneumonia may result when large amounts of tubercle bacilli are discharged from granulomas into the lung or lymph nodes.
The clinical manifestations are similar to those of bacterial pneumonia.
Because TB can infect organs throughout the body, various acute and long-term complications can result. TB in the spine (Pott’s disease) can lead to destruction of the intervertebral disc and adjacent vertebrae.
Central nervous system TB can cause severe bacterial meningitis.
Abdominal tuberculosis can lead to peritonitis, especially in HIV-positive patients.
The kidneys, adrenal glands, lymph nodes, and urogenital tract may also be affected.
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18. Diagnostic Studies Tuberculin skin test (TST) AKA: Mantoux test
Uses purified protein derivative (PPD) injected intradermally
Assess for induration in 48 – 72 hours
Presence of induration (not redness) at injection site indicates development of antibodies secondary to exposure to TB.
The tuberculin skin test (TST) (Mantoux test) using purified protein derivative (PPD) is the standard method to screen people for M. tuberculosis.
The test is administered by injecting 0.1 mL of PPD intradermally on the dorsal surface of the forearm.
The test is read by inspection and palpation 48 to 72 hours later for the presence or absence of induration.
The indurated area (if present) is measured and recorded in millimeters.
Induration (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. (Antibody formation would occur 2 to 12 weeks after the initial exposure to the organisms.)
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19. Diagnostic Studies Tuberculin skin test (TST)
Positive if ≥15 mm induration in low-risk individuals
Response ↓ in immune-compromised patients
Reactions ≥5 mm considered positive
The induration is measured, and, based on the size of the induration and the risk factors, an interpretation is made according to diagnostic standards for determining a positive test reaction. An induration of 15 mm or more is considered positive in all low-risk individuals. Results for patients at higher risk would be considered positive if induration 10 mm or higher.
Because the immunocompromised patient may have a decreased response to TST, even smaller induration reactions (≥5 mm) are considered positive.
The figure shows a positive tuberculin skin test. This adolescent boy became infected as a result of living with and helping to care for a grandfather whose chronic “smoker's cough” was ultimately discovered to be a manifestation of chronic cavitary tuberculosis. He had a greater than 15-mm induration.
Basil J. Zitelli, MD and
Holly W. Davis, MD,
Atlas of Pediatric
Physical Diagnosis,
Mosby Elsevier, 2007.
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20. Diagnostic Studies Tuberculin skin test (TST)
A waning immune response can cause false negative results.
Repeating TST may boost reaction.
Two-step testing recommended for health care workers getting repeated testing and those with decreased response to allergens
Two-step testing ensures future positive results accurately interpreted.
Some people who were previously infected with TB may have a waning immune response to the TST.
This may result in a false negative result. However, the repeated TST may stimulate (boost) the body's ability to react to tuberculin in future tests. A positive reaction to a subsequent test could then be misinterpreted as a new infection, rather than the result of the boosted reaction to an old infection.
To prevent misinterpretation in future testing, a two-step testing process is recommended for initial testing for health care workers (who get repeated testing) and for individuals who have a decreased response to allergens. A negative two-step TST ensures that any future positive results can be accurately interpreted as being caused by a new infection.
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21. Diagnostic Studies Interferon-γ release assays (IGRAs)
Detects T-cell lymphocytes in response to mycobacteria
Includes QuantiFERON-TB and the T- SPOT.TB tests
Rapid results
Several advantages over TST but more expensive
Interferon-γ release assays (IGRAs) provide another screening tool for TB.
These whole blood assays detect INF-γ released from T-cell lymphocytes in response to mycobacterial antigens.
Examples of IGRAs include QuantiFERON-TB test and the T-SPOT.
Test results are available in a few hours.
IGRAs offer several advantages over the TST in that they require only one patient visit, are not subject to reader bias, have no booster phenomenon, and are not affected by prior BCG vaccination.
The cost of an IGRA is substantially higher than the TST.
Current guidelines suggest that both tests are viable options and that selection should be based on context and reasons for testing.
Neither IGRAs or TST can distinguish between LTBI and active TB infection. LTBI can only be diagnosed by excluding active TB.
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22. Diagnostic Studies Chest x-ray Cannot make diagnosis solely on x-ray
Upper lobe infiltrates, cavitary infiltrates, and lymph node involvement suggest TB.
Although the findings on chest x-ray examination are important, it is not possible to make a diagnosis of TB solely on chest x-ray findings as other diseases can mimic the appearance of TB.
The chest x-ray may also appear normal in a patient with TB.
Findings suggestive of TB include upper lobe infiltrates, cavitary infiltrates, and lymph node involvement.
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23. Diagnostic Studies Bacteriologic studies Required for diagnosis
Sputum samples obtained (usually) on 2-3 consecutive days
Stained sputum smears examined for acid-fast bacilli
Culture results can take up to 8 weeks.
Can also examine samples from other suspected TB sites
The diagnosis of TB requires the demonstration of tubercle bacilli bacteriologically.
The initial testing involves a microscopic examination of stained sputum smears for acid-fast bacilli (AFB test).
Three consecutive sputum specimens collected on different days are obtained and sent for smear and culture. The culture to grow the organisms for confirmatory diagnosis can take up to 8 weeks. Treatment is warranted pending results for patients in which clinical suspicion of TB is high.
Samples for other suspected TB sites can be collected from gastric washings, cerebrospinal fluid (CSF), or fluid from an effusion or abscess.
Picture shows a positive red stain (arrow) for acid-fast bacilli.
Picture from:Richard L. Kradin, MD Diagnostic Pathology of Infectious Disease, Saunders, 2010.
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24. Case Study
iStockphoto/Thinkstock
S.C.’s chest x-ray and sputum smear for AFB confirm the TB diagnosis.
What treatment would you expect the health care provider to order for S.C.?
Do you think S.C. needs to stay in the hospital at this point?
A four-drug therapy regimen of INH, rifampin (Rifadin), pyrazinamide (PZA), and ethambutol.
Although most people do not need hospitalization , S.C.’s history and living situation do not provide adequate support to ensure compliance.
S.C. should stay in the hospital for at least a few days in order to allow social services time to identify available support and make necessary arrangements.
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25. Collaborative Care Hospitalization not necessary for most patients
Infectious for first 2 weeks after starting treatment if sputum +
Drug therapy used to prevent or treat active disease
Need to monitor compliance
Most patients with TB are treated on an outpatient basis.
Many people can continue to work and maintain their lifestyles with few changes.
Patients with sputum smear positive TB are generally considered infectious for the first 2 weeks after starting treatment. Advise these patients to restrict visitors, travel on public transportation, and trips to public places.
Hospitalization may be needed for the severely ill or debilitated.
The mainstay of TB treatment is drug therapy.
Promoting and monitoring compliance is critical for treatment to be successful.
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26. Drug Therapy Active disease Treatment is aggressive.
Two phases of treatment
Initial (8 weeks)
Continuation (18 weeks)
Four-drug regimen
INH
Rifampin (Rifadin)
Pyrazinamide (PZA)
Ethambutol
Because of the growing prevalence of multidrug-resistant TB, it is important to manage the patient with active TB aggressively.
Drug therapy is divided into two phases: initial and continuation.
In most circumstances, the treatment regimen for patients with previously untreated TB consists of a 2-month initial phase with four-drug therapy (INH, rifampin [Rifadin], pyrazinamide [PZA], and ethambutol).
If drug susceptibility test results indicate that the bacteria are susceptible to all drugs, ethambutol may be discontinued.
If PZA cannot be included in the initial phase (due to liver disease, pregnancy, etc.), the remaining three drugs are used for the initial phase.
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27. Drug Therapy Active disease
Patients should be taught about side effects and when to seek medical attention.
Liver function should be monitored.
Teaching patients about the side effects of these drugs and when to seek prompt medical attention is critical.
The major side effect of isoniazid, rifampin, and pyrazinamide is nonviral hepatitis.
Baseline liver function tests are done at the start of treatment. Monthly monitoring of liver function tests is done if baseline tests are abnormal.
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28. Drug Therapy Directly observed therapy (DOT)
Noncompliance is major factor in multidrug resistance and treatment failures.
Requires watching patient swallow drugs
Preferred strategy to ensure adherence
May be administered by public health nurses at clinic site
Noncompliance is a major factor in the emergence of multidrug resistance and treatment failures. Many individuals do not adhere to the treatment program in spite of understanding the disease process and the value of treatment. Directly observed therapy (DOT) involves providing the antituberculous drugs directly to patients and watching as they swallow the medications.
It is the preferred strategy for all patients with TB to ensure adherence and is recommended for all patients at risk for noncompliance.
DOT is an expensive but essential public health issue. The risk for reactivation of TB and MDR-TB is increased in patients who do not complete the full course of therapy.
In many areas, the public health nurse administers DOT at a clinic site.
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29. Drug Therapy Latent TB infection
Usually treated with INH for 6 to 9 months
HIV patients should take INH for 9 months.
Alternative 3-month regimen of INH and rifapentine OR 4 months of rifampin
In people with LTBI, drug therapy helps prevent a TB infection from developing into active TB disease.
Because there are fewer bacteria in a person with LTBI, treatment is much easier. Usually, only one drug is needed.
The standard treatment regimen for LTBI is 9 months of daily isoniazid (INH). It is an effective and inexpensive drug that the patient can take orally.
The 9-month regimen is more effective, but compliance issues may make the 6-month regimen preferable.
For HIV patients and those with fibrotic lesions on chest x-ray, INH is given for 9 months.
An alternative 3-month regimen of INH and rifapentine (Priftin) may be used for otherwise healthy patients who are not presumed to be infected with drug-resistant bacilli.
A 4-month therapy with rifampin may be indicated if the patient is resistant to INH. Due to reports of severe liver injury and deaths, the CDC does not recommend the combination of rifampin and pyrazinamide for treatment of LTBI.
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30. Drug Therapy
Vaccine
Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world.
In United States, not recommended except for very select individuals
Can result in positive PPD reaction
Bacille Calmette-Guérin (BCG) vaccine is a live, attenuated strain of Mycobacterium bovis.
The vaccine is given to infants in parts of the world where there is a high prevalence of TB.
In the United States, it is typically not recommended because of the low risk of infection, the vaccine’s variable effectiveness against adult pulmonary TB, and potential interference with TB skin test reactivity.
The BCG vaccine should be considered only for very select individuals who meet specific criteria (e.g., health care workers continually exposed to patients with MDR-TB and infection control precautions are not successful).
The BCG vaccination can result in a false-positive TST. IGRA results are not affected.
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31. Nursing Assessment History Physical symptoms Sputum collection
Productive cough
Night sweats
Afternoon temperature elevation
Weight loss
Pleuritic chest pain
Crackles over apices of lungs
Sputum collection
Ask the patient about a previous history of TB, chronic illness, or any immunosuppressive medications.
Obtain social and occupational history to determine risk factors for transmission of TB.
Assess the patient for productive cough, night sweats, afternoon temperature elevation, weight loss, pleuritic chest pain, and abnormal lung sounds.
If the patient has a productive cough, early morning is the ideal time to collect sputum specimens for an acid-fast bacillus (AFB) smear.
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32. Nursing Diagnoses Ineffective breathing pattern
Ineffective airway clearance
Noncompliance
Ineffective self-health management
Nursing diagnoses for the patient with TB may include, but are not limited to, the following:
Ineffective breathing pattern related to decreased lung capacity
Ineffective airway clearance related to increased secretions, fatigue, and decreased lung capacity
Noncompliance related to lack of knowledge of disease process, lack of motivation, and long-term nature of treatment and lack of resources
Ineffective self-health management related to lack of knowledge about the disease process and therapeutic regimen
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33. Planning Goals Comply with therapeutic regimen.
Have no recurrence of disease.
Have normal pulmonary function.
Take appropriate measures to prevent spread of disease.
The overall goals are that the patient with TB will
comply with the therapeutic regimen,
have no recurrence of disease,
have normal pulmonary function, and
take appropriate measures to prevent the spread of the disease.
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34. Nursing Implementation
Health Promotion
Ultimate goal in the United States is eradication.
Selective screening programs in high-risk groups to detect TB
Treatment of LTBI
Follow-up positive TST results
Reportable disease
Address social determinants of TB
The ultimate goal is to eradicate TB worldwide.
Screening programs in known risk groups are of value in detecting individuals with TB.
Treatment of LTBI reduces the number of TB carriers in the community.
The person with a positive tuberculin skin test should have a chest x-ray to assess for the presence of active TB disease.
Individuals with a diagnosis of TB must be reported to the public health authorities for identification and assessment of contacts and risk to the community.
Programs to address the social determinants of tuberculosis are necessary to decrease transmission of TB. Reducing poverty, over-crowded living conditions, malnutrition, smoking, and drug/alcohol abuse can help minimize TB infection rates. Improving access to health care and education is also important.
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35. Case Study What is the primary nursing management for S.C.?
What hygiene measures can you teach him to minimize transmission?
iStockphoto/Thinkstock
Place him in airborne isolation and begin drug therapy as ordered.
Cover his nose and mouth with paper tissue every time he coughs, sneezes, or produces sputum. The tissues should be thrown into a paper bag and disposed of with the trash, burned, or flushed down the toilet. Emphasize careful hand washing after handling sputum and soiled tissues. If he needs to be out of the negative-pressure room, the patient must wear a standard isolation mask to prevent exposure to others. Minimize prolonged visitation to other parts of the hospital.
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36. Nursing Implementation
Acute Intervention
Airborne isolation
Single-occupancy room with 6-12 airflow exchanges/hour
Health care workers wear high-efficiency particulate air (HEPA) masks
Immediate medical workup
Appropriate drug therapy
Patients admitted to the emergency department or directly to the nursing unit with respiratory symptoms should be triaged for the possibility of TB.
Those strongly suspected of having TB should (1) be placed on airborne isolation; (2) receive a medical workup, including chest x-ray, sputum smear, and culture; and (3) receive appropriate drug therapy.
Airborne infection isolation refers to isolation of patients infected with organisms spread by the airborne route. It requires a single-occupancy room with negative pressure and airflow of 6 to 12 exchanges per hour.
High-efficiency particulate air (HEPA) masks are worn whenever entering the patient’s room. These masks are highly effective at protecting from small particles 5 μm or less in diameter.
Airborne infection isolation is indicated for the patient with pulmonary or laryngeal TB until the patient is noninfectious (usually defined as effective drug therapy, improving clinically, and negative AFB smears or cultures [at least 2]).
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37. Nursing Implementation
This is a picture of a high-efficiency particulate air (HEPA) mask. Health care providers should be ‘fit-tested’ to assure proper mask size. To be effective, the mask must be molded to fit tightly around the nose and mouth.
From: 3M™,
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38. Nursing Implementation
Teach patient to prevent spread.
Cover nose and mouth with tissue when coughing, sneezing, or producing sputum
Hand washing after handling sputum- soiled tissues
Patient wears mask if outside of negative-pressure room.
Identify and screen close contacts.
Teach patients to cover the nose and mouth with paper tissues every time they cough, sneeze, or produce sputum. The tissues should be thrown into a paper bag and disposed of with the trash, burned, or flushed down the toilet.
Emphasize careful hand washing after handling sputum and soiled tissues.
If patients need to be out of the negative-pressure room, they must wear a standard isolation mask to prevent exposure to others. Minimize prolonged visitation to other parts of the hospital.
Identify and screen close contacts of the person with TB. Anyone testing positive for TB infection will undergo further evaluation and needs to be treated for either LTBI or active TB disease.
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39. Case Study S.C. is now ready for discharge.
iStockphoto/Thinkstock
S.C. is now ready for discharge.
What other patient teaching should you do with him?
What can you do to help ensure that he continues medications after discharge?
Emphasize the importance of complying with his medication regimen. Teach him how to minimize exposure to close contacts. He should open windows and ventilate rooms in which he is living. Until his sputum is negative for AFB, he should sleep alone, spend as much time as possible outdoors, and minimize time in close proximity with other people and on public transportation. Emphasize importance of treatment compliance.
Strategies to improve adherence to drug therapy include teaching and counseling, reminder systems, incentives or rewards, contracts and DOT. Because of his history and the fact that S.C. is living in a shelter, the Department of Health should provide DOT.
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40. Nursing Implementation
Ambulatory and Home Care
Can go home even if cultures positive
Monthly sputum cultures
Teach patient how to minimize exposure to others.
Ensure that patient can adhere to treatment.
Patients who have responded clinically are discharged home (even with positive cultures) if their household contacts have already been exposed and the patient is not posing a risk to susceptible persons.
Teach patient how to minimize exposure to close contacts and household members. Homes should be well-ventilated, especially the areas where the infected person spends a lot of time. While still infectious, the patient should sleep alone, spend as much time as possible outdoors, and minimize time in congregate settings or public transportation.
Teach the patient and caregiver about compliance with the prescribed regimen. This is very important as most treatment failures occur because the patient neglects to take the drug, discontinues it prematurely, or takes it irregularly. Strategies to improve adherence to drug therapy include teaching and counseling, reminder systems, incentives or rewards, contracts and DOT.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

41. Nursing Implementation
Ambulatory and Home Care
Notify health department.
Teach symptoms of recurrence.
Instruct about factors that could reactivate TB.
Smoking cessation
Notification of the public health department is required. The public health nurse will be responsible for follow-up on household contacts and assessment of the patient for compliance. If compliance is an issue, the public health agency may be responsible for DOT. Most individuals can be considered adequately treated when the therapy regimen has been completed and there is evidence of negative cultures, clinical improvement, and improvement on chest x-ray.
Because about 5% of individuals experience relapses, teach the patient to recognize the symptoms that indicate recurrence of TB. If these symptoms occur, the patient should seek immediate medical attention.
Instruct the patient about certain factors that could reactivate TB, such as immunosuppressive therapy, malignancy, and prolonged debilitating illness. If the patient experiences any of these events, the health care provider must be told so that reactivation of TB can be closely monitored. In some situations, it is necessary to put the patient on anti-TB therapy.
Because smoking is associated with poor outcomes in TB, patients should be encouraged to quit. Provide patients with teaching and resources to help them stop smoking.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

42. Evaluation Expected Outcomes Complete resolution of disease
Normal pulmonary function
Absence of any complications
No transmission of TB
The expected outcomes are that the patient with TB will have
Complete resolution of the disease
Normal pulmonary function
Absence of any complications
No transmission of TB
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.