1. Mr. Dhas 42 years old male is admitted with the diagnosis of pulmonary tuberculosis.
a) Define and list out the clinical manifestation of pulmonary tuberculosis.
b) Explain DOTs therapy.
c) Write the nursing care for pulmonary tuberculosis
Definition
Infection of the lung by the gram negative bacillus (bacteria) Mycobacterium tuberculosis
Clinical Manifestations
Evening rise of temperature
Decreased appetite
Night sweats
Cough (Chronic = more than 15 days to 30 days)
Sputum - blood tinged - hemoptysis
Decreasing body weight - emaciation
Breathlessnes - dyspnea on exertion
Chest pain
Commonly upper lobes affected; esp right upper lobe
Crepitations - fine or coarse in the lung fields - rales - bronchial breathing - cavernous breathing (cavity in the lung)
At times clubbing of the nails (tuberculous lung abscess, bronchiectasis)
Comorbidity : Diabetes mellitus
DOT (Directly Observed Therapy)
Health care provider watches the person take their medications
Six months of a combination of antibiotics containing rifampicin, INH ( isoniazid isonicotinic acid hydrazide), pyrazinamide, and ethambutol for the first two months
Only rifampicin and isoniazid for the last four months.
Where resistance to isoniazid is high, ethambutol may be added for the last four months as an alternative.
Nursing Care
History
Physical examination
Monitor fever, anorexia, weight loss, night, sweats, fatigue, cough, and sputum production
Evaluate breath sounds
Look for Dullness on percussion
Look for Enlarged, painful lymph nodes
Monitor AST (SGOT)and
ALT (SGPT)
Monitor uric acid, AST
(SGOT), ALT (SGPT)
Nursing Diagnoses
• Ineffective airway clearance related to copious tracheobronchial secretions
• Deficient knowledge about treatment regimen and preventive health measures and related ineffective individual management of the therapeutic regimen (noncompliance)
• Activity intolerance related to fatigue, altered nutritional status, and fever
• Malnutrition
• Adverse side effects of medication therapy:
• Multidrug resistance
• Spread of TB infection (miliary TB)
Planning and Goals
Maintenance of a patent airway,
Increased knowledge about the disease and treatment regimen
Adherence to the medication regimen,
Increased activity tolerance
Absence of complications.
Nursing Interventions
Airway clearance AIRWAY CLEARANCE
Increasing fluid intake
Postural drainage
Preventing transmission
hygiene measures :- mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene.
Promoting activity and adequate nutrition - small, frequent meals. Liquid nutritional supplements
Assess medication side effects and reduce them
Medication either on an empty stomach or at least 1 hour before meals
Look for side effects of the drugs
* * * * * * * *
COMMONLY USEDAGENTS
First-Line Antitubercular Medications
isoniazid (INH) 300 mg
rifampin (Rifadin)
streptomycin
pyrazinamide
ethambutol (Myambutol)
Side effects to be anticipated
Peripheral neuritis, hepatic
enzyme elevation, hepatitis,
hypersensitivity
Hepatitis, febrile reaction,
purpura (rare), nausea,
vomiting
8th cranial nerve damage - deafness
nephrotoxicity
Hyperuricemia,
Hepatotoxicity
skin rash,
Arthralgias,
GI distress
Optic neuritis (may lead to blindness)
* * * * * * * * * * * * * * *
In addition, rifampin can increase the metabolism of other
medications, making them less effective. These medications include
beta-blockers, oral anticoagulants such as warfarin (Coumadin),
digoxin, quinidine, corticosteroids, oral hypoglycemic agents, oral
contraceptives, theophylline, and verapamil. This issue should be
discussed with the physician and pharmacist so that medication
dosages can be adjusted accordingly. The nurse informs the patient
that rifampin may discolor contact lenses, so the patient may
want to wear eyeglasses during treatment. The nurse monitors
for other side effects of anti-TB medications, including hepatitis,
neurologic changes (hearing loss, neuritis), and rash. Liver enzyme,
blood urea nitrogen, and serum creatinine levels are monitored
to detect medication-related changes in liver and kidney
function. Sputum culture results are monitored for acid-fast
bacillus to evaluate the effectiveness of the treatment regimen and
adherence to therapy.
Multidrug Resistance
The nurse carefully monitors vital signs and observes for spikes in
temperature or changes in the clinical status. The nurse reports
any change in the patient’s respiratory status to the primary
Chapter 23 Management of Patients With Chest and Lower Respiratory Tract Disorders 537
health care provider. The nurse instructs the patient about the
risk of drug resistance if the medication regimen is not strictly and
continuously followed.
Spread of TB Infection
Spread of TB infection to nonpulmonary sites of the body is
known as miliary TB. It is the result of invasion of the bloodstream
by the tubercle bacillus (Ghon tubercle). Usually it results
from late reactivation of a dormant infection in the lung or elsewhere.
The origin of the bacilli that enter the bloodstream is either
a chronic focus that has ulcerated into a blood vessel or multitudes
of miliary tubercles lining the inner surface of the thoracic
duct. The organisms migrate from these foci into the bloodstream,
are carried throughout the body, and disseminate throughout
all tissues, with tiny miliary tubercles developing in the lungs,
spleen, liver, kidneys, meninges, and other organs.
The clinical course of miliary TB may vary from an acute,
rapidly progressive infection with high fever to an indolent
process with low-grade fever, anemia, and debilitation. At first,
there may be no localizing signs except an enlarged spleen and a
reduced number of leukocytes. Within a few weeks, however, the
chest x-ray reveals small densities scattered diffusely throughout
both lung fields; these are the miliary tubercles, which gradually
grow.
The possibility of TB in nonpulmonary sites in the body requires
careful monitoring for this very serious form of the infection.
The nurse monitors vital signs and observes for spikes
in temperature as well as changes in renal and cognitive function.
Few physical signs may be elicited on physical examination
of the chest, but at this stage the patient has a severe cough
and dyspnea. Treatment of miliary TB is the same as for pulmonary
TB.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching Patients Self-Care
The nurse plays a vital role in caring for the patient with TB and
the family, which includes assessing the patient’s ability to continue
therapy at home. The nurse instructs the patient and family
about infection control procedures, such as proper disposal of
tissues, covering the mouth during coughing, and hand hygiene.
Assessment of the patient’s adherence to the medication regimen
is imperative because of the risk of developing resistant strains of
TB if the regimen is not followed faithfully. In some cases, when
the patient’s ability to comply with the medication regimen is in
question, referral to an outpatient clinic for daily medication administration
may be required. This is referred to as directly observed
therapy (DOT).
Continuing Care
The nurse evaluates the patient’s environment, including home
or workplace and social setting, to identify other people who
may have been in contact with the patient during the infectious
stage. It is important to arrange follow-up screening for any contacts
of the infected person. Nurses who have contact with the
patient in home, shelter, hospital, clinic, or work settings assess
the patient’s physical and psychological status and ability to adhere
to the prescribed treatment. The nurse assesses the patient
for adverse effects of medications and adherence to the therapeutic
regimen (eg, taking medications as prescribed, practicing
safe hygiene, consuming a nutritious and adequate diet, and
participating in an appropriate level of activity). The nurse reinforces
previous teaching and emphasizes the importance of
keeping scheduled appointments with the primary health care
provider. In addition, the patient is reminded of the importance
of other health promotion activities and recommended health
screening.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Maintains a patent airway by managing secretions with hydration,
humidification, coughing, and postural drainage
2. Demonstrates an adequate level of knowledge
a. Lists medications by name and the correct schedule for
taking them
b. Names expected side effects of medications
c. Identifies how and when to contact health care provider
3. Adheres to treatment regimen by taking medications as
prescribed and reporting for follow-up screening
4. Participates in preventive measures
a. Disposes of used tissues properly
b. Encourages people who are close contacts to report for
testing
c. Adheres to hand hygiene recommendations
5. Maintains activity schedule
6. Exhibits no complications
a. Maintains adequate weight or gains weight if indicated
b. Exhibits normal results of tests of liver and kidney
function
7. Takes steps to minimize side effects of medications
a. Takes supplemental vitamins (vitamin B), as prescribed,
to minimize peripheral neuropathy
b. Avoids use of alcohol
c. Avoids foods containing tyramine and histamine
d. Has regular physical examinations and blood tests to
evaluate liver and kidney function, neuropathy, hearing
and visual acuity
