TuberculosisCausative Organism

Mycobacterium Tuberculosis

Gram-positive, acid-fast bacillus (AFB)

Etiology and PathophysiologyBrief exposure rarely causes infectionTransmission 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 DiseaseSpread via airborne droplets when infected personCoughsSpeaksSneezesSings

Ask Yourself?Can the disease be spread by:

Hands Books Glasses Dishes Clothing Bedding

Individuals at Risk 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

No TB exposureNot infected

No history of exposureNegative reaction to tuberculin skin test

TB exposureNo evidence of infection

History of exposureNegative reaction to tuberculin skin test

TB infectionNo disease

Positive reaction to tuberculin skin testNegative bacteriologic studies (if done)No clinical, bacteriological, or radiographic evidence of active TB

TB, clinically active M. tuberculosis cultured (if done)Clinical, bacteriological, or radiographic evidence of current disease

TBNot clinically active

History of episode(s) of TBor

Abnormal but stable radiographic findingsPositive reaction to the tuberculin skin testNegative bacteriologic studies (if done)

andNo clinical or radiographic evidence of current disease

TB suspected Diagnosis pending

Class Type Description

0

1

2

3

4

5

What can trigger What can trigger reactivation of reactivation of latent TB infection latent TB infection (LTBI)(LTBI)

Answer:Host’s defenses become impaired

Which of the following are Signs and Symptoms?

Select all that apply

a. Fatigueb. Non-productive coughc. Weight lossd. Sudden onset of high fever >1020

e. Night sweatsf. Anorexiag. Decreased movement of chest wall

Signs and Symptoms

Cough becomes frequentProduces white, frothy sputumHemoptysis is not common and is usually associated with advanced disease

ComplicationsPleural effusion and empyema

Caused by bacteria in pleural spaceInflammatory reaction with plural exudates of protein-rich fluid

TB pneumoniaLarge amounts of bacilli discharging from granulomas into lung or lymph nodes

TB Skin Test (Mantoux)TB Skin Test (Mantoux)

Uses purified protein derivative (PPD)intradermal

Administering the Tuberculin Skin TestAdministering the Tuberculin Skin Test•Inject intradermally

•Produce wheal 6 mm to 10 mm in diameter

•Do not recap, bend, or breakneedles, or remove needles from syringes

•Follow universal precautions for infection control

Reading the Tuberculin Skin TestRead 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 Factors that May Affect the Skin Test ReactSkin Test Reactionion

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-RayChest 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 StudiesSputum for AFB

QuantiFERON-TBBlood 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.

AFB (shown in red) are

tubercle bacilli

Sputum CulturesSputum 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 CareGoals:

Comply with therapeutic regimenHave no recurrence of diseaseHave normal pulmonary functionTake appropriate measures to prevent spread of disease

Four Drug Regimenisoniazid [INH]

rifampin [Rifadin]

pyrazinamide [PZA]

ethambutol

Drug TherapyActive disease

Patients should be taught about side effects and when to seek medical attention

Liver function should be monitored

Drug Side effects Nursing Implications

Isoniazid (INH) Noninfections hepatitisPeripheral neuropathyHypersensitivity

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 stomachAvoid 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 disturbancesOrange discoloration of body fluids (sputum, urine, sweat, tears)

Metabolism of other meds and makes them ineffective such as cardiac meds and steroids.

Inform patient about orange discoloration of fluids/ urine

Discolor contact lenses

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 GuidelinesInitiation Phase of Treatment

Multiple-medication regimen of all 4 medsAdministered daily for 8 weeks

Continuation Phase of Treatmentd/c ethambutol and continue other 3 meds Administered for 4-7 monthsPatient begins to feel better in this phase

Drug TherapyLatent 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 TreatmentMonitor 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 The patient asks how long before he can be considered before he can be considered

non-contagious?non-contagious?

What is the appropriate What is the appropriate response? response?

Answer this

How would the nurse assess if the patient has been

compliant with taking their medications?

Direct Observation TherapyUsed 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 TherapyVaccine

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 InterventionsWhat type of isolation is typically ordered? What PPE is worn? Who wears this equipment?What type of room are they in?

Patient TeachingCover nose and mouth with tissue when

coughing, sneezing, or producing sputum Hand washing after handling sputum-soiled

tissuesAmbulatory and home care

Fungal Infections - Who is at RiskSeriously ill patients being treated withCorticosteroidsAntineoplastic drugsImmunosuppressive drugs

Patients with AIDSPatients with Cystic Fibrosis

Fungal InfectionsHistoplasmosisCocciidiodomycosi

sBlastomycosisCryptococcosisAspreigillosis

Pneumocystis pneumonia

NocardiosisActinomycosisCandidiasis

Diagnosis

Drug therapyAmphotericin B

IntravenousSide effects

Hypersensitivity reactionsFever and chillsMalaiseNausea and vomitingThrombophlebitis at injection site

Pre-medicate with Benadryl to increase tolerance and decrease hypersensitivity

Monitor renal functionEnsure adequate hydration

Drug TherapyOral Antifungal agents

ketoconazole (Nizoral)fluconazole (Sporanox; Difulcan)Flucytosine (Anobon)Monitor effectiveness with serology testing

Side EffectsN/V liver enzymesBone marrow depression – monitor WBC,

platelets

Lung Abscess

Pus-containing lesion of the lung

Formed by necrosis of lung tissue

Lung AbscessCauses

Aspiration of material from GI tract into lungs

Lung cancerTuberculosis

Signs and SymptomsProductive cough of purulent foul smelling and foul tasting sputum

Fever and chillsPleuritic painDyspneaWeight loss

Diagnosis

Sputum cultures – obtained first so can confirm

treatment modalities

Chest x-ray

Bronchoscopy

Treatment and Nursing CareDrug Therapy- Antibiotics

PenicillinClindamycin**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 CareDrug Therapy

Increase fluid intakeRestGood nutrition

Nursing CareHow do you know if the treatment is

effective?