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Tuberculosis TB is an infectious disease caused by bacteria (Mycobacterium tuberculosis) that are usually spread from person to person through the air. Tuberculosis (TB) is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded, poorly ventilated conditions are most likely to become infected. It usually infects the lung but can occur at virtually any site in the body. HIV-infected patients are especially at risk. In patients with strains that are sensitive to the usual antitubercular agents, the prognosis is excellent with correct treatment. However, in those with strains that are resistant to two or more of the major antitubercular agents, mortality is 50%.

Pathophysiology

  • The bacilli of Tuberculosis TB infect the lung, forming a tubercle (lesion).
  • The tubercle:  May heal, leaving scar tissue. May continue as a granuloma, then heal, or be reactivated. May eventually proceed to necrosis, liquefaction, sloughing, and cavitation.
  • The initial lesion may disseminate tubercle bacilli by extension to adjacent tissues, by way of the bloodstream, by way of the lymphatic system, or through the bronchi.
  • Extrapulmonary Tuberculosis TB occurs more commonly in children and immunocompromised individuals and can involve lymph nodes, bones, joints, pleural space, pericardium, CNS, GU tissue, and the peritoneum.

Transmission

  1. The term Mycobacterium is descriptive of the organism, which is a bacterium that resembles a fungus. The organisms multiply at varying rates and are characterized as acid-fast aerobic organisms that can be killed by heat, sunshine, drying, and ultraviolet light.
  2. Tuberculosis TB is an airborne disease transmitted by droplet nuclei, usually from within the respiratory tract of an infected person who exhales them during coughing, talking, sneezing, or singing.
  3. When an uninfected susceptible person inhales the droplet-containing air, the organism is carried into the lung to the pulmonary alveoli.
  4. Most people who become infected do not develop clinical illness, because the body’s immune system brings the infection under control.

The primary infectious agent of Pulmonary Tuberculosis TB is, Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection.

Risk Factors for Pulmonary Tuberculosis

  • Close contact with someone who has active Tuberculosis TB. Inhalation of airborne nuclei from an infected person is proportional to the amount of time spent in the same air space, the proximity of the person, and the degree of ventilation.
  • Immunocompromised status (e.g. those with HIV infection, cancer, transplanted organs, and prolonged high-dose corticosteroid therapy)
  • Substance abuse (IV or injection drug users and alcoholics)
  • Any person without adequate health care (the homeless, impoverished, minorities, particularly children under age 15 years and young adults between ages 15 and 44 yrs)
  • Preexisting medical conditions or special treatment (e.g. Diabetes Mellitus, chronic renal failure, malnourishment, selected malignancies, hemodialysis, transplanted organ, gastrectomy, or jejunoileal bypass)
  • Immigration from countries with a high prevalence of Tuberculosis TB (southeastern Asia, Africa, Latin America, Caribbean)
  • Institutionalization (e.g. long-term care facilities, psychiatric institutions, prisons)
  • Living in overcrowded, substandard housing
  • Being a health care worker performing high-risk activities: administration of aerosolized pentamidine and other medications, sputum induction procedures, Bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient, home care with the high-risk population, and administering anesthesia and related procedures (e.g. intubation, suctioning)

Clinical Manifestations

Patient may be asymptomatic or may have insidious symptoms that may be ignored.

  • Constitutional symptoms; Fatigue, anorexia, weight loss, low-grade fever, night sweats, indigestion. Some patients have acute febrile illness, chills, and flu-like symptoms.
  • Pulmonary signs and symptoms; Cough (insidious onset) progressing in frequency and producing mucoid or mucopurulent sputum. Hemoptysis; chest pain; dyspnea (indicates extensive involvement).
  • Extrapulmonary Tuberculosis TB: pain, inflammation, and dysfunction in any of the tissues infected.

COMPLICATIONS

  1. Pleural effusion
  2. TB pneumonia; Tuberculosis TB can cause massive pulmonary tissue damage, with inflammation and tissue necrosis eventually leading to respiratory failure. Bronchopleural fistulas can develop from lung tissue damage, resulting in pneumothorax. The disease can also lead to hemorrhage, and pneumonia.
  3. Other organ involvement with Tuberculosis TB; Small mycobacterial foci can infect other body organs, including the kidneys and the central nervous and skeletal systems.
  4. The patient also might develop Serious reactions to drug therapy
  • INH may produce asymptomatic elevation in liver enzymes, rare peripheral neurotoxicity, hepatitis that may, rarely, be fatal, CNS effects (dysarthria, irritability, seizures, dysphoria, diminished concentration), lupus-like syndrome, hypersensitivity reactions, and monoamine poisoning (rarely occurring with consumption of some wines and cheeses). Patients with pre-existing liver disease should be monitored closely.
  • Ethambutol may cause retrobulbar optic neuritis with decreased visual acuity and decreased red-green discrimination in one or both eyes, although this occurs rarely with daily doses of 15 mg/kg/day. EMB may also cause peripheral neuritis and cutaneous reactions. Patients should have baseline visual acuity and color discrimination (Ishihara test) testing as well as monthly monitoring.
  • Pyrazinamide may cause hepatotoxicity, GI symptoms, nongouty polyarthralgia, asymptomatic hyperuricemia, and acute gouty arthritis.
  • Any anti-TB drug may cause rash. If rash occurs, withhold all medications until rash subsides. Rechallenge drugs sequentially every 3 to 4 days to find cause. Usual sequence is INH, rifampin, PZA, EMB, using the first line (most important) drug first.
  • Rifampin may cause pruritus with or without rash, GI adverse effects, flu-like symptoms, hepatotoxicity, rare severe immunologic reactions, orange discoloration of body fluids, and drug interactions with hormonal contraceptives, methadone, and warfarin.

Classification of Pulmonary Tuberculosis TB
An infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis. Often involves the lungs but may involve other parts of the body as well. Data from the history, physical examination, skin test, chest x-ray, and microbiologic studies are used to classify Pulmonary Tuberculosis TB into one of five classes. A classification scheme provides public health officials with a systematic way to monitor epidemiology and treatment of the disease (American Thoracic Society, 2000).

Classification of Pulmonary Tuberculosis TB

  • Class 0: no exposure; no infection
  • Class 1: exposure; no evidence of infection
  • Class 2: latent infection; no disease (e.g. positive PPD reaction but no clinical evidence of active TB)
  • Class 3: disease; clinically active
  • Class 4: disease; not clinically active
  • Class 5: suspected disease; diagnosis pending

Primary tuberculosis

This stage of infection, primary tuberculosis, is usually clinically and radio graphically silent. In most persons with intact cell-mediated immunity, T cells and macrophages surround the organisms in granulomas that limit their multiplication and spread. The infection is contained but not eradicated, since viable organisms may lie dormant within granulomas for years to decades.

Latent tuberculosis infection

Individuals with this latent tuberculosis infection do not have active disease and cannot transmit the organism to others. However, reactivation of disease may occur if the host’s immune defenses are impaired. Active tuberculosis will develop in approximately 10% of individuals with latent tuberculosis infection who are not given preventive therapy; half of these cases occur in the 2 years following primary infection. Up to 50% of HIV-infected patients will develop active tuberculosis within 2 years after infection with tuberculosis. Diverse conditions such as gastrectomy, silicosis, and diabetes mellitus and disorders associated with immunosuppression (e.g. HIV infection or therapy with corticosteroids or other immunosuppressive drugs) are associated with an increased risk of reactivation.

Progressive primary tuberculosis

In approximately 5% of cases, the immune response is inadequate and the host develops progressive primary tuberculosis, accompanied by both pulmonary and constitutional symptoms that are described below. Standard teaching has held that 90% of tuberculosis in adults represents activation of latent disease. New diagnostic technologies such as DNA fingerprinting suggest that as many as one-third of new cases of tuberculosis in urban populations are primary infections resulting from person-to-person transmission.

Pulmonary Tuberculosis Treatment

Antitubercular therapy with daily oral doses of isoniazid, rifampin, and pyrazinamide for at least 6 months usually cures Tuberculosis TB. After 2 to 4 weeks, the disease is no longer infectious and the patient can resume normal activities while continuing to take medication. A longer course of treatment may be necessary if the patient is slow to respond to treatment, require extended treatment for patients with AIDS

Treatment for Pulmonary Tuberculosis

  • A combination of drugs to which the organisms are susceptible is given to destroy viable bacilli as rapidly as possible and to protect against the emergence of drug-resistant organisms.
  • Current recommended regimen of uncomplicated, previously untreated Pulmonary Tuberculosis TB is an initial phase of 2 months of bactericidal drugs, including isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (EMB). This regimen should be followed until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance.
  1. If drug susceptibility results are known and organism is fully susceptible, EMB does not need to be included.
  2. For children whose visual acuity cannot be monitored, EMB is not normally recommended except with increased likelihood of INH resistance or if the child has upper lobe infiltration and/or cavity formation Pulmonary Tuberculosis TB.
  3. Due to increasing frequency of global streptomycin resistance, streptomycin is not considered interchangeable with EMB unless organism is known to be susceptible to streptomycin.
  4. PZA may be withheld for severe liver disease, gout and possibly, pregnancy.
  5. Adverse effects including liver injury have been noted with rifampin and pyrazinamide in a once daily or twice weekly combination, therefore this combination is not recommended for the treatment of latent Pulmonary Tuberculosis TB infection.
  • Follow with 4 months of isoniazid and rifampin. Six months of therapy is usually effective for killing the three populations of bacilli: those rapidly dividing, those slowly dividing, and those only intermittently dividing.
  • Sputum smears may be obtained every 2 weeks until they are negative; sputum cultures do not become negative for 3 to 5 months.
  • Rifabutin (Mycobutin) is used as a substitute for rifampin if the organism is susceptible to rifabutin and for patients taking medications that may interact with rifampin.
  • Second-line drugs, such as cycloserine (Seromycin), ethionamide (Trecator-SC), streptomycin, Amikacin (Amikin), kanamycin (Kantrex), capreomycin (Capastat),
    para-aminosalicylic acid, and some fluoroquinolones, are used in patients with resistance, for retreatment, and in those with intolerance to other agents. Patients taking these drugs should be monitored by health providers experienced in their use.
  • For people suspected of having latent Pulmonary Tuberculosis TB infection (LTBI), treatment should begin after active TB has been ruled out.

Nursing Care Plans Pulmonary Tuberculosis TB

Common nursing diagnosis found in Nursing Care Plans Pulmonary Tuberculosis TB; Ineffective Airway Clearance, Risk for impaired Gas Exchange, Imbalanced Nutrition: Less than Body Requirements, Risk for Infection, Deficient Knowledge

Nursing Care Plans Pulmonary Tuberculosis TB

Nursing diagnosis ineffective Airway Clearance related to Thick, viscous, or bloody secretions Fatigue, poor cough effort Tracheal or pharyngeal edema

Nursing goal: Respiratory Status: Airway Patency

Nursing Intervention Nursing Care Plans Pulmonary Tuberculosis TB

Airway Management:

  • Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles. Rationale Diminished breath sounds may reflect Atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory muscles and increased work of breathing.
  • Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of Hemoptysis Rationale Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Blood tinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention
  • Place client in semi- or high Fowler’s position. Assist client with coughing and deep-breathing exercises Rationale Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open Atelectasis areas and promote movement of secretions into larger airways for expectoration.
  • Clear secretions from mouth and trachea, suction as necessary. Rationale Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions.
  • Maintain fluid intake of at least 2,500 ML/day unless contraindicated Rationale High fluid intake helps thin secretions, making them easier to expectorate
  • Humidify inspired oxygen Rationale Prevents drying of mucous membranes and helps thin secretions
  • Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst) Rationale Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance
  • Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur) Rationale Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery
  • Corticosteroids (prednisone) Rationale May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening
  • Be prepared for and assist with emergency intubation Rationale Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.

Evaluation (Expected Out Come) Nursing Care Plans Pulmonary Tuberculosis TB Nursing diagnosis ineffective Airway Clearance:

  • Maintain patent airway.
  • Expectorate secretions without assistance.
  • Demonstrate behaviors to improve or maintain airway clearance.
  • Participate in treatment regimen, within the level of ability and situation.
  • Identify potential complications and initiate appropriate actions.

Complete Sample Nursing Care Plans Pulmonary Tuberculosis Tb

Patient Teaching Home Health Guidance for Patient with Pulmonary Tuberculosis

Patient teaching discharge and home healthcare guidelines for Patient with Pulmonary Tuberculosis. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol. Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel.

Patient Teaching & Home Health Guidance for Patient with Pulmonary Tuberculosis

  • Improve ventilation  by opening windows in room of affected person, and keeping bedroom door closed as much as possible.
  • Instruct patient to cover mouth with fresh tissue when coughing or sneezing and to dispose of tissues promptly in plastic bags.
  • Discuss Tuberculosis TB testing of people residing with patient.
  • Investigate living conditions, availability of transportation, financial status, alcohol and drug abuse, and motivation, which may affect compliance with follow-up and treatment. Initiate referrals to a social worker for interventions in these areas.
  • Report new cases of Tuberculosis TB to public health department for screening of close contacts and monitoring.
  • Review possible complications: hemorrhage, pleurisy, symptoms of recurrence (persistent cough, fever, or Hemoptysis).
  • Instruct patient on avoidance of job-related exposure to excessive amounts of silicone (working in foundry, rock quarry, sand blasting), which increases risk of reactivation.
  • Encourage patient to report at specified intervals for bacteriologic (smear) examination of sputum to monitor therapeutic response and compliance.
  • Instruct patient in basic hygiene practices and investigate living conditions. Crowded, poorly ventilated conditions contribute to development and spread of Tuberculosis TB.
  • Encourage regular symptom screening and follow-up chest X-rays for rest of life to evaluate for recurrence.
  • Show the patient and family how to perform postural drainage and chest percussion. Also teach the patient coughing and deep-breathing exercises. Instruct him to maintain each position for 10 minutes and then to perform percussion and cough.
  • Instruct patient on prophylaxis with isoniazid for people infected with the tubercle bacillus without active disease to prevent disease from occurring, or to people at high risk of becoming infected.
  • Educate asymptomatic people about PPD testing and treatment of latent Tuberculosis TB for positive results, based on risk grouping.

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