Tuberculosis Nclex - this is a compilation of multiple sources for notes on this topic PDF

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Tuberculosis NCLEX  NCLEX Peds  Nurse Sarah  Concept map  Added lecture material  Highly communicable disease caused by Mycobacterium tuberculosis M. tuberculosis is nonmotile, non-sporulating, acid-fast rod that secretes niacin; when the bacillus reaches a susceptible site, it multiplies freely Bc M. TB. Is an aerobic bacterium, it primarily affects the pulmonary system, esp. the upper lobes, where O2 is the highest but can also affect other areas of the body; brain, intestines, peritoneum, kidney, joints and liver. Exudative response causes a nonspecific pneumonitis and the development of granulomas in the lung tissues Insidious onset; most ppl don’t know they have it but its well advanced Improper or noncompliant use of treatment programs may cause the development of mutations in the tubercle bacilli, resulting in a multidrug resistant strain of TB (MDR-TB) The goal of treatment is to prevent transmission, control symptoms and prevent progression of the disease

Risk factors  Child under 5  Unpasteurized milk if cow is infected with bovine TB  Homeless, minority group and refugee  In constant, frequent contact with untreated or undiagnosed person  Living in crowded areas, long term care, prisons, etc  Old  Malnutrition, infection, immune dysfunction, HIV and immunosuppressed from med therapy  Alcohol and IV drug use Multidrug-Resistant Tuberculosis (MDR-TB)  Resistance to 2 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 • Incorrect prescribing • Lack of case management • Nonadherence Etiology and Pathophysiology  Spread via airborne particles  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

 TB granuloma  Local inflammatory reaction occurs  Only 5% to 10% will develop active TB Classification  Primary infection  Latent TB infection (LTBI) • Infected but no active disease  Active TB disease • Primary TB • Reactivation TB (post-primary) 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  Cough becomes frequent • Hemoptysis is not common and is usually associated with advanced disease • Dyspnea is unusual  Can also present more acutely • High fever • Chills, generalized flulike symptoms • Pleuritic pain • Productive cough • Crackles and/or adventitious breath sounds  Extrapulmonary TB manifestations dependent on organs infected  Immunosuppressed people and older adults are less likely to have fever and other signs of an infection  Carefully investigate respiratory problems in HIV patients  Rule out opportunistic diseases  A change in cognitive function may be the only initial sign of TB in an older person 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 ventral 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, a palpable, raised, hardened area or swelling (not redness) at the injection site means the person has been exposed to TB and has developed antibodies. (Antibody formation occurs 2 to 12 weeks after initial exposure to the bacteria.)  Tuberculin skin test (TST) • Positive if ≥15 mm induration in low-risk individuals • Response ↓ in immunocompromised patients  Reactions ≥5 mm considered positive  Tuberculin skin test (TST) • 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  Interferon-γ gamma release assays (IGRAs) • Detects T-cells in response to Mycobacterium tuberculosis • Includes QuantiFERON-TB and  T-SPOT.TB tests • Rapid results • Several advantages over TST but more expensive • Chest x-ray • May appear normal in a patient with TB • Upper lobe infiltrates, cavitary infiltrates, lymph node involvement, and pleural and/or pericardial effusion suggest TB • Bacteriologic studies • Required for diagnosis • Consecutive sputum samples obtained on 3 different days • Stained sputum smears examined for AFB • Culture results can take up to 8 weeks Interprofessional 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 Drug Therapy  Active disease • Treatment is aggressive • Two phases of treatment  Initial (8 weeks)

 Continuation (18 weeks) Four-drug regimen  Isoniazid  Rifampin (Rifadin)  Pyrazinamide  Ethambutol Active disease • Patients should be taught about side effects and when to seek medical attention • Liver function should be monitored • Alternatives are available for those who develop a toxic reaction to primary drugs Directly observed therapy (DOT) • Noncompliance is major factor in multidrug resistance and treatment failures Latent TB infection • Usually treated with Isoniazid for 6 to 9 months • HIV patients should take Isoniazid for 9 months • Alternative 3-month regimen of Isoniazid and rifapentine OR 4 months of rifampin Vaccine • Bacille-Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of world • Can result in positive PPD reaction •

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Nursing Assessment  History  Physical symptoms • Productive cough • Night sweats • Afternoon temperature elevation • Weight loss • Pleuritic chest pain • Crackles  Sputum collection Nursing Diagnoses  Ineffective breathing pattern  Ineffective airway clearance  Risk for infection  Noncompliance  Ineffective health management Planning  Goals

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Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease

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  Acute Care • Airborne isolation • Immediate medical workup • Appropriate drug therapy  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  Ambulatory 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 • Negative cultures are needed to declare the patient not infectious • Notify health department • Teach symptoms of recurrence • Instruct about factors that could reactivate TB • Smoking cessation Evaluation  Expected Outcomes • Resolution of disease • Normal pulmonary function • Absence of any complications • No further transmission of TB

Tuberculosis NCLEX (Peds)  Contagious disease caused by mycobacterium tuberculosis, an acid-fast bacillus  Multidrug resistant strains of M. tuberculosis bc child/ family noncompliance  Route of transmission; inhalation of droplet of person with active TB Assessment  May be asymptomatic or develop symptoms such as malise, fever, cough, weight loss, anorexia and lymphadenopathy  Specific symptoms are related to site of infection; lungs, brain or bone  With time asymmetrical expansion of lungs, decreased breath sounds, crackles and dullness develop TST (Mantoux test)  Produces positive reaction in 2 – 10 weeks after initial infection  Determines whether a child has been infected and has developed a sensitivity for the protein of the tubercle bacillus; positive reaction foes not confirm, active disease  After reacting positive, always will; a positive reaction in a previous neg child indicates that the child has been infected since last test  TB testing not done at the same time as measles immunization; may cause a false neg.  Results o >15mm: (+)  everyone 4 yrs or older  do not have any risks factors o >10mm (+)  Positive reaction in children less than 4 yr  Or at high risk  immigrant, IV drug user, work/living, tight living quarters (parents; high risks) o >5mm (+) HIV, contact with TB pt., organ transplant, immunosuppression  Positive in high risk groups; immunosuppressive, HIV) Sputum culture  A definite diagnosis by mycobacteria in culture  Chest Xray are supplemental to sputum but not definitive alone  Bc infants and young children often swallows sputum rather than expectorating, gastric washings (aspiration of lavages contents from the fasting stomach) may be done to obtain a specimen; obtained early morning before breakfast Interventions:  Medications o 9 month course of isoniazid to prevent latent infection from progressing to clinically active TB and to prevent initial infection in children in high-risk situations; 10 month course may be Rx for child infected with HIV o Recommendation for child with active TB may include combo admin of isoniazid, rifampin, and pyrazinamide daily for 2 month and then isoniazid and rifampin twice weekly for 4 months

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o Inform parent and child that bodily fluids including urine, may turn orange- red with some TB meds o Directly observed therapy may be necessary for some children Place children with active disease who are contagious on resp. isolation until medication have been initiated, sputum cultures show a low number of organisms, and improving; this includes use of a personally fitted air-purifying N95 or N100 respirator by the nurse caring for the child Stress adequate rest and diet Instruct family and child about avoiding transmission Case finding and follow up with known contacts is crucial; to decrease cases with active TB

Oxygen delivery systems  Oxygen mask o Advantage  various sizes, delivers higher O2 concentration than cannula  Provide predictable concentration of oxygen is venturi mask if used whether child breaths through the mouth or not o Disadvantages  Skin irritation  Fear of suffocation accumulation of moisture on face  Possibility of aspiration  Difficult controlling O2 concentration (except when venturi mask used)  Cannula o Advantages  Low – moderate O2 concentration (22-40%)  Able to eat and talk with  Possibility of more complete observation of child because nose and mouth remain unobstructed o Disadvantages  Must have patent nasal passages  May cause abdominal distention and discomfort or vomiting  Difficult controlling O2 concentrations if child breaths through mouth  Inability to provide mist if desired  Oxygen tent o Advantages  Provides lower O2 concentration  Child can get desired inspired O2 concentrations, even with eating o Disadvantages  Necessity for tight fit around bed to prevent leakage of oxygen  Cool and wet tent environment  Poor access to child; inspired levels fall when entered  Oxygen face tent

o Advantages  Provides high concentration  Free access to childs chest for assessment

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Tuberculosis Nurse Sarah Contagious bacterial infection caused by mycobacterium tuberculosis Lungs mainly affected (upper)

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Also brain, joints, liver, spine, kidneys Airborne N95 mask

Mycobacterium tuberculosis  Acid-fast (stains red)  Aerobic (loves O2)  Very small; suspends in air w/ ACTIVE infection  Respirator o Special ventilation and negative pressure room TB RISK  Tight living quarters  Below poverty line  Refugee (immigrant)  Immune system issues (ex;HIV)  Substance abusers  Kids 15mm: (+) everyone 4 yr or over o >10mm (+) immigrant, IV drug user, work/living, tight living quarters, child 5mm (+) HIV, contact with TB pt., organ transplant, immunosuppression o A positive result does NOT mean its active  Blood test o Interferon Gamma Release Assay (IGRA)  QuantiFERON TB gold (QFG)  T- spot  Benefits: o No return to read results o Great for pt with the BCG vaccine; no false positive o DOES NOT TELL IF LATENT OR ACTIVE  You need a CxR or sputum Cx  Sputum Cx o AFB smear  Coughs  Bronch o Sputum: 3 diff collections on 3 diff days o Best in the morning before breakfast o CxR

Nursing interventions and treatment o Active TB: Airborne precautions o Standard precautions + N95 & neg. pressure room o Pt. has to leave room for testing?  wear surgical mask o Most pt. are treated outpt. o Long treatment (6-12 month) o Active TB o Insolation; zero visitors, no school, no work, no public outings (medical appointments only) o Cough & sneeze in paper towel flush or airtight o Criteria for discharge  3. Neg cultures  Decreased s/s  On meds for three weeks Medications PERI o Pyrazinamide  Bactericidal effect (kills the bacteria)  Watch diabetics, kidney problems or gout (cause by increase uric acid) start in big toe, painful, red, warm, limited mobility)  Monitor uric acid levels, liver and kidney function (jaundice, urinary output)  GI commonly upset; administer with food o Ethambutol  Stops RNA synthesis (bacteriostatic)   prevents bacteria from reproducing)  Inflamed optic nerve:  needs reg. eye checks; blurred or color change  ALWAYS assess the pt. vision!  Peripheral neuropathy: damage to nerves  Numbness or burning in extremities  ALWAYS assess for this as well o Rifampin  Stops RNA- polmerse (Kills bacteria)  Education on  Orange body fluids; will stain contact lenses... wear hard lenses  Birth control less effective  Sunburn easy  NO alcohol; monitory for s/s of liver disease; jaundice, issues w/ bleeding, etc. o Isoniazid (INH)  Kills bacteria and stops its growth

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Condition: Tuberculosis

Decreased bit. B6 levels Need to take supplements Watch for peripheral (tingling extremities, tired, depression, etc.) Monitor liver function and neurotoxicity Stops protein synthesis and kills bacteria Monitor hearing Watch for reports of ringing in ears Ototoxicity; affects CN 8 (Vlll)

Adult o Highly communicable; Mycobacterium tuberculosis o Aerobic bacterium (loves O2); primarily effects pulmonary system (upper) o Can also affect brain, intestines, peritoneum, kidneys, joints and liver o Insidious onset; don’t know you have it until its advanced o Goal of treatment to prevent transmission, control symptoms and prevent progression o Airborne; N95, mask and gloves and neg pressure room RISK factors  Tight living quarters  Below poverty line  Refugee (immigrant)  Immune system issues (ex;HIV)  Substance abusers  Kids 15mm: (+) everyone 4 yr or over o >10mm (+) immigrant, IV drug user, work/living, tight living quarters, child 5mm (+) HIV, contact with TB pt., organ transplant, immunosuppression o A positive result does NOT mean its active Sputum culture o Color, consistency, odor o Morning before breakfast o 3 different collections on 3 diff days

Active TB  Contagious  s/s  abnormal CXR  Positive sputum Cx  Positive PPD blood test  Weak immune system  Most cases are from TBI  Can spread though lymphatic system Pediatrics  May be asymptomatic or develop symptoms such as malise, fever, cough, weight loss, anorexia and lymphadenopathy  Specific symptoms are related to site of infection; lungs, brain or bone  With time asymmetrical expansion of lungs, decreased breath sounds, crackles and dullness develop

Pediatrics o May be asymptomatic or develop symptoms such as malaise, fever, cough, weight loss, anorexia and lymphadenopathy o Specific symptoms are related to site of infection; lungs, brain or bone o With time asymmetrical expansion of lungs, decreased breath sounds, crackles and dullness develop TST (Mantoux test) o Produces positive reaction in 2 – 10 weeks after initial infection o Positive reaction does not confirm diagnosis o After reacting positive, always will o Not to be done at the same time as a measles vaccine; false neg. o Results o >15mm: (+)  everyone 4 yrs or older  do not have any risks factors o >10mm (+)  Positive reaction in children less than 4 yr  Or at high risk  immigrant, IV drug user, work/living, tight living quarters (parents; high risks) o >5mm (+) HIV, contact with TB pt., organ transplant, immunosuppression  Positive in high risk groups; immunosuppressive, HIV) Sputum culture  A definite diagnosis by mycobacteria in culture  Bc infants and young children often swallows sputum rather than expectorating, gastric washings (aspiration of lavages contents from the fasting stomach) may be done to obtain a specimen; obtained early morning before breakfast

Interventions: Adult o Active TB: Airborne precautions o Standard precautions + N95 & neg. pressure room o Pt. has to leave room for testing?  wear surgical mask o Most pt. are treated outpt. So interventions are mainly for while in hospital for diagnosis o Long treatment (6-12 month) o Active TB o Insolation; zero visitors, no school, no work, no public outings (medical appointments only) o Cough & sneeze in paper towel flush or airtight o Criteria for discharge  3. Neg cultures  Decreased s/s  On meds for three weeks Pediatrics  Medications o 9 month course of isoniazid to prevent latent infection from progressing to clinically active TB and to prevent initial infection in children in high-risk situations; 10 month course may be Rx for child infected with HIV o Recommendation for child with active TB may include combo admin of isoniazid, rifampin, and pyrazinamide daily for 2 month and then isoniazid and rifampin twice weekly for 4 months o Inform parent and child that bodily fluids including urine, may turn orange- red with some TB meds

Treatments: Adult Drug Therapy  Active disease • Treatment is aggressive • Two phases of treatment  Initial (8 weeks)  Continuation (18 weeks) • Four-drug regimen  Isoniazid  Rifampin (Rifadin)  Pyrazinamide  Ethambutol  Active disease • Patients should be taught about side effects and when to seek medical attention • Liver function should be monitored • Alternatives are available for those who develop a toxic reaction to primary drugs  Directly observed therapy (DOT) • Noncompliance is major factor in multidrug resistance and treatment failures  Latent TB infection • Usually treated with Isoniazid for 6 to 9 months • HIV patients should take Isoniazid for 9 months • Alternative 3-month regimen of Isoniazid and rifapentine OR 4 months of rifampin  Vaccine • Bacille-Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of world • Can result in positive PPD reaction PERI  Pyrazinamide o Bactericidal effect (kills the bacteria)

Directly observed therapy may be necessary for some children Place children with active disease who are contagious on resp. isolation until medication have been initiated, sputum cultures show a low number of organisms, and improving; this includes use of a personally fitted air-purifying N95 or N100 respirator by the nurse caring for the child o

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 Education  Stress adequate rest and diet  Instruct family and child about avoiding transmission  Case finding and follow up with known contacts is crucial; to decrease...