Tuberculosis

Chapter 28

Tuberculosis (TB)
Infectious

disease caused by
Mycobacteriumtuberculosis
Lungsmost commonlyinfected
Primarycauseof deathworldwide
Leading causeofdeathinpatients
with HIV/AIDs
Greaterthan2billionpeopleinfected
worldwide

Risk Factors

Homeless

Residents of inner-city neighborhood

Foreign-born persons

Living or working in institutions

(includes health care workers)

IV injecting drug users

Poverty, poor access to health care

Multidrug-ResistantTuberculosis
(MDR-TB)

Occurs whena strain develops resistanc

to two of the most potent first-line anti
TB drugs

Extensively drug-resistantTB (XDR-TB)

resistant to any fluoroquinolone plus an
injectable antibiotic

Several causes for resistance occur

Etiology and Pathophysiology

Spread
via airborne droplets

Can be suspended in air for minutes t

hours

Transmission requires close, frequen

or prolonged exposure.

NOT spread by touching, sharing foo

utensils, kissing, or other physical
contact

Etiology and Pathophysiology

inhaled, particles lodge in
Once
bronchiole and alveolus

Local inflammatory reaction occurs

Ghon focus develops into granulom

Infection walled of and further sprea

stopped

Only 5-10% will develop activeTB

Etiology and Pathophysiology

M.
tuberculosisis aerophilic (oxygenloving) causes affinity for lungs

Infection can spread via lymphatics a

grow in other organs as well:

Kidneys

Bones

Brain

Adrenal glands

Classification

Classes

NoTB exposure
0=

1 = Exposure, no infection

2=
LatentTB, no disease

3 =TB, clinically active

4 =TB, not clinically active

5 =TB suspected

Classification

Primary
infection

When bacteria are inhaled

LatentTB infection (LTBI)

Infected
but no active disease

ActiveTB disease
PrimaryTB

ReactivationTB
(post-primary)

Clinical Manifestations

LTBI
asymptomatic

PulmonaryTB

Takes 2-3 weeks to develop symptoms.

Initial dry cough that becomes productiv
Constitutional symptoms (fatigue, malai
anorexia, weight loss, low-grade fever,
night sweats)
Dyspnea and hemoptysis late symptoms

Clinical Manifestations

Cough
becomesfrequent.

Hemoptysis is not common and is usually

associated with advanced disease.
Dyspnea is unusual.

Clinical Manifestations
also present more acutely
Can

fever
High

Chills, generalized flulike symptoms

Pleuritic
pain

Productive
cough

ExtrapulmonaryTB
manifestations
Adventitious breath sounds
dependenton organs infected

Complications

MiliaryTB

Large numbers of organisms spread via t

bloodstream to distant organs.
Fatal if untreated
Manifestations progress slowly and vary
depending on which organs are infected.
Can include hepatomegaly, splenomegal
and generalized lymphadenopathy

Complications

PleuralTB

Pleural efusion

Bacteria in pleural space cause inflammation.

Pleural exudatesof protein-richfluid

Empyema

Large numbers of tubercular organisms in ple

space

Complications
TBpneumonia

Large amounts of bacilli discharged from

granulomas into lung or lymph nodes
Manifests as bacterial pneumonia

Other organ development

Spinal destruction
Bacterial meningitis
Peritonitis

DiagnosticStudies

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 toTB.

DiagnosticStudies

Tuberculin
skin test (TST)

Positive if 15 mm induration in low-risk

individuals
Response in immune-compromised
patients
Reactions 5 mm consideredpositive

DiagnosticStudies

Tuberculin skin test (TST)

A waning immune response can cause fals

negative results.
RepeatingTST may boost reaction.
Two-step testing recommended for health
care workers getting repeated testing and
those with decreased response to allerge
Two-step testing ensures future positive
results accurately interpreted.

DiagnosticStudies

Interferon- release assays (IGRAs)

Detects T-cell lymphocytes in response t

mycobacteria
IncludesQuantiFERON-TB and theTSPOT.TB tests
Rapid results
Several advantages overTST but more
expensive

DiagnosticStudies

Chest
x-ray

Cannot make diagnosis solely on x-ray

Upper lobe infiltrates, cavitary infiltrates
and lymph node involvement suggestTB.

DiagnosticStudies

Bacteriologic studies

Required for diagnosis

Sputum samples obtained (usually) on 2
consecutive days
Stained sputum smears examined for
acid-fast bacilli
Culture results can take up to 8 weeks.
Can also examine samples from other
suspectedTB sites

CollaborativeCare

Hospitalization
not necessary for mo
patients

Infectious for first 2 weeks after

starting treatment if sputum +

Drug therapy used to prevent or trea

active disease

Need to monitor compliance

DrugTherapy

Active
disease

Treatment is aggressive.
Two phases of treatment
Initial (8 weeks)
Continuation (18 weeks)

Four-drug regimen

INH

Rifampin (Rifadin)

Pyrazinamide
(PZA)
Ethambutol

DrugTherapy

Active
disease

Patients should be taught about side

efects and when to seek medical
attention.
Liver function should be monitored.

DrugTherapy

Directly

observed therapy (DOT)

Noncompliance is major factor in multidr

resistance and treatment failures.
Requires watching patient swallow drugs
Preferred strategy to ensure adherence
May be administered by public health
nurses at clinic site

DrugTherapy

LatentTB

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
rifapentineOR 4 months of rifampin

DrugTherapy

Vaccine

BacilleCalmette-Gurin (BCG) vaccine to

preventTB is currently in use in many par
of the world.
InUnitedStates, not recommended excep
for very select individuals
Can result in positive PPD reaction

NursingAssessment
History

Physical symptoms

Productivecough

Night sweats

Afternoontemperature
elevation

Weight loss

Pleuritic chest pain

Sputum collection

Crackles over apices of lungs

Nursing Diagnoses

Inefectivebreathing
pattern
Inefectiveairway clearance

Noncompliance

Inefectiveself-health management

Planning
Goals

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 theUnitedStates is

eradication.
Selective screening programs in high-risk
groups to detectTB
Treatment of LTBI
Follow-up positiveTST results
Reportable disease
Address social determinants ofTB

Nursing Implementation

Acute Intervention
Airborne isolation
Single-occupancy room with 6-12 airflow
exchanges/hour
Healthcare workers wear high-efficiency
particulate air (HEPA) masks

Immediate medical workup

Appropriate drug therapy

Nursing Implementation

Nursing Implementation

Teach
patient to prevent spread.

Covernose and mouth with tissue when

coughing,sneezing, orproducingsputum
Hand washing afterhandling sputum-soiled
tissues

Patient wears mask if outside of

negative-pressure room.

Identify and screen close contacts.

Nursing Implementation

Ambulatory
and HomeCare

Can go home evenif cultures positive

Monthly sputum cultures
Teach patient how to minimize exposure to
others
Ensurethat patient can adhereto treatment

Nursing Implementation

Ambulatory
and HomeCare
Notifyhealth
department

Teach symptoms ofrecurrence

Instruct
about factors that could reactivateTB

Smoking cessation

Evaluation

ExpectedOutcomes

Complete
resolution of disease

Normal pulmonary function

Absence
ofanycomplications

Notransmission ofTB