Nursing BScN Acute Bronchitis, Pneumonia, TB.pptx

Acute Nursing information for Class

1. Lower Respiratory Health Challenges Acute bronchitis; Pneumonia; Tuberculosis; 1

2. Acute Bronchitis (large lower airways) “an inflammation of the bronchi in the lower respiratory tract usually caused by infection” (Seneviratne, 2019, p. 601); one of most common conditions seen in primary care (Recall last wk… chronic bronchitis is excessive production of mucus in the bronchi, with recurrent cough persisting for at least 3 months of the year for at least 2 successive years & all other causes of cough ruled out- ch. 31-COPD) 2

3. The most common cause of acute bronchitis is viral…but can also be caused by bacteria. (Seneviratne, 2019, p. 601) 3

4. Acute Bronchitis: Causes Usually is sequela to upper respiratory tract infection (URTI) ( e.g. acute viral rhinitis-common cold; influenza; sinusitis; acute pharyngitis ) Most cases: rhinovirus; influenza virus Common bacterial causes: smokers ( Streptococcus pneumonia, Haemophilus influenzae ); non-smokers ( Mycoplasma pneumonia; Chlamydia pneumonia ) Can also be an acute exacerbation of chronic bronchitis (AECB) ( i.e. acute infection superimposed on chronic ) and can lead to respiratory failure 4

5. Acute Bronchitis: Clinical Manifestations Most common symptom : persistent cough following an acute upper airway infection ( such as rhinitis; pharyngitis ) Clear, mucoid sputum; some produce purulent sputum Fever, headache, malaise, SOB on exertion Mild ↑ T, pulse, RR Normal breath sounds or expiratory wheeze Chest x-ray-no consolidation or infiltrates 5

6. Acute Bronchitis: Treatment Usually self-limiting Supportive treatment: fluids; rest; anti-inflammatory agents Cough suppressants and/or bronchodilators for nocturnal cough or wheezing Usually no antibiotics prescribed exceptions: prolonged infection; smoker; hx COPD AECB-broad spectrum antibiotics Early antibiotics for AECOPD can ↓hospitalizations 6

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25. Respiratory Defence Mechanisms Why is this important? Simply put : The mucociliary escalator sounds like what it is. The cilia in our bronchi beat rapidly to propagate mucus-trapped debris or particles up from our lungs and into the pharynx. The mucus is either spit out from the mouth or swallowed into the esophagus to the stomach, where the trapped bacteria, dust, or viruses are dissolved and broken down by the stomach’s strong acid. 25

26. …Respiratory Defence Mechanisms Nasal hairs/mucous membranes-filtration; warming Mucociliary clearance system (trachea to bronchioles) IgA in mucous protects against microbes Impaired by dehydration, smoking, high [O2], infection, anaesthetics , alcohol, cocaine Cilia are destroyed by infection causing impaired secretion clearance (e.g. COPD, chronic bronchitis, cystic fibrosis) 26

27. Pneumonia acute inflammation of the lung parenchyma caused by infection Initial diagnosis is usually based on chest x-ray and clinical findings. Causes, symptoms, treatment, preventive measures, and prognosis differ depending on whether: the infection is bacterial, mycobacterial, viral, fungal, or parasitic; it is acquired in the community or hospital; it occurs in a patient treated with mechanical ventilation ; and it develops in a patient who is immunocompetent or immunocompromised Leading cause of death & hospitalization in older adults and people with chronic diseases 27

28. CASE STUDY Read Carefully ND is a 82-year-old female who lives in a skilled nursing facility. She suffers from rheumatoid arthritis, coronary artery disease, chronic bronchitis and hypertension. She is wheel chair bound and tends to spend most of her days in bed. She smoked for 52 years but quit 14 years ago. She has lost 10 pounds in the last month and has a productive cough for about 2 weeks that has copious amounts of white to yellow mucous. Over the last 3 days she has refused to get out of bed and has been refusing to eat or drink. This morning she is confused, has a fever, and is coughing continuously. Her sputum now is rust-colored. Her lungs sounds are coarse rhonchi throughout with crackles and diminished lung sounds in her right middle lobe area. Her vital signs are BP 86/54, HR 98, RR 28 and temperature 102.4. She is being admitted to the hospital. 28

29. Case study….DO YOU KNOW? Pneumonia can be classified many different ways. Discuss the different classifications and pick which classification of pneumonia best fits ND’s situation. 29

30. What type of pneumonia does this patient have? Case Study… classification of Pneumonia CAP: Community Acquired pneumonia is when a patient’s pneumonia is developed while not in the hospital setting. Most common forms are bacterial in nature. HAP: Hospital Acquired pneumonia is when pneumonia is developed after 48 hour of hospitalization. Pneumonias can also be divided into the causative organisms such as bacterial, atypical and viral. Bacterial organisms are broken down into gram+ and gram negative organisms. Streptococcus and staphylococcus bacteria are the most common gram+ bacteria. The most common gram negative organisms are Klebsiella, Haemophilus influenza, and Pseudomonas aeruginosus . Atypical pneumonias are mycoplasma, legionnaire and pneumocystis (carinii) jeroveci pneumonia. 30

31. What type does the pt have? ND most likely has a CAP, community-acquired pneumonia, staphylococcus or streptococcus. 31

32. Re read the case study… ND is a 82-year-old female who lives in a skilled nursing facility. She suffers from rheumatoid arthritis, coronary artery disease, chronic bronchitis and hypertension. She is wheel chair bound and tends to spend most of her days in bed. She smoked for 52 years but quit 14 years ago. She has lost 10 pounds in the last month and has a productive cough for about 2 weeks that has copious amounts of white to yellow mucous. Over the last 3 days she has refused to get out of bed and has been refusing to eat or drink. This morning she is confused, has a fever, and is coughing continuously. Her sputum now is rust-colored. Her lungs sounds are coarse rhonchi throughout with crackles and diminished lung sounds in her right middle lobe area. Her vital signs are BP 86/54, HR 98, RR 28 and temperature 102.4. She is being admitted to the hospital. What is the most probable cause of ND’s pneumonia? 32

33. What is the probable cause? ND is elderly and is immobilized. She primarily stays in bed and is not ambulating. She is immunosuppressed by her autoimmune disease and she is chronically ill. ND’s long history of smoking and her damaged lungs make it easier for the bacteria to multiply and harder for her to expectorate the mucous. 33

34. Case study questions 3. What diagnostic tests would you expect to be done to diagnose ND’s pneumonia? 4.Describe what “ CURB 65” is and does ND meet the criteria? 34

35. …Pneumonia: Diagnostics History & physical CURB-65 or Pneumonia Severity Score (PSI) Calculator Chest x-ray Sputum for C&S (before antibiotics) Sputum gram stain 2 blood cultures before tx (if seriously ill) Pulse oximetry or ABGs (hypoxemia) CBC (↑WBC) (>15x10 9 /L with band neutrophils) 35 A : Normal chest x-ray. B : Abnormal chest x-ray with shadowing from effusion in the right lung (white area, left side of image).

36. Describe CURB… Answer:  “CURB 65” is a set of data points that will help you decide whether or not to admit the patient to the hospital . Usually this is used if a gram negative bacteria is considered in a patient who has been hospitalized or has a chronic illness such as ND, the patient in the case study, does. The data points are: (1)  c onfusion, (2) B U N > 19.6 mg/dl, (3)  R espiratory rate > 30 breaths per minute, (4) systolic  B P < 90 mm Hg, and diastolic  B P ≤ 60 mm Hg, (5) age ≥ 65 years. ND has 4 of the 5 data points and should be hospitalized. 36

37. Pneumonia: Predisposing Factors Defence mechanisms overwhelmed (e.g. ↑virulence or quantity of microbes) ↓LOC…↓ cough; ↓epiglottal reflexes;↓ mucocilliary clearance (MC) Tracheal intubation Air pollution, cigarette smoking, URIs, aging Malnutrition-↓macrophage ↓leukocyte function Leukemia, alcoholism, DM…↑Gram neg. bacilli in oropharynx Chronic diseases (e.g. DM; COPD; CRD) & HIV infection Altered oropharyngeal flora due to antibiotic tx for infection elsewhere in body Intestinal and gastric feedings Bedrest /prolonged immobility (see table in text) 37

38. Pneumonia: Acquisition of Organisms Aspiration of microbes in secretions from nasopharynx or oropharynx Inhalation of microbes (e.g. M. pneumonia; fungal) Hematogenous spread of infection elsewhere in body (e.g. S taphylococcus aureus ) 38

39. Community Acquired versus Hospital Acquired Pneumonia (CAP vs HAP) CAP “lower respiratory tract infection of the lung parenchyma with onset in the community or during the first 2 days of hospitalization” (p. 601-602) Highest incidence in winter Smoking key risk factor Most common cause: Streptococcus pneumonia HAP “pneumonia occurring 48 hrs or longer after hospitalization and not incubating [time between exposure and onset symptoms] at the time of hospitalization” ( p. 602) 25% of all ICU infections High morbidity/mortality rates Majority caused by bacteria entering lungs from pharyngeal secretion aspiration Predisposing factors: immunosuppression; ET tube; general disability Contaminated respiratory equipment (e.g. suctioning, ventilators) 39

40. 40 How could YOU decrease or prevent VAP

41. To prevent VAP Keep the head of the patient’s bed raised between 30 and 45 degrees unless other medical conditions do not allow this to occur. Check the patient’s ability to breathe on his or her own every day so that the patient can be taken off of the ventilator as soon as possible. Clean hands with soap and water or an alcohol-based hand rub before and after touching the patient or the ventilator. Clean the inside of the patient’s mouth on a regular basis. Clean or replace equipment between use on different patients. 41

42. Pneumonia Classification: Fungal Pneumonia Organisms (e.g. Candidiasis; Aspergillosis )[ FYI see table ] Increasing in incidence Most frequent in seriously ill patients (e.g. corticosteroid tx ; antineoplastic & immunosuppressive drugs; AIDs; cystic fibrosis) No person-to-person transmission ; isolation not necessary Clinical manifestations similar to bacterial pneumonia Treatment: IV Amphotericin B: highly toxic+++ Many adverse effects (hypersensitivity; fever, chills, malaise, N&V, renal impairment; thrombophlebitis at IV site); premed with Benadryl or anti-inflammatory; monitor renal function; hydrate; Must be given IV as poor GI absorption Treatment: oral antifungals (e.g. fluconazole) Fungal serology titres 42

43. Pneumonia Classification: Aspiration Pneumonia Aspiration pneumonia- “sequelae of abnormal entry of secretions or substances into the lower airway” (p. 602) Usually follows aspiration of material from mouth or stomach into trachea and lungs Risk factors: ↓LOC (seizure; anaesthesia; head injury; stroke; alcohol intake) with ↓gag/cough reflexes; tube feedings; Forms of aspiration pneumonia: Obstructive (inert substances e.g. barium); Chemical (e.g. gastric enzymes); Bacterial (oropharyngeal flora). Aspiration pneumonia is a serious problem among elderly patients; it is caused by many risk factors including dysphagia, poor oral hygiene , malnutrition, and sedative medications (Nishizawa et al., 2019) Aspiration pneumonia represents 5 – 15% of pneumonias in the hospitalized population ( DiBardino , 2015, from Canadian Patient Safety Institute on Aspiration Pneumonia). 43

44. Pneumococcal Pneumonia (PP) Streptococcus pneumoniae is known in medical microbiology as the pneumococcus , referring to its morphology and its consistent involvement in pneumococcal pneumonia . Most common cause of bacterial pneumonia 44 + Gram Stain of sputum smear

45. Pneumonia: Clinical Manifestations Typical: sudden onset of fever, chills, cough productive of purulent sputum , pleuritic chest pain in some; confusion (older adults); pulmonary consolidation (  region of normally compressible lung tissue that has filled with liquid instead of air. ; dullness to percussion; bronchial breath sounds; crackles Atypical : gradual onset ; dry cough ; extra-pulmonary symptoms (headache, myalgia, fatigue, sore throat, nausea, vomiting, diarrhea) - usually caused by Mycoplasma pneumoniae – “Walking pneumonia” Viral pneumonia: chills, fever, dry nonproductive cough; extra-pulmonary symptoms; also associated with measles, varicella-zoster, and herpes simplex 45

46. True or False? The term “walking pneumonia” is generally used to describe Mycoplasma pneumonia Viral pneumonia is associated with chicken pox A cough that produces green, yellow, or bloody mucus/ sputum is the most common symptom of pneumonia. People can develop bacterial pneumonia after a case of the flu. 46

47. Pneumonia: Complications Pleurisy -inflammation of the pleura Pleural effusion (fluid in pleural space) Atelectasis Delayed resolution Lung abcess Empyema (puss in pleural space) Pericarditis -infection of pericardium Bacteremia Meningitis-CSF infection Endocarditis-infection of endocaridium and /or valves 47

48. 48 A closer look at the pleural space

49. Analyze the following… 49

50. 50 ACID Normal BASE pH CO2 HCO3 - pH 7.35 – low normal PaCO2 46 mmHg - high HCO3 34 mmol/L - high Fully Compensated Respiratory Acidosis

51. 51 https://www.mdcalc.com/calc/324/curb-65-score-pneumonia-severity#next-steps

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53. Pneumonia: Collaborative Care Appropriate antibiotic therapy (for bacterial & mycoplasm ) Limited activity and rest Antipyretics (Tylenol); analgesics O2 therapy as required Outpatient vs inpatient tx : depends on risk category Nutritional therapy: ↑ fluid intake (at least 3 L/day if not contraindicated); IV fluids; 1500 calories (small, frequent meals ) Droplet/contact precautions (minimum 72 hrs) 53

54. Pneumonia: Collaborative Care… vaccine Pneumococcal vaccine: Indicated for: those at risk: chronic illness (e.g. lung and/or heart disease; DM) Recovering from severe illness 65 years or older Residing in LTC Current recommendations (PHAC, 2022) Can be given at same time as flu vaccine, but each should be given in a different site – x1 per lifetime or…Every 5 years: asplenic ; nephrotic syndrome; renal failure; AIDS; transplant recipient 54

55. Clinical response (well-being) Clinical response to therapy is evaluated by: Do they have fever? Is there sputum purulence, leukocytosis? What is their oxygenation status? Are there radiographic changes? Response to therapy usually occurs in 48 to 72 hours If no improvement, consider changing the antibiotic regimen; testing for other pathogens (e.g. Legionella; TB? ); further imaging, or alternate diagnoses Patients who deteriorate require aggressive investigation to assess for underlying noninfectious disorders or comodbidities 55

56. Which of the following indicates a positive clinical response to treatment for HAP ? Select All that Apply WBC 8 x 10 9 /L PaO2 95 mmHg ABG: pH 7.5 T 38.5 °C 56 Know your norms for these labs!

57. Which of the following indicates a positive clinical response to treatment for HAP? Select All that Apply WBC 8 x 10 9 /L PaO2 95 mmHg ABG: pH 7.5 T 38.5 °C 57

58. Pneumonia: Prevention CAP Prevention: ↑natural resistance: diet, hand hygiene, rest, exercise Treat URIs promptly with supportive measures; see MD if symptoms persist after 7 days Vulnerable: flu (annual) & pneumococcal vaccines (at least once) 58 This Photo by Unknown Author is licensed under CC BY-NC

59. How to prevent CAP? (Select all that Apply) Healthy diet, rest, exercise Frequent hand hygiene See MD for all URIs lasting 5 days Annual flu shot Annual pneumococcal vaccine A) d, e B) c, d, e C) a, b, d D) a, b, c, d, e 59

60. How to prevent CAP? (Select all that Apply) Healthy diet, rest, exercise Frequent hand hygiene See MD for all URIs lasting 3 days Annual flu shot Annual pneumococcal vaccine A) d, e B) c, d, e C) a, b, d D) a, b, c, d, e 60

61. Identify 5 or more nursing interventions to prevent HAP? 61

62. …Pneumonia: Prevention HAP Prevention: Identify at risk clients Altered LOC-↓ risk aspiration (side lying upright) Turn and reposition q 2h Oral hygiene Feeding tube precautions Dysphasia-feeding precautions Immobile-turning & DB&C/incentive spirometry Strict medical asepsis and IPAC Maintenance inhalers Handwashing or alcohol rub Exercise & early mobilization 62

63. Pneumonia: Acute Intervention Respiratory assessment ↑HOB (if not contraindicated) Oxygen, inc. spirometry Medications (bronchodilators, analgesics, antibiotics) position “good lung down” (lateral) position-promotes max lung expansion Mobilize Systemic fluids to liquefy secretions Balance rest/activity (see nursing care plan in text) 63

64. The classification of pneumonia as community acquired (CAP) versus hospital acquired (HAP) is clinically useful because: A) Atypical pneumonia syndrome is more likely to occur in HAP B) Diagnostic testing does not have to be used to identify causative agents C) Causative agents can be predicted and empirical treatment is often effective D) Intravenous antibiotic therapy is necessary for HAP while oral therapy is adequate for CAP 64

65. The classification of pneumonia as community acquired (CAP) versus hospital acquired (HAP) is clinically useful because: A) Atypical pneumonia syndrome is more likely to occur in HAP B) Diagnostic testing does not have to be used to identify causative agents C) Causative agents can be predicted and empirical treatment is often effective D) Intravenous antibiotic therapy is necessary for HAP while oral therapy is adequate for CAP 65 Empirical treatment-therapy based on observation & experience p. 604

66. What clinical manifestation should the nurse expect when assessing a client with pneumococcal pneumonia? Nonproductive cough, night sweats Fever, chills, productive cough, purulent sputum Gradual onset nasal stuffiness, sore throat, purulent cough Abrupt onset fever, nonproductive cough, formation lung abscesses 66

67. What clinical manifestation should the nurse expect when assessing a client with pneumococcal pneumonia? Nonproductive cough, night sweats Fever, chills, productive cough, purulent sputum Gradual onset nasal stuffiness, sore throat, purulent cough Abrupt onset fever, nonproductive cough, formation lung abscesses 67

68. Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?  Turn and reposition immobile patients at least every 2 hours.  Place patients with altered consciousness in side-lying positions.  Correct  Monitor for respiratory symptoms in patients who are immuno-suppressed.  Provide for continuous subglottic aspiration in patients receiving enteral feedings. 68

69. Which of the following nursing actions is most effective in preventing aspiration pneumonia in patients who are at risk?  Turn and reposition immobile patients at least every 2 hours.  Place patients with altered consciousness in side-lying positions.  Monitor for respiratory symptoms in patients who are immuno-suppressed.  Provide for continuous subglottic aspiration in patients receiving enteral feedings. 69

70. Which of the following prescriptions should the nurse implement first for a patient who has just been admitted with probable bacterial pneumonia and sepsis? 70

71. The nurse is providing teaching to a patient with pneumonia. Which of the following patient statements indicate a good understanding of the discharge instructions given by the nurse? 71

72. Deep breathing exercises 72

73. Tuberculosis (TB) I nfectious disease usually caused by  Mycobacteriumtuberculosis  (MTB) bacteria. Tuberculosis generally affects the lungs but can also affect other parts of the body. Kills more people worldwide than any other infectious disease Most infections show no symptoms, known as  latent tuberculosis . About 10% of latent (dormant) infections progress to active disease which, if left untreated, kills about half of those affected. The classic symptoms of active TB are a chronic cough with blood-containing mucus, fever, night sweats, and weight loss. TB was historically called  consumption  due to the weight loss. Infection of other organs can cause a wide range of symptoms. 73

74. TB incidence 1/3 of the world's population is infected with TB and TB is the second leading cause of death from an infectious disease. The incidence of TB in Canada is among the lowest in the world. However, certain sub-populations in Canada remain at risk: Aboriginal persons in areas with a high prevalence of TB (particularly infants), Canadian-born elderly persons, immigrants, homeless persons and those infected with HIV. REVIEW https://www.tbinfocus.ca/tb-epidemiology-in-canada/ Review current stats on TB https://www.tbinfocus.ca/tb-epidemiology-in-canada/ 74

75. True or False TB is spread by fomites and droplets of tiny particles that can remain in the air for hours. Transmission usually requires close, frequent or prolonged exposure 75 This Photo by Unknown Author is licensed under CC BY-SA-NC

76. TB –Etiology/Patho Mycobacterium tuberculosis  (MTB)  Gram-positive bacteria Airborne droplet transmission of tiny particles that indoors can remain airborne minutes to hours; inhaled and lodge in bronchiole and alveolus MTB replicates and spreads via lymphatic system; upper lung lobes, kidneys, epiphyses of bone, cerebral cortex, adrenal glands Transmission usually requires close, frequent or prolonged exposure; brief exposure not likely to cause infection Cannot be spread by fomites (i.e. hands, books, dishes) 76

77. TB – Pathogenesis 77 Pathogenesis Overview 9:06 min https://www.youtube.com / watch?v =sF3rdBd5yDI Ghon tubercle - central portion of Granuloma; granuloma tissue mass becomes necrotic forming a caseous or “cheesy mass”;

78. Ghon complex: seen on x ray 1. A granuloma is formed. About 3 weeks after the initial infection, more specific immune cells ( such as T cells ,  B cells , and  Neutrophils ) surround the site of TB infection, creating a wall of immune cells known as a  granuloma , which isolates the bacteria and prevents it from spreading. 2. Ghon focus is a necrotic area. The tissue inside the granuloma then dies during a process referred to as caseous necrosis, or cheese-like necrosis. This necrotic area is known as a Ghon focus.  3. Ghon complex is made. TB infection can also spread to nearby hilar lymph nodes, either carried through the lymph or by direct  extension  of the Ghon focus. Together, the caseating tissue and associated lymph node involvement make up the characteristic “ Ghon complex.” 78 https://www.osmosis.org/answers/Ghon-complex

79. TB-clinical manifestations Early stages : may be symptom free Systemic: fatigue, malaise, anorexia, weight loss, low-grade fever, night sweats Pulmonary: frequent cough; mucopurulent sputum; (dyspnea is unusual); chest pain- “dull” “tightness”; hemoptysis (not common; usually late findings); May have acute/sudden onset: high fever, chills, flu-like symptoms, pleuritic pain, productive cough If HIV positive-atypical findings; careful not to confuse with pneumocystis pneumonia (PCP) 79

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81. TB -Complications MilIary Tuberculosis: necrotic “ Gohn complex ” (seen on X-ray) erodes a blood vessel-bacteria spread to all organs; acute (fever, dyspnea, cyanosis) or chronic (weight loss, fever, GI upset) presentation; hepatomegaly, generalized lymphadenopathy may be present Pleural Effusion (excess fluid in pleural space) and empyema (pus in pleural space): caused by ulceration of granuloma & release of caseous or “cheesy” material into pleural space Tuberculosis pneumonia: release of tubercle bacilli into lung and/or lymph nodes on rupture of a granuloma; manifests as bacterial pneumonia (chills, fever, productive cough, pleuritic chest pain, elevated WBC) Other organ involvement: meninges, bones, joints, kidneys, adrenal glands, lymph nodes, genital tract (male & female) 81

82. Tuberculosis- Diagnostics Mantoux Tuberculin Skin Test: injecting 0.1 ml of tuberculin purified protein derivative (PPD) into the inner surface of the forearm; tuberculin syringe; bevel facing upward; read between 48-72 hours after administration by trained personnel; reaction measured in mm of the induration (firm swelling or hardness) not erythema . www.cdc.gov/tb/publications/factsheets/testing/skintesting.pdf Review: https://www.healthlinkbc.ca/tests-treatments-medications/medical-tests/tuberculin-skin-test 82

83. Tuberculosis-Diagnostics Chest x-ray : reveal useful findings, but cannot use to diagnose TB Bacteriological Studies: Sputum Smear -acid-fast bacilli-3 consecutive specimens collected on different days; sent for smear and culture and sensitivity (C&S); culture can take 6-8 weeks for the mycobacteria to grow Nucleic acid amplification (NAA) -rapid diagnostic test of sputum; results in a few hours ; supports the diagnosis of TB in a patient for whom there is a reasonable index of suspicion; does not replace the need for sputum smear and C&S QuantiFERON - rapid diagnostic-TB Gold In-Tube- pt’s blood is mixed with mycobacterial antigens-if infected the lymphocytes in blood recognize the antigens 83

84. Tuberculosis-Collaborative Care Active TB treatment: global prevalence of multidrug-resistant TB (MDR TB) (i.e. resistance to 2 or more drugs) is rising Initial phase of treatment is 8 months Managed aggressively Combination of at least 4 drugs increases effectiveness & decreases development of resistant strains First line Canadian drugs : isoniazid (INH), rifampin (RMP), pyrazinamide (PZA); ethambutol (EMB)-monitoring liver enzymes due to risk of hepatitis and liver failure Common second line drugs: fluoroquinolones (e.g. moxifloxacin, levofloxacin) and injectables (e.g. streptomycin, amikacin) Sputum specimens weekly (initially) then monthly to assess effectiveness of medications; negative sputum=effective treatment Follow-up care – essential to avoid non-adherence leading to MDR Directly observed therapy (DOT)- recommended for those at risk for non-adherence 84

85. Tuberculosis-Collaborative Care Latent TB Infection treatment (LTBI): Drug therapy may prevent from developing into clinical disease Older terms were confusing- “preventative therapy” “chemoprophylaxis” Drug of choice is Isoniazid (INH) 85

86. Tuberculosis - Collaborative Care 86

87. TB Vaccination Why is it not recommended for routine use in Canada? Bacillus Calmette – Guérin  ( BCG ) vaccine is in use in many parts of the world Millions vaccinated despite questionable effectiveness of vaccine Can result in positive PPD (skin test) reaction; therefore a positive test is considered greater than or equal to 10 mm induration BCG vaccine is not recommended for routine use in any Canadian population; following consideration of local TB epidemiology and if a program of early detection and treatment of latent TB infection cannot be implemented, BCG vaccination may be considered in exceptional circumstances, such as for infants in high-risk communities, for persons at high risk of repeated exposure, for certain long-term travelers to high prevalence countries, and in infants born to mothers with infectious TB disease. (https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-2-bacille-calmette-guerin-vaccine.html) 87

88. Tuberculosis Acute Care (seldom required for persons with TB but if it is…) Respiratory isolation (negative pressure room (  6 exchanges /hr); airborne precautions (mask fit with high efficiency particular air (HEPA) mask; UV radiation of air in upper part of room (if available) Four drug therapy Chest x-ray, sputum smear, sputum C&S Patient Teaching Cover nose and mouth with tissue for coughing, sneezing, sputum expectoration Discard tissues in paper bag for removal during daily cleaning processes for room Handwashing technique 88 N 95-Fitted

89. Tuberculosis Ambulatory and Home Care Client-centred approaches to care planning throughout course of treatment (increases chance of adherence) Important that patient fully understands the potential consequences of non-adherence Public health nurse may be involved and responsible for DOT when patients are unable to adhere to self-medication regime Evidence of negative sputum cultures is end treatment goal; 5% pf patient relapse (must be taught to recognize symptoms) Risk factors for reactivation of TB: Immunosuppressive therapy, cancer, prolonged illness 89 Direct Observation

90. IPAC precautions for the client with TB include: Restrict all visitors Gown, gloves for direct care Mask, gown, gloves for direct care Negative pressure private room and N95 mask 90

91. IPAC precautions for the client with TB include: Restrict all visitors Gown, gloves for direct care Mask, gown, gloves for direct care Negative pressure private room and N95 mask 91

92. DO YOU KNOW The nurse is caring for patients with active  t u b erculosis (TB) who misuse alcohol and/or are homeless. Which of the following interventions by the nurse will be most effective in ensuring adherence with the treatment regimen?  Educating the patient about the long-term impact of TB on health  Giving the patient written instructions about how to take the medications  Teaching the patient about the high risk for infecting others unless treatment is followed  Arranging for a daily noontime meal at a community centre and giving the medication then  92

93. DO YOU KNOW The nurse is caring for patients with active  t u b erculosis (TB) who misuse alcohol and/or are homeless. Which of the following interventions by the nurse will be most effective in ensuring adherence with the treatment regimen?  Educating the patient about the long-term impact of TB on health  Giving the patient written instructions about how to take the medications  Teaching the patient about the high risk for infecting others unless treatment is followed   Arranging for a daily noontime meal at a community centre and giving the medication then  Correct 93

94. The nurse is providing teaching to a patient with pulmonary  t u b erculosis (TB) regarding the transmission of TB. Which of the following patient actions indicate that the teaching has been effective?  Demonstrates correct use of a nebulizer.  Washes dishes and personal items after use.  Covers the mouth and nose when coughing.  Correct  Reports daily to the public health department. 94