Pulmonary tuberculosis and its management

Pulmonary tuberculosis and its management

1. PULMONARY TUBERCULOSIS AND ITS MANAGEMENT

2. INTRODUCTION Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma. It may also be transmitted to other parts of the body, including the meninges, kidneys, bones, and lymph nodes. The primary infectious agent, Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. 30-04-2020 2

3. TB is a worldwide public health problem, and the mortality and morbidity rates continue to rise. The estimated TB incidence in India is 27 Lakhs (2018). Affected population is mainly in the age group of 15-69 years and 2/3rd being males. HIV co-infection among TB was nearly fifty thousand cases amounting to TB HIV coinfection rate of 3.4%. 30-04-2020 3

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5. ETIOLOGY •Mycobacterium tuberculosis •Mycobacterium africanum •Mycobacterium microti •Mycobacterium Bovis All cause tuberculosis (TB) and are members of the tuberculosis species complex but the main cause is Mycobacterium tuberculosis. 30-04-2020 5

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7. RISK FACTORS •Close contact with someone who has active TB. •Immunocompromised status •Substance abuse •Any person without adequate health care •Pre-existing medical conditions •Immigration from countries with a high prevalence of TB (south-eastern Asia, Africa, Latin America, Caribbean) •Institutionalization •Living in overcrowded, substandard housing •Being a health care worker performing high-risk activities: sputum induction procedures, bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient, etc. 30-04-2020 7

8. PATHOPHYSIOLOGY Initial infection or primary infection Entry of micro organism through droplet nuclei Bacteria is transmitted to alveoli through airways Deposition and multiplication of bacteria Bacilli are also transported to other parts of the body through blood stream 30-04-2020 8

9. Phagocytosis by neutrophils and macrophages Accumulation of exudate in alveoli Broncho pneumonia New tissue masses of live and dead bacilli are surrounded by macrophages which form a protective mass around granulomas Granulomas then transforms to fibrous tissue mass and central portion of which is called ghon tubercle 30-04-2020 9

10. The material (bacteria and macrophages) becomes necrotic forming cheesy mass Mass becomes calcified and becomes collagenous scar Bacteria become dormant and no further progression of active disease Active disease or re infection Inadequate immune response Activation of dormant bacteria 30-04-2020 10

11. Ghon tubercle ulcerates and releasing cheesy material into bronchi Bacteria then become airborne resulting in further spread of infection Ulcerated tubercle heals and becomes scar tissue Infected lung become inflammed Further devolopment of pneumonia and tubercle formation Unless the process is arrested it spreads downwards to the hilum of lungs and later extends to adjacent lobes 30-04-2020 11

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14. CLASSIFICATION OF TB 30-04-2020 14

15. GENERAL SYMPTOMS 30-04-2020 15

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20. PULMONARY SYMPTOMS 30-04-2020 20

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24. Both the systemic and pulmonary symptoms are usually chronic and may have been present for weeks to months. The elderly usually presents with less pronounced symptoms than do younger patients. In patients with AIDS, extrapulmonary disease is more prevalent and may occur in up to 70% of cases. 30-04-2020 24

25. DIAGNOSTIC EVALUATION Complete history collection Physical examination Tuberculin skin test Chest x-ray Acid-fast bacillus smear Sputum culture QuantiFERON-TB Gold Test CBNAAT 30-04-2020 25

26. TUBERCULIN SKIN TEST Tubercle bacillus extract (tuberculin), purified protein derivative (PPD), is injected into the intradermal layer of the inner aspect of the forearm, approximately 4 inches below the elbow. Tuberculin syringe with a half-inch 26- or 27-gauge needle is used. The needle, with the bevel facing up, is inserted beneath the skin. Then 0.1 mL of PPD is injected, creating an elevation in the skin, a wheal or bleb. The test result is read 48 to 72 hours after injection. 30-04-2020 26

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30. Interpretation of Results The size of the induration determines the significance of the reaction. •A reaction of 0 to 4 mm is considered not significant. •A reaction of 5 mm or greater may be significant in individuals who are considered at risk. •An induration of 10 mm or greater is usually considered significant in individuals who have normal or mildly impaired immunity. A significant reaction indicates that a patient has been exposed to M. tuberculosis recently or in the past or has been vaccinated with bacilli Calmette-Guerin (BCG) vaccine. 30-04-2020 30

31. A reaction of 5 mm or greater is defined as positive for patients who are HIV-positive or have HIV risk factors and are of unknown HIV status, those who are close contacts with an active case, and those who have chest x-ray results consistent with tuberculosis. A nonsignificant (negative) skin test does not exclude TB infection or disease because patients who are immunosuppressed cannot develop an immune response adequate to produce a positive skin test. This is referred to as anergy . 30-04-2020 31

32. Chest X-Ray The chest x-ray may also appear normal in a patient with TB. Findings suggestive of TB include upper lobe infiltrations, cavitary infiltrates and lymph node involvement. 30-04-2020 32

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34. QuantiFERON-TB Gold Test The QuantiFERON-TB Gold (QFT-G) test is an enzyme-linked immunosorbent assay (ELISA) that detects the release of interferon-gamma by white blood cells when the blood of a patient with TB is incubated with peptides similar to those in M. tuberculosis. The results of the QFT-G test are available in less than 24 hours and are not affected by prior vaccination with BCG. Additional rapid tests for TB include the QuantiFERON-TB Gold in-tube test (QFT-GIT), the T-SPOT TB test (T-spot), and the Xpert MTB/RIF, which was endorsed by WHO. 30-04-2020 34

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41. Medical Management 30-04-2020 41

42. DOTS (directly observed treatment, short-course) It is the name given to the World Health Organization-recommended tuberculosis control strategy that combines five components: 1. Government commitment (including both political will at all levels, and establishing a centralized and prioritized system of TB monitoring, recording and training) 2. Case detection by sputum smear microscopy 3. Standardized treatment regimen directly observed by a healthcare worker or community health worker for at least the first two months 4. A regular drug supply 5.A standardized recording and reporting system that allows assessment of treatment results. 30-04-2020 42

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44. INH also may be used as a prophylactic (preventive) measure for those at risk for significant disease, including: • Household family members of patients with active disease. • HIV-infected patients with a PPD test reaction of 5 mm of induration or more. • Patients with fibrotic lesions detected on a chest x-ray, suggestive of old TB, and a PPD reaction of 5 mm of induration or more. • Patients whose current PPD test results show a change from former test results, suggesting recent exposure to TB and possible infection (also called skin test converters). • Drug (intravenous or injectable) users with PPD test results of 10 mm of induration or more. • Patients with high-risk comorbid conditions with a PPD result of 10 mm of induration or more . 30-04-2020 44

45. Other candidates for preventive INH therapy are those 35 years or younger with PPD test results of 10 mm of induration or more and one of the following criteria: • Foreign-born individuals from countries with a high prevalence of TB • High-risk, medically underserved populations • Institutionalized patients 30-04-2020 45

46. Prophylactic INH treatment involves taking daily doses for 6 to 12 months. Liver enzyme, blood urea nitrogen, and creatinine levels are monitored monthly. Sputum culture results are monitored for acid-fast bacillus to evaluate the effectiveness of treatment and the patient’s compliance with therapy. The objectives of TB therapy are: •Cure the individual patient and minimize risk of death and disability •Reduce transmission of M. tuberculosis to other persons •Prevent the development of drug resistance during therapy 30-04-2020 46

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49. COMPLICATIONS •Adverse side effects of medication therapy: hepatitis, neurologic changes (deafness or neuritis), skin rash, gastrointestinal upset •Meningitis •Spread of TB infection (miliary TB) 30-04-2020 49

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52. NURSING ASSESSMENT •Perform a complete history and physical examination. •Assess for fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum production. •Assess the lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds, crackles), fremitus, and dullness on percussion. Enlarged, painful lymph nodes may be palpated as well. •Assess the patient’s living arrangements, perceptions and understanding of TB and its treatment, and readiness to learn. 30-04-2020 52

53. Nursing Diagnosis Ineffective airway clearance related to copious tracheobronchial secretions. Imbalanced nutrition: less than body requirements related to inability to ingest adequate nutrients. Activity intolerance related to imbalance between oxygen supply and demand. Risk for impaired gas exchange related to decrease in effective lung surface. Risk for infection related to inadequate primary defenses and lowered resistance. Deficient knowledge about treatment regimen and preventive health measures and related ineffective individual management of the therapeutic regimen (noncompliance). 30-04-2020 53

54. CDC Recommendations for Preventing Transmission of Tuberculosis in Health Care Settings 1. Early identification and treatment of persons with active TB. 2. Prevention of spread of infectious droplet nuclei by source control methods and by reduction of microbial contamination of indoor air. 3. Surveillance for TB transmission. 30-04-2020 54

55. Patient education 1.Malnutrition 2.Side Effects of Medication Therapy •Patients taking INH should avoid foods containing tyramine and histamine (red wine, soy sauce, yeast extracts). Eating these types of foods while taking INH may result in headache, flushing, hypotension, light-headedness, palpitations, and diaphoresis. •The nurse informs the patient that rifampin may discolor contact lenses, so the patient may want to wear eyeglasses during treatment. 3.Multidrug Resistance 30-04-2020 55

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58. RESEARCH ARTICLES Nutritional status of tuberculosis patients, a comparative cross-sectional study Berhanu Elfu Feleke , Teferi Elfu Feleke & Fantahun Biadglegne conducted a comparative cross-sectional study in Ethiopia in 2019. A total of 5045 study participants were included. The prevalence of underweight patients was 57.17% and 88.52% of TB patients were anemic. The nutritional status of TB patients was determined by site of infection, gender of the patient, residence, intestinal parasite infection, problematic alcohol use. It concluded that high proportions of TB patients were malnourished. TB patients were highly susceptible to malnutrition and even a very distal reason for malnutrition in the community became a proximal cause for TB patients. 30-04-2020 58

59. The Prevalence and Demographic Risk Factors for Latent Tuberculosis Infection (LTBI) Among Healthcare Workers in Semarang, Indonesia. Meira Erawati and Megah Andriany conducted a cross-sectional study involving 195 healthcare workers from 34 primary health centers from August to October 2019 to determine the prevalence and demographic risk factors for latent tuberculosis infection (LTBI) among healthcare workers in Semarang, Indonesia. The prevalence of LTBI among healthcare workers in this study was 23.6%. Comorbidities were the only risk factor for LTBI identified among other risk factors. Other demographic factors such as age, gender, smoking habits, and length of work were not significant risk factors for LTBI. It concluded that healthcare workers suffering from comorbidity have a high risk for tuberculosis infection, and should not work in areas where they would be exposed to patients with tuberculosis. Healthcare workers need to apply occupational safety standards during contact with TB patients or specimens to minimize the disease transmission. 30-04-2020 59

60. SUMMARY AND CONCLUSION • As discussed throughout the presentation, learning about pulmonary tuberculosis and its management will help nurses to care for patients with pulmonary tuberculosis. • Nurses can do assessment of patients with pulmonary tuberculosis, observe the sign and symptoms, provide the necessary nursing care and support the patient psychologically. • Nurses can also counsel the patients and their family for various options available in treatment for pulmonary tuberculosis. 30-04-2020 60

61. REFERENCES 1.Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 1. Pg. no. 586-591. 2.Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private Limited. Volume II. Pg. No.1604-1609. 3.Lewis. Medical Surgical Nursing Assessment and Management of clinical problems.2015. New Delhi. Elsevier. 2nd Edition. Volume I. Pg. no. 553-559. 4.INDIA TB REPORT 2019. Available from https://tbcindia.gov.in/WriteReadData/India%20TB%20Report%202019.pdf [cited 4 April 2020] 5.Feleke, B.E., Feleke , T.E. & Biadglegne , F. Nutritional status of tuberculosis patients, a comparative cross-sectional study. BMC Pulm Med 19, 182 (2019). https://doi.org/10.1186/s12890-019-0953-0. 6.PubMed. The Prevalence and Demographic Risk Factors for Latent Tuberculosis Infection (LTBI) Among Healthcare Workers in Semarang, Indonesia. J Multidiscip Healthc . 2020; 13: 197–206. doi : 10.2147/JMDH.S241972 30-04-2020 61

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63. 1.A 55-year old male patient is admitted with an active tuberculosis infection. The nurse will place the patient in ___________________ precautions and will always wear _____________________ when providing patient care? A. Droplet, respirator B. Airborne, respirator C. Contact and airborne, surgical mask D. Droplet, surgical mask Ans- A 30-04-2020 63

64. 2.A patient has a positive PPD skin test that shows an 8 mm induration. As the nurse you know that: A. The patient will need to immediately be placed in droplet precautions and started on a medication regime. B. The patient will need a chest x-ray and sputum culture to confirm the test results before treatment is provided. C. The patient will need a test to differentiate between a latent tuberculosis infection versus an active tuberculosis infection. D. The patient will need to repeat the skin test in 48-72 hours to confirm the results. Ans- B 30-04-2020 64

65. 3. A patient has a PPD skin test (Mantoux test). As the nurse you tell the patient to report back to the office in _________ so the results can be interpreted? A. 24-48 hours B. 12-24 hours C. 48-72 hours 24-72 hours Ans- C 30-04-2020 65

66. 4.You note your patient’s sweat and urine is red-orange colored. You reassure the patient and educate him that which medication below is causing this finding? A. Ethambutol B. Streptomycin C. Isoniazid Rifampin Ans- D 30-04-2020 66

67. ASSIGNMENT Write down 3 nursing care plans of patient with pulmonary tuberculosis. 30-04-2020 67

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