Nursing Care and Pathophysiology for Tuberculosis (TB)
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Outline
Pathophysiology: TB is a bacterium known as M. tuberculosis that is transmitted through airborne droplets and embeds itself in the lung periphery and multiplies. The bacilli can travel through the lymphatic system and cause an immune response. Neutrophils and macrophages attempt to defend the body and prevent the spread.
Overview
- Lung infection → pneumonitis and granulomas
- Noncompliance → multi-drug resistance (MDR-TB)
- Airborne transmission (infectious particles aerosolized)
Nursing Points
General
- Risk Factors
- Foreign travel
- Living in tight quarters
- College
- Prison
- Homeless Shelters
- Past exposure
- Diagnostics
- Chest X-ray shows granulomas
- TB Skin Test
- Anyone – >15 mm induration
- High Risk – >10 mm induration
- Immunocompromised – >5 mm induration
- Quantiferon Gold (gold standard)
- Sputum Cultures
- Mycobacterium tuberculosis
Assessment
- Night sweats
- Weight Loss
- Chills
- Fatigue
- Persistent cough
- Hemoptysis (coughing up blood)
- Chest Pain
- Anorexia
Therapeutic Management
- Therapeutic Management
- Negative Pressure Room
- Place, then measure skin test
- Particulate respirator (i.e. N95)
- Should be fitted correctly
- RIPE Therapy:
- Rifampin
- Isoniazide
- Pyrazinamide
- Ethambutol
- Treatment for 6-12 months
- Risk of transmission reduced after 2-3 weeks of medication regimen
Nursing Concepts
- Oxygenation
- Monitor resp status and lung sounds
- Monitor SpO2
- Infection Control
- Obtain sputum and blood cultures before initiating antimicrobial therapy
- Administer RIPE therapy
- Adhere to Airborne Isolation Precautions
- Patient Education
Patient Education
- Must continue entire course of treatment
- Risk for developing MDR-TB
- Signs and symptoms to report to PCP
- Eat small, frequent meals
- Cluster activities if SOB
- Contagious for 3 weeks after initiation of medication
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ADPIE Related Lessons
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Transcript
In this lesson we’ll cover tuberculosis. Tuberculosis or TB is a contagious bacterial infection that can actually present in multiple places within the body. But, most commonly it’s seen in the lungs, so that’s what we’ll be discussing today.
In this lesson we’ll cover tuberculosis. Tuberculosis or TB is a contagious bacterial infection that can actually present in multiple places within the body. But, most commonly it’s seen in the lungs, so that’s what we’ll be discussing today.
There are situations that put patients at higher risk for TB. One is that there are countries where TB is more common and therefore patients who are either from these countries or who have traveled there recently will be at higher risk for having been exposed to or being a carrier of TB. You can see it’s mostly Asian and African countries, as well as some in South America. It’s also common in those who live in tight quarters or near lots of people – examples would be prisons, homeless shelters, and even college dorms. Anyone who has been exposed in the past will be at higher risk for contracting TB statistically. And, of course, those who are immunocompromised are at risk – that would be patients with HIV or AIDS, patients on chemotherapy, or patients who have recently had organ transplants.
So how do we diagnose TB? Well the gold-standard is to see the mycobacterium on a sputum culture. However, most facilities use Acid-Fast Bacilli or AFB smears instead because they’re cheaper. We will also use a chest x-ray to look for infection and the classic granulomas, as well as do a TB skin test to determine exposure. This is a test that you’ve all likely had done at least once already since it’s required for nursing school. You’ll also get one annually when you’re working as a nurse. The tuberculin is placed intradermally and the skin is evaluated 48-72 hours later. What we’re looking for is what’s called induration. That means it is raised and hard. Some people, like myself, will have severe skin reactions and have very large red areas, but since it isn’t raised, it’s considered negative. So how do we know what’s positive. Well for anyone, if the area of induration (the raised hard part) is greater than 15 mm in diameter, that’s considered positive. However, for those at higher risk, we have a lower threshold. For those with higher risk, for example healthcare workers or people who’ve traveled to high-risk countries, an induration greater than 10 mm is considered positive. And for anyone who is immunosuppressed or with known exposure, anything over 5mm is considered positive. Then, for people like me who have the crazy redness whose tests are deemed inconclusive, they can do this super expensive lab test called the Quantiferon Gold. It’s more accurate than the PPD skin test, but it’s cost-prohibitive to do it for everyone, so the TB skin test is standard.
There are some classic symptoms of TB that you need to know. If you see a patient coming in with a persistent cough who complains of night sweats and reports they’ve lost 15 pounds in a month without even trying – I want your VERY first thought to be TB. These are classic symptoms. Night sweats and unexplained weight loss especially. Remember this is an infectious process, so that’s where the fever, chills, night sweats come from. It’s a lung infection, so you’ll see a cough, chest pain, and possibly even hemoptysis (coughing up blood). Then, because their body is working hard to fight off the infection and they’re likely struggling to breathe, we see fatigue, anorexia, and weight loss because they aren’t eating as much and their body is working overtime.
So if you even remotely suspect your patient might have TB, and especially if the doctors order AFB smears to rule it out, you need to put your patient in Airborne Isolation as soon as possible. Airborne rooms are negative pressure rooms. That means when you open the door, the air flows into the room instead of out. That keeps the aerosolized particles in the room so they don’t float throughout the hospital. You’ll wear a gown and gloves and a special particulate respirator. This is different than a standard surgical mask. You usually have to go through a special fitting process to be allowed to care for these patients. This is so important – you want to make sure your respirator fits perfectly so that you don’t risk exposure. We’ll place and read TB skin tests for patients we suspect have TB and then we’ll start them on RIPE therapy. RIPE stands for Rifampin, Isoniazide, Pyrazinamide, and Ethambutol – these are THE TB drugs – if you see these drugs, you know you’re dealing with tuberculosis. Notice that this therapy can go on for 6-12 months. This is because TB can lay dormant in the body if we don’t treat it fully. Patients are considered to not be contagious anymore after 3 weeks of therapy, but if they don’t complete the whole course, they are at risk for that multi-drug resistant TB we talked about earlier. Then, of course, with our hospitalized patients we are going to support their respiratory system and give oxygen as needed.
Make sure you check out the care plan attached to this lesson. As you probably suspected, our priority concepts for patients with tuberculosis are oxygenation, infection control, and patient education. We support their respiratory status, manage their infection and prevent it from spreading, and educate them on how important it is to take their full course of medications.
So remember that TB is a lung infection that causes pneumonitis and granulomas. It is spread by airborne transmission so we use negative pressure rooms and particulate respirator masks to contain it. Remember the classic signs of TB are night sweats and weight loss, plus a persistent cough, fever, chills, and fatigue. We use RIPE therapy for anywhere from 6-12 months to prevent the TB from laying dormant or becoming resistant. Educating our patients on the importance of compliance with their meds is a top priority.
You will see patients with TB frequently in your clinicals and when you are on the floor as a nurse – make sure you know the classic signs to look for and how to use proper airborne isolation precautions. Now, go out and be your best self today. And, as always, happy nursing!
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