3. Tuberculosis Causative Organism Mycobacterium Tuberculosis Gram-positive, acid-fast bacillus ( AFB)

4. Etiology and Pathophysiology Brief exposure rarely causes infection Transmission requires close, frequent, or prolonged exposure Inhaled bacilli pass down and lodge in the alveoli Replicates slowly and spreads via the lymphatic system Body immune system responds by initiating the inflammatory response.

5. Transmission of Tuberculosis  How is Tuberculosis transmitted?

6. Transmission of Disease Spread via airborne droplets when infected person Coughs Speaks Sneezes Sings

7. Ask Yourself? Can the disease be spread by:  Hands  Books  Glasses  Dishes  Clothing  Bedding

9. Individuals at Risk  Poor, underserved  Homeless persons  Residents of inner-city neighborhoods  Foreign-born person  Older adults  Those in institutions (long-term care facilities, prisons)  Injection drug users  Immunosuppressed  Asian, native Hawaiian have highest reported cases

10. Classification System for TB No TB exposure Not infected No history of exposure Negative reaction to tuberculin skin test TB exposure No evidence of infection History of exposure Negative reaction to tuberculin skin test TB infection No disease Positive reaction to tuberculin skin test Negative bacteriologic studies (if done) No clinical, bacteriological, or radiographic evidence of active TB TB, clinically activeM. tuberculosis cultured (if done) Clinical, bacteriological, or radiographic evidence of current disease TB Not clinically active History of episode(s) of TB or Abnormal but stable radiographic findings Positive reaction to the tuberculin skin test Negative bacteriologic studies (if done) and No clinical or radiographic evidence of current disease TB suspected Diagnosis pending Class Type Description 0 1 2 3 4 5

11. What can trigger reactivation of latent TB infection (LTBI) What can trigger reactivation of latent TB infection (LTBI) Answer: Host’s defenses become impaired

12. Which of the following are Signs and Symptoms? Select all that apply a. Fatigue b. Non-productive cough c. Weight loss d. Sudden onset of high fever >102 0 e. Night sweats f. Anorexia g. Decreased movement of chest wall

13. Signs and Symptoms Cough becomes frequent Produces white, frothy sputum Hemoptysis is not common and is usually associated with advanced disease

14. Complications  Pleural effusion and empyema Caused by bacteria in pleural space Inflammatory reaction with plural exudates of protein-rich fluid  TB pneumonia Large amounts of bacilli discharging from granulomas into lung or lymph nodes

16. TB Skin Test (Mantoux) Uses purified protein derivative (PPD) intradermal

17. Administering the Tuberculin Skin Test Inject intradermally Produce wheal 6 mm to 10 mm in diameter Do not recap, bend, or break needles, or remove needles from syringes Follow universal precautions for infection control

18. Reading the Tuberculin Skin Test  Read reaction 48-72 hours after injection  Measure only induration  Record reaction in millimeters  Positive reaction => 5 mm induration – high risk persons => 10 mm induration – moderate risk persons => 15 mm induration – low risk persons Means that the person has been exposed to Tb and developed antibodies, does not differentiate between active and dormant Tb infection.

20. Factors that May Affect the Skin Test React ion Type of Reaction Possible Cause False-positive Nontuberculous mycobacteria BCG vaccination Anergy False-negative Recent TB infection Very young age (< 6 months old) Live-virus vaccination Overwhelming TB disease

23. If a person has other symptoms and has a negative skin test, then the HCP would likely order a __________ ________?

24. Chest X-Ray Does this chest x-ray confirm the diagnosis of Tb? Abnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower lobe Arrow points to cavity in patient's right upper lobe.

25. Bacteriologic Studies Sputum for AFB QuantiFERON-TB Blood is obtained from patient and placed in container with mycobacterial antigens. If the patient is infected with TB, the lympocytes in the blood will recognize these antigens and secrete interferon, a cytokine produced by lymphocytes. Test results are available in a few hours. AFB (shown in red) are tubercle bacilli

26. Sputum Cultures Use to CONFIRM diagnosis of TB Culture all specimens, even if smear negative Results in 4 to 14 days when liquid medium systems used Colonies of M. tuberculosis growing on media

28. Goals of Nursing Care Goals: Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease

30. Four Drug Regimen isoniazid [INH] rifampin [Rifadin] pyrazinamide [PZA] ethambutol

31. Drug Therapy Active disease Patients should be taught about side effects and when to seek medical attention Liver function should be monitored

32. DrugSide effectsNursing Implications Isoniazid (INH) Noninfections hepatitis Peripheral neuropathy Hypersensitivity Give B 6 pyridoxine as prophylactic against peripheral neuropathy Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritus) Take on empty stomach Avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts) Check liver enzymes, BUN, Creatinine levels monthly Rifampin (Rifadin) GI disturbances Orange discoloration of body fluids (sputum, urine, sweat, tears)  Metabolism of other meds and makes them ineffective such as cardiac meds and steroids. Inform patient about orange discoloration of fluids/ urine Discolor contact lenses

33. DrugSide effectsNursing Implications EthambutolRetrobulbar neuritis (decreased red-green color discrimination) Get a baseline Snellen vision test and color discrimination and monthly when on high doses Pyrazinamide (PZA)Hepatoxicity, polyarthritis, Skin rash, hyperuricemia Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritus) Monitor uric acid levels Have newer drugs with combinations of these

34. Treatment Guidelines Initiation Phase of Treatment Multiple-medication regimen of all 4 meds Administered daily for 8 weeks Continuation Phase of Treatment d/c ethambutol and continue other 3 meds Administered for 4-7 months Patient begins to feel better in this phase

35. Drug Therapy Latent TB infection Individual is infected with M. tuberculosis, but does not have the disease. Usually has been exposed to someone with tuberculosis. Usually treated with INH for 6 to 9 months

36. Monitoring Response to Treatment  Monitor patients bacteriologically monthly until cultures convert to negative  After 3 months of therapy, if cultures are positive or symptoms do not resolve, reevaluate for  Potential drug-resistant disease  Nonadherence to drug regimen  If cultures do not convert to negative despite 3 months of therapy, consider initiating DOT

37. Monitoring Response to Treatment The patient asks how long before he can be considered The patient asks how long before he can be considerednon-contagious? What is the appropriate response?

38. Answer this How would the nurse assess if the patient has been compliant with taking their medications?

39. Direct Observation Therapy Used with those patients who are noncompliant and do not show signs of improvement after treatment. Noncompliance is major factor in multidrug resistance and treatment failures Provide drugs directly to the patient and watch patient swallow drugs Costly, but preferred to ensure adherence If refuses DOT then may have to put involuntarily in treatment facility to protect the community.

40. Drug Therapy Vaccine Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world - once person receives this vaccine, will have a false testing with the TST (TB Skin Test). For assessment, must have chest x-ray.

41. Nursing Interventions What type of isolation is typically ordered? What PPE is worn? Who wears this equipment? What type of room are they in? Patient Teaching Cover nose and mouth with tissue when coughing, sneezing, or producing sputum Hand washing after handling sputum-soiled tissues Ambulatory and home care

43. Fungal Infections - Who is at Risk Seriously ill patients being treated with Corticosteroids Antineoplastic drugs Immunosuppressive drugs Patients with AIDS Patients with Cystic Fibrosis

44. Fungal Infections Histoplasmosis Cocciidiodomycosis Blastomycosis Cryptococcosis Aspreigillosis Pneumocystis pneumonia Nocardiosis Actinomycosis Candidiasis

45. Diagnosis SkinSerologyBiopsy

47. Drug therapy Amphotericin B Intravenous Side effects Hypersensitivity reactions Fever and chills Malaise Nausea and vomiting Thrombophlebitis at injection site Pre-medicate with Benadryl to increase tolerance and decrease hypersensitivity Monitor renal function Ensure adequate hydration

48. Drug Therapy Oral Antifungal agents ketoconazole (Nizoral) fluconazole (Sporanox; Difulcan) Flucytosine (Anobon) Monitor effectiveness with serology testing Side Effects N/V  liver enzymes Bone marrow depression – monitor WBC, platelets

50. Lung Abscess Pus-containing lesion of the lung Formed by necrosis of lung tissue

51. Lung Abscess Causes Aspiration of material from GI tract into lungs Lung cancer Tuberculosis

52. Signs and Symptoms Productive cough of purulent foul smelling and foul tasting sputum Fever and chills Pleuritic pain Dyspnea Weight loss

53. Diagnosis Sputum cultures – obtained first so can confirm treatment modalities Chest x-ray Bronchoscopy

54. Treatment and Nursing Care Drug Therapy- Antibiotics Penicillin Clindamycin **Large doses of IV are required because the antibiotic must penetrate the necrotic tissue and fluid in the abscess. **May need to make home health referral for IV to be given at home Antipyretics Chest physiotherapy and postural drainage

55. Treatment and Nursing Care Drug Therapy Increase fluid intake Rest Good nutrition

56. Nursing Care How do you know if the treatment is effective?