1. Tuberculosis

2. What is Tuberculosis?

3. Prevalence
Tuberculosis is a bacterial infection that causes more deaths in the world than any other disease.
About 2 billion people are infected with the bacilli and about 2 million people die annually.
8 to 9 million deaths occur d/t TB
14,000 new cases in the U.S. each year
2. What percentage and number of people in the world are infected with TB? How many new cases of TB are reported each year in the US?

4. Tuberculosis (TB) Caused by: In the United States:
Mycobacterium tuberculosis
In the United States:
Rates declining
Incidence decreased with:
Improved sanitation
Surveillance
Treatment of people with active disease
Rates still high in selected populations
The Disease Process:
Chronic and recurrent
Affects the lungs
Can invade any organ

5. Resurgence of Tuberculosis!!
1980s and 1990s
Causes
HIV AIDS
Multiple drug resistant strains
Social Factors
Immigration
Poverty
Homelessness
Drug Use
Continues to decline
TB-control programs
Initiation and completion of appropriate medications
2. What has lead to the resurgence of TB? What is MDR-TB?

6. Worldwide TB Countries that account for 90% of world cases of TB
Countries of Asia
Africa
Middle East
Latin America
In Austin, Texas
Large number of immigrants, college students, and visitors from:
India
2. What percentage and number of people in the world are infected with TB? How many new cases of TB are reported each year in the US? Which cultural and ethnic groups have the highest rates of infection?

7. Other Risk Factors for TB
Overcrowded Conditions
Nursing homes, rehabilitation facilities and hospitals
Homeless shelters
Drug treatment centers and prisons
People with Altered Immune Functions
Older adults
People with AIDS
People on chemotherapy
2. Who is at highest risk for TB?

8. Spreading the Disease Mycobacterium tuberculosis Transmission
Slow-growing, rod shaped, acid fast bacillus
***Waxy outer capsule which makes it resistant to destruction
Transmission
Infectious person
Coughs, sneezes, sings, or talks
Airborne droplets
Remain suspended in the air for several hours
Susceptible Host
Breaths in microorganism
Normal defenses of the upper respiratory system do not protect.
3. Describe the microorganism that causes tuberculosis (TB). What does AFB stand for?

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

10. Risk For Infection Characteristics of the Infected Person
TB is active
How much of the lung is involved
Coughing
Extent of Contamination of the Air
Overcrowded conditions
Air circulation
Susceptibility of the Host
Immuno-compromised
Nutrition
Health
2. Who is at highest risk for TB?

11. Infection Takes Hold Minute droplet nuclei inhaled
Upper lobe
Lodges in alveolus or bronchiole
Leads to inflammation
Neutrophils and macrophages isolate seal off but cannot destroy
Sealed off colony of bacilli (tubercle)
Inside infected tissue dies
Creating a cheese-like center
4. Describe the pathophysiologic processes by which TB spreads in the body.

12. The Immune Response Adequate Inadequate
Scar tissue encapsulates the bacilli
Inadequate
Tuberculosis develops
Extensive lung destruction can occur
Spread by the blood to other organs
Genitourinary tract
Brain (meningitis)
Skeletal

13. Common Sites of TB Disease
Lungs – most common
Pleura
Bones and joints
Lymphatic system
Genitourinary systems
Central nervous system
Disseminated (miliary TB)
4. Which organ does TB most commonly affect? What other organs and systems can be involved?
Miliary spreads to other parts of the body.

14. Tuberculosis Can Spread within the Body

15. What is the difference between a
TB infection and
TB disease?
4. Differentiate between TB infection, LTBI, and TB disease. Describe the classification system for TB. What can trigger reactivation of LTBI?

16. Tuberculosis Infection
The bacteria is inhaled but the immune system encapsulates the bacteria preventing it from becoming active and progressing to a disease.
TB infection that does not have an active case is not considered a case of TB, but referred to as latent TB.
TB tubercle usually stays inactive for life, a small percent converts to active disease
What can trigger reactivation of latent TB infection (LTBI)

17. Tuberculosis Disease
The immune system is not sufficient to stop the disease so active bacteria multiply and cause clinically active disease.

18. Signs & Symptoms Fatigue, malaise (late afternoon)
Low grade fever, night sweats
Anorexia, weight loss
Hemoptysis
Frequent productive cough
mucoid or mucopurulent
Tight, dull chest
Joint pain
5. Describe the signs and symptoms of pulmonary TB.

19. 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
6. What are the complications of TB, and what are the S & S of the complications?

20. Skin Testing Tuberculin Skin Test (Mantoux)
positive test does not signify active disease
0.1 ml PPD intradermally
Read in hours
7. Describe the procedure for administering a tuberculin skin test (TST) using purified protein derivative (PPD)..
(See Lewis, p. 529, table 26-12)

21. Administering the Tuberculin Skin Test
Inject intradermally 0.1 ml of 5
TU PPD tuberculin
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

22. Results Measure induration Repeat x2 or x3 if any clinical signs
Positive 10 mm
Possible 5-9 mm
Negative 0-4
Repeat x2 or x3 if any clinical signs
25% false negative

23. Diagnosing Skin test positive 3-12 weeks after exposure Chest x-ray
Sputum - Acid Fast Bacillus (AFB)
Smear not definitive
Culture is only definitive diagnosis
May need up to 8 weeks to grow
7. How valuable is a chest x-ray in diagnosing TB? What diagnostic studies are needed to positively diagnose TB disease? What nursing responsibilities are involved? What is the role of the QuantiFERON-TB (QFT) test?

24. Chest X-Ray Abnormalities often seen in apical
or posterior segments of upper
lobe or superior segments of
lower lobe
May have unusual appearance in
HIV-positive persons
Cannot confirm diagnosis of TB
10. How valuable is a chest x-ray in diagnosing TB?
Arrow points to cavity in
patient's right upper lobe.

25. 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
7. What diagnostic studies are needed to positively diagnose TB disease? What nursing responsibilities are involved? What is the role of the QuantiFERON-TB (QFT) test?
Colonies of M. tuberculosis growing on media

26. Newly converted to positive PPD
Isoniazid 300 mg X 6-9 months prophylactive prevents active Tb

27. Drug Therapy Active disease
Patients should be taught about SE and when to seek attention (Lewis p. 573)
Liver funtion should be monitored

28. Drug Therapy Active disease Latent TB infection
Patients should be taught about side effects and when to seek medical attention (see Lewis p.573)
Liver function should be monitored
Latent TB infection
Individual is infected with M. tuberculosis, but is not acutely ill
Usually treated with INH for 6 to 9 months
Patients with HIV should take INH for 9 months
8. What are the indications for treating LTBI? What drug regimen is used?

29. Medications
Newly diagnosed clients with active disease typical treated with four medications
isoniazid (INH) oral 300 mg daily or 900 mg twice a week.
rifampin oral 600 mg daily or twice a week
pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G per day or 30 to 70 mg/kg once a week
minimum 9 months
take in AM
90% have negative sputum in 3 months
ethambutal oral 15 mg/kg daily
Other medications
rifabutin
rifapentine
7. Describe the CDC’s four drug regimen options for initial treatment of TB. What is the initial phase vs. the continuation phase?

30. Drug
Side effects
Nursing Implications
Isoniazid (INH)
Noninfections hepatitis
Peripheral neuropathy
Hypersensitivity
Give B6 pyridoxine as prophylactic against peripheral neuropathy
Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritis)
Rifampin (Rifadin)
GI disturbances
Orange discoloration of body fluids (sputum, urine, sweat, tears)
Inform patient about orange discoloration of fluids/ urine
Ethambutol
Retrobulbar 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

31. Isoniazid Most effective TB drug Take in AM with food
Continue until sputum negative 6 months
Adverse Effects:
peripheral neuropathy
hepatitis
Monitor
Liver Functions Studies (AST and ALT)
Avoid hepatotoxins (ETOH, acetaminophen)

32. Rifampin Take on empty stomach Monitor liver function tests Can cause:
Hepatitis
Suppression of oral contraceptives
Do not stop medication
Will cause flu-like syndrome and fever when resumed
Colors body fluids
Sweat urine saliva tears: turn orange-red
Will stain tears, ruin contacts

33. Pyrazinamide Increase fluids Take with food Adverse Effects Monitor
Hepatotoxicity
Hyperuricemia
Monitor
Uric acid levels
AST and ALT
Avoid hepatotoxins (ETOH; Tylenol)

34. Ethambutol Protect from light
Adverse effects: retrobulbar neuritis, skin rash, reversible with discontinuation of the drug
Monitor color vision and acuity
Retrobulbar neuritis is a form of optic neuritis in which the optic nerve, which is at the back of the eye, becomes inflamed. The inflamed area is between the back of the eye and the brain. The optic nerve contains fibers that carry visual information from the nerve cells in the retina to the nerve cells in the brain. When these fibers become inflamed, visual signaling to the brain becomes disrupted, and vision is impaired.

35. Symptoms of Liver Toxicity
loss of appetite
N/V
dark urine
jaundice
malaise
unexplained elevated temperature for longer than 3 days
abdominal tenderness

36. Close Monitoring While Taking Antituberculosis Medications
Monitor liver functions
Regular office visits
Check for compliance
Rifampin
Check color of urine
INH
Check urine for metabolites
Give medication
Twice week in the office if compliance is a problem

37. 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
What factors put a person at high risk for noncompliance with a TB drug regimen. Describe the role of the nurse in facilitating compliance with long term treatment for TB.

38. Monitoring Response to Treatment
The patient asks how long before he can be considered non-contagious?
Answer: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli.

39. When can a TB patient be considered noninfectious?
When they meet all three criteria (CDC)
Received adequate TB treatment for a minimum of two weeks
Symptoms have improved
Has three consecutive negative sputum smears from sputum collected in an 8-24 hr interval (one being early morning specimen)

40. Answer this Urine would be orange Cultures would be negative for AFB
How would the nurse assess if
the patient has been
compliant with taking their medications?
Urine would be orange
Cultures would be negative for AFB

41. Drug Therapy Directly observed therapy (DOT)
Used with those clients 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 client and watch client swallow drugs
Costly, but preferred to ensure adherence
7. What is DOT? Why is it used?

42. 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.
9. What is the BCG vaccine? How effective is it? What are the implications for TST screening in people who have received the BCG?

43. Nursing Diagnosis labels appropriate for the client with tuberculosis
Ineffective airway clearance
Impaired gas exchange
Nutrition, less than body requirements
Activity intolerance
Risk for noncompliance
Knowledge deficit
Ineffective health maintenance
10. List possible nursing diagnoses for the patient diagnosed with TB. Formulate measureable goals/outcomes for each nursing diagnosis.

44. Nursing Assessment Assess for: Productive cough Night sweats
Afternoon temperature elevation
Weight loss
11. What are measures for health promotion related to TB?
Ultimate goal in the United States is eradication

45. Isolation negative flow room vent to outside masks, not ordinary
molded to fit face
patient wears a standard mask when outside room
ultraviolet light
12. Describe in-hospital care of a patient suspected of or diagnosed with TB.
13. What teaching is needed for a patient with TB?

46. General Teaching cover mouth and nose to cough dispose of tissues
hand washing
take meds as prescribed
35% noncompliant
monitor side effects

47. Criteria for Patient to return home (CDC)
Follow up plan with local TB program
Patient on treatment with DOT arranged
No infants or children under 4 years old or persons with immunocompromised condition at home
All household members have already been exposed
Pt willing to not travel outside home until sputum smear are (-)

48. Patient returning home
Should be instructed to:
Cover mouth and nose with tissues when coughing or sneezing
Sleep alone
No visitors until non-infectious

49. Chronic Management Follow up in 12 months 5% recurrence, relapse
Test frequent contacts
Factors which can cause relapse
immunosuppression
HIV/AIDS
prolonged debilitating illness
16. How do you evaluate the effectiveness of interventions for TB?
Evaluation

50. Compliance Therapeutic, consistent relationship
Understand lifestyle flexibility
Education
Reassurance, reduce social stigma
Take meds at clinic

51. The End