NURSING PROCESS: THE PATIENT WITH TUBERCULOSIS
The nurse performs a complete history and physical examina-tion. Clinical manifestations of fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum production prompt a more thorough assessment of respiratory function—for example, as-sessing the lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds, crackles), fremitus, egophony, and dullness on percussion. Enlarged, painful lymph nodes may be palpated as well. The nurse also assesses the patient’s living arrangements, perceptions and understanding of TB and its treat-ment, and readiness to learn.
Based on the assessment data, the nursing diagnoses may include:
· Ineffective airway clearance related to copious tracheo-bronchial secretions
· Deficient knowledge about treatment regimen and preven-tive health measures and related ineffective individual man-agement of the therapeutic regimen (noncompliance)
· Activity intolerance related to fatigue, altered nutritional status, and fever
Based on the assessment data, collaborative problems or poten-tial complications that may occur include:
· Adverse side effects of medication therapy: hepatitis, neu-rologic changes (deafness or neuritis), skin rash, gastro-intestinal upset
· Multidrug resistance
· Spread of TB infection (miliary TB)
The major goals for the patient include maintenance of a patent airway, increased knowledge about the disease and treatment reg-imen and adherence to the medication regimen, increased activ-ity tolerance, and absence of complications.
Copious secretions obstruct the airways in many patients with TB and interfere with adequate gas exchange. Increasing fluid intake promotes systemic hydration and serves as an effective expecto-rant. The nurse instructs the patient about correct positioning to facilitate airway drainage (postural drainage);.
The multiple-medication regimen that a patient must follow can be quite complex. Understanding the medications, sched-ule, and side effects is important. The patient must understand that TB is a communicable disease and that taking medications is the most effective means of preventing transmission. The major reason treatment fails is that patients do not take their medications regularly and for the prescribed duration. The nurse carefully instructs the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene.
Patients with TB are often debilitated from a prolonged chronic illness and impaired nutritional status. The nurse plans a progres-sive activity schedule that focuses on increasing activity tolerance and muscle strength. Anorexia, weight loss, and malnutrition are common in patients with TB. The patient’s willingness to eat may be altered by fatigue from excessive coughing, sputum production, chest pain, generalized debilitated state, or cost, if the person has few resources. A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements.
This may be a consequence of the patient’s lifestyle, lack of knowledge about adequate nutrition and its role in health main-tenance, lack of resources, fatigue, or lack of appetite because of coughing and mucus production. To counter the effects of these factors, the nurse collaborates with the dietitian, physician, social worker, family, and patient to identify strategies to ensure an ad-equate nutritional intake and availability of nutritious food. Iden-tifying facilities (eg, shelters, soup kitchens, Meals on Wheels, and other community resources) that provide meals in the pa-tient’s neighborhood may increase the likelihood that the patient with limited resources and energy will have access to a more nu-tritious intake. High-calorie nutritional supplements may be sug-gested as a strategy for increasing dietary intake using food products normally found in the home. Purchasing food supple-ments may be beyond the patient’s budget, but a dietitian can help develop recipes to increase caloric intake despite minimal resources.
It is important to assess medication side effects because they are often a reason the patient fails to adhere to the prescribed medica-tion regimen. Efforts are made to reduce the side effects to increase the patient’s willingness to take the medications as prescribed.
The nurse instructs the patient to take the medication either on an empty stomach or at least 1 hour before meals, because food interferes with medication absorption (although taking medications on an empty stomach frequently results in gastro-intestinal upset). Patients taking INH should avoid foods con-taining tyramine and histamine (tuna, aged cheese, 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.
In addition, rifampin can increase the metabolism of other medications, making them less effective. These medications include beta-blockers, oral anticoagulants such as warfarin (Coumadin), digoxin, quinidine, corticosteroids, oral hypoglycemic agents, oral contraceptives, theophylline, and verapamil. This issue should be discussed with the physician and pharmacist so that medication dosages can be adjusted accordingly. The nurse informs the pa-tient that rifampin may discolor contact lenses, so the patient may want to wear eyeglasses during treatment. The nurse monitors for other side effects of anti-TB medications, including hepatitis, neurologic changes (hearing loss, neuritis), and rash. Liver en-zyme, blood urea nitrogen, and serum creatinine levels are mon-itored to detect medication-related changes in liver and kidney function. Sputum culture results are monitored for acid-fast bacillus to evaluate the effectiveness of the treatment regimen and adherence to therapy.
The nurse carefully monitors vital signs and observes for spikes in temperature or changes in the clinical status. The nurse reports any change in the patient’s respiratory status to the primary health care provider. The nurse instructs the patient about the risk of drug resistance if the medication regimen is not strictly and continuously followed.
Spread of TB infection to nonpulmonary sites of the body is known as miliary TB. It is the result of invasion of the blood-stream by the tubercle bacillus (Ghon tubercle). Usually it results from late reactivation of a dormant infection in the lung or else-where. The origin of the bacilli that enter the bloodstream is either a chronic focus that has ulcerated into a blood vessel or multi-tudes of miliary tubercles lining the inner surface of the thoracic duct. The organisms migrate from these foci into the blood-stream, are carried throughout the body, and disseminate through-out all tissues, with tiny miliary tubercles developing in the lungs, spleen, liver, kidneys, meninges, and other organs.
The clinical course of miliary TB may vary from an acute, rapidly progressive infection with high fever to an indolent process with low-grade fever, anemia, and debilitation. At first, there may be no localizing signs except an enlarged spleen and a reduced number of leukocytes. Within a few weeks, however, the chest x-ray reveals small densities scattered diffusely throughout both lung fields; these are the miliary tubercles, which gradually grow.
The possibility of TB in nonpulmonary sites in the body re-quires careful monitoring for this very serious form of the in-fection. The nurse monitors vital signs and observes for spikes in temperature as well as changes in renal and cognitive func-tion. Few physical signs may be elicited on physical examina-tion of the chest, but at this stage the patient has a severe cough and dyspnea. Treatment of miliary TB is the same as for pul-monary TB.
The nurse plays a vital role in caring for the patient with TB and the family, which includes assessing the patient’s ability to con-tinue therapy at home. The nurse instructs the patient and fam-ily about infection control procedures, such as proper disposal of tissues, covering the mouth during coughing, and hand hygiene. Assessment of the patient’s adherence to the medication regimen is imperative because of the risk of developing resistant strains of TB if the regimen is not followed faithfully. In some cases, when the patient’s ability to comply with the medication regimen is in question, referral to an outpatient clinic for daily medication ad-ministration may be required. This is referred to as directly ob-served therapy (DOT).
The nurse evaluates the patient’s environment, including home or workplace and social setting, to identify other people who may have been in contact with the patient during the infectious stage. It is important to arrange follow-up screening for any con-tacts of the infected person. Nurses who have contact with the patient in home, shelter, hospital, clinic, or work settings assess the patient’s physical and psychological status and ability to ad-here to the prescribed treatment. The nurse assesses the patient for adverse effects of medications and adherence to the thera-peutic regimen (eg, taking medications as prescribed, practicing safe hygiene, consuming a nutritious and adequate diet, and participating in an appropriate level of activity). The nurse re-inforces previous teaching and emphasizes the importance of keeping scheduled appointments with the primary health care provider. In addition, the patient is reminded of the importance of other health promotion activities and recommended health screening.
Expected patient outcomes may include:
1. Maintains a patent airway by managing secretions with hy-dration, humidification, coughing, and postural drainage
2. Demonstrates an adequate level of knowledge
a. Lists medications by name and the correct schedule for taking them
b. Names expected side effects of medications
c. Identifies how and when to contact health care provider
3. Adheres to treatment regimen by taking medications as prescribed and reporting for follow-up screening
4. Participates in preventive measures
a. Disposes of used tissues properly
b. Encourages people who are close contacts to report for testing
c. Adheres to hand hygiene recommendations
5. Maintains activity schedule
6. Exhibits no complications
a. Maintains adequate weight or gains weight if indicated
b. Exhibits normal results of tests of liver and kidney function
7. Takes steps to minimize side effects of medications
a. Takes supplemental vitamins (vitamin B), as prescribed, to minimize peripheral neuropathy
b. Avoids use of alcohol
c. Avoids foods containing tyramine and histamine
d. Has regular physical examinations and blood tests to evaluate liver and kidney function, neuropathy, hearing and visual acuity
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