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:
·
Malnutrition
·
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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