TUBERCULOSIS

DESCRIPTION/ETIOLOGY: Tuberculosis is a highly communicable disease caused by Mycobacterium tuberculosis.

It is the most common bacterial infection worldwide.

Transmitted via airborne droplet nuclei

High Risk Groups:

Those in constant, frequent contact with an untreated person

Those who have decreased immune function or HIV

People who live in crowded areas such as long-term care facilities, prisons, and mental health facilities

Older homeless people

Abusers of injection drugs or alcohol

Lower socioeconomic groups

 Foreign immigrants

Travel outside the US where TB is endemic

Cases of active TB are reported to the health department, a child diagnosed with TB is considered a sentinel case and the adult contact with active TB must be found. PATHOPHYSIOLOGY Primary TB occurs when the patient is initially infected with the mycobacterium.

After being inhaled into the lung, the organism causes a localized reaction. As the macrophages and sensitized T-lymphocytes attempt to isolate and kill off the mycobacterium within the lung, damage is also caused to the surrounding lung tissue.

A well-defined granulomatous lesion develops that contains the mycobacterium, macrophages and other cells. Necrotic changes occur within this lesion. Caseous granulomas develop along lymph node channels during the same time.

These areas create a Ghon's complex, which is a combination of the area initially infected by the airborne bacillus called the Ghon's focus and a lymphatic lesion.

The majority of people with newly acquired infections and an adequate immune system will develop latent infection, as the body walls off the infecting organism within these granulomas. Disease is not active in these patients at this point and will not be transmitted until there is some manifestation of the disease.

 In patients with inadequate immune response, the tuberculosis will be progressive, lung tissue destruction will continue, and other areas of the lung will also become involved.

In secondary TB, the disease is reactivated at a later stage. The patient may be reinfected from droplets, or from a prior primary lesion. Since the patient has previously been infected with TB, the immune response is to rapidly wall off the infection. Cavitation of these areas occurs as the organism travels along the airways.

Latent TB infection occurs when a person has a positive tuberculin skin test but no symptoms of disease. Chest x-ray may show granuloma or calcification. CLINICAL MANIFESTATIONS: Persistent cough with chest tightness and a dull aching pain

Purulent sputum- may be blood streaked

Wheezing

Decreased breath sounds

Fatigue and lethargy

Weight loss and anorexia

Nausea

 Irregular menses

Night sweats

Low-grade fever in the afternoon

DIAGNOSTIC/LAB TESTS:

Chest X-rays show nodular lesions, patchy infiltrates (many in upper lobes), cavity formation, scar tissue, and calcium deposits. However, they may not distinguish active from inactive TB.

Stains and cultures of sputum, CSF, urine, drainage from abscesses, or pleural fluid show heat-sensitive, nonmotile, aerobic, acid-fast bacilli and confirm the diagnosis.

There are two skin testing methods for determining a persons exposureto TB:

The Mantoux TB skin test uses tuberculin purified protein derivative (PPD) injected intradermally and will produce a local inflammatory Reaction at the site within 48 to 72 hours. False positives can occur with repeat testing.

The newer QuantiFERON-TB Gold test (QFT-G) is a blood test that provides results in 24 hours, and unlike the TB skin test using PPD, False-positives dont occur with repeat testing.

 Thoracentesis to obtain pleural fluid for cytology will reveal heat sensitive, nonmotile, aerobic acid-fast bacillus.

Bronchoscopy will reveal inflammation and pathologic changes in lung tissue. Sputum for cytology can be collected via the bronchoscope if the patient is unable to produce an adequate specimen. MEDICAL MANAGEMENT: Combination drug therapy is the most effective method of treating TB and preventing transmission (ATI Med-Surg book page 291):

First-line therapy uses 4 drugs: isoniazid and rifampin throughout the therapy

Pyrazinamide for the first 2 months to allow for a shorter length of treatment (6 months vs. 6 to 12 months)

Ethambutol is the recommended fourth drug in first-line therapy.

NURSING MANAGEMENT/PATIENT EDUCATION: Prevent infection transmission: Wear an N95 or HEPA respirator when caring for clients who are hospitalized with TB. Place the patient in a negative airflow room and implement airborne precautions

 Use barrier protection when the risk of hand or clothing contamination exists. Have the client wear a mask if transportation to another department is necessary. The client should be transported using the shortest and least busy route. Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided sacks. Administer prescribed medications and educated the patient about side effects and the importance of taking them every day as directed to ensure the infection is cured and that the patient does not develop drug resistant TB. Meds should be taken on an empty stomach Oxygen therapy as ordered Encourage fluid intake and a well balanced diet Encourage foods that are rich in protein, iron and vitamin c Instruct the patient to continue with follow up care for 1 full year. Expose family member should be tested Inform the patient that sputum samples are needed every 2 to 4 weeks to monitor therapy effectiveness. Patients are no longer considered infectious after three negative sputum cultures.