PULMONARY TUBERCULOSIS (TB) I. Pathophysiology a. Bacterial infection by Mycobacterium tuberculosis bacilli (TB) i.

Primarily affects the lungs (70% per Centers for Disease Control and Prevention [CDC], 2004) although it can invade other body systems ii. Airborne droplets are inhaled, with the droplet nuclei deposited within the alveoli of the lung. b. Primary infection followed by a latent or dormant phase, or by active disease in some individuals c. When the immune system weakens, dormant TB organisms can reactivate and multiply (reactivation TB). II. Classifications a. Latent: Bodys immune system has encapsulated the bacteria into tiny capsules called tubercles, infection not transmissible to others. b. Active: Infection is spreading in the body and can be transmitted to others. III. Etiology a. Following exposure, the bacilli may (1) be killed by the immune system, (2) multiply and cause primary TB, (3) become dormant and remain asymptomatic, or (4) proliferate after a latency period (reactivation disease) (Herchline & Amorosa, 2007). b. Multidrug-resistant tuberculosis (MDR-TB) i. Primary: caused by person-to-person transmission of a drug-resistant organism ii. Secondary: usually the result of nonadherence to therapy or inappropriate treatment iii. On the rise especially in large cities, in those previously treated with antitubercular drugs, or in those who failed to follow or complete a drug regimen iv. Can progress from diagnosis to death in as little as 4 to 6 weeks c. Risk factors: individuals with weakened immune systems due to chronic conditions, advanced age, and malnutrition; higher among persons with HIV infection, the homeless, drug-addicted, and impoverished populations, as well as among immigrants from or visitors to countries in which TB is endemic IV. Statistics (Centers for Disease Control and Prevention [CDC], 2005, 2007) a. Morbidity: In 2005, 14,903 cases of TB were reported in the United States (down from a peak of 25,287 cases in 1993), with foreign-born individuals accounting for a steadily increasing proportion (54%) of all reported TB cases (Herschline, 2007); globally, 9.2 million new cases reported annually. b. Morbidity: Globally, 1.7 million deaths from TB occurred in 2006, of which 0.2 million deaths were in HIV-positive individuals (World Health Organization [WHO], 2008). Care Setting Most clients are treated in community clinics, but may be

hospitalized for diagnostic evaluation or initiation of therapy, adverse drug reactions, or severe illness or debilitation. This plan of care is intended to reflect care of the person with active (rather than latent) TB, although if latent, when TB is diagnosed, treatment will be initiated. Nursing Priorities 1. Achieve and maintain adequate ventilation and oxygenation. 2. Prevent spread of infection. 3. Support behaviors and tasks to maintain health. 4. Promote effective coping strategies. 5. Provide information about disease process, prognosis, and treatment needs. Discharge Goals 1. Respiratory function adequate to meet individual need. 2. Complications prevented. 3. Lifestyle and behavior changes adopted to prevent spread of infection. 4. Disease process, prognosis, and therapeutic regimen understood. 5. Plan in place to meet needs after discharge. NURSING DIAGNOSIS: risk for Infection [spread/reactivation] Risk factors may include Inadequate primary defenses, decreased ciliary action and stasis of secretions Tissue destruction, extension of infection Lowered resistance, suppressed inflammatory process Malnutrition Environmental exposure Insufficient knowledge to avoid exposure to pathogens Possibly evidenced by (Not applicable; presence of signs and symptoms establishes an actual diagnosis) Desired Outcomes/Evaluation CriteriaClient Will Risk Control Identify interventions to prevent or reduce risk of spread of infection. Demonstrate techniques and initiate lifestyle changes to promote safe environment. ACTIONS/INTERVENTIONS Infection Control Independent Review pathology of diseaseactive or inactive phases, dissemination of infection through bronchi to adjacent tissues or via bloodstream and lymphatic systemand potential spread of infection via airborne droplet during coughing, sneezing, spitting, talking, laughing, and singing. Identify others at risk, such as household members, close associates, and friends. Instruct client to cough, sneeze, and expectorate into tissue and to refrain from spitting. Review proper disposal of tissue and good hand-washing techniques. Request return demonstration. Review necessity of infection control measures, such as temporary respiratory isolation. Monitor temperature, as indicated.

Identify individual risk factors for reactivation of tuberculosis, such as lowered resistance associated with alcoholism, malnutrition, intestinal bypass surgery, use of immunosuppressant drugs, presence of diabetes mellitus or cancer, or postpartum. Stress importance of uninterrupted drug therapy. Evaluate clients potential for cooperation. Review importance of follow-up and periodic reculturing of sputum for the duration of therapy. Encourage selection and ingestion of well-balanced meals. Provide frequent small snacks in place of large meals as appropriate. Collaborative Administer anti-infective agents, as indicated, for example: Primary drugs: isoniazid (INH, Liniazid), rifampin (RIF, Rifadin, Rimactane), pyrazinamide (PZA, Tebrazid), and ethambutol (Etbi, Myambutol) Rufabutin (Mucobutin) Second-line drugs, such as ethionamide (Trecator-SC), paraaminosalicylate (PAS), cycloserine (Seromycin), amikacin (Amikin), and levofloxacin (Levoquin) Investigational agents such as diarylquinoline (R207910) Monitor laboratory studies, such as the following: Sputum smear results Liver function studies, such as aspartate aminotransferase (AST), alinine aminotransferase (ALT) Notify local health department. RATIONALE Helps client realize and accept necessity of adhering to medication regimen to prevent reactivation and complications. Understanding of how the disease is passed and awareness of transmission possibilities help client and significant other (SO) take steps to prevent infection of others. Those exposed may require a course of drug therapy to prevent development of infection. Behaviors necessary to prevent spread of infection. May help client understand need for protecting others while acknowledging clients sense of isolation and social stigma associated with communicable diseases. Note: AFB can pass through standard masks; therefore, particulate respirators are required. Febrile reactions are indicators of continuing presence of infection. Knowledge about these factors helps client alter lifestyle and avoid or reduce incidence of exacerbation. Contagious period may last only 2 to 3 days after initiation of drug regimen, but in the presence of cavitation or moderately advanced disease, risk of spread of infection may continue up to 3 months. Compliance with multidrug regimens for prolonged periods is difficult; therefore, DOT should be considered. Aids in monitoring the effects of medications and clients response to therapy. Presence of anorexia or preexisting malnutrition lowers resistance to infectious process and impairs healing. Small

snacks may enhance overall intake. The goals for treatment of TB are to cure the individual and to minimize transmission to other persons. It is essential that treatment be tailored and supervision be based on each clients clinical and social circumstances. DOT may be the most effective way to maximize the completion of therapy. These four drugs should not be given in divided doses; all four drugs should be given together. Evidence shows this promotes the therapys effectiveness (CDC, 2005). INH is usually drug of choice for those exposed and who are at risk for developing TB. Extended therapy for up to 24 months is indicated for reactivation cases, extrapulmonary reactivated TB, or in the presence of other medical problems, such as diabetes mellitus or silicosis. Prophylaxis with INH for 12 months should be considered in HIV-positive clients with positive PPD test. Therapeutic agent for atypical mycobacterium. May be used in client with advanced HIV disease with TB. These second-line drugs may be required when infection is resistant to or intolerant of primary drugs or may be used concurrently with primary antitubercular drugs. Note: MDR-TB requires minimum of 18 to 24 months therapy with at least three drugs in the regimen known to be effective against the specific infective organism and that client has not previously taken. Treatment is often extended to 24 months in clients with severe symptoms or HIV infection. Innovative compounds are being developed based on new drug targets and structure to provide shorter and more effective treatment options. This agent, currently starting human trials, cuts off the energy supply of the mycobacterium and may be effective against drug-resistant forms of TB. Client who has three consecutive negative sputum smears over a 3- to 5-month period is adhering to drug regimen and who is asymptomatic will be classified as a nontransmitter. The most common serious adverse effect of drug therapyparticularly RIF, but possibly others as wellis drug-induced hepatitis. Required by law, and should be reported within 1 week of diagnosis. Helpful in identifying contacts to reduce spread of infection. Treatment course is long and usually handled in the community, with public health nurse monitoring. http://nursingcareplan.blogspot.com/2011/05/nursing-care-plan-pulmonary.html