Course Proposal Form

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• hydration to thin secretions

• supplemental oxygen to alleviate hypoxemia,

• bed rest

• chest physical therapy and postural drainage (techniques that involve manual pounding or clapping to loosen secretions and positioning of the client to drain and remove secretions from specific areas of the lungs),

• bronchodilators, analgesics, antipyretics, and cough expectorants or suppressants, depending on the nature of the client’s cough.

If a client is hospitalized, treatment is more vigorous, depending on the potential or actual complications. Fluid and electrolyte replacement sometimes is necessary secondary to fever, dehydration, and inadequate nutrition. If the client experiences severe respiratory difficulty and thick, copious secretions, he or she may require intubation along with mechanical ventilation.

Nursing Management

The nurse auscultates lung sounds and monitors the client for signs of respiratory difficulty. He or she checks oxygenation status with pulse oximetry and monitors arterial blood gases (ABGs). Assessments of cough and sputum production also are necessary. The nurse places the client in the semi-Fowler’s position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Identifying clients at risk for pneumonia provides a means to practice preventive nursing care.

In addition, nurses encourage at-risk and elderly clients to receive vaccination against pneumococcal and influenza infections. Because the nursing care of clients with infectious lung disorders is similar regardless of the etiology.

acid-51 fast bacillus (AFB), which means that when it is stained in the laboratory and then washed with an acid, the stain remains, or stays fast. M.

tuberculosis can live in dark places in dried sputum for months, but a few hours in direct sunlight kills it. It is spread by inhalation of the tuberculosis bacilli from respiratory droplets (droplet nuclei) of an infected person. Once the bacilli enter the lungs, they multiply and begin to disseminate to the lymph nodes and then to other parts of the body. The patient is then infected but may or may not go on to develop clinical (active) disease.

During this time, the body develops immunity, which keeps the infection under control. The immune system surrounds the infected lung area with neutrophils and alveolar macrophages.

This process creates a lesion called a tubercle, which seals off the bacteria and prevents spread. The bacteria within the tubercle die or become dormant, and the patient is no longer infectious. If the patient’s immune system becomes compromised, however, some of the dormant bacteria can become active again, causing reinfection and active disease. Only 5 to 10 percent of infected individuals in the United States actually develop the disease, and even then, it may not occur for many years.

Signs and Symptoms

Active tuberculosis is characterized by a chronic productive cough, blood-tinged sputum, and drenching night sweats. A low-grade fever may be present. If effective treatment is not initiated, a downhill course occurs, with pulmonary fibrosis, hemoptysis, and progressive weight loss.

Complications

Spread of the tuberculosis bacilli throughout the body can result in pleurisy, pericarditis, peritonitis, meningitis, bone and joint infection, genitourinary or gastrointestinal infection,

or infection of many other organs.

Diagnostic Tests

Routine screening for tuberculosis infection is usually done with a purified protein derivative (PPD) skin test. The PPD is injected intradermally; the test is considered positive if a raised area of induration occurs within 48 to 72 hours. If there is a red area around the induration, this is not measured.

The size of induration that indicates a positive test varies based on the individual’s history. A red area without induration is not considered a positive result. A positive result indicates that a person has been exposed; it does not mean that active TB disease is present. Some health care institutions use a two-step process for baseline testing of employees and residents. If an individual has a negative test, he or she is retested in 1 to 3

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weeks. This is because someone who was exposed many years ago may not react to the first test. The first test acts as a “reminder” to the immune system to react. The second test will then be positive in the person with a past TB infection.BOX 28–2

The reduction in immune system function from aging can decrease the effectiveness of the tuberculosis antibodies in someone who previously had dormant disease. The tuberculosis bacilli can be reactivated, causing active disease. If the physician orders “sputum culture for AFB,” tuberculosis is suspected. Ask whether isolation precautions should be taken while waiting for culture results.

Etiology

Crowded or poorly ventilated living conditions place people at risk for becoming infected with tuberculosis. Although tuberculosis can infect any age group, the elderly are especially at risk. Elders may have contracted the disease many years before, but it reactivates as the aging process diminishes immune function. Patients with AIDS and chronic alcohol abuse have a very high risk because of their compromised immune function. In the United States, tuberculosis is also prevalent among the urban poor and minority groups. Before 1985 the incidence of TB was steadily decreasing.

Now it is again on the rise, in part because of the prevalence of AIDS, the development of antibiotic-resistant strains of the TB bacillus, and ineffective treatment programs. TB kills 2 million people each year worldwide.

Prevention

Clean, well-ventilated living areas are essential to the health of all people.

If a hospitalized patient is known or suspected to have tuberculosis, he or she is placed in respiratory isolation to prevent spread to staff or other patients. Special isolation rooms are ventilated to the outside. Staff should wear special high-efficiency filtration masks when in the patient’s room. A regular surgical mask is not effective against TB. Verify with the institution’s infection control department that the masks provided are effective for use with TB patients. If the patient must travel through the hallway for tests or other activities, the patient must wear a mask.

Additional protective barriers, such as gowns, gloves, or goggles, are used when contact with sputum is likely.

Nursing Care

Perform thorough respiratory and psychosocial assessments of the patient with TB. The severity of the disease determines the impact on the patient’s lifestyle. It is also imperative to determine the patient’s knowledge of the

53 disease and treatment and his or her compliance with drug treatment.

Possible nursing diagnoses include impaired gas exchange, ineffective airway clearance, ineffective breathing pattern, anxiety, imbalanced nutrition, risk for infection of patient’s contacts, and possible noncompliance with drug therapy or ineffective therapeutic regimen management.

Diagnoses should be chosen based on individual patient data. Anxiety may be reduced by educating the patient in self-care measures and by reassuring the patient that the disease can be controlled by careful compliance with treatment. The patient who is emaciated because of the disease will benefit from a dietitian consultation to provide specific recommendations or supplements. To prevent spread of infection to others, teach the patient to use a tissue to cover the mouth and nose when coughing or sneezing.

Tissues should be flushed down the toilet or disposed of carefully in the trash. Teach all family members the importance of careful handwashing, how to manage drug therapy, and when to report side effects. Forewarn the patient that rifampin turns the urine and body fluids red. A visiting nurse is essential to evaluate the home environment and assess the patient’s ability to comply with therapy. If the patient is unable to comply with therapy, measures must be instituted to ensure that medications are taken to protect both the patient and the public. Directly observed therapy at a local health clinic or by a home health nurse may be necessary. The patient will be followed periodically by the physician for sputum cultures and drug monitoring. Once sputum cultures are negative, the patient is no longer contagious.

Antibiotics Used in Treatment of Tuberculosis 28–3 Isoniazid

Ethionamide Rifampin Kanamycin Streptomycin

Para-aminosalicylic acid Ethambutol

Cycloserine Pyrazinamide

Medical Treatment

Treatment consists of specific antibiotic therapy. First-line drugs have the fewest adverse effects. However, these drugs can be toxic to the liver and nervous system, as well as having other side effects. Second-line drugs are

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more toxic and are reserved for cases that do not respond to firstline drug therapy. Generally, two or three antibiotics are given simultaneously to allow lower doses of each individual drug and to reduce the incidence of serious side effects. Drugs must be taken for 6 to 8 months or longer.

Because of the length of therapy and the incidence of side effects, you must anticipate that compliance may be a problem.