Tuberculosis (TB) is a common and often deadly infectious disease that can be traced back to the ancient times. Neil (2008) states that Egyptian mummies from 2400 BC show signs of tubercular decay. It is caused by an acid-fast, Gram- positive bacillus called Myobacterium tuberculosis, which is known to be the most widespread bacterial infection in the world and continues to reemerge as a public health concern. TB is also known to be the leading infectious disease causing death, more than acquired immunodeficiency syndrome (AIDS) and malaria (Neil 2008). According to the Association of periOperative Registered Nursing (AORN) Journal (2008), about 1.7 billion people are infected and about 3 million people per year die from this disease. This paper will explain the pathophysiology as well as the nursing process involved with a patient that has been diagnosed with TB.
Tuberculosis grows in three stages which are transmission and acquisition of infection, latency, and progression of latent infection to active disease (Neil 2008). Myobacterium tuberculosis is transmitted through aerosolization. When a patient who is diagnosed with TB coughs, sneezes, or laughs, droplets become airborne resulting to possible inhalation by others around. As the individual inhales the droplets, the organisms enter the lungs and are deposited into the alveoli. It is usually implanted in the middle and lower lung fields (Weston 2010). The individual's immune system starts to contain the infection by sending leukocytes, lymphocytes and macrophages to surround the bacteria forming granulomas. In weaker immune systems, the wall of the granulomas loses integrity allowing the bacteria to escape and spread to other alveoli and other organs of the body (Workman 2010).
According to Knechel (2009) due to having different statuses of the immune system, patients' responses to the bacteria are different. Latent tuberculosis shows no signs or symptoms. Individuals usually do not feel sick and are not contagious. However, it continues to stay in the immune system and can be reactivated later on. Primary pulmonary tuberculosis is asymptomatic that the only evidence of contamination is a based upon the results of diagnostic tests such as chest radiography or a tuberculin skin test. Primary progressive TB is nonspecific with early signs and symptoms. It is usually manifested by fatigue and weight loss. Wasting is a common feature of TB because it is the result of lack of appetite and altered metabolism. Due to wasting, loss of both fat and lean tissues contributes to fatigue. Dyspnea or orthopnea may be the result from the increased interstitial volume that can cause a decrease in lung diffusion capacity. Leukocytosis occurs because of the large number of white blood cells needed to fight off the infection (Knechel 2009).
Tuberculosis in the United States have decreased during time, however, it remains to increase in other countries. People who are in constant contact with untreated individuals are at the greatest risk at developing this infection. Other risk factors include patients who are immunocompromised such as persons with the human immunodeficiency virus (HIV), malnourished, history of cancer, history of chronic respiratory disease, diabetes mellitus, living in crowded facilities, history substance abuse, lower socioeconomic status as well as immigrants from other countries such as Mexico and Philippines (Chamanga 2010). Complications that may manifest include extrapulmonary tuberculosis, tuberculosis pneumonia, and pleuritis. Massive destruction of the lungs due to liquefaction and cavitations of lung tissue may be an end result if individual is without treatment. Even though, TB usually attacks mainly the lungs, it can affect other parts of the body as well. Miliary TB is when the organism invades the blood stream and can be spread to multiple body organs such as the brain, meninges, liver, kidneys or bone marrow (Neil, 2008). This could lead to multiorgan involvement and is difficult to diagnose for its systemic and non-specific signs and symptoms. Extrapulmonary TB occurs in "more than 20% of immunocompetent patients and the risk increases from immunosuppression" (Knechel, 2009). The most fatal location in which TB can be infected is the central nervous system. This can result to meningitis which is deadly in most cases (Knechel 2009).
Workman (2010) noted that more individuals are infected by the organism than having actual active TB. According to Knechel (2009), "Active tuberculosis develops in only 5% to 10% of persons exposed to Myobacterium tuberculosis" (p. 38). Because of the slow onset of TB, many are unaware that they are contaminated until the symptoms and disease itself has advanced. People who are infected are not contagious until signs and symptoms start to appear. Some signs and symptoms include persistent cough, bloody sputum, weight loss, night sweats and fatigue. In later stages, chest pain and hemoptysis are present. If a patient starts to cough up blood, it is advised to seek medical attention immediately. It is best to detect this disease at an early stage and treatment is crucial. If left untreated, TB can kill more than 50% of its victim (Neil, 2008).
E. B. is a 46 year old female with a medical history of upper respiratory tract infection. She was admitted due to the complaint of difficulty breathing. She states that her condition started 6 months as an onset non productive cough and an intermittent fever. According to the patient, she was able to relieve and tolerate her symptoms with medication. However, her condition worsened a week prior to admission. She began to have productive cough with non -bloody, whitish sputum. The patient's husband states that his wife has lost her appetite for food and complains of a stabbing pain to her chest that radiates to her back. Upon admission, E.B. was alert and fairly oriented to person, place, and time. The patient's temperature was 99.5 F, pulse rate was 84 beats per minute, respiration was 36, blood pressure of 90/70, oxygen saturation on room air was 88%, and body max index (BMI) of 12.5. The patient shows hollowness in the eyes due to malnutrition and shows symptoms of dehydration. Crackles can be heard on the upper and lower thorax as well as on the anterior and middle parts of the right and left lungs. During the physical assessment, the patient states she travels to Mexico every other week where she works at a factory. According to AORN Journal (2008), the patient shows signs and symptoms of pulmonary tuberculosis such as intermittent fever, difficulty breathing, coughing, chest pain and weight loss. She is also malnourished, an immigrant from another country and works at a crowded facility.
There are several diagnostic tests that can be performed to identify tuberculosis. A sputum smear detects acid fast bacilli. However, this test is not specific to diagnose TB. Due to the quick method, it can help determine whether TB precautions should be started. A sputum culture will be able to confirm the diagnosis for TB. The most common and reliable test to detect TB is the tuberculin test also known as the Mantoux test (Workman 2010). It is the standard method of determining whether a person is infected with Myobacterium tuberculosis. The individual is injected 0.1 mL of tuberculin purified protein derivative (PPD) intradermally into the inner surface of the forearm (Neil, 2008). The test should be read between 48 and 72 hours after administration. The individual should avoid scratching or applying cream or lotion to the area because it may cause a reaction. A positive reaction would appear as a palpable, elevated, hardened area around the injection site. This is caused by edema and inflammation from antigen- antibody reaction and is measured in millimeters. An area of indurations measuring 10 mm or greater in diameter indicates exposure or infection of TB. A positive reaction does not determine whether the exposure to TB is inactive or active. It is recommended that after a positive skin test, the individual should verify with a chest x-ray to detect if the TB is active (Ignatavicius 2010).
According to Workman (2010), arterial blood gases (ABG) levels as well as oxygen saturations should be continuously monitored. They are both good indicators of the patient's lung ability to oxygenate the blood. Collecting sputum samples will help monitor the progress of the disease and treatment. Respiratory status along with vital signs, breath sounds and skin color should also be closely monitored to distinguish the patient's severity and progress.
Tuberculosis is can be cured. Treatment should be started once detected and is very important. To treat TB, combination drug therapy is the most effective. Ignatavicius (2010) discuss how therapy is to be continued until the disease is under control. Current first line therapy includes Isoniazid (INH), Rifampin, Pyrazinamide, and Ethambutol. When administering INH, the patient's stomach should be empty. Hepatitis and neurotoxicity should be monitored. Rifampin will cause the patient's urine as well as other secretions to be orange in color. Hepatotoxity should be observed with Rifampin and Pyrazinamide. With Ethambutol, visual acuity should be tested. If the patient cannot tolerate the standard first line drugs, a variation of other first line drugs could be used. Multidrug resistant (MDR) TB is huge threat for TB control. This is caused by the bacteria being resistant to INH or Rifampin. It is described by "prolonged treatment, high morbidity and mortality, and high relapse rates" (Knechel, 2009). The main concern about drug resistant TB is the reliance on second line medications that require 24 months of treatment. Second line medications are more costly, more toxic and less effective (Neil 2008). It is important that treatment and patient's response to medication are closely monitored. Oxygen therapy should also be administered to relief symptoms of hypoxemia and hypoxia. Promoting adequate nutrition is very important part of the treatment for TB. Fluid intake and a well balanced caloric intake including foods rich in protein, iron and vitamin C are encouraged.
Surgical management that includes collapse therapy with therapeutic pneumothoraces is used as an intervention for TB. The purpose of surgery is to remove diseased tissue and cavities to enhance the effectiveness of medications. AORN Journal (2008) explains that surgery is usually performed on patients who have MDR TB, have a resistant to four or more medications, history of relapse, or who have continuous positive sputum with four to six months of therapy.
When caring for a patient diagnosed with TB is it important to control the working environment. Health care providers (HCP) are at a high risk for infection with TB because of the constant contact with infectious diseases. Preventing infection transmission is crucial. HCP should wear an N95 or high efficiency particulate air (HEPA) respirator when caring for TB patients. Masks should also be used by patients during transport. TB patients should be placed in a negative airflow isolated room. Everyone that will come in contact with the infected patient should implement airborne precautions (Workman 2010). Nurses play an important role in TB control. Because TB can be difficult to be diagnosed promptly, it results to not getting the patient into isolation right away causing further spread of the disease. Nurses should be able to recognize clinical signs and symptoms of tuberculosis, which would put them in the position to for early detection. They promote health in order to prevent people from becoming vulnerable to the disease, prevent illness by reducing transmission of TB in the community by finding and treating all cases, restore health by ensuring that all patients can receive treatment, and they offer support by helping ease the suffering to the individual is experiencing (Aziz 2008). It is the nurses responsibility that the nursing process should be applied throughout the patient's care.
E.B. was informed by the physician to continue taking the anti-TB drugs. She was told that intensive phase is for 2 months and the maintenance phase if for 4 months. She was advised to continue to practice deep breathing exercises as well as coughing exercises. The physician instructed her to resume with previous activities but to prevent extraneous work. She is able to return back to work. She notified that for financial insufficiency, there are government drug stores available for her disposal. She was instructed to practice hand washing regularly and to cover her mouth and nose when coughing and sneezing. She was also instructed to spit in a single container to prevent a transfer of Myobacterium tuberculosis. She is to follow up at least once a week to monitor treatment progression and to report any difficulty breathing, chest pain, fatigue, or productive cough. She was placed in a high caloric diet which includes lots of water, fruits and vegetables, and vitamin C rich foods to strengthen her immune system.
Tuberculosis has been a major public health concern throughout history. Having an understanding of the pathophysiology, transmission, and diagnostic as well as the clinical manifestation of this infectious airborne disease is important. It will not only help nurses become aware of the signs and symptoms of tuberculosis, but they will be able prevent and treat this disease.
