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906 Tuberculosis

• Patient’s or family members’ mood and emotional response to the diagnosis of toxoplasmosis
and the associated poor prognosis
• Physical responses: Status of lymph nodes (enlargement, any changes from baseline), presence
of fever, response to interventions
• Abnormal assessment findings from organs commonly affected by acute toxoplasmosis: Heart,
liver, lungs, eyes (visual disturbances)

DISCHARGE AND HOME HEALTHCARE GUIDELINES

Teach the patient and family about the medications. Pyrimethamine can cause folic acid defi-
ciency. The patient should report bleeding, bruising, visual changes, and feelings of fatigue. Folic
acid supplements may be recommended by the physician. Pyrimethamine should be taken just
before or after meals to minimize gastric distress. Sulfadiazine can cause decreased white blood
cell count, cause fever and rash, and lead to crystals in the urine; it should be taken with a full
glass of water, and daily fluid intake should be at least 2000 mL. Sulfadiazine causes increased
sensitivity to the sun; the patient should avoid prolonged sun exposure and wear sunscreen when
going outdoors.
If the patient has AIDS or some other condition that causes a permanent immunocompro-
mised state, emphasize that these drugs probably are needed throughout the patient’s lifetime. If
the patient has neuromuscular defects, teach family members the exercises needed to maintain
muscle strength and joint range of motion. If the patient has neurological involvement and is not
on antiseizure medications, teach the patient and significant others how to recognize a seizure
and what to do if it occurs. Discuss the long-term prognosis for acquired toxoplasmosis; assist
the patient and family in drawing up an appropriate plan of action.

Tuberculosis DRG Category: 079

Mean LOS: 8.3 days
Description: MEDICAL: Respiratory Infections and
Inflammations, Age 17 with CC

T uberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis, an aerobic

acid-fast bacillus. Although it is most frequently a pulmonary disease, more than 15% of patients
experience extrapulmonary TB that can infect the meninges, kidneys, bones, or other tissues.
Pulmonary TB can range from a small infection of bronchopneumonia to diffuse intense
inflammation, necrosis, pleural effusion, and extensive fibrosis.
Although TB was thought to be preventable and treatable, the number of cases increased dur-
ing the late 1980s. In 1990, more than 25,000 cases were reported in the United States, which
was a 10% increase from the previous year. The increase was thought to be due to a high infec-
tion rate in patients with the human immunodeficiency virus (HIV) and patients who were
exposed to others hospitalized with TB, as well as a new strain of the disease that is resistant to
traditional drugs such as isoniazid (INH) and rifampin. Recent decreases are due to intensive
public health efforts to prevent and control the disease.

CAUSES
TB is transmitted by respiratory droplets through sneezing or coughing by an infected person.
Most infected persons have had a sustained exposure to the active agent, rather than a single one.
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Tuberculosis 907

The M. tuberculosis bacilli are inspired into the respiratory tract and usually lodge in the lower
part of the upper lobe or the upper part of the lower lobe. The TB bacilli need high levels of oxy-
gen to survive. When they reach the lungs, they multiply rapidly.
Mycobacteria that are not destroyed lie dormant until there is a decrease in the host’s resist-
ance. Of individuals who inhale mycobacteria 5% develop clinical TB at that time, 95% have
been infected and have no clinical symptoms but enter a latent phase and are at risk to develop TB
later.

GENETIC CONSIDERATIONS
Mutations in several genes have been associated with increasing susceptibility to TB. These
include variants in human leukocyte antigen (HLA) type NRAMP1, the vitamin D receptor, and
the mannose-binding protein. These gene variants have been studied in populations where TB
was endemic.

GENDER, ETHNIC/RACIAL, AND LIFE SPAN CONSIDERATIONS

TB can affect both genders at any age but is most common in the elderly population and in
those who are immunosuppressed. Overall, the incidence is twice as high in men as in women.
Since 1980, the largest increase in TB has been in men aged 25 to 44, in children under 15, and
in Hispanic/Latino, African American, and Asian populations. In the United States, approxi-
mately 70% of TB cases occur among minorities. Other high-risk groups are hospital employ-
ees, urban dwellers, drug and alcohol abusers, nursing home residents, and people who are
incarcerated.

ASSESSMENT
HISTORY. Ask patients about a previous history of TB or Hodgkin’s disease, diabetes melli-
tus, leukemia, gastrectomy, silicosis (a disease resulting from inhalation of quartz dust), and
immunosuppressive disorders. A history of corticosteroid or immunosuppressive drug therapy
can also increase the likelihood of TB infection. Other risk factors include a history of multi-
ple sexual partners and abuse of drugs or alcohol. Determine if the patient has had recent con-
tact with a newly diagnosed TB patient or has resided in any type of long-term facility. Take
an occupational history as well to determine if the patient is a healthcare worker and therefore
at risk.
Ask the patient to describe any symptoms. The patient often reports generalized weakness
and fatigue, activity intolerance, and shortness of breath on exertion. Anorexia and weight loss
occur because of altered taste and indigestion. The patient may also describe difficulty sleeping,
chills or night sweats (or both), and either a productive or a nonproductive cough.
PHYSICAL EXAMINATION. The patient looks acutely ill on inspection, with muscle wast-
ing, poor muscle tone, loss of subcutaneous fat, poor skin turgor, and dry flaky skin. When you
auscultate the chest, you may hear a rapid heart rate, rapid and difficult breathing, and stridor.
Diminished or absent breath sounds may be present bilaterally or unilaterally from pleural effu-
sion or pneumothorax. Tubular breath sounds or whispered pectoriloquies may be heard over
large lesions, as may crackles over the apex of the lungs during quick inspiration after a short
cough.
The sputum appears green, purulent, yellowish, mucoid, or blood tinged. The patient may
have pain, stiffness, and guarding of the affected painful area. Accumulation of secretions can
decrease oxygenation of vital organs and tissues. You may note cyanosis or a change in skin
color, mucous membranes, or nail beds and changes in mental status, such as distraction, rest-
lessness, inattention, or marked irritability.
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908 Tuberculosis

PSYCHOSOCIAL. Patients dependent on alcohol or drugs, those who are economically disad-
vantaged, and those who live in crowded conditions are at risk. The living environment needs care-
ful assessment. Ask about living conditions, including the number of people in the household.
Patients may have recent or long-standing stress factors, financial concerns, and feelings of help-
lessness or hopelessness. They may experience feelings of alienation or rejection because they have
a communicable disease and are in isolation. They may have changes in patterns of responsibility,
physical strength, and capacity to resume roles because of TB. Assess the patient’s ability to cope.
Assess the degree of anxiety or depression about the illness, the change in health status, and the
change in roles.

Diagnostic Highlights
Abnormality with
Test Normal Result Condition Explanation
Fluorochrome or Negative Positive; three samples Mycobacterium tuberculosis
acid-fast bacilli are often obtained is a bacterium that resists
sputum decolarizing chemicals after
staining
Chest x-ray Normal lung structures Identification of active TB Radiographic assessment of
or old lesions the lungs

Other Tests: Histology or tissue analysis, needle biopsy, purified protein derivative
(PPD; Mantoux test)

PRIMARY NURSING DIAGNOSIS

Risk of infection related to tissue inflammation and infiltration caused by the TB bacilli

OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection;
Treatment behavior: Illness or injury

INTERVENTIONS. Infection control; Medication management; Environmental management;

Surveillance; Nutrition management; Teaching: Disease process

PLANNING AND IMPLEMENTATION

Collaborative
Because TB typically becomes resistant to any single-drug therapy, patients generally
receive a combination of drugs. The most common combination of drugs prescribed in the
United States is INH, rifampin, pyrazinamide, and either ethambutol or streptomycin. Some
experts recommend up to 9 months of drug therapy, whereas patients with drug-resistant
strains of TB may require as much as 18 months of treatment. Intravenous fluids, total par-
enteral nutrition, and food supplements may be needed for those with nutritional compro-
mise. Humidity and oxygen are administered to correct hypoxia and to decrease the thick-
ness of secretions. Emergency intubation and mechanical ventilation may be needed in
extreme cases.
Teach the patient how and when to take medication and to complete the course of drug ther-
apy because one of the primary reasons for the development of drug-resistant TB strains is the
failure of patients to complete medication regimens. If you suspect that the patient may not
adhere to the medication regimen, a home health referral is important after the patient is dis-
charged.
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Tuberculosis 909

Pharmacologic Highlights
Medication or
Drug Class Dosage Description Rationale
Isoniazid (INH) 5 mg/kg per day Antitubercular Inhibits synthesis of bacterial cell wall and
PO once a day hinders cell division
Rifapin 10 mg/kg per day Antitubercular Interferes with RNA synthesis; able to kill
PO once a day slower-growing organisms that reside in
granuloma in lungs or other organs
Pyrazinamide 15–30 mg/kg PO Antitubercular Bacteriostatic or bacteriocidal
once a day
Ethambutol 15 mg/kg PO Antitubercular Interferes with cell metabolism and multi-
once a day plication by inhibiting bacterial metabolites
Streptomycin 1000 mg IM or IV Aminoglycoside Transported across cell membrane, binds
daily antibiotic to receptor proteins, and prevents cell
reproduction

Other Drugs: Second-line medications include cycloserine, ethionamide, and capre-

omycin sulfate. Mucolytics are used to thin secretions and facilitate expectoration.
Increased fluid intake decreases secretions. Bronchodilators increase the lumen size of
the bronchial tree and decrease resistance to airflow. Corticosteroids are used in
extreme cases when inflammation causes life-threatening hypoxia. Newer drugs:
rigapentine and immune amplifiers.

Independent
Nursing priorities are to maintain and achieve adequate ventilation and oxygenation; prevent the
spread of infection; support behaviors to maintain health; promote effective coping strategies;
and provide information about the disease process, prognosis, and treatment needs.
Use respiratory isolation precautions (masks only) for all patients with pulmonary TB who
require hospitalization. Whenever they leave their rooms or receive treatment from the hospital
staff, patients should wear masks to help prevent transmission of TB. The masks need to fit
tightly and not gap. Teach the patient to cover the mouth when coughing and to dispose of all tis-
sues. For patients with excessive secretions or those who are unable to cooperate with respira-
tory isolation, gowns and gloves may be necessary for hospital staff. The nurse should always
remember to wash the hands before and after patient contact.
Position the patient in a Fowler or semi-Fowler position, and assist with coughing and deep-
breathing exercises. Demonstrate and encourage pursed-lip breathing on expiration, especially
for patients with fibrosis or parenchymal destruction. Promote bedrest and activity restrictions,
and assist with self-care activities as needed.
Teach the patient and family how to use proper protection methods to prevent infection or
reinfection. In the case of treatment at home, the family has probably already been exposed
to the patient before diagnosis, so wearing masks is not necessary. Advise the family mem-
bers that they need regular TB testing to ensure that they have not contracted TB. Teach the
patient about complications of TB, such as recurrence and hemorrhage, and the need for
proper nutrition.

DOCUMENTATION GUIDELINES
• Physical changes: Breath sounds, quality and quantity of sputum, vital signs, mental status
• Tolerance to activity and level of fatigue
• Complications and changes in oxygen exchange or airway clearance
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910 Tuberculosis

DISCHARGE AND HOME HEALTHCARE GUIDELINES

Advise the patient to quit smoking, avoid excess alcohol intake, maintain adequate nutrition, and
avoid exposure to crowds and others with upper respiratory infections. Teach appropriate pre-
ventive measures. Be sure the patient understands all medications, including the dosage, route,
action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer
for eye examination after starting, then every month while taking, ethambutol. Teach the patient
to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that
should be reported to healthcare personnel. Discuss the patient’s living condition and the num-
ber of people in the household. Give the patient a list of referrals if she or he is homeless or eco-
nomically at risk.