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  • Subject Name : Nursing

Tuberculosis (TB)

Question 1. Analyse and interpret relevant objective and subjective data and explain then based on the pathophysiological changes associated with TB.

Answer: In the given case study the following objective findings were noted:

1). Pulse rate: 110;

2). Blood pressure: 130/76 mmHg;

3). Weight 70 kg; He lost 10 Kgs of weight in a period of 5 months: Weight loss in tuberculosis patients occurs because of suppression of pro-inflammatory cytokines. They play a significant role in carrying out the metabolic activities within the body. For instance, the hormone leptin functions as an agent for cell mediated immunity as well as is useful in regulating the intake of food in the body. It is secreted in the blood stream and the brain gets a signal to stop eating. Therefore, in case of Boris, an inflammatory response caused a higher level of leptin in the blood, leading to decreased hunger and thus loss of weight (Ye, M. & Bian, 2018). This occurs by inhibiting the sensory input signal which is sent to the brain to cause hunger. (Yazidi et al., 2019)

4) Temperature: 38-degree Celsius. Temperature of low grade clinically validates infection within the body. This occurs due to the pyrogens secreted by the bacteria in the blood stream. Pyrogens reach the hypothalamus, which is called the temperature regulating organ of the body (Alirol et Al., 2016).

5) Oxygen saturation (PO2): 98 per cent: Decrease in the oxygen saturation is indicative of in the lack of adequate oxygen supply reaching the blood due to compromised airway breathing mechanism.

6) Crepitations: They suggest decrease air flow in the lungs. (Fang et al., 2016).

The subjective examination of Borris includes:

  • Clammy skin
  • Sharp chest pain
  • Severe was shortness of breath
  • Productive cough.

Chest Pain & shortness of breath occur due to the infection caused by Mycobacterium Tuberculosis. It increases the production of fluid as a product of inflammatory process of the lung tissue. The accumulation of fluid occurs between the thin membranes of the pleura which occupies the pleural cavity. The pleural cavity exits between the lungs and the chest wall. This condition is termed as “pleural effusion”. In certain conditions there is a presence of air in the pleural cavity and it is termed as “pneumothorax”.

Chest pain is a body’s response to the inflammation of the lung tissue caused by the bacteria.

Question 2: Evaluate and critique the pharmacological management prescribed for the patient?

Answer: Pharmacological management of Borris is comprised of standard protocol of antitubercular drugs- Rifampicin 600 mg OD; Myambutol 150 mg OD; Isoniazid 150 mg BO and Pyroxin 10 mg TDS. Isoniazid is known to cause dysfunction of the liver and also hypertoxicity due to its interaction with various drugs. As per chang et al.,2018, “INH is usually drug of choice for infected patient and those at risk for developing TB, including Rifampin for at least a period of 6 months, PZA, and ethambutol or streptomycin, is given for at least 2 months (or until sensitivities are known or until serial sputums are clear) followed by 3 more months of therapy with INH. Ethambutol should be given if central nervous system or disseminated disease is present or if INH resistance is suspected.” Nearly 3 percent of tuberculosis patients produce symptoms of acute liver dysfunction due to the prescribed regime within a period of only two months, however the risk is higher in the patients above the age of sixty years (Dedun, Borisagar & Solanki, 2017). The hypertoxicity of this drug regimen may also cause HIV infection. As per the research done by Robert Horseburgh et al., 2015, It is vital to regularly monitor these patients as this drug regime has multiple side effects such as nausea, vomiting, headache, feelings of weakness, etc. Severe hepatotoxicity can also be caused in case of high amount of Pyroxin is administered (> 30mg/kg). The dosages of the drug regime provided top Boris were of standard dosage. (Allen 2017; chang et al.,2018)

Question 3: Identify nursing diagnosis relevant to the case study and develop nursing care plan with rationales.

Answer: As per the NMBA standard 1.1,” accesses, analyses, and uses the best available evidence, that includes research findings for safe quality practice.” I would gather all the necessary information about tuberculosis and recall the information from my previous lectures on infectious diseases, its causative factors, signs and symptoms of the disease as well as nurse’ diagnostic criteria. In the case study the factors that point towards the diagnosis of an lung infection are, productive cough, continuous weight loss, low grade fever, shortness of breath and chest pain is a common sign. To further confirm my diagnosis, I would review the chest radiographs of the patient (Bruce, 2020). The CXR revealed presence of infiltrates in the upper lobe of the lung as well as in the cavity, which are strongly suggestive of Tuberculosis. However, I would conduct tuberculin skin test or PPD (purified protein derivative). As per the “Management, control and Prevention of Tuberculosis, Guidelines for healthcare providers”, Tuberculin PPD can be delivered into the skin by the Mantoux test, the Heaf test and the tuberculin tine test. These are used as alternatives of the tuberculin skin test (TST). In Australia, the Mantoux test is used most often used. “The Mantoux test is subject to inconsistency in both injection technique and reading technique, but many of the inherent variations in the administration and interpretation of the test can be avoided by careful attention to detail.”

Nursing care plan:

1) Increasing the awareness of the disease. Helping the patient to understand the cause and signs and symptoms of the disease. It is also important that the prognosis of the disease is disclosed to the patient. Rationale: Decreases level of anxiety and helps in making correct decisions pertaining to compliance with the treatment protocol.

2) Regular temperature monitoring: If the temperature persists, it may lead to increase severity of infection. This may need change in the dosage of medication.

3) Management of drug regime. Checking the dosage of the medications on a regular basis is to ensure compliance from the patient.

5) Oxygen therapy: In order to maintain adequate oxygen supply to the body organs.

Question 4: Discuss patient education topics relevant to the patient prior to his discharge from the hospital?

Answer: The following points are necessary for the nurse to educate the patient who is undertaking the tuberculosis treatment:

1). Controlling the infection: patient must be explained the need for using masks before coming in contact with anyone, awareness related to the transmission of the disease to avoid the risk of spreading the infection should be provided to the patient before discharge.

2) Dietary Management: Diet is an essential part in the recovery process in case of tuberculosis patients. This is because they develop inability to feel “hunger” and may lead to malnutrition and weakness. (Dedun, Borisagar & Solanki, 2017).

3) Medication management: It is important that the Boris is compliant with the treatment. If the minimal treatment is not received, it may lead to relapse as well as increase progression of the disease, affecting other organs of the body, such as it can infection if reached to the spinal cord, may cause meningitis (inflammation of the sheath which provides covering of spinal cord and brain). And if left untreated may even cause death. (Chang et al.,2018)

4) Regular follow ups and routine examination: It is important to ensure that there is no adverse drug reaction or side effects from the drug experienced by the patient. In that case the dosage of the drug is altered. Therefore, the patient must be educated on the importance of regular follow ups and undertaking routine chest X-rays to monitor the progress of the treatment.

Conclusion: From this case study I have learnt about drug interaction and importance of optimal dosage of antitubercular drug regimen. I was able to make a step by step nursing plan for the patient by encircling important points such as educating the patient, encouraging medical compliance and following NMBA standards of ethical nursing practice. 

References for Tuberculosis

Al Yazidi, L., Marais, B., Wickens, M., Palasanthiran, P., Isaacs, D., Outhred, A., ... & Britton, P. (2019). Overview of paediatric tuberculosis cases treated in the Sydney Children’s Hospitals Network, Australia. Public health research & practice, 29(2).

Alirol, E., Horie, N. S., Barbé, B., Lejon, V., Verdonck, K., Gillet, P., ... & El Safi, S. (2016). Diagnosis of persistent fever in the tropics: set of standard operating procedures used in the NIDIAG febrile syndrome study. PLoS neglected tropical diseases, 10(11).

Allen Jr, L. V. (2017). Ethambutol Hydrochloride Compounded Oral Suspension USP (100 mg/mL). US Pharm, 42(8), 48-49.

Bucknall, T., Fossum, M., Hutchinson, A. M., Botti, M., Considine, J., Dunning, T., ... & Manias, E. (2019). Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting. Journal of advanced nursing, 75(6), 1316-1327.

Bruce, C. G., & Rojas, R. P. (2020). Study of Images in Respiratory Diseases. In Pediatric Respiratory Diseases (pp. 107-126). Springer, Cham.

Chang, T. E., Huang, Y. S., Chang, C. H., Perng, C. L., Huang, Y. H., & Hou, M. C. (2018). The susceptibility of anti-tuberculosis drug-induced liver injury and chronic hepatitis C infection: A systematic review and meta-analysis. Journal of the Chinese Medical Association, 81(2), 111-118.

Dedun, A. R., Borisagar, G. B., & Solanki, R. N. (2017). Impact of adverse drug reaction of first line anti-tuberculous drugs on treatment outcome of tuberculosis under revised national tuberculosis control programme. Int J Adv Med, 4(3), 645-9.

Fang, Y., Xiao, H., Tang, S., Liang, L., Sha, W., & Fang, Y. (2016). Clinical features and treatment of drug fever caused by anti‐tuberculosis drugs. The clinical respiratory journal, 10(4), 449-454.

Hemanth Kumar, A. K., Kannan, T., Chandrasekaran, V., Sudha, V., Vijayakumar, A., Ramesh, K., ... & Ramachandran, G. (2016). Pharmacokinetics of thrice-weekly rifampicin, isoniazid and pyrazinamide in adult tuberculosis patients in India. The International Journal of Tuberculosis and Lung Disease, 20(9), 1236-1241.

Management, control and Prevention of Tuberculosis, (n.d.) Guidelines for healthcare providers. Retrieved from https://www.thermh.org.au/sites/default/files/media/documents/Management,%20control%20and%20prevention%20of%20tuberculosis%20-%20Guidelines%20for%20health%20care%20providers%20-

Nazir, T., Farhat, S., Adil, M., & Asraf, Z. (2019). Adverse drug reactions associated with first line anti-tubercular drugs, their prevalence and causality assessment in patients on Directly Observed Treatment Short-course (DOTS) in a tertiary care hospital. International Journal of Basic & Clinical Pharmacology, 8(1), 147.

NMBA, (2016). Professional Standards. Retrieved from https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Ye, M., & Bian, L. F. (2018). Association of serum leptin levels and pulmonary tuberculosis: a meta-analysis. Journal of thoracic disease, 10(2), 1027.

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