Introduction: This assignment is based on reflection on the case study of TB patient, Borris, who is a 62-year-old; factory worker, who presented with chief complaints of chest pain, shortness of breath, coughing up blood, and history of weight loss. He was diagnosed with pulmonary tuberculosis. His treatment included standard dose of anti-tubercular drugs. The assignment further discussed the pathophysiology of TB in the patient, critical evaluation of prescribed drugs, and establishment of nursing diagnosis and care plan.
Question 1. Analyse and interpret relevant objective and subjective data and explain then based on the pathophysiological changes associated with TB.
Answer: Objective findings in the case study include pulse rate 110; blood pressure, 130/76 mmHg; weight 70 kg and temperature 38-degree Celsius- this raise in temperature clinically justifies infection within the body. As Per the research of Alirol et Al., 2016, “it occurs due to the pyrogens secreted by the bacteria in the blood stream. When these pyrogens reach the hypothalamus (which is called the temperature regulating organ of the body), the temperature of the body is changed. His oxygen saturation was 98 per cent on room air. Less of oxygen in the blood is due to the fact that less air and less oxygen is reaching the blood due to damage in the lungs. Boris also exhibited unilateral crepitations, which are indicative of lack of entry of the air into the lungs on the left side, which may have caused the lung to collapse. (Fang et al., 2016)
The subjective symptoms encompass clammy skin and sharp chest pain, and he had severe was shortness of breath, productive cough for 5 months and a 10 kilograms weight loss over the same period of time. Both pain in chest as well as shortness of breath occur due to the infection caused by Mycobacterium Tuberculosis which causes increase production of fluid as a product of inflammatory process of the lung tissue. This fluid is accumulated between the thin membrane of the pleura occupying the pleural cavity which exists between the lungs and the chest wall. This condition is termed as “pleural effusion”. The chest pain is a body’s response to the inflammation of the lung tissue caused by the bacteria. Loss of weight in case of tuberculosis occurs as a result of suppression of pro-inflammatory cytokines which play the vital and a primarily role in carrying out the metabolic changes in the body such as leptin is a useful hormone which helps in regulating food-intake in the body. It is secreted in the blood stream and the brain gets a signal to stop eating. It also plays a major role in promoting cellular immunity. Thus, in case of tuberculosis, as an inflammatory response, higher levels of leptin are produced in the blood as a mechanism of immune response to the inflammatory process (Ye, M. & Bian, 2018). This in turn leads to lack of hunger by inhibiting sensory control related to food-intake. (Yazidi et al., 2019)
Question 2: Evaluate and critique the pharmacological management prescribed for the patient?
Answer: Medications prescribed to Borris comprise of a standard antitubercular drug regime with Rifampicin 600 mg OD; Myambutol 150 mg OD; Isoniazid 150 mg BO and Pyroxin 10 mg TDS. According to Robert Horseburgh et al., 2015, “it is vital to monitor the patients on the aforementioned medicine due to their high adverse effects index”. Research conducted by Chang et al., 2018 explained the toxic effects of Isoniazid, which causes hepatotoxicity by causing tissue damage in the liver if used for prolonged period of time. It also has high intractability index with other drugs (Chang et al., 2018). This accounts for the primary reason for its discontinuity after 6 months. Almost 3 percent of TB patients exhibit acute dysfunction of the liver within a period of first two months, however, patients above the age of 60 years are at higher risk of developing liver damage (Dedun, Borisagar & Solanki, 2017). Using sub-therapeutic dosage of the antitubercular regime stated above, can surge the risk of relapse and lead to failure of the treatment and in severe cases, it may also lead to death. Therefore, in case of TB patients, close monitoring of the drug dosage is critical in any case of tuberculosis. If the dosage of Pyroxin is administered more than 30mg/kg, it may also cause severe hepatotoxicity. Research conducted by Hest et al., 2004 concluded that, “Preventive treatment with rifampin-pyrazinamide causes severe hepatotoxicity more often than does preventive treatment with isoniazid or curative treatment for tuberculosis.” In the case of Boris the dosages were given within the safe units and showed no signs or symptoms of any adverse effects. (Allen 2017)
Question 3: Identify nursing diagnosis relevant to the case study and develop nursing care plan with rationales.
Answer. Nursing diagnosis relevant to this case study are lack of appetite and weight loss, productive sputum and difficulty in breathing, as the patient exhibits shallow breathing or shortness of breath. As a nurse, it my responsibility to know thoroughly examine the patient and do the complete assessment, to know the disease, cause, symptom and pathophysiology of the disease in order to form the exact diagnosis of the patient (NMBA, 2016). The following nursing interventions will be recommended. First is to explain the patient the nature of the disease, its stages. It occurs in four stages-
1) macrophagic response, in which the TB bacilli reach the alveoli via inhalation and most of them are destroyed by macrophages (occurs in first week of infection),
2) Immune response (strong bacillus of TB reproduce, weakening the immune response (occurs in the second week) ,
3) Stage of lung cavitation, this stage is non-contagious, they have invaded the lung tissue but are not coughed up and
4) Re-activation of bacilli, causing further lung damage, the immune response fails in this stage and the symptoms start developing (Kumar, 2016).
Rationale for this intervention is to avoid further spread of infection to others, since the infection occurs in the lung, it is highly contagious and be easily spread to others by the droplet transmission. Therefore, use of masks and maintaining hygiene is encouraged for the patient. The second most important nursing intervention is to improve the diet of the patient. Rationale for this intervention is based on the fact that lack of appetite causes decrease in weight of the patient and there by decreasing the strength. Thus, it is vital to maintain a diet including fruits, proteins and frequent meals in order to have optimal energy in the body to deal with the infection and the side effects of the antitubercular drugs (Bucknall et al.,2019)
Conclusion: This case study helped me to learn about the optimal dosage of drug regime and toxicity, pathophysiology of TB. 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.
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