Integrated Nursing Practice

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

Answer: In case of Boris the objective findings comprised of pulse rate, which was 110; blood pressure, which was 130/76 mmHg; his weight was 70 kg and temperature showed 38-degree Celsius- this raise in temperature clinically justifies infection within the body. This occurs due to the pyrogens secreted by the bacteria in the bloodstream. Pyrogens reach the hypothalamus, which is called the temperature regulating organ of the body (Alirol et Al., 2016). His oxygen saturation was 98 per cent on room air. Less 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)

His subjective symptoms included 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. Both pain in the 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 the 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 primary 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 bloodstream 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 a 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: As per the medical review chart. Borris is taking the following medications: Rifampicin 600 mg OD; Myambutol 150 mg OD; Isoniazid 150 mg BO and Pyroxin 10 mg TDS. As per the research done by Robert Horseburgh et al., 2015, the prescribes medication is a standard protocol for treatment of tuberculosis, especially latent tuberculosis. However, it is vital to monitor the patients on the aforementioned medicine due to their high adverse effects index (LoBue & Moser, 2003). Isoniazid is known to cause acute injury to the liver due to its continuous use and also raises concern for causing hypertoxicity due to its interaction with various drugs (chang et al.,2018). Therefore, it is usually discontinued after 6 months duration. Nearly 3 per cent of tuberculosis patients produce symptoms of acute liver dysfunction due to the prescribed regime within 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. Use of sub-therapeutic drug may increase the chances of relapse and may even cause failure of the treatment and even lead to death. Therefore, 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; chang et al.,2018)

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

Answer: From the nursing point of view, it is impertinent to have the complete knowledge of the disease, causative factors and various signs and symptoms which are particular of the disease in order to effective rule it from various differential diagnosis. As a nurse I should use the following diagnostic criteria in case of patient Boris:

  1. Weight loss. Weight loss accompanied by low grade fever and shortness of breath and chest pain is a common sign and symptom of the lung infection or a heart disease.
  2. Further diagnosis can be made by viewing the chest radiographs of the patient (Bruce, 2020). As it can be seen, there was presence of infiltrates in the upper lobe of the lung as well as in the cavity are strongly suggest Tuberculosis. However, its vital to ensure the same with relevant diagnostic testing.
  3. Conducting 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) Understanding the disease pathology. Realizing the phase, the patient is in. Boris is in an active phase which means there could be a potential spread of the infection as it is an air-borne droplet infectious disease. Rationale: Explain the patient the use of masks while talking/laughing, give the awareness related to the transmission of the disease to avoid the risk of spreading the infection.

2) Monitoring of patient’s temperature: If the temperature persists, it may lead to increase severity of infection. This may need change in the dosage of medication.

3) Periodic medical review. It is rationale for reviewing the medications on a regular basis is to ensure compliance from the patient.

4). Periodic follow up visits: This is done to monitor the progress of the patient, to make sure that he does not experience any adverse side effect of the drug regimen. (Kumar, 2016; Nazir et al., 2019)

5) Provide supplemental oxygen: This is done in order to maintain the level of oxygen in the blood of the patient.

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). Compliance to medication: In case of Boris, it is essential that he continues to take the medications even if he has now started to feel better. They minimum time duration of the dosage is 2 months (Dedun, Borisagar & Solanki, 2017).

2) Have a proper diet: It is vital that Boris has a consult from a dietician to maintain his weight (NMBA, 2016). From the history provided it can be seen that he has lost 10 kgs over a period of 05 months. Therefore, it is essential that the patient is asked to eat timely meals and maintain his weight to avoid feelings of weakness or fatigue and experience muscular loss (Bucknall et al.,2019)

3) Encourage rest: It is important that the Boris has frequent rest intervals during work, so that there is no increase in fever and can conserve energy.

4) Positioning: As a nurse I will educate Boris to sleep in semi-fowler or high fowler position in order to ease the breathing process, by maximizing ventilation. (World Health Organization, 2017)

5) Educate the patient about the disease and the side-effects of the medication (NMBA, 2016). It is important to inform the patient regarding the condition which he is suffering from. It reduces the stress and anxiety level of the patient. It also helps him to be more compliant with the treatment protocol.

References for Integrated Nursing Practice

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 & practice29(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 diseases10(11).

Allen Jr, L. V. (2017). Ethambutol Hydrochloride Compounded Oral Suspension USP (100 mg/mL). US Pharm42(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 nursing75(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 Association81(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 Med4(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 journal10(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 Disease20(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 Pharmacology8(1), 147.

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

Tweed, C. D., Wills, G. H., Crook, A. M., Dawson, R., Diacon, A. H., Louw, C. E., ... & Murphy, M. E. (2018). Liver toxicity associated with tuberculosis chemotherapy in the REMoxTB study. BMC medicine16(1), 46.

World Health Organization. (2017). Guidelines for treatment of drug-susceptible tuberculosis and patient care. Retrieved from https://www.who.int/tb/publications/2017/dstb_guidance_2017/en/

Ye, M., & Bian, L. F. (2018). Association of serum leptin levels and pulmonary tuberculosis: a meta-analysis. Journal of thoracic disease10(2), 1027.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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