1247 Final exam

Home Care

-Need for monthly sputum cultures -Ensure that patient can adhere to treatment -Teach symptoms of recurrence -Instruct about factors that could reactivate TB -Smoking cessation

Medication Therapy for Active Tuberculosis

-Patients should be taught about side effects and when to seek medical attention -3 of the 4 drugs can cause hepatotoxicity. SO - * Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritus) * Check liver enzymes monthly (BUN, Creatinine) * Teach not to drink alcohol

Direct Observation Therapy (DOT)

-Used with those patients who are noncompliant and do not show signs of improvement after treatment. Noncompliance is major factor in multidrug resistance and treatment failures - -Provide drugs directly to the patient; watch them swallow drugs - -Costly, but preferred to ensure adherence -If refuses DOT then may have to put involuntarily in treatment facility to protect the community.

What is necessary to confirm the patient is non-infectious?

2 consecutive negative sputum cultures

Which one of these classifications of body weight gives an accurate picture of obesity?

A.Body Mass Index (BMI)

Monitoring Response to Treatment for the Patient with active TB

After 3 months of therapy, if cultures are positive or symptoms do not resolve - what would you expect to happen? Non compliant, directly observed therapy DOT, done to insure adherence

Pear Shape (Gynoid) •Most fat is below the waist •More subcutaneous fat • Health Risks •Osteoporosis •Varicose veins •Cellulite •

Apple Shape (Android) •Most fat is above waist - usually abdomen •More visceral (abdominal) fat Health Risks •Heart disease and HTN •Diabetes Mellitus •Breast & endometrial cancer •↑ triglycerides (which → ↑ risk of CAD) •↓ HDL cholesterol

Active TB: Treatment Guidelines

Be Aggressive with Treatment Initiation Phase of Treatment Multiple-medication regimen of all 4 meds Administered daily for 8 weeks Continuation Phase of Treatment d/c ethambutol and continue other 3 meds Administered for 18 weeks = 6 months 2 weeks Patient begins to feel better in this phase

Does a positive reaction mean the person has TB? No, exposed to antibodies

Does it differentiate between latent & active TB? No, the person has been exposed

Nutrition •What is the criteria for feeding this patient? Water sugar free liquids 30 mls every 2 hours while there awake • • •What type of diet are they sent home on? high protein liquid • •What is included in patient teaching r/t diet? Eat slowly, realize your full don't consume liquids with solids • •Should fluids be taken with meals? No, 6 small meals

Expected outcomes •Long-term weight loss •Improvement in obesity-related co-morbidities •Integration of healthy practices into lifestyle Improved self-image

Etiology and Pathophysiology

Genetic/Biologic link, influenced by: •Physiologic factors •Environmental factors •Psychological factors These are interrelated!

Goals of Nursing Care

Goals: Comply with therapeutic regimen Have no recurrence of disease Have normal pulmonary function Take appropriate measures to prevent spread of disease

What can trigger reactivation of latent TB infection (LTBI)

Host's defenses become impaired - but how? Immunosupreesion in any way. Poor nutrition, pregnancy, aging, stress, chronic disease, consequent treatment of latent disease.

Therapy for the Patient with Latent TB Infection (LTBI)

Individual is infected with M. tuberculosis, but does not have the disease. Usually has been exposed to someone with tuberculosis. Will have a positive TB test. Medication helps prevent TB infection from developing into TB disease. Only need 1 drug because fewer bacteria Usually treated with INH for 6- 9 months So they wont develp active tb

TB Blood Test

Interferon Gamma Release Assay (IGRAs) QuantiFERON®-TB (QFT-GIT) T-SPOT®.TB (T-Spot) If the patient is infected with TB, the lympocytes in their blood will secrete interferon. Test results are available in a few hours. -Requires only one visit -Not affected by BCG vaccination -Cost is substantially higher than TST DX: latent tb- just by ruling out active tb

Obesity

It is not merely a condition, it is a disease characterized by fat that accumulates to the extent that health is impaired.

Metabolic Syndrome

Lifestyle modifications are first-line interventions •Reduce glucose levels •Stop smoking •Reduce LDL cholesterol & triglycerides •Lower blood pressure •Loose weight/healthy diet •Increase physical activity

Why is this organism difficult to treat?

Lodge into the alveoli in the lungs then calcified TB granuloma. When purpose is to wall off the infection and prevent spread. Different strains

What is the Underlying Cause?

M Tuberculosis (causative organism) Gram-positive, acid-fast bacillus (AFB) Spread via airborne particles

Can you get an accurate picture of a person's obesity with one type of assessment measurement?

No two or more methods combined

Are a TB infection and Latent TB the same?

No, the body incapsulates organisms. Primary infection is prevent from becoming a disease. Immune is not adequate, bacteria starts to replicate in immunocompromed. Positive TB skin test can not transmit TB at some point my become active

Treatment and Nursing Care

Nutritional Therapy/ Weight reduction Plan •Low calorie with adequate amounts of fruits, vegetables, & fiber •Avoid concentrated sweets •Small Portions •Do not skip meals •Reduce fat intake

Nursing Interventions What type of isolation is typically ordered? •What PPE is worn? Who wears this equipment? •What type of room are they in? N95 mask, negative pressure

Patient Teaching •Cover nose and mouth with tissue when coughing, sneezing, producing sputum, discard appropriately •Hand washing after handling sputum-soiled tissues

Start with Behavior Modification

Patient must be ready for change in their lifestyle Must decide upon a plan that is best for them What would the nurse ask the patient? See table 40-6, p. 881

•Exercise •Essential part of weight loss program •Recommend: 30 - 60 minutes 6-7 days/week •Increases cardiovascular conditioning

Patients desire to change lifestyle + Exercise + Diet control Weight Loss

What is the rationale for the health care provider ordering more than one medication?

Resistance, avoid the bacteria to develop resistance to one single drug

How would the nurse assess if S.C. has been compliant with taking hismedications?

Signs and symptoms are improving, follow up with sputum and culture

How is Tuberculosis Transmitted?

Spread via airborne particles when infected person ◦Coughs ◦Speaks ◦Sneezes ◦Sings ◦Laughs ◦Shouts ◦ Particles can remain suspended in the air for minutes to hours, BUT they replicate slowly.

DIAGNOSIS

TB Skin Test: TST (Mantoux or PPD) Intradermal injection of 0.1 mL PPD antigen on ventral surface of arm.

What are complications to anticipate?

TB usually heals without complications, except for scarring. Rare complications can occur if poorly treated or no response to treatment. Miliary TB Spreads to other organs via bloodstream - can be fatal if untreated Pleural TB - effusion and empyema Bacteria in pleural space →inflammatory response →fluid or pus in pleural space Unilateral pleura infusion

Treatment for Active TB Initial Phase: Four Medication Regimen 27-5

Taken daily for 8 weeks: isoniazid [INH] rifampin [Rifadin] pyrazinamide [PZA] Ethambutol Know side effects, liver toxicity

What treatment would you expect the health care provider to order for S.C.?

Treating aggressively, pg 509 27-12 four meds, daily for 2 months be aware of these medication and side effects. Contraindicated to some people, pt teaching

Factors that May Affect the Skin Test Reaction

Type of Reaction Possible Cause False-positive Nontuberculous mycobacteria BCG vaccination False-negative Recent TB infection Very young age (< 6 months old) Weakened immune system

Prevention of Tuberculosis

Vaccine -Bacille Calmette-Guérin (BCG) vaccine to prevent TB is currently in use in many parts of the world. Given to infants. -In United States, typically not recommended due to low risk of infection. -Can cause false positive TB skin test (TST) -Does not affect TB blood test (IGRA)

Body Mass Index •It is the individual's body mass/ weight(fat stores) divided by the square of his or her height. • •Used to screen for weight categories that may lead to health problems •

Waist Circumference Health risks ↑ if waist circumference is >35 in a female? > 40 in a male?

the weaker the immune system is the wall loses integrity and the bacilli are able to escape and spread to other alveoli or other organs

macrophages and T lymphocytes act to gather to try to contain the infection by forming granulomas.

What about exposure to those who live with him?

§Infectious for 2 weeks, during that time he should not have visitors, avoid travel on public transportiation and public placed, good hygiene, difficult amount of time , frequent open room cover mouth throw used tissues. Short amount of time in common areas, strictly adhear to drs orders

Reading the Tuberculin Skin Test

§Read reaction 48-72 hours after injection §Measure only induration (not redness) palpable raised § §Record reaction in millimeters A positive reaction means that the person has been exposed to TB and developed antibodies Does NOT differentiate between active and latent TB infection. table 25.11 472

Is the apple or pear shape more prone to major complications?

•Apple

Who is at High Risk for TB?

•Born in foreign country with high prevalence of TB -#1 Asia, #2 Pacific Islanders/ native Hawaiians •Living or work in congregate settings (prisons, shelters) •Residents of long-term care centers •Health Care Workers •Alcohol abuse or IV drug users •Poverty, poor access to health care •Homeless •HIV/AIDS Diabetes

If a person has symptoms of TB and has a negative skin test, then the HCP would likely order additional testing.

•Chest x-ray: Important, but cannot diagnose TB with just a chest x-ray. -Other diseases can mimic appearance of TB. -X-ray might be normal in someone with TB • •Sputum smear & culture: Definitive diagnosis of TB with culture -Take sputum swabs on 3 consecutive days. -Initially do stained sputum smear for acid fast bacteria (AFB) -Then grow sputum culture of M tuberculosis - can take 8 weeks.

Medication Therapy

•Drugs will not cure obesity. •Drugs should never be used alone. •Must also have reduced calorie diet, exercise, & behavior modification. Without these, weight will return after drug therapy stops. •Drugs should be reserved for adults with •BMI > 30 (obese) OR •BMI > 27 AND at least one weight related health condition •Drugs are not covered by many insurance companies •

Post Operative Complications

•Dumping syndrome - gastric contents empty too rapidly into the small intestine •Symptoms - vomiting, nausea, weakness, sweating, faintness, and diarrhea •Prevention - eat small meals; avoid high CHO foods/concentrated sweets, choose foods with high fibe, fat, and protein, and no fluids with meals WHY? • •Iron & Calcium Deficiency & Anemia •In which type of bariatric surgery would this be more likely? malaborbtion •Increase intake of protein, iron, calcium, and B12

TB S/S

•Initial S/S 2-3 weeks after infection or reactivation ocurrs -Cough that becomes productive (mucoid/mucopurulent sputum) -Fatigue/malaise -Anorexia -Unexplained weight loss -Low grade fever -Night sweats •Late S/S -Dyspnea -Hemoptysis -Chest wall pain

Goals of Care

•Modify eating patterns • •Participate in a regular physical activity program • •Achieve and maintain weight loss to a specified level • •Minimize or prevent health problems related to obesity

TB is NOT Highly Infectious

•ONLY spread via airborne particles. •Cannot be spread by physical contact, sharing eating utensils, or kissing. • •Brief exposure rarely causes TB. • •Must have close, frequent, or prolonged exposure. •Most adults with healthy immune system can kill the TB bacteria, even if exposed.

Post Op Complications

•Rapid oxygen desaturation due to re-sedation •watch for altered mental status •use pulse oximeter •Wound evisceration and dehiscence •What position helps decrease stress on the abdomen? •What should be done to support incision during coughing? • •Wound Infection •Skin assessment & care Increase protein intake

•Obesity is usually due to the consumption of more calories than are needed by the body for energy. •Other causes: congenital anomalies, metabolic problems, medication side effects, CNS disorders

•These extra calories are then converted by the body into fat and stored as energy for a "rainy day". The "rainy day", however, never arrives and the fat is not consumed

•Restricive Surgery: •reduces size of stomach by banding, removing part of the stomach, or inserting a balloon into stomach •Less food is eaten •Digestion is not altered, so low risk for anemia • •Malabsorptive Surgery: •Small intestine is shortened or bypassed •Less food is absorbed •Better long term weight loss than with restrictive •Risk for anemia & vitamin deficiencies. •Can cause dumping syndrome

•Trained staff should assist transfer of unconscious patient . During transfer ensure that patient's •Airway is stabilized •Pain is managed • •Assess vital signs. What is of particular concern ? Why? • • •Elevate head of bed at 35- 400 Why? Lung expansion, weight offadn

Bariatric Surgeriesfor Obesity

•Used to treat morbid obesity •Currently the only treatment found to have sustained weight loss with extreme obesity

Tuberculosis (TB)

•Usually involves the lungs, but can infect any organ -Brain, kidneys, bones - •1/3 of worlds population are infected with TB •Leading cause of death in HIV patients •TB occurs disproportionately in poor, racial & ethnic minorities, and underserved

•Body mass index (BMI) - most commonly used ••Waist circumference •People with excessive abdominal (visceral) fat are more prone to cardiovascular disease and metabolic syndrome

•Waist-to-hip ratio (WHR) •Waist measurement is divided by hip measurement • •Body Shape: Pear (Gynoid) orApple (Android)

Does the nurse have to notify the health department of his discharge?

•Yes, must be notified in every case of TB, reasponable for assessing for adherence