NURSING 101 TB.Case study.docx
INSTRUCTIDNS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significanc
...
NURSING 101 TB.Case study.docx
INSTRUCTIDNS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.
Scenario
You are a public health nurse working at a county immunization and tuberculosis (TB) clinic. B.A. is a 61-year-old woman who wishes to obtain a food handler's license and is required to show proof of a negative Mantoux (purified protein derivative [PPD]) test before being hired. She came to your clinic 2 days ago to obtain a PPD test for TB. She has returned to have you evaluate her reaction.
1. What is TB, and what microorganism causes it? TB is a highly communicable disease that normally affects the lungs. It is caused by Mycobacterium tuberculosis.
2. What is the route of transmission for TB? TB is spread person-to-person via airborne droplets.
3. The Centers for Disease Control and Prevention (CDC) recommends screening people at high risk for TB. List five populations at high risk for developing active disease.
1. Children younger than five years old or older adults
2. Homeless people
3. Individuals in contact with an untreated person with TB
4. Individuals living in crowded areas
5. Individuals with malnutrition, infection, immune dysfunction or HIV
6. Individuals who are intravenous drug users or who abuse alcohol
4. Describe the two methods for TB screening.
TB Skin test:
Tuberculin skin test, PPD: Often called the Mantoux tuberculin skin test. A positive reaction indicates previous exposure or the presence of inactive disease. A positive reaction does not mean that active disease is present. The test is conducted by injecting 0.1 ml of tuberculin purified protein derivative into the forearm via intradermal injection. After injection, the patient should return to have the test read 24 to 72 hours after administration. If there is a reaction it should be measured in millimeters, anything over 15 mm is considered positive. Specific risk factors or populations could be considered positive with smaller millimeter readings.
TB Blood test:
Quantinterferon-TB gold test: a blood analysis test by an enzyme-linked immunosorbent assay. This test is sensitive and rapid; results can be available in 24 hours. Results from this test do not confirm a diagnosis.
5. How do you determine whether a Mantoux test is positive or negative?
The test reading is dependent on two things; the measurement in millimeters of the induration and the person’s risk of being infected with TB. See chart below:
Induration = 5 or >5mm,
positive Induration = 10 or
>10mm, positive Induration = 15 or >15
mm, positive
HIV infected person Recent immigrants from Any person
Recent contact with high-prevalence
person with TB countries
Chest x-ray consistent Injection drug users
with TB Those in high-risk
Organ transplant clients congested settings
Immunosuppressed Laboratory personnel
clients Those with clinical conditions that increase
risk
Young children under 4
*Chart information from Saunders
CASE STUDY PROGRESS
B.A. consumes 3 to 4 ounces of alcohol (ETOH) per day and has smoked 1.5 packs of cigarettes per day for 40 years. She is a natural-born American, has no risk factors according to the CDC guidelines, lives with her daughter,and becomes angry at the suggestion that she might have TB. She admits that her mother had TB when she was a child but says she herself has never tested positive. She says, "I feel just fine and I don't think all this is necessary:'
6. What additional information would you want to obtain from A. before interpreting her skin test result as positive or negative?
The client would be asked about recent history of influenza, pneumonia, febrile illness, cough or foul-smelling sputum production. She would be asked if she had received bacilli calmette-Guerin vaccine, which could skew test results. Though many patients with latent with TB have no symptoms, it would be beneficial to ask B.A. targeted questions to see if she has any of the following symptoms: weight loss, loss of appetite, night sweats, fever or fatigue. It is also important to
7. Determine whether B.A.'s skin test is positive or negative.
The skin test is positive for Tuberculosis because the raised area of the skin is about 15mm.
8. A. asks you what a positive PPD result means. How will you respond?
A positive test does not mean that a patient has active disease; however, it is an indicator that a patient has had previous exposure to tuberculosis or that the patient has a dormant form of the disease.
9. What steps will need to be done to determine whether A. has an active TB infection?
We would assess her symptoms. Also, we would perform a chest x-ray, because if the disease is active inflammation would be seen on an x-ray. A chest x-ray is not definitive; therefore, we would perform a sputum culture. A confirmed diagnosis of TB can only be done via a sputum culture that indentifies M. tuberculosis.
The physician orders a chest x-ray (CXR) and informs B.A. that her CXR is clear (shows no signs ofTB). He tells her that she has a latent TB infection and that he will report her condition to the local public health department. The health department will monitor her over time and initiate treatment if she gets TB.
10. What is a latent TB infection (LTBI)?
When the bacterium enters the lungs, the bacteria forms a tubercle lesion. As a defense mechanism, the body encapsulates the tubercle. These are called primary lesions and can lie dormant. An individual with a TB infection has dormant primary lesions, and is not contagious.
What parameters are used to determine whether treatment should be initiated for LTBI?
According to the CDC, B.A. should received treatment due to the indicator of a skin test that measures approximately 15mm. The CDC recommends treating latent disease for patients who are at increased risk including HIV and immunosuppression and also for patients that have a skin test that measures at or more than 15mm. It is important to treat latent disease because the disease can become active and harm the patient, and also treating the disease is wise in order to control the infectious agent in the United States.
12. According to the most current CDC guidelines, what constitutes usual preventive therapy for LTBI?
The CDC recommends that patients with LTBI adhere to the 12-dose regimen over the course of 12 weeks that consists of taking Rifapentine and Isoniazid once a week.
13. Different medications are associated with different side effects. Identify the test used to monitor each possible side effect listed as follows: .
5_ A. Peripheral neuropathy – physical exam and monofilament testing 4_ B. clinical hepatitis – AST/ALT
2_ c. fever and bleeding problems – CBC (WBC and platelets)
3_ D. nephrotoxicity/renal failure ---Cr/BUN, Cr Cl (creatinine clearance) 7_ E. hyperuricemia --- uric acid
6_ F. optic neuritis – red-green discrimination and visual acuity
1_ G. hearing neuritis --- audiogram
14. Nonadherence to drug therapy is a major problem that leads to treatment failure, drug resistance, and continued spread of TB. The CDC recommends two methods to ensure compliance with medication for all patients who have drug-resistant TB and for those who take medication two or three times every week. Identify one of those methods.
Directly Observed Therapy (DOT) in which a healthcare worker meets with the patient daily or a few times a week to monitor a patient taking their prescribed medication. The health worker will bring the patient the pills to take and observe them taking the pills. Patients should also receive extensive education about the importance of adhering to their medication regime.
15. What information should A. receive before leaving the clinic?
Provide A. with information about TB and mitigate concerns about the contagious elements of the disease. Instruct A to follow the medication regime exactly as prescribed. Answer any questions A has about the side effects and offer ways to mitigate them to ensure compliance. Instruct A. of the importance of a healthy, well-balanced lifestyle in order to promote healing. It would be helpful to give A. education on the harmful effects of smoking and how it can harm the lung tissue. Instruct A. to inform the provider if they experience signs of hepatitis, which would require laboratory testing. Also, mechanisms to promote adherence to the medication regime should be discussed. A. should also be asked if DOT therapy
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