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20553929 NCP Pulmonary Tuberculosis

20553929 NCP Pulmonary Tuberculosis



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Published by: verleen on Oct 25, 2009
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PULMONARY TUBERCULOSIS (TB)Although many still believe it to be a problem of the past, pulmonary tuberculosis(TB) is on the rise. Most frequently seen as a pulmonary disease, TB can beextrapulmonary and affect organs and tissues other than the lungs. In the UnitedStates, incidence is higher among the homeless, drug-addicted, and impoverishedpopulations, as well as among immigrants from or visitors to countries in which TBis endemic. In addition, persons at highest risk include those who may have beenexposed to the bacillus in the past and those who are debilitated or have loweredimmunity because of chronic conditions such as AIDS, cancer, advanced age, andmalnutrition. When the immune system weakens, dormant TB organisms can reactivateand multiply. When this latent infection develops into active disease, it is knownas reactivation TB, which is often drug resistant. Multidrug-resistanttuberculosis (MDR-TB) is also on the rise, especially in large cities, in thosepreviously treated with antitubercular drugs, or in those who failed to follow orcomplete a drug regimen. It can progress from diagnosis to death in as little as4–6 weeks. MDR tuberculosis can be primary or secondary. Primary is caused byperson-to-person transmission of a drug-resistant organism; secondary is usuallythe result of nonadherence to therapy or inappropriate treatment.CARE SETTINGMost patients are treated as outpatients, but may be hospitalized for diagnosticevaluation/initiation of therapy, adverse drug reactions, or severeillness/debilitation.RELATED CONCERNSExtended care Pneumonia: microbial Psychosocial aspects of carePatient Assessment DatabaseData depend on stage of disease and degree of involvement.ACTIVITY/RESTMay report: Generalized weakness and fatigue Shortness of breath with exertionDifficulty sleeping, with evening or night fever, chills, and/or sweats NightmaresTachycardia, tachypnea/dyspnea on exertion Muscle wasting, pain, and stiffness(advanced stages)May exhibit:EGO INTEGRITYMay report: Recent/long-standing stress factors Financial concerns, povertyFeelings of helplessness/hopelessness Cultural/ethnic populations: Native-Americanor recent immigrants from Central America, Southeast Asia, Indian subcontinentDenial (especially during early stages) Anxiety, apprehension, irritabilityMay exhibit:FOOD/FLUIDMay report: Loss of appetite Indigestion Weight loss Poor skin turgor, dry/flakyskin Muscle wasting/loss of subcutaneous fatMay exhibit:PAIN/DISCOMFORTMay report: Chest pain aggravated by recurrent cough
May exhibit:Guarding of affected area Distraction behaviors, restlessnessRESPIRATIONMay report: Cough, productive or nonproductive Shortness of breath History oftuberculosis/exposure to infected individual Increased respiratory rate (extensivedisease or fibrosis of the lung parenchyma and pleura) Asymmetry in respiratoryexcursion (pleural effusion) Dullness to percussion and decreased fremitus(pleural fluid or pleural thickening) Breath sounds diminished/absent bilaterallyor unilaterally (pleural effusion/pneumothorax); tubular breath sounds and/orwhispered pectoriloquies over large lesions; crackles may be noted over apex oflungs during quick inspiration after a short cough (posttussive crackles) Sputumcharacteristics green/purulent, yellowish mucoid, or blood-tinged Trachealdeviation (bronchogenic spread) Inattention, marked irritability, change inmentation (advanced stages)May exhibit:SAFETYMay report: Presence of immunosuppressed conditions, e.g., AIDS, cancer PositiveHIV test/HIV infection Visit to/immigration from or close contact with persons incountries with high prevalence of TB (e.g., Philippines, Vietnam, Cambodia, Laos,Puerto Rico, Haiti, Russia, Mexico) Low-grade fever or acute febrile illnessMay exhibit:SOCIAL INTERACTIONMay report: Feelings of isolation/rejection because of communicable disease Changein usual patterns of responsibility/change in physical capacity to resume roleTEACHING/LEARNINGMay report: Familial history of TB General debilitation/poor health statusUse/abuse of substances such as IV drugs, alcohol, cocaine, and crack Failure toimprove/reactivation of TB Nonparticipation in therapy DRG projected mean lengthof inpatient stay: 6.3–8.3 days May require assistance with/alteration in drugtherapy and temporary assistance in selfcare and homemaker/maintenance tasks Referto section at end of plan for postdischarge considerations.Discharge plan considerations:DIAGNOSTIC STUDIESSputum culture: Positive for Mycobacterium tuberculosis in the active stage of thedisease. Ziehl-Neelsen (acid-fast stain applied to a smear of body fluid):Positive for acid-fast bacilli (AFB). Skin tests (purified protein derivative[PPD] or Old tuberculin [OT] administered by intradermal injection [Mantoux]): Apositive reaction (area of induration 10 mm or greater, occurring 48–72 hr afterinterdermal injection of the antigen) indicates past infection and the presence ofantibodies but is not necessarily indicative of active disease. Factors associatedwith a decreased response to tuberculin include underlying viral or bacterialinfection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficientantigen injection, and conscious or unconscious bias. A significant reaction in apatient who is clinically ill means that active TB cannot be dismissed as adiagnostic possibility. A significant reaction in healthy persons usuallysignifies dormant TB or an infection caused by a different mycobacterium. Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV. Chestx-ray: May show small, patchy infiltrations of early lesions in the upper-lungfield, calcium deposits of healed primary lesions, or fluid of an effusion.
Changes indicating more advanced TB may include cavitation, scar tissue/fibroticareas. CT or MRI scan: Determines degree of lung damage and may confirm adifficult diagnosis.

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