tuberculosis tuberculosis (tb) caused by: caused by: mycobacterium tuberculosis mycobacterium...
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TuberculosisTuberculosis
Tuberculosis (TB)Tuberculosis (TB) Caused by:Caused by:
Mycobacterium tuberculosisMycobacterium tuberculosis In the United States:In the United States:
Rates decliningRates declining Incidence decreased with:Incidence decreased with:
Improved sanitationImproved sanitation Surveillance Surveillance Treatment of people with active diseaseTreatment of people with active disease
Rates still high in selected populationsRates still high in selected populations The Disease Process:The Disease Process:
Chronic and recurrentChronic and recurrent Affects the lungsAffects the lungs Can invade any organCan invade any organ
Resurgence of Tuberculosis!!Resurgence of Tuberculosis!!
1980s and 1990s1980s and 1990s CausesCauses
HIV AIDSHIV AIDS Multiple drug resistant strainsMultiple drug resistant strains Social FactorsSocial Factors
ImmigrationImmigration PovertyPoverty HomelessnessHomelessness Drug UseDrug Use
Continues to declineContinues to decline TB-control programsTB-control programs Initiation and completion of appropriate medicationsInitiation and completion of appropriate medications
Worldwide TBWorldwide TB Countries that account for 90% of world Countries that account for 90% of world
cases of TBcases of TB Countries of ASIACountries of ASIA AfricaAfrica Middle EastMiddle East Latin AmericaLatin America
In Austin TexasIn Austin Texas Large number of immigrants, college students Large number of immigrants, college students
and visitors FROM:and visitors FROM: INDIAINDIA MIDDLE EASTMIDDLE EAST LATIN AMERICALATIN AMERICA
Other Risk Factors for TBOther Risk Factors for TB
Overcrowded ConditionsOvercrowded Conditions Nursing homes, Rehabilitation Facilities Nursing homes, Rehabilitation Facilities
and Hospitalsand Hospitals Homeless sheltersHomeless shelters Drug treatment centers and PrisonsDrug treatment centers and Prisons
People with Altered Immune FunctionsPeople with Altered Immune Functions Older AdultsOlder Adults People with AIDSPeople with AIDS People on ChemotherapyPeople on Chemotherapy
Spreading the DiseaseSpreading the Disease M. tuberculosisM. tuberculosis
Slow-growing, rod shaped, acid fastSlow-growing, rod shaped, acid fast ***Waxy outer capsule which makes it resistant to ***Waxy outer capsule which makes it resistant to
destructiondestruction TransmissionTransmission
Infectious personInfectious person Coughs, sneezes, sings or talksCoughs, sneezes, sings or talks
Airborne dropletsAirborne droplets Remain suspended in the air for several hoursRemain suspended in the air for several hours
Susceptible HostSusceptible Host Breaths in microorganismBreaths in microorganism Normal defenses of the upper respiratory system do not Normal defenses of the upper respiratory system do not
protect.protect.
Risk For InfectionRisk For Infection Characteristics of the Infected PersonCharacteristics of the Infected Person
TB is active TB is active How much of the lung is involvedHow much of the lung is involved CoughingCoughing
Extent of contamination of the AirExtent of contamination of the Air Overcrowded ConditionsOvercrowded Conditions Air circulationAir circulation
Susceptibility of the HostSusceptibility of the Host Immuno-compromisedImmuno-compromised NutritionNutrition HealthHealth
Infection Takes HoldInfection Takes Hold Minute droplet nuclei inhaled ->Minute droplet nuclei inhaled ->
Upper lobeUpper lobe Lodges in Alveolus or BronchioleLodges in Alveolus or Bronchiole Leads to InflammationLeads to Inflammation
Neutrophils and macrophages isolate Neutrophils and macrophages isolate seal off but cannot destroyseal off but cannot destroy
Sealed off colony of bacilli (tubercle)Sealed off colony of bacilli (tubercle) Inside infected tissue diesInside infected tissue dies Creating a cheese-like centerCreating a cheese-like center
The Immune ResponseThe Immune Response
AdequateAdequate Scar Tissue encapsulates the bacilliScar Tissue encapsulates the bacilli
InadequateInadequate Tuberculosis developsTuberculosis develops Extensive lung destruction can occurExtensive lung destruction can occur Spread by the blood to other organsSpread by the blood to other organs
Genitourinary tractGenitourinary tract Brain (meningitis)Brain (meningitis) SkeletalSkeletal
Tuberculosis Can Spread within Tuberculosis Can Spread within The BodyThe Body
Signs & SymptomsSigns & Symptoms
Fatigue, malaise (late afternoon)Fatigue, malaise (late afternoon) Low grade fever, Night sweatsLow grade fever, Night sweats Anorexia, weight lossAnorexia, weight loss HemoptysisHemoptysis Frequent productive coughFrequent productive cough
mucoid or mucopurulentmucoid or mucopurulent Tight, dull chestTight, dull chest Joint PainJoint Pain
Skin testingSkin testing
Tuberculin Skin Test (Mantoux)Tuberculin Skin Test (Mantoux) positive test does not signify active positive test does not signify active
diseasedisease 0.1 ml PPD intradermally0.1 ml PPD intradermally Read in 48-72 hoursRead in 48-72 hours
ResultsResults
Measure indurationMeasure induration Positive 10 mmPositive 10 mm Possible 5-9 mmPossible 5-9 mm Negative 0-4Negative 0-4
Repeat x2 or x3 if any clinical signsRepeat x2 or x3 if any clinical signs 25% false negative25% false negative
DiagnosingDiagnosing
Skin test positive 3-12 weeks after Skin test positive 3-12 weeks after exposureexposure
Chest x-rayChest x-ray Sputum - Sputum - Acid Fast Bacillus (AFB)Acid Fast Bacillus (AFB)
Smear not definitiveSmear not definitive Culture is only definitive diagnosisCulture is only definitive diagnosis
May need up to 8 weeks to growMay need up to 8 weeks to grow
Newly converted to positive Newly converted to positive PPDPPD
Isoniazid 300 mg X 6-9 months Isoniazid 300 mg X 6-9 months prophylactive prevents active Tbprophylactive prevents active Tb
MedicationsMedications Newly Diagnosed Patients with active disease Newly Diagnosed Patients with active disease
typical treated with typical treated with Four medicationsFour medications isoniazidisoniazid (INH) oral 300mg daily or 900mg twice a (INH) oral 300mg daily or 900mg twice a
week.week. rifampinrifampin oral 600mg daily or twice a week oral 600mg daily or twice a week pyrazinamide pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G (PZA) oral 15 to 30 mg/kg up to 2G
per day or 30 to 70 mg/kg once a weekper day or 30 to 70 mg/kg once a week minimum 9 monthsminimum 9 months take in AMtake in AM 90% have negative sputum in 3 months90% have negative sputum in 3 months
ethambutalethambutal oral 15 mg/kg daily oral 15 mg/kg daily Other MedicationsOther Medications
rifabutinrifabutin rifapentinerifapentine
isoniazidisoniazid
Most effective TB drugMost effective TB drug Take in AM with foodTake in AM with food Continue until sputum negative 6 monthsContinue until sputum negative 6 months Adverse Effects:Adverse Effects:
peripheral neuropathy peripheral neuropathy hepatitishepatitis
MonitorMonitor Liver Functions Studies (AST and ALT)Liver Functions Studies (AST and ALT) Avoid hepatotoxins (alcohol, acetominophen)Avoid hepatotoxins (alcohol, acetominophen)
rifampinrifampin
Take on empty stomachTake on empty stomach Monitor liver function testsMonitor liver function tests Can cause:Can cause:
HepatitisHepatitis Suppression of oral contraceptivesSuppression of oral contraceptives Do not stop medicationDo not stop medication
Will cause flu-like syndrome and fever when resumedWill cause flu-like syndrome and fever when resumed Colors body fluidsColors body fluids
Sweat urine saliva tears: turn orange-redSweat urine saliva tears: turn orange-red
pyrazinamidepyrazinamide
Increase fluidsIncrease fluids Take with foodTake with food Adverse Effects Adverse Effects
HepatotoxicityHepatotoxicity HyperuricemiaHyperuricemia
MonitorMonitor Uric Acid LevelsUric Acid Levels AST and ALTAST and ALT Avoid hepatotoxins (ETOH; Tylenol)Avoid hepatotoxins (ETOH; Tylenol)
ethambutolethambutol
Protect from lightProtect from light
Adverse effects: retrobulbar neuritis, Adverse effects: retrobulbar neuritis, skin rash, reversible with skin rash, reversible with discontinuation of the drugdiscontinuation of the drug
Monitor color vision and acuityMonitor color vision and acuity
Symptoms of Liver ToxicitySymptoms of Liver Toxicity
loss of appetiteloss of appetite N/VN/V dark urinedark urine juandicejuandice malaisemalaise unexplained elevated temperatureunexplained elevated temperature
for longer than 3 daysfor longer than 3 days abdominal tendernessabdominal tenderness
Close Monitoring While Taking Close Monitoring While Taking Antituberculosis MedicationsAntituberculosis Medications
Monitor liver FunctionsMonitor liver Functions Regular Office visitsRegular Office visits Check for complianceCheck for compliance
RifampinRifampin Check color of urineCheck color of urine
INHINH Check urine for metabolitesCheck urine for metabolites
Give medicationGive medication Twice week in the office if compliance is a Twice week in the office if compliance is a
problemproblem
IsolationIsolation
negative flow roomnegative flow room vent to outsidevent to outside masks, not ordinarymasks, not ordinary
molded to fit facemolded to fit face patient wears a standard mask when patient wears a standard mask when
outside roomoutside room ultraviolet lightultraviolet light
General teachingGeneral teaching
cover mouth and nose to coughcover mouth and nose to cough dispose of tissuesdispose of tissues hand washinghand washing take meds as prescribedtake meds as prescribed
35% noncompliant35% noncompliant monitor side effectsmonitor side effects
Chronic ManagementChronic Management
Follow up in 12 monthsFollow up in 12 months 5% recurrence, relapse5% recurrence, relapse Test frequent contactsTest frequent contacts Factors which can cause relapseFactors which can cause relapse
immunosuppressionimmunosuppression HIV/AIDSHIV/AIDS prolonged debilitating illnessprolonged debilitating illness
ComplianceCompliance
Therapeutic, consistent relationshipTherapeutic, consistent relationship Understand lifestyle flexibilityUnderstand lifestyle flexibility EducationEducation Reassurance, reduce social stigmaReassurance, reduce social stigma Take meds at clinicTake meds at clinic
Nursing Diagnosis labels appropriate Nursing Diagnosis labels appropriate for the patient with tuberculosisfor the patient with tuberculosis
Ineffective airway clearanceIneffective airway clearance Impaired gas exchangeImpaired gas exchange Nutrition, less than body requirementsNutrition, less than body requirements Activity intoleranceActivity intolerance Risk for noncomplianceRisk for noncompliance Knowledge deficitKnowledge deficit Ineffective health maintenanceIneffective health maintenance
The EndThe End