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Tb -copy

  1. 1 TUBERCULOSIS (TB) By LOGMAN MOHAMMED ALSHAIKH MSs - MSN
  2. Introduction It is caused the mycobacteria species which are responsible for the disease and these are: 1. Mycobacterium tuberculosis which is a major cause of infection 2
  3. cont 2. Mycobacterium bovis which is endemic in cattle.this type may spread to man by drinking contaminated milk 3.Opportunistic Mycobacteria which are rare.they may cause pulmonary or general infection in the immunocomperomised 3
  4. Spread of infection TB is an airborne disease transmitted by droplet nuclei, usually from the respiratory tract of an infected person who exhales them during coughing, talking, sneezing. by the following methods: 1- direct droplet spread : From person to person by inhalation of airborne bacilli in to the atmosphere 4
  5. 2-indirect spread: Via dishes ,clothing and other articles of daily used laden with bacilli. 3- via ingested milk: Ingested contaminated milk with M. tuberculosis bovine causes intestinal TB. 5
  6. Pathology  The first infection with M. tuberculosis is known as primary tuberculosis. It is usually sub pleural, often in the mid to upper zones (Ghon focus). Within an hour of reaching the lung, tubercle bacilli reach the draining lymph nodes at the hilum of the lung and a few escape into the bloodstream.
  7. cont  Granulomatous lesions consist of a central area of necrotic material of a cheesy nature, called caseation, surrounded by epithelioid cells and Langhans' giant cells with multiple nuclei, both cells being derived from the macrophage.
  8. cont  Lymphocytes are present and there is a varying degree of fibrosis. Subsequently the casemated areas heal completely and many become calcified.  It is known that at least 20%of these calcified primary lesions contain tubercle bacilli, initially lying dormant but capable of being activated by depression of the host defense system.
  9. cont  Reactivation leads to typical post primary pulmonary tuberculosis with cavitation, usually in the apex or upper zone of the lung.  'Post-primary tuberculosis' refers to all forms of tuberculosis that occur after the first few weeks of the primary infection when immunity to the mycobacterium has developed.
  10.  Extra pulmonary TB occurs more commonly in children and immune compromised individuals and can involve lymph nodes, bones, joints, pleural space, pericardium, CNS, GU tissue, and the peritoneum. 10
  11. Predisposing factors 1- Environmental factors Poverty ,Overcrowding ,Unhygienic condition 2- Pathologic factors DM ,Chronic lung disease ,Malnutrition ,Immune compromised, HIV 3- Children younger than age 4 4- prolonged corticosteroid use in organ transplanted patient 5- history of untreated or inadequately treated TB. 11
  12. Clinical Manifestations  Patient may be Asymptomatic or may have insidious symptoms that may be ignored. 1. Constitutional symptoms a. Fatigue, anorexia, weight loss, low-grade fever, night sweats. b. Some patients have acute febrile illness, chills, and flu-like symptoms. 12
  13. Clinical Manifestations 2. Pulmonary signs and symptoms a. Cough progressing in frequency and producing mucoid or mucopurulent sputum, hemoptysis b. Chest pain; dyspnea (suggest extensive involvement) 3. Extrapulmonary TB: pain, inflammation, and dysfunction in any of the tissues infected. 13
  14. Type of tuberculosis  Primary tuberculosis  Secondary tuberculosis  Miliary tuberculosis 14
  15. INVESTIGATION Diagnosis of TB is based on history, examination ,chest X-ray finding and sputum examination . 1- chest x-ray Define nodular or reticulonodular situated in one of the upper lobes Also shows the cavity in the lung . 15
  16. 2- Sputum for AFB (fast acid bacilli)smear:  Microscopic examination of 3 specimen of sputum collected early morning and detection of acid-fast bacilli (AFB) in stained smears.  A positive acid-fast test suggests an active infection.  The diagnosis is confirmed by a positive culture for Mycobacterium tuberculosis. 3- Sputum culture  Isolated the M .bactirium TB on solid medium 4-8 weeks .  a positive culture for M. Tuberculosis confirms a diagnosis of TB. 4-Plural fluid aspiration 16
  17. 5- Mantoux test  In this test 0.1ml of standard purified protein derivative (PPD)is injected intradermal on the anterior surface of forearm then the skin test site observe and recorded after 48-72 hrs.  Negative test dos not rule out the diagnosis of TB.  An induration (palpable, raised, hardened area) of 10 mm or greater in diameter indicates a positive skin test. 17
  18. cont  An induration of 5 mm is considered a positive test for immunocompromised clients.  A positive Mantoux test indicates that the client has developed an immune response to TB.  It does not confirm that active disease is present. Clients who have been treated for TB may retain a positive reaction. 18
  19. cont  Individuals who have latent TB may have a positive Mantoux test and may receive treatment to prevent development of an active form of the disease.  Clients who have received a Bacillus Calmette- Guerin (BCG) vaccine within the past10 years may have a false-positive Mantoux test. These clients will need a chest x-ray toevaluate the presence of active TB infection. 19
  20. 20
  21. 6.CT Scan. 7.Trans-bronchial biopsies. 8.Biopsy and culture of liver and bone marrow may be necessary in patients presenting with a pyrexia of unknown origin (PUO). 9. PCR & ELISA 21
  22. Treatment for TB Disease  DOT .  6 Months regimen .  Longer regimen .( 9- 12) month .  Patient who not take the drugs correctly, the germs that are still alive may become resistant to those drugs.  isolation is not important unless children at risk  Rest is also of no use 22
  23. First line drugs  6 months duration using:  Initial stage for 2monhts(ethambutol/streptomycin+isoniaside+r efampicin+pyrzinamide)  Continuation stage for 4months( isoniazide +refampicin) 23
  24. cont  9 mnths duration:  Initial stage for 2monhts(Ethambutol/Streptomycin+Isoniaside+ Refampicin)  Continuation stage for 7months( Isoniazide +Refampicin) 24
  25. cont  The long term regimens are expensive used in developing countries. These take 12mnths and are either Streptomycine 1g/IM+Isoniazide 15mg/kg+Pyridoxine10mg twice weekly or Isoniazide 300mg+ Thiacetazone150mg daily. 25
  26.  Coticosteroids may be used to supress cell mediated reactions induced by bacilli but may also promote arapid dissemination of infection unless given with effective antituberculous drugs 26
  27. Second-line drugs Include the following drugs :  Sodium aminosalicylate ,Ethionamide,Capreomycin, Cycloserine,Clarithromycin, Azithromycin, Ciprofloxacin, Ofloxacin, kanamycin, Amikacin, Aoxifloxacin and Rifabutin. 27
  28. Complications of TB  1. Pleural effusion  2. TB pneumonia  3. Other organ involvement with TB  4. Serious reactions to drug therapy 28
  29. prevention  Improvement of socio-economic status  Case finding and treatment  Vaccination with BCG (Bacille Calmette- Guerin).  Chemoprophylaxis 29
  30. Patient-Centered Care  Prevent infection transmission.  Wear an N95 or HEPA respirator when caring for clients who are hospitalized with TB.  Place the client in a negative airflow room, and implement airborne precautions.  Use barrier protection when the risk of hand or clothing contamination exists.  Have the client wear an N95 or HEPA respirator if transportation to another department is necessary. The client should be transported using the shortest and least busy route.  Teach the client to cough and expectorate sputum into tissues that are disposed of by the client into provided sacks.
  31. cont  Administer medications as prescribed. Promote adequate nutrition.  Encourage fluid intake and a well-balanced diet for adequate caloric intake.  Encourage foods that are rich in protein, iron, and vitamin C.  Provide emotional support.
  32. Medications ■ Isoniazid, commonly referred to as INH, is bactericidal and inhibits growth of mycobacteria by preventing synthesis of mycolic acid in the cell wall. ■■ Nursing Considerations  This medication should be taken on an empty stomach.  Monitor for hepatotoxicity and neurotoxicity, such as tingling of the hands and feet.  Vitamin B6 (pyridoxine) is used to prevent neurotoxicity from isoniazid.  Client Education  Advise the client not to drink alcohol while taking isoniazid because it may increase the risk for hepatotoxicity.
  33. Medications  Rifampin, commonly referred to as RIF, is a bacteriostatic and bactericidal antibiotic that inhibits DNA-dependent RNA polymerase activity in susceptible cells.  ■■ Nursing Considerations  Observe for hepatotoxicity.  ■■ Client Education  Inform the client that urine and other secretions will be orange.  Advise the client to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately.  Inform the client this medication may interfere with the efficacy of oral contraceptives.
  34. Medications  Pyrazinamide  Pyrazinamide, commonly referred to as PZA, is a bacteriostatic and bactericidal, and its exact mechanism of action is unknown.  Nursing Considerations  Observe for hepatotoxicity.  Client Education  Instruct the client to drink a glass of water with each dose and increase fluids during the day.  Advise the client to report yellowing of the skin, pain or swelling of joints, loss of appetite, or malaise immediately.  Advise the client to avoid using alcohol while taking pyrazinamide.
  35. Medications  Ethambutol (Myambutol)  ■■ Ethambutol, commonly referred to as EMB, is a bacteriostatic and works by suppressing RNA synthesis, subsequently inhibiting protein synthesis.  Nursing Considerations  Obtain baseline visual acuity tests.  Determine color discrimination ability.  This medication should not be given to children younger than 13 years of age.  Client Education  Instruct the client to report changes in vision immediately.
  36. Medications  Streptomycin sulfate (Streptomycin)  Streptomycin sulfate is an aminoglycoside antibiotic. It potentiates the efficacy of macrophages during phagocytosis.  Nursing Considerations  Due to its high level of toxicity, this medication should be used only in clients who have multidrug-resistant TB (MDR-TB).  It can cause ototoxicity, so monitor hearing function and tolerance often.  Report significant changes in urine output and renal function studies.  Client Education  Advise the client to drink at least 2 to 3 L of fluid daily.  Advise the client to notify the provider if hearing declines.
  37. Client Education  Provide the client and family education because TB is often treated in the home setting.  Exposed family members should be tested for TB.  Educate the client and family to continue medication therapy for its full duration of 6 to 12 months. Emphasize that failure to take the medications may lead to a resistant strain of TB.  Instruct the client to continue with follow-up care for 1 full year.  Inform the client that sputum samples are needed every 2 to 4 wks to monitor therapy effectiveness. Clients are not considered infectious after 3 –ve sputum cultures.
  38.  Encourage proper hand hygiene.  Instruct the client to cover mouth and nose when coughing or sneezing.  Inform the client that contaminated tissues should be disposed of in plastic bags.  Advise clients who have active TB to wear an N95 or HEPA respirator when in public places.
  39. THANKS 39
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