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Definition Pulmonary tuberculosis (TB) is a contagious bacterial infection that mainly involves the lungs, but may spread to other organs. Alternative Names TB; Tuberculosis - pulmonary Causes Pulmonary tuberculosis (TB) is caused by the bacteriaMycobacterium tuberculosis (M. tuberculosis). You can get TB by breathing in air droplets from a cough or sneeze of an infected person. This is called primary TB. In the United States, most people will recover from primary TB infection without further evidence of the disease. The infection may stay asleep or nonactive (dormant) for years. However, in some people it can reactivate. Most people who develop symptoms of a TB infection first became infected in the past. However, in some cases, the disease may become active within weeks after the primary infection. The following people are at higher risk for active TB: Elderly Infants People with weakened immune systems, for example due to AIDS, chemotherapy, or antirejection medicines given after an organ transplant
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Your risk of contracting TB increases if you: Are in frequent contact with people who have the disease Have poor nutrition Live in crowded or unsanitary living conditions
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The following factors may increase the rate of TB infection in a population: Increase in HIV infections Increase in number of homeless people (poor environment and nutrition) The appearance of drug-resistant strains of TB
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In the United States, there are approximately 10 cases of TB per 100,000 people. However, rates vary dramatically by area of residence and socioeconomic class. See also: Disseminated tuberculosis Symptoms
The primary stage of the disease usually doesn't cause symptoms. When symptoms of pulmonary TB occur, they may include: Cough (sometimes producing phlegm) Coughing up blood Excessive sweating, especially at night Fatigue Fever Unintentional weight loss
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Other symptoms that may occur with this disease: Breathing difficulty Chest pain Wheezing
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Exams and Tests Examination may show: Clubbing of the fingers or toes (in people with advanced disease) Enlarged or tender lymph nodes in the neck or other areas Fluid around a lung Unusual breath sounds (crackles)
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Tests may include: Biopsy of the affected tissue (rare) Bronchoscopy Chest CT scan Chest x-ray Interferon-gamma blood test such as the QFT-Gold test to test for TB infection Sputum examination and cultures Thoracentesis Tuberculin skin test
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Treatment The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of active pulmonary TB will always involve a combination of many drugs (usually four drugs). All of the drugs are continued until lab tests show which medicines work best. The most commonly used drugs include: Isoniazid Rifampin Pyrazinamide Ethambutol
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You may need to take many different pills at different times of the day for 1 year or longer. It is very important that you take the pills the way your health care provider instructed. When people do not take their tuberculosis medications as recommended, the infection becomes much more difficult to treat. The TB bacteria may become resistant to treatment, and sometimes, the drugs no longer help treat the infection. When there is a concern that a patient may not take all the medication as directed, a health care provider may need to watch the person take the prescribed drugs. This is called directly observed therapy. In this case, drugs may be given 2 or 3 times per week, as prescribed by a doctor. You may need to be admitted to a hospital for 2 - 4 weeks to avoid spreading the disease to others until you are no longer contagious. Your doctor or nurse is required by law to report your TB illness to the local health department. Your health care team will be sure that you receive the best care for your TB. Support Groups You can ease the stress of illness by joining a support group where members share common experiences and problems. See: Lung disease - support group Outlook (Prognosis) Symptoms may improve in 2 - 3 weeks. A chest x-ray will not show this improvement until later. The outlook is excellent if pulmonary TB is diagnosed early and treatment is begun quickly. Possible Complications Pulmonary TB can cause permanent lung damage if not treated early. Medicines used to treat TB may cause side effects, including liver problems. Other side effects include: Changes in vision Orange- or brown-colored tears and urine Rash
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A vision test may be done before treatment so your doctor can monitor any changes in your eyes' health over time. When to Contact a Medical Professional Call your health care provider if:
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You have been exposed to TB You develop symptoms of TB Your symptoms continue despite treatment New symptoms develop
Prevention TB is a preventable disease, even in those who have been exposed to an infected person. Skin testing (PPD) for TB is used in high risk populations or in people who may have been exposed to TB, such as health care workers. A positive skin test indicates TB exposure and an inactive infection. Discuss preventive therapy with your doctor. People who have been exposed to TB should be skin tested immediately and have a follow-up test at a later date, if the first test is negative. Prompt treatment is extremely important in controlling the spread of TB from those who have active TB disease to those who have never been infected with TB. Some countries with a high incidence of TB give people a BCG vaccination to prevent TB. However, the effectiveness of this vaccine is controversial and it is not routinely used in the United States. People who have had BCG may still be skin tested for TB. Discuss the test results (if positive) with your doctor. References Iseman MD. Tuberculosis. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 345.
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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 be extrapulmonary and affect organs and tissues other than the lungs. In the United States, incidence is higher among the homeless, drug-addicted, and impoverished populations, as well as among immigrants from or visitors to countries in which TB is endemic. In addition, persons at highest risk include those who may have been exposed to the bacillus in the past and those who are debilitated or have lowered immunity because of chronic conditions such as AIDS, cancer, advanced age, and malnutrition. When the immune system weakens, dormant TB organisms can reactivate and multiply. When this latent infection develops into active disease, it is known as reactivation TB, which is often drug resistant. Multidrug-resistant tuberculosis (MDR-TB) is also on the rise, especially in large cities, in those previously treated with antitubercular drugs, or in those who failed to follow or complete a drug regimen. It can progress from diagnosis to death in as little as 4 6 weeks. MDR tuberculosis can be primary or secondary. Primary is caused by person-to-person transmission of a drug-resistant organism; secondary is usually the result of nonadherence to therapy or inappropriate treatment. CARE SETTING Most patients are treated as outpatients, but may be hospitalized for diagnostic evaluation/initiation of
therapy, adverse drug reactions, or severe illness/debilitation. RELATED CONCERNS Extended care Pneumonia: microbial Psychosocial aspects of care Patient Assessment Database Data depend on stage of disease and degree of involvement. ACTIVITY/REST May report: Generalized weakness and fatigue Shortness of breath with exertion Difficulty sleeping, with evening or night fever, chills, and/or sweats Nightmares May exhibit: Tachycardia, tachypnea/dyspnea on exertion Muscle wasting, pain, and stiffness (advanced stages) EGO INTEGRITY May report: Recent/long-standing stress factors Financial concerns, poverty Feelings of helplessness/hopelessness Cultural/ethnic populations: Native-American or recent immigrants from Central America, Southeast Asia, Indian subcontinent May exhibit: Denial (especially during early stages) Anxiety, apprehension, irritability FOOD/FLUID
May report: Loss of appetite Indigestion Weight loss May exhibit: Poor skin turgor, dry/flaky skin Muscle wasting/loss of subcutaneous fat PAIN/DISCOMFORT May report: Chest pain aggravated by recurrent cough May exhibit: Guarding of affected area Distraction behaviors, restlessness RESPIRATION May report: Cough, productive or nonproductive Shortness of breath History of tuberculosis/exposure to infected individual May exhibit: Increased respiratory rate (extensive disease or fibrosis of the lung parenchyma and pleura) Asymmetry in respiratory excursion (pleural effusion) Dullness to percussion and decreased fremitus (pleural fluid or pleural thickening) Breath sounds diminished/absent bilaterally or unilaterally (pleural effusion/pneumothorax); tubular breath sounds and/or whispered pectoriloquies over large lesions; crackles may be noted over apex of lungs during quick inspiration after a short cough (posttussive crackles) Sputum characteristics green/purulent, yellowish mucoid, or blood-tinged Tracheal deviation (bronchogenic spread) Inattention, marked irritability, change in mentation (advanced stages) SAFETY May report: Presence of immunosuppressed conditions, e.g., AIDS, cancer
Positive HIV test/HIV infection Visit to/immigration from or close contact with persons in countries with high prevalence of TB (e.g., Philippines, Vietnam, Cambodia, Laos, Puerto Rico, Haiti, Russia, Mexico) May exhibit: Low-grade fever or acute febrile illness SOCIAL INTERACTION May report: Feelings of isolation/rejection because of communicable disease Change in usual patterns of responsibility/change in physical capacity to resume role TEACHING/LEARNING May report: Familial history of TB General debilitation/poor health status Use/abuse of substances such as IV drugs, alcohol, cocaine, and crack Failure to improve/reactivation of TB Nonparticipation in therapy Discharge plan DRG projected mean length of inpatient stay: 6.3 8.3 days considerations: May require assistance with/alteration in drug therapy and temporary assistance in selfcare and homemaker/maintenance tasks Refer to section at end of plan for postdischarge considerations. DIAGNOSTIC STUDIES Sputum culture: Positive for Mycobacterium tuberculosis in the active stage of the disease. 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]): A positive reaction (area of induration 10 mm or greater, occurring 48 72 hr after interdermal injection of the antigen) indicates past infection and the presence of antibodies but is not necessarily indicative of active disease. Factors associated with a decreased response to tuberculin include underlying
viral or bacterial infection, malnutrition, lymphadenopathy, overwhelming TB infection, insufficient antigen injection, and conscious or unconscious bias. A significant reaction in a patient who is clinically ill means that active TB cannot be dismissed as a diagnostic possibility. A significant reaction in healthy persons usually signifies dormant TB or an infection caused by a different mycobacterium. Enzyme-linked immunosorbent assay (ELISA)/Western blot: May reveal presence of HIV. Chest x-ray: May show small, patchy infiltrations of early lesions in the upper-lung field, calcium deposits of healed primary lesions, or fluid of an effusion. Changes indicating more advanced TB may include cavitation, scar tissue/fibrotic areas. CT or MRI scan: Determines degree of lung damage and may confirm a difficult diagnosis. Bronchoscopy: Shows inflammation and altered lung tissue. May also be performed to obtain sputum if patient is unable to produce an adequate specimen. Histologic or tissue cultures (including gastric washings; urine and cerebrospinal fluid [CSF]; skin biopsy): Positive for Mycobacterium tuberculosis and may indicate extrapulmonary involvement. Needle biopsy of lung tissue: Positive for granulomas of TB; presence of giant cells indicating necrosis. Electrolytes: May be abnormal depending on the location and severity of infection; e.g., hyponatremia caused by abnormal water retention may be found in extensive chronic pulmonary TB. ABGs: May be abnormal depending on location, severity, and residual damage to the lungs. Pulmonary function studies: Decreased vital capacity, increased dead space, increased ratio of residual air to total lung capacity, and decreased oxygen saturation are secondary to parenchymal infiltration/fibrosis, loss of lung tissue, and pleural disease (extensive chronic pulmonary TB). NURSING PRIORITIES 1. 2. 3. 4. 5. Achieve/maintain adequate ventilation/oxygenation. Prevent spread of infection. Support behaviors/tasks to maintain health. Promote effective coping strategies. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS 1. 2. 3. 4. 5. Respiratory function adequate to meet individual need. Complications prevented. Lifestyle/behavior changes adopted to prevent spread of infection. Disease process/prognosis and therapeutic regimen understood. Plan in place to meet needs after discharge.