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Pulmonary Tuberculosis- drugs, medical, nursing management

Medical Management

Pulmonary TB is treated primarily with chemotherapeutic agents (anti tuberculosis agents) for 6 to 12 months. Prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse. A worldwide concern and challenge in TB therapy is the continuing (since the 1950s) and increasing resistance of M. tuberculosis to TB medications. Several types of drug resistance must be considered when planning effective therapy

Primary drug resistance: resistance to one of the first-line anti tuberculosis agents in a person who has not had previous treatment

Secondary or acquired drug resistance: resistance to one or more anti tuberculosis agents in a patient undergoing therapy

Multidrug resistance: resistance to two agents, isoniazid (INH) and rifampin. The populations at highest risk for multidrug resistance are those who are HIV-positive, institutionalized, or homeless. The increasing prevalence of drug resistance points out the need to begin TB treatment with four or more medications, to ensure completion of therapy, and to develop and evaluate new pharmacologic management

Medications used for TB may be divided into first and second line drugs. First line drugs are almost always initially prescribed until culture and sensitivity laboratory reports are available. Clients with previous history of incomplete chemotherapy may have developed resistant organisms. The duration of treatment varies. It has two phase approach

  • An intensive phase using two or three drugs aimed at destroying large numbers of rapidly multiplying organisms.
  • A maintenance phase usually with two drugs directed at eliminating most remaining bacilli.

The length of each phase depends on the success of treatment and the client’s compliance. Some courses are as short as 6 months others last 24 months. The average is 9 to 12 months.

 

COMMONLY USED AGENTS

ADULT DAILY DOSAGE

MOST COMMON SIDE EFFECTS

isoniazid (INH) 5 mg/kg(300 mg maximum daily) Peripheral neuritis, hepatic enzyme elevation, hepatitis, hypersensitivity
rifampin (Rifadin) 10 mg/kg(600 mg

maximum daily)

Hepatitis, febrile reaction,purpura (rare), nausea, vomiting
streptomycin 15 mg/kg(1g maximum daily) 8th cranial nerve damage(may lead to deafness), nephrotoxicity
pyrazinamide 15 to 30 mg/kg(2g maximum daily) Hyperuricemia, hepatotoxicity,skin rash, arthralgias, GI distress
Ethambutol(Myambutol) 15 to 25 mg/kg (nomaximum daily dose, but base on lean body wt) Optic neuritis (may lead to blindness; very rare at 15 mg/kg), skin rash
Combinations:INH+ rifampin(eg, Rifamate) 150-mg & 300-mgcaps (2 caps daily)

 

DOTS CHEMOTHERAPY

DOTS – Directly Observed Treatment, Short Course

o   Two phases –

  • Intensive Phase
  • Continuation Phase

o   Reduces relapse of TB disease and acquired drug resistance

o   Health care worker watches patient swallowing each dose of medication.

o   Drugs are provided in patient wise boxes.

o   Treatment is given for 6-8 months.

TABLE SHOWING CATEGORIES OF PATIENT UNDER DOTS THERAPY

    Category of patient           Type of patient       Regimen
     Category I  New sputum smear positiveSeriously ill sputum negative

Seriously ill extra pulmonary

 

2 (HRZE)34(HR)3
   Category II  Sputum smear positive:- Relapse

– Treatment failure

-Treatment after interruption

 

2(HRZES)31(HRZE)3

 

5(HRE)3

 

   Category III  New sputum smear –ve, not seriously illNew extra pulmonary , not seriously ill

 

2(HRZ)34(HR)3

 

 

PROPHYLAXIS FOR TB

  • BCG vaccine is live bacterial vaccine
  • Given anytime from birth to 15 days of life along with zero dose of oral polio vaccine
  • A wheal or swelling of 6 mm is raised above the surface.
  • No spirit or antiseptic should be applied over the site before injection
  • After 6-8 weeks a swelling reappears, which looks, like a mosquito bite.
  • It grows in size & forms a nodule, which breaks open & discharges some fluid & forms an ulcer.
  • The ulcer heals by forming a scar. The whole process takes 2-5 weeks

 NURSING MANAGEMENT

Nursing Assessment

  • The nurse performs a complete history and physical examination.
  • Clinical manifestations of fever, anorexia, weight loss, night sweats, fatigue, cough, and sputum production prompt a more thorough assessment of respiratory function—for example, assessing the lungs for consolidation by evaluating breath sounds (diminished, bronchial sounds, crackles), fremitus, egophony, and dullness on percussion.
  • Enlarged, painful lymph nodes may be palpated as well. The nurse also assesses the patient’s living arrangements, perceptions and understanding of TB and its treatment, and readiness to learn.

Nursing Diagnosis

Based on the assessment data, the nursing diagnoses may include

• Ineffective airway clearance related to copious  tracheobronchial secretions

• Deficient knowledge about treatment regimen and preventive health measures and related ineffective individual management of the therapeutic regimen (noncompliance)

• Activity intolerance related to fatigue, altered nutritional status, and fever

POTENTIAL COMPLICATIONS

  • Malnutrition
  • Adverse side effects of medication therapy: hepatitis, neurologic changes (deafness or neuritis), skin rash, gastrointestinal upset
  • Multidrug resistance
  • Spread of TB infection (miliary TB)

Planning and Goals

The major goals for the patient include maintenance of a patent airway, increased knowledge about the disease and treatment regimen and adherence to the medication regimen, increased activity tolerance, and absence of complications.

NURSING INTERVENTIONS

PROMOTING AIRWAY CLEARANCE

  • Copious secretions obstruct the airways in many patients with TB and interfere with adequate gas exchange.
  • Increasing fluid intake promotes systemic hydration and serves as an effective expectorant.
  • The nurse instructs the patient about correct positioning to facilitate airway drainage (postural drainage).

ADVOCATING ADHERENCE TO TREATMENT REGIMEN

  • The multiple-medication regimen that a patient must follow can be quite complex. Understanding the medications, schedule, and side effects is important.
  • The patient must understand that TB is a communicable disease and that taking medications is the most effective means of preventing transmission.
  • The major reason treatment fails is that patients do not take their medications regularly and for the prescribed duration.
  • The nurse carefully instructs the patient about important hygiene measures, including mouth care, covering the mouth and nose when coughing and sneezing, proper disposal of tissues, and hand hygiene.

PROMOTING ACTIVITY AND ADEQUATE NUTRITION

  • Patients with TB are often debilitated from a prolonged chronic illness and impaired nutritional status.
  • The nurse plans a progressive activity schedule that focuses on increasing activity tolerance and muscle strength.
  • Anorexia, weight loss, and malnutrition are common in patients with TB.
  • The patient’s willingness to eat maybe altered by fatigue from excessive coughing, sputum production, chest pain, generalized debilitated state, or cost, if the person has few resources.
  • A nutritional plan that allows for small, frequent meals may be required. Liquid nutritional supplements may assist in meeting basic caloric requirements.

Evaluation

1. Maintains a patent airway by managing secretions with hydration ,humidification, coughing, and postural drainage

2. Demonstrates an adequate level of knowledge

a. Lists medications by name and the correct schedule for taking them

b. Names expected side effects of medications

3. Adheres to treatment regimen by taking medications as prescribed and reporting for follow-up screening

4. Participates in preventive measures

a. Disposes of used tissues properly

b. Encourages people who are close contacts to report for testing

c. Adheres to hand hygiene recommendations

5. Maintains activity schedule

6. Exhibits no complications

a. Maintains adequate weight or gains weight if indicated

b. Takes supplemental vitamins (vitamin B), as prescribed, to minimize peripheral neuropathy

c. Avoids use of alcohol

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