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Outline
Mrs. Bull is a 39 year old female who presents to the Emergency Department (ED) complaining of a persistent cough for the last 3 months. In the last 3 days, she’s been experiencing chills and night sweats and today she noticed she was coughing up blood.
You suspect Mrs. Bull may have tuberculosis. What other personal and/or medical history questions do you need to ask to be sure?
- Recent Travel
- Other symptoms
- Fever, chills, night sweats, fatigue, unexplained weight loss
- History of tuberculosis or exposure to someone else with tuberculosis recently
What nursing assessments should be performed at this time for Mrs. Bull?
- Full set of vital signs
- Heart and lung assessment
- Subjective assessment of symptoms (OLDCARTS)
- Observe and document any sputum from productive cough
You assessment findings include rhonchi in the right upper lobe of Mrs. Bull’s lungs, normal S1 and S2 heart sounds heard, active bowel sounds, and 2+ peripheral pulses x 4 extremities. Her skin appears clammy and somewhat pale. Upon further questioning, Mrs. Bull reports recent travel to South America. She denies knowingly having a fever, but acknowledges she has been more fatigued lately and reports a recent unintentional weight loss of 20 lbs in the last 2 months. Vital signs are as follows:
BP 146/78 mmHg HR 92 bpm
RR 24 bpm Temp 101.2°F
SpO2 90% on room air
What nursing action(s) should be taken at this time?
- Charge nurse because the patient will need to be moved to a negative pressure room, meaning patients may need to be moved around
- Provider because he needs to order diagnostic test ASAP
- Place the patient in Airborne Isolation in a negative pressure room as soon as possible
- ‘Apply oxygen for SpO2 90%
- Notify provider and charge nurse immediately that you suspect TB
What diagnostic tests would you anticipate the provider ordering?
- CBC, Blood Cultures, Sputum Cultures
- Quantiferon Gold is usually saved for when other tests are inconclusive
- Chest X-ray
- Labs
- PPD Tuberculin Skin Test
The ED Provider orders the following:
Chest X-Ray, Sputum Culture with AFB Smear, Blood Cultures x 2, Place PPD tuberculin skin test, Keep SpO2 > 92%, Administer the following medications:
-
Rifampin 600 mg PO daily
-
Isoniazide 300 mg PO daily
-
Pyrazinamide 1500 mg PO daily
-
Ethambutol 1200 mg PO daily
Which order should you implement first? Second? Why?
- Apply O2 if you haven’t already because the patient’s SpO2 is below 92%
- Obtain blood and sputum cultures – needs to be done before initiating therapy to prevent from contaminating the culture samples
What education should you provide to Mrs. Bull and her family at this time?
- Proper protocol for airborne isolation – each family member is also required to wear a particulate respirator when in the room with the patient – patient should not leave the room – keep the door closed at all times
- Educate Mrs. Bull on s/s to report that may indicate worsening – further hemoptysis, difficulty breathing, worsening cough
- Inform them that this medication course could be 6-12 months long
Mrs. Bull’s sputum cultures reveal she is, indeed, positive for Mycobacterium tuberculosis. Her PPD skin test reveals a 17 mm induration on her left arm after 48 hours. She is admitted to a general medical-surgical floor into a negative pressure room. She has now completed 3 weeks of RIPE therapy, which she tolerated well, and she no longer has a cough or other symptoms. Since she is no longer considered contagious, the doctor has ordered for her to be discharged home to continue the rest of her medication course.
What discharge teaching will be required for Mrs. Bull?
- Medication regimen should be taken every day for as long as the provider ordered (6-12 months). She should continue taking them even if she feels better and even though she is no longer contagious.
- S/S to report to healthcare provider – new cough, fever, chills, night sweats, hemoptysis
- Avoid any travel to high-risk countries for the next 6 months
Explain why medication compliance is so important for Mrs. Bull.
- If Mrs. Bull stops taking her medications, the Tuberculosis infection could lay dormant in her body as Latent TB and could resurface later
- She could also develop Multi-Drug Resistant TB if she doesn’t complete the full course of treatment, which could cause further problems later
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