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Tuberculosis (TB) Case Study (60 min)

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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.

Critical Thinking Check
Bloom's Taxonomy: Analysis

You suspect Mrs. Bull may have tuberculosis. What other personal and/or medical history questions do you need to ask to be sure?

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Critical Thinking Check
Bloom's Taxonomy: Application

What nursing assessments should be performed at this time for Mrs. Bull?

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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

Critical Thinking Check
Bloom's Taxonomy: Application

What nursing action(s) should be taken at this time?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic tests would you anticipate the provider ordering?

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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

Critical Thinking Check
Bloom's Taxonomy: Analysis

Which order should you implement first? Second? Why?

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Critical Thinking Check
Bloom's Taxonomy: Application

What education should you provide to Mrs. Bull and her family at this time?

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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.

Critical Thinking Check
Bloom's Taxonomy: Application

What discharge teaching will be required for Mrs. Bull?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

Explain why medication compliance is so important for Mrs. Bull.

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