A patient with a known diagnosis of tuberculosis presents with worsening symptoms despite adherence to the medication regimen. The patient exhibits significant weight loss, increased hemoptysis, and hypoxemia. Laboratory tests reveal anemia and an elevated white blood cell count. Which nursing intervention is the most critical to address the patient's current condition and prevent further deterioration?

C) Administer supplemental oxygen to improve tissue oxygenation and reduce dyspnea.

A) Increase the patient's caloric intake to address weight loss and support recovery.

B) Educate the patient on the importance of strict adherence to the current medication regimen.

C) Administer supplemental oxygen to improve tissue oxygenation and reduce dyspnea.

D) Initiate contact precautions to prevent the spread of potential drug-resistant tuberculosis.

A patient with tuberculosis presents with worsening symptoms, including increased hemoptysis, weight loss, and decreased oxygen saturation despite adherence to the treatment regimen. Given these findings, which nursing intervention is the priority to address the patient's current condition?

A) Initiate supplemental oxygen therapy to address hypoxemia.

B) Educate the patient on the importance of medication adherence to prevent drug resistance.

C) Advise the patient to increase nutritional intake to counteract weight loss.

D) Prepare the patient for immediate bronchoscopy to assess airway obstruction.

A patient with multidrug-resistant tuberculosis and a secondary bacterial pneumonia is being treated with a modified anti-tuberculosis regimen and high-dose amoxicillin-clavulanate. Despite improved oxygenation with supplemental oxygen, he continues to experience fatigue and dyspnea. Which of the following nursing interventions is most appropriate to address the patient's ongoing symptoms?

B) Encourage deep breathing and coughing exercises to clear secretions.

A) Increase the flow rate of oxygen to 4 liters per minute.

B) Encourage deep breathing and coughing exercises to clear secretions.

C) Administer an additional dose of amoxicillin-clavulanate.

D) Consult the healthcare provider for potential blood transfusion.

A patient with multidrug-resistant tuberculosis and a secondary bacterial pneumonia is receiving a revised treatment regimen including linezolid, moxifloxacin, and high-dose amoxicillin-clavulanate. Which nursing intervention is most important to monitor for potential adverse effects of this new regimen?

B) Observe for signs of peripheral neuropathy and visual disturbances.

A) Monitor blood glucose levels for signs of hyperglycemia.

B) Observe for signs of peripheral neuropathy and visual disturbances.

C) Assess for symptoms of gastrointestinal upset and diarrhea.

D) Check for signs of hepatotoxicity, such as jaundice and elevated liver enzymes.

A patient with multidrug-resistant tuberculosis is experiencing peripheral neuropathy and gastrointestinal disturbances after starting a new medication regimen including linezolid. What is the most appropriate nursing intervention to address these complications while ensuring adherence to the treatment plan?

B) Encourage the patient to continue the medication regimen and administer prescribed antiemetics.

A) Discontinue linezolid immediately and notify the healthcare provider.

B) Encourage the patient to continue the medication regimen and administer prescribed antiemetics.

C) Suggest increasing the caloric intake by adding more protein-rich foods to the diet.

D) Recommend reducing the dosage of linezolid to minimize side effects.

A patient on a second-line anti-tuberculosis regimen including linezolid presents with peripheral neuropathy and gastrointestinal disturbances. As a nurse, what is the most appropriate intervention to address these complications while ensuring the patient’s nutritional needs are met?

B) Collaborate with the dietitian to modify the patient's diet to include nutrient-dense, easily digestible foods and administer prescribed antiemetics.

A) Discontinue linezolid immediately to prevent further neuropathy and notify the physician.

B) Collaborate with the dietitian to modify the patient's diet to include nutrient-dense, easily digestible foods and administer prescribed antiemetics.

C) Increase the patient's protein intake by adding more high-protein supplements to his diet.

D) Suggest switching the patient's antibiotic regimen to avoid any adverse effects.

A patient undergoing treatment for tuberculosis develops peripheral neuropathy and gastrointestinal disturbances. The healthcare team is considering substituting linezolid with bedaquiline and has initiated ondansetron for nausea. What is the most appropriate nursing intervention to address the patient's ongoing tingling and numbness in the extremities?

B) Educate the patient on the importance of adhering to the vitamin B6 supplementation regimen.

A) Advise the patient to elevate the affected limbs above heart level to improve circulation.

B) Educate the patient on the importance of adhering to the vitamin B6 supplementation regimen.

C) Suggest the patient alternate between warm and cold compresses on the affected areas.

D) Encourage the patient to perform daily hand and foot exercises to improve nerve function.

A patient undergoing treatment for tuberculosis is experiencing peripheral neuropathy and gastrointestinal disturbances. The healthcare team has substituted linezolid with bedaquiline and initiated vitamin B6 supplementation. What nursing intervention is most appropriate to address the patient's ongoing neuropathic symptoms?

C) Educate the patient on the importance of adhering to vitamin B6 supplementation to potentially relieve neuropathy.

A) Encourage the patient to perform regular physical therapy exercises to improve circulation.

B) Advise the patient to increase dietary fiber intake to manage neuropathic symptoms.

C) Educate the patient on the importance of adhering to vitamin B6 supplementation to potentially relieve neuropathy.

D) Suggest the use of cold compresses on affected areas to reduce tingling sensations.

A patient with pulmonary tuberculosis is experiencing worsening peripheral neuropathy and mild elevation in liver enzymes after a week on a revised treatment plan. What is the priority nursing intervention to address these complications?

D) Conduct frequent liver function tests and assess for signs of hepatotoxicity.

A) Administer prescribed gabapentin and monitor pain levels.

B) Educate the patient on the importance of adhering to the tuberculosis regimen despite side effects.

C) Initiate a referral to a dietitian for a liver-friendly diet.

D) Conduct frequent liver function tests and assess for signs of hepatotoxicity.

A patient with pulmonary tuberculosis is experiencing worsening peripheral neuropathy and elevated liver enzymes. Which nursing action is the priority in managing this patient's care?

C) Monitor liver function tests closely and report significant changes to the healthcare provider.

A) Administer vitamin B6 and gabapentin as ordered to manage neuropathic symptoms.

B) Educate the patient on the importance of adhering to the tuberculosis medication regimen despite side effects.

C) Monitor liver function tests closely and report significant changes to the healthcare provider.

D) Encourage the patient to maintain a nutrient-dense diet to support liver function.

Pulmonary tuberculosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Inhalation of Mycobacterium tuberculosis leads to alveolar macrophage phagocytosis, but the bacteria resist destruction, proliferating within the macrophages and forming granulomas, which are aggregates of immune cells attempting to contain the infection.

• Secondary mechanism: The immune response causes caseous necrosis within granulomas. If the immune system weakens, these granulomas can liquefy, leading to cavitary lesions in the lungs, which facilitate bacterial spread and damage lung tissue.

• Key complication: Progressive lung tissue destruction can result in respiratory failure. Additionally, the erosion of blood vessels by expanding cavities can lead to hemoptysis, a potentially life-threatening condition.

Patient Profile

Demographics:

45-year-old male, construction worker

History:

• Key past medical history: History of smoking for 20 years, occasional alcohol use, no prior history of tuberculosis

• Current medications: Isoniazid, Rifampin, Pyrazinamide, Ethambutol (standard TB treatment regimen)

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and weight loss

• Key symptoms: Chronic cough with blood-tinged sputum, night sweats, fever, chest pain, fatigue, and shortness of breath

• Vital signs: Temperature 100.8°F (38.2°C), Heart rate 110 bpm, Respiratory rate 24 breaths per minute, Blood pressure 130/85 mmHg, Oxygen saturation 89% on room air

Section 1

Change in Patient Status:

Two weeks into his treatment regimen, the patient returns to the clinic with worsening symptoms. Despite adherence to the medication schedule, he reports increased fatigue, significant weight loss of an additional 5 pounds, and more frequent episodes of hemoptysis. His cough has become more productive, and the volume of blood in his sputum has increased. Upon examination, he appears visibly pale and is experiencing more pronounced dyspnea, even at rest. His vital signs reveal a further decrease in oxygen saturation to 85% on room air, a slight increase in heart rate to 115 bpm, and persistent low-grade fever at 101°F (38.3°C). Auscultation of the lungs indicates diminished breath sounds in the upper lobes and the presence of coarse crackles, suggestive of further pulmonary involvement.

Given the concerning progression of symptoms, a repeat chest X-ray is conducted, revealing enlargement of the existing cavitary lesions and new areas of consolidation, indicating potential superimposed bacterial infection. Blood tests show a decrease in hemoglobin levels to 10 g/dL, consistent with anemia likely due to chronic disease and recent blood loss. The patient's elevated white blood cell count of 14,000 cells/mm³ suggests an ongoing inflammatory response and possible secondary bacterial pneumonia. These findings necessitate a reassessment of the current treatment strategy, considering both the potential development of drug-resistant TB and the need for adjunctive therapies to address the new complications.

In response, the healthcare team considers modifying the antibiotic regimen and initiating supplemental oxygen therapy to improve the patient's hypoxemia. Further diagnostic tests, including sputum cultures and sensitivity testing, are ordered to evaluate for drug resistance or additional pathogens. The patient is advised on the importance of maintaining nutritional support to counteract weight loss and optimize recovery. These steps are crucial in stabilizing his condition and preventing further deterioration, reflecting the complex interplay between disease progression and treatment efficacy.

Section 2

Response to Interventions:

Following the adjustment of the treatment plan, the patient is placed on supplemental oxygen therapy via nasal cannula at 2 liters per minute to address his hypoxemia. Over the next 48 hours, his oxygen saturation improves modestly, stabilizing at 90% on supplemental oxygen. Despite the improved oxygenation, the patient continues to experience significant fatigue and dyspnea, particularly with minimal exertion. His heart rate remains elevated at 110 bpm, and his low-grade fever persists, indicating ongoing systemic inflammation.

The sputum culture and sensitivity tests return, revealing the presence of a multidrug-resistant strain of Mycobacterium tuberculosis. Additionally, the cultures indicate a secondary infection with Streptococcus pneumoniae, explaining the recent consolidation observed on the chest X-ray. In response to these findings, the healthcare team promptly modifies the anti-tuberculosis regimen to include second-line medications such as linezolid and moxifloxacin, while also initiating high-dose amoxicillin-clavulanate to target the bacterial pneumonia.

Nutritional support is emphasized, with the introduction of a high-protein, high-calorie diet, and the involvement of a dietitian to address the patient's significant weight loss and anemia. Despite these interventions, the patient's hemoglobin levels show only slight improvement, rising to 10.5 g/dL, indicating the need for ongoing monitoring and potential further interventions. As the patient adapts to the new treatment regimen, close observation for adverse effects of the stronger medications and continuous assessment of respiratory function are critical. The multidisciplinary team's focus on vigilant monitoring and comprehensive care aims to prevent further complications and promote gradual recovery.

Section 3

New Complications:

As the patient progresses through the modified treatment regimen, the healthcare team remains vigilant for any adverse effects or new complications. Approximately one week into the new medication protocol, the patient begins to exhibit signs of peripheral neuropathy, characterized by tingling and numbness in his hands and feet. This symptom is a known side effect of linezolid, one of the second-line anti-tuberculosis medications. The team conducts a thorough neurological assessment and confirms the onset of peripheral neuropathy, necessitating a careful evaluation of the risk-benefit ratio of continuing linezolid.

In addition to neurological symptoms, the patient develops gastrointestinal disturbances, including nausea and occasional vomiting, which are possibly related to his new antibiotic regimen. His nutritional status becomes a growing concern as these symptoms hinder his ability to adhere to the high-protein, high-calorie diet essential for recovery. The dietitian works closely with the medical team to adjust the patient's nutritional plan, incorporating easily digestible, nutrient-dense foods and considering the use of antiemetic medications to manage symptoms and minimize nutritional deficits.

Despite these complications, there is a silver lining. The patient's secondary bacterial pneumonia shows signs of improvement, with a reduction in fever and a slight decrease in white blood cell count from an initial 15,000/mm³ to 12,500/mm³. His oxygen saturation remains stable at 92% on 2 liters of oxygen via nasal cannula, indicating a modest improvement in respiratory function. The healthcare team continues to monitor his response to the antibiotics and the potential need for further adjustments to the treatment plan to address the ongoing challenges of managing multidrug-resistant tuberculosis and its associated complications.

Section 4

The healthcare team decides to focus on the new complications, specifically the peripheral neuropathy and gastrointestinal disturbances, as they continue to monitor the patient's response to the modified treatment regimen. To address the peripheral neuropathy, the clinical team considers the possibility of substituting linezolid with another agent, such as bedaquiline, while weighing the risks of potential side effects against the need to maintain effective anti-tuberculosis coverage. A neurology consult is requested to explore adjunct therapies, such as vitamin B6 supplementation, which may help alleviate neuropathic symptoms. Meanwhile, the dietitian's revised nutritional plan includes small, frequent meals with a focus on high-calorie, nutrient-dense options like smoothies and fortified soups, aiming to enhance oral intake despite ongoing nausea.

In a parallel effort, the medical team initiates a regimen of ondansetron to combat the patient's nausea and vomiting, while closely monitoring for any adverse reactions. Over the next few days, the patient's gastrointestinal symptoms show slight improvement, with a reduction in the frequency of vomiting episodes. However, the tingling and numbness in his extremities persist, prompting further evaluation of nerve conduction studies to assess the extent of neuropathy.

These adjustments in the treatment plan require regular follow-up and re-evaluation. The patient's vital signs remain relatively stable, with a blood pressure of 120/78 mmHg, heart rate of 88 beats per minute, and respiratory rate of 20 breaths per minute. Serum electrolytes are within normal limits, but the healthcare team remains vigilant for any deviations that could indicate further complications. As the patient continues to navigate the complexities of his condition, the healthcare team prepares for the next phase of his care, exploring options to optimize his treatment while minimizing adverse effects. The ongoing challenge is to strike a balance between effective tuberculosis management and the mitigation of drug-induced complications, laying the groundwork for a potential transition to outpatient care.

Section 5

A week into the revised treatment plan, the healthcare team observes a significant change in the patient’s status. Although his gastrointestinal symptoms have improved modestly with the administration of ondansetron, the peripheral neuropathy has worsened. The patient now reports increased tingling and painful burning sensations in his hands and feet, which are interfering with his ability to perform daily activities. A neurology consult confirms the diagnosis of peripheral neuropathy and suggests a more aggressive approach with vitamin B6 supplementation, combined with gabapentin to manage the neuropathic pain.

Simultaneously, a new set of diagnostic results reveals a mild elevation in liver enzymes, specifically ALT and AST, suggesting potential hepatotoxicity, likely related to the anti-tuberculosis medications. The clinical team faces the challenge of balancing the need to prevent further liver damage while ensuring the tuberculosis regimen remains effective. They consider reducing the dosage of isoniazid and rifampin, recognizing the potential impact on drug efficacy but prioritizing the prevention of significant hepatic injury.

In response to these developments, the patient’s care plan is adjusted once more. The team implements more frequent monitoring of liver function tests and nerve conduction studies to track progress and anticipate any further complications. Additionally, the dietitian continues to emphasize nutrient-dense meals to support liver function and overall nutrition. As the patient navigates these new challenges, the healthcare team remains committed to tailoring his treatment, aiming to stabilize his condition and facilitate a transition to outpatient care when feasible. This ongoing adaptation underscores the importance of dynamic clinical reasoning in managing complex cases of pulmonary tuberculosis with multifaceted complications.