A patient with confirmed active pulmonary tuberculosis and potential extrapulmonary spread is beginning antitubercular therapy. Which nursing intervention is essential to implement at the start of treatment to prevent complications?

B) Schedule regular liver function tests to monitor for hepatotoxicity.

A) Initiate a high-calorie, high-protein diet to support nutritional status.

B) Schedule regular liver function tests to monitor for hepatotoxicity.

C) Educate the patient about avoiding exposure to people with respiratory infections.

D) Encourage increased fluid intake to promote renal clearance of medications.

A patient has been diagnosed with active pulmonary tuberculosis, and a CT scan showed enlarged lymph nodes suggesting potential extrapulmonary spread. When developing the patient's care plan, which nursing intervention should be prioritized to effectively manage the patient's condition?

B) Initiate airborne precautions to prevent the spread of infection to healthcare staff and visitors.

A) Educate the patient on the importance of adhering to the full course of antitubercular medications.

B) Initiate airborne precautions to prevent the spread of infection to healthcare staff and visitors.

C) Schedule routine liver function tests to monitor for hepatotoxicity during treatment.

D) Arrange for nutritional support to address potential weight loss and malnutrition.

A patient undergoing antitubercular therapy with isoniazid, rifampin, ethambutol, and pyrazinamide develops persistent fatigue, night sweats, and mild hemoptysis within the first two weeks of treatment. A repeat chest X-ray shows new areas of consolidation in the lower lobes. Which nursing intervention should take priority in managing this patient's care?

D) Collect sputum samples for culture and sensitivity to determine the presence of drug-resistant tuberculosis.

A) Encourage increased fluid intake to help with drug metabolism and excretion.

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

C) Monitor the patient closely for signs of hepatotoxicity and report abnormal liver function tests to the healthcare provider.

D) Collect sputum samples for culture and sensitivity to determine the presence of drug-resistant tuberculosis.

A patient with tuberculosis on a regimen of isoniazid, rifampin, ethambutol, and pyrazinamide develops persistent fatigue, night sweats, and mild hemoptysis within two weeks of treatment. A repeat chest X-ray shows new areas of consolidation. Laboratory tests reveal persistent lymphocytosis and a slight increase in eosinophils, but normal liver function tests. What should be the nurse's priority action in response to these findings?

B) Collaborate with the healthcare provider to assess the need for modifying the treatment regimen.

A) Advise the patient to increase fluid intake to manage potential side effects of medication.

B) Collaborate with the healthcare provider to assess the need for modifying the treatment regimen.

C) Educate the patient about the importance of adhering to their current medication regimen.

D) Suggest the initiation of corticosteroids to manage potential allergic reactions.

A patient with a confirmed drug-resistant Mycobacterium tuberculosis infection and concurrent Streptococcus pneumoniae infection is being treated with a modified regimen. What is the primary nursing priority when assessing this patient following the recent changes in medication?

B) Assess for improvement in respiratory status and signs of infection resolution.

A) Monitor for signs of hepatotoxicity due to the addition of levofloxacin.

B) Assess for improvement in respiratory status and signs of infection resolution.

C) Evaluate for potential hypersensitivity reactions due to the new antibiotic regimen.

D) Check electrolyte levels to prevent potential imbalances caused by the new medications.

A patient diagnosed with drug-resistant tuberculosis and secondary bacterial pneumonia is currently being treated with a modified regimen including a fluoroquinolone and intravenous levofloxacin. The patient's eosinophil count has increased to 8%, prompting a temporary halt of ethambutol. Which nursing intervention is most important to prioritize at this time?

B) Assess for improvement in respiratory status following the introduction of levofloxacin.

A) Monitor for signs of nephrotoxicity due to fluoroquinolone therapy.

B) Assess for improvement in respiratory status following the introduction of levofloxacin.

C) Evaluate the patient's skin for signs of hypersensitivity reactions.

D) Educate the patient about the importance of hydration to prevent renal complications.

A patient with drug-resistant tuberculosis and secondary bacterial pneumonia is being treated with intravenous levofloxacin. The patient now presents with diffuse crackles throughout both lung fields, decreased oxygen saturation, and rising serum creatinine levels. Which nursing intervention is most appropriate to address the patient's current condition?

C) Collaborate with the healthcare provider to adjust the levofloxacin dosage

A) Increase the rate of intravenous fluids to promote renal perfusion

B) Initiate high-flow oxygen therapy to improve oxygenation

C) Collaborate with the healthcare provider to adjust the levofloxacin dosage

D) Encourage ambulation to enhance lung expansion and oxygenation

A patient with drug-resistant tuberculosis is being treated with intravenous levofloxacin. After 48 hours, the patient develops diffuse crackles in the lungs and a drop in oxygen saturation, alongside rising serum creatinine levels. As the nurse, what is your priority action to address the patient's evolving condition?

B) Hold the levofloxacin dose until further renal assessment.

A) Increase the oxygen flow rate to 4 liters per minute via nasal cannula.

B) Hold the levofloxacin dose until further renal assessment.

C) Encourage the patient to take deep breaths and cough regularly.

D) Initiate a high-protein diet to support renal function.

A patient with worsening pulmonary edema and hyponatremia secondary to renal impairment is being treated with low-dose furosemide. What is the most important nursing intervention to prioritize in this scenario?

B) Assess the patient's lung sounds and respiratory status frequently.

A) Monitor the patient's blood pressure every 4 hours.

B) Assess the patient's lung sounds and respiratory status frequently.

C) Encourage the patient to increase fluid intake to correct hyponatremia.

D) Educate the patient about potential side effects of furosemide.

A patient with pulmonary edema and renal impairment is being managed with low-dose furosemide for fluid overload. The nurse notes the patient's serum sodium level is 130 mmol/L. What is the most appropriate nursing action to prioritize?

B) Monitor the patient's neurological status and report any changes.

A) Increase the furosemide dose to enhance fluid removal.

B) Monitor the patient's neurological status and report any changes.

C) Restrict fluid intake to 1 liter per day to correct hyponatremia.

D) Administer a hypertonic saline infusion to raise serum sodium levels.

Tuberculosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Tuberculosis is caused by the inhalation of Mycobacterium tuberculosis, which primarily affects the lungs. Macrophages engulf the bacteria, but they survive and replicate within these immune cells, leading to the formation of granulomas, which are collections of immune cells attempting to contain the infection.

• Secondary mechanism: The immune response within the granulomas leads to tissue necrosis and the formation of caseous necrosis (cheesy-like tissue). This process can result in the breakdown of the granuloma structure, allowing the bacteria to spread through the lungs or enter the bloodstream, causing further dissemination.

• Key complication: If untreated, the breakdown of lung tissue can lead to cavitation, facilitating the spread of bacteria and increasing the risk of transmission. Additionally, systemic spread can cause extrapulmonary tuberculosis, affecting organs such as the kidneys, spine, and brain, leading to significant morbidity.

Patient Profile

Demographics:

35-year-old female, school teacher

History:

• Key past medical history: History of smoking, no prior TB or respiratory illnesses

• Current medications: Multivitamin, oral contraceptive

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and fatigue

• Key symptoms: Night sweats, unintentional weight loss, low-grade fever, hemoptysis (coughing up blood), chest pain

• Vital signs: Temperature 100.8°F (38.2°C), heart rate 110 bpm, respiratory rate 24 breaths per minute, blood pressure 100/60 mmHg, oxygen saturation 92% on room air

Section 1

New Diagnostic Results:

Following the initial presentation, the patient underwent a series of diagnostic tests to confirm the suspicion of tuberculosis and assess the extent of the disease. A chest X-ray revealed multiple cavitary lesions in the upper lobes of the lungs, indicative of advanced pulmonary tuberculosis. Sputum samples were collected for acid-fast bacilli (AFB) stain and culture. The AFB stain was positive, confirming the presence of Mycobacterium tuberculosis. Further testing, including a nucleic acid amplification test (NAAT), was conducted to assess the bacterial load and check for any drug resistance, particularly given the patient's history of smoking, which may complicate the disease progression and response to treatment.

Laboratory results showed elevated white blood cell count with lymphocytosis, consistent with an ongoing infection. The patient's liver function tests were within normal limits, an important consideration before initiating antitubercular therapy, which can be hepatotoxic. Blood cultures were negative for disseminated infection, but a CT scan of the abdomen and pelvis revealed enlarged lymph nodes, raising concern for potential extrapulmonary spread. This finding necessitates further evaluation to determine if there is involvement of other organ systems, such as the kidneys or spine, which could complicate the clinical picture and require more extensive treatment.

These diagnostic results confirm the diagnosis of active tuberculosis with significant pulmonary involvement and potential extrapulmonary spread. The healthcare team must now develop a comprehensive treatment plan that includes a combination of antitubercular medications, monitoring for drug efficacy and side effects, and assessing the need for adjunctive therapies to manage symptoms and prevent further complications. The patient's response to the initial phase of treatment will be crucial in determining the next steps in her care, as well as the need for any additional interventions.

Section 2

As the patient begins antitubercular therapy, including isoniazid, rifampin, ethambutol, and pyrazinamide, the healthcare team closely monitors her clinical status for any signs of improvement or complications. Within the first two weeks of treatment, her symptoms initially seem to stabilize, but she soon develops new complaints of persistent fatigue, night sweats, and mild hemoptysis, raising concerns about possible treatment failure or additional complications. A repeat chest X-ray shows some reduction in the size of the cavitary lesions, suggesting partial response to therapy, but also reveals new areas of consolidation in the lower lobes, indicating potential secondary infection or drug-resistant tuberculosis.

Laboratory tests are conducted to explore the cause of these new symptoms. A complete blood count shows persistent lymphocytosis and a slight increase in eosinophils, which could suggest an allergic reaction to medication or a parasitic infection. Liver function tests remain within normal limits, ruling out hepatotoxicity from the medications as a cause of her fatigue. Sputum samples are recollected for repeat AFB stain and culture, and a new NAAT is ordered to reassess bacterial load and check for the presence of drug-resistant strains. These findings prompt the healthcare team to consider modification of the treatment regimen, adding a fluoroquinolone or linezolid while awaiting drug susceptibility results.

The patient’s clinical course underscores the complexity of managing tuberculosis with potential drug resistance and secondary infections. The healthcare team must employ clinical reasoning to distinguish between drug side effects, treatment failure, and new infections, adjusting the therapeutic approach accordingly. Consistent monitoring of her response to the revised treatment plan will be crucial, as will addressing any psychosocial factors, such as smoking cessation, that could impact her recovery and overall health. This ongoing assessment will guide the next steps in her treatment journey and help prevent further deterioration of her condition.

Section 3

New Diagnostic Results:

As the healthcare team awaits the results of the new drug susceptibility tests, the patient undergoes a CT scan to gain further insight into the cause of the consolidations in the lower lobes observed on the chest X-ray. The CT scan reveals patchy areas of ground-glass opacities and nodular infiltrates, suggestive of atypical pneumonia, raising the suspicion of a secondary bacterial infection. Concurrently, the repeat sputum culture and NAAT results return, indicating the presence of a drug-resistant strain of Mycobacterium tuberculosis, specifically resistant to isoniazid. This crucial finding necessitates an immediate modification of the treatment regimen to include a fluoroquinolone, while discontinuing isoniazid.

Laboratory data further complicate the picture, as the patient's eosinophil count continues to rise, now reaching 8%, which is notably higher than the normal range. This increase raises the possibility of a hypersensitivity reaction to one of the antitubercular drugs, most likely ethambutol or pyrazinamide. Given the patient's persistent fatigue and recent onset of pruritus, the team decides to temporarily halt ethambutol administration and monitor for changes in symptoms. Moreover, blood cultures taken to rule out bacteremia return positive for Streptococcus pneumoniae, confirming a concurrent bacterial infection that could explain the new pulmonary consolidations.

These new diagnostic insights prompt the healthcare team to refine their clinical reasoning and therapeutic strategy, focusing on both the drug-resistant nature of the tuberculosis infection and the confirmed secondary bacterial pneumonia. Broadening antibiotic coverage to address the pneumococcal infection while adjusting the anti-tuberculosis regimen becomes a priority. The team monitors the patient's vital signs, noting a temperature of 38.2°C, heart rate of 98 bpm, and blood pressure of 118/76 mmHg. The plan includes initiating intravenous levofloxacin to tackle the bacterial pneumonia and assessing the patient's response over the coming days to ensure stabilization and improvement of her clinical status. This strategic adjustment aims to mitigate complications and steer the patient towards a more favorable recovery trajectory.

Section 4

As the healthcare team implements the adjusted treatment plan, including the introduction of intravenous levofloxacin, careful monitoring of the patient's response becomes paramount. Over the next 48 hours, the patient shows initial signs of clinical improvement, with a gradual reduction in fever to 37.5°C and stabilization of heart rate at 92 bpm. However, the patient's respiratory status reveals new concerns; auscultation of the lungs now reveals diffuse crackles throughout both lung fields, suggestive of evolving pulmonary edema. Oxygen saturation drops to 92% on room air, prompting the initiation of supplemental oxygen via nasal cannula at 2 liters per minute to maintain adequate oxygenation.

Laboratory results further elucidate the patient's condition as renal function tests reveal a rising serum creatinine level of 1.9 mg/dL from a baseline of 1.2 mg/dL, indicating potential acute kidney injury. The team suspects that the nephrotoxic potential of the antitubercular regimen, particularly levofloxacin, may be contributing to this complication. The patient's urine output has also mildly decreased, reinforcing concerns regarding renal impairment. In response, the healthcare team decides to adjust the dosage of levofloxacin, ensuring it remains within safe therapeutic levels while consulting with the nephrology team for further recommendations.

These developments necessitate a reevaluation of the patient's treatment strategy, emphasizing a balance between effectively managing the drug-resistant tuberculosis and the secondary bacterial pneumonia while safeguarding renal function. The team plans to conduct a thorough review of the medication regimen, considering potential alternative treatments with a more favorable renal profile. This evolving clinical scenario underscores the complexity of managing multi-faceted infections and the importance of ongoing assessment and adaptation of the treatment approach to optimize patient outcomes.

Section 5

As the healthcare team continues to monitor the patient's condition, the focus turns to the new diagnostic results that have emerged. A repeat chest X-ray is performed to assess the progression of the patient's respiratory status. The imaging reveals bilateral infiltrates consistent with pulmonary edema, confirming the initial auscultation findings of diffuse crackles. Additionally, a high-resolution CT scan of the chest is ordered to further evaluate the extent of lung involvement. The CT scan corroborates the presence of widespread ground-glass opacities and interstitial thickening, suggestive of worsening pulmonary edema potentially exacerbated by levofloxacin-induced pulmonary toxicity.

Meanwhile, a comprehensive metabolic panel is re-evaluated, revealing an electrolyte imbalance characterized by hyponatremia, with serum sodium levels dropping to 130 mmol/L. This finding raises concerns about the patient's fluid status, potentially linked to both the renal impairment and fluid retention associated with pulmonary edema. The nephrology consult further emphasizes the importance of optimizing fluid management to prevent worsening renal function and advises on the cautious use of diuretics to alleviate the pulmonary congestion.

In light of these results, the healthcare team decides to initiate low-dose furosemide to manage the fluid overload, with careful monitoring of the patient's electrolyte levels and renal function. The team also considers transitioning the patient to an alternative antibiotic with a safer renal profile, pending further input from infectious disease specialists. These strategic adjustments aim to stabilize the patient's respiratory and renal status while continuing to address the underlying infectious processes. This dynamic scenario highlights the necessity of integrating diagnostic findings with clinical decision-making to tailor the patient's treatment plan effectively and mitigate potential complications.