A patient with active pulmonary tuberculosis and poorly controlled diabetes mellitus presents with increased respiratory distress and decreased oxygen saturation. Which nursing intervention is the priority to address the patient's immediate needs?

B) Initiate supplemental oxygen therapy to maintain adequate oxygen saturation.

A) Administer a bronchodilator to improve airway patency.

B) Initiate supplemental oxygen therapy to maintain adequate oxygen saturation.

C) Educate the patient on the importance of adhering to diabetic dietary recommendations.

D) Obtain a sputum sample for acid-fast bacilli testing to confirm tuberculosis diagnosis.

A patient with active pulmonary tuberculosis and poorly controlled diabetes is experiencing increased respiratory distress and decreased oxygen saturation. What is the priority nursing intervention to address the patient's current condition?

B) Initiate supplemental oxygen therapy to improve oxygen saturation.

A) Administer prescribed anti-tubercular medications immediately.

B) Initiate supplemental oxygen therapy to improve oxygen saturation.

C) Educate the patient on proper use of incentive spirometry to enhance lung expansion.

D) Monitor blood glucose levels and administer insulin as prescribed to manage hyperglycemia.

A patient with tuberculosis has started anti-tubercular therapy and now presents with fatigue, abdominal pain, dark urine, jaundice, and elevated liver enzymes. What is the most appropriate nursing action to address these findings?

B) Notify the healthcare provider immediately due to suspected drug-induced hepatotoxicity.

A) Increase the patient's fluid intake to flush out the medications.

B) Notify the healthcare provider immediately due to suspected drug-induced hepatotoxicity.

C) Administer acetaminophen to help manage the patient's abdominal pain.

D) Encourage the patient to continue the medication regimen and reassess in a week.

A patient with tuberculosis has started on a regimen including isoniazid, rifampin, ethambutol, and pyrazinamide. Within 48 hours, the patient develops fatigue, abdominal pain, dark urine, and jaundice, and liver function tests indicate elevated ALT and AST levels. What is the most appropriate initial nursing intervention to address these findings?

C) Hold the medications and notify the healthcare provider immediately

A) Continue medication and increase monitoring frequency

B) Administer vitamin B6 to prevent further liver damage

C) Hold the medications and notify the healthcare provider immediately

D) Encourage increased fluid intake to support liver function

A patient with tuberculosis is experiencing acute respiratory distress syndrome (ARDS) and hepatotoxicity. The healthcare team has stopped pyrazinamide and adjusted the doses of isoniazid and rifampin. The patient is now on high-flow nasal cannula with an FiO2 of 60%. What is the nurse's priority action to support the patient's respiratory needs?

B) Prepare for possible intubation as consulted by the pulmonologist.

A) Increase the FiO2 to 90% to improve oxygen saturation.

B) Prepare for possible intubation as consulted by the pulmonologist.

C) Initiate chest physiotherapy to mobilize secretions.

D) Encourage deep breathing exercises to improve ventilation.

A patient with tuberculosis is experiencing acute respiratory distress syndrome (ARDS) and hepatotoxicity due to anti-tubercular medications. The healthcare team has adjusted the treatment regimen and initiated supportive care measures. As a nurse, what is the priority intervention to ensure the patient’s safety and stability during this critical period?

D) Increase the frequency of monitoring vital signs and respiratory status to detect changes promptly.

A) Administer N-acetylcysteine to support liver recovery while monitoring for adverse reactions.

B) Prepare the patient for possible intubation by ensuring airway equipment is readily available.

C) Educate the patient and family about potential side effects of second-line anti-tubercular medications.

D) Increase the frequency of monitoring vital signs and respiratory status to detect changes promptly.

A patient with a history of tuberculosis is experiencing worsening respiratory distress and has been initiated on BiPAP therapy. Despite this intervention, her oxygen saturation remains borderline. As a nurse, what is your priority action to optimize the patient's respiratory status?

B) Reassess the patient's positioning to ensure optimal lung expansion.

A) Increase the flow rate of the high-flow nasal cannula.

B) Reassess the patient's positioning to ensure optimal lung expansion.

C) Prepare for intubation and mechanical ventilation.

D) Administer a second dose of bronchodilator therapy.

A patient with a history of tuberculosis presents with increased respiratory distress, tachypnea, chest tightness, and fatigue. The patient's ABG shows respiratory acidosis with worsening hypoxemia on high-flow nasal cannula. Non-invasive ventilation (NIV) with BiPAP is initiated, but oxygen saturation remains borderline. What is the most appropriate initial nursing intervention to optimize the patient's respiratory status?

B) Reassess the patient's positioning to ensure optimal lung expansion.

A) Increase the FiO2 on the BiPAP machine.

B) Reassess the patient's positioning to ensure optimal lung expansion.

C) Administer an additional dose of bronchodilator therapy.

D) Prepare the patient for possible intubation and mechanical ventilation.

A patient with worsening respiratory acidosis and hypoxemia is being considered for thoracentesis due to a moderate pleural effusion. Which of the following nursing interventions is most appropriate to prioritize before the procedure?

C) Ensure informed consent is obtained for the thoracentesis

A) Administer a bronchodilator to improve airway patency

B) Position the patient in a semi-Fowler's position to ease breathing

C) Ensure informed consent is obtained for the thoracentesis

D) Encourage the patient to perform incentive spirometry to expand the lungs

A patient with a history of tuberculosis is experiencing worsening respiratory acidosis and hypoxemia despite BiPAP therapy. The healthcare team discovers a left-sided pleural effusion. Which nursing intervention should be prioritized to address the patient's respiratory compromise?

B) Prepare the patient for a thoracentesis to relieve the pleural effusion

A) Administer supplemental oxygen to maintain an oxygen saturation above 90%

B) Prepare the patient for a thoracentesis to relieve the pleural effusion

C) Increase the BiPAP pressure settings to improve ventilation

D) Reassess the patient's anti-tubercular medication regimen for potential resistance

Tuberculosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Tuberculosis is caused by the inhalation of Mycobacterium tuberculosis, which primarily targets the lungs. The bacteria are engulfed by alveolar macrophages but resist destruction due to their waxy cell wall, leading to granuloma formation as the immune system attempts to contain the infection.

• Secondary mechanism: Within the granulomas, a necrotic core forms, known as caseous necrosis, which can liquefy and lead to cavitation. This process allows the bacteria to spread within the lung and potentially throughout the body, causing systemic infection.

• Key complication: If the immune response is weakened, latent TB can reactivate, leading to active disease. This reactivation increases the risk of transmission and can cause widespread tissue damage, respiratory failure, and disseminated TB, affecting other organs.

Patient Profile

Demographics:

45-year-old female, school teacher

History:

• Key past medical history: History of smoking, type 2 diabetes

• Current medications: Metformin, lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and fatigue

• Key symptoms: Night sweats, weight loss, hemoptysis, shortness of breath

• Vital signs: Temperature 38.2°C, heart rate 110 bpm, blood pressure 130/85 mmHg, respiratory rate 24 breaths per minute

Section 1

Initial Assessment Findings:

Upon further assessment, the patient presents with increased respiratory distress, evidenced by labored breathing and the use of accessory muscles. Auscultation reveals decreased breath sounds and crackles in the upper lobes of both lungs, suggesting consolidation and possible cavitation. The patient's oxygen saturation has dropped to 88% on room air, necessitating supplemental oxygen to maintain adequate SpO2 levels. The patient's skin appears pale and diaphoretic, and she reports feeling lightheaded upon standing, indicating possible orthostatic hypotension.

The patient's laboratory results show a white blood cell count slightly elevated at 12,000/mm³, indicating an inflammatory response, while her hemoglobin level is low at 10.5 g/dL, suggesting anemia. Her blood glucose level is elevated at 220 mg/dL, which could be due to stress-induced hyperglycemia or poor control of her diabetes in the context of acute illness. A chest X-ray reveals bilateral upper lobe infiltrates with cavitary lesions, consistent with active pulmonary tuberculosis. Sputum analysis is pending for acid-fast bacilli (AFB) to confirm the diagnosis.

These findings indicate a significant progression of the disease, with potential complications including respiratory failure and further dissemination of the infection. The patient's diabetes may be exacerbating her condition by impairing her immune response, thus complicating the management of tuberculosis. This situation necessitates immediate initiation of anti-tubercular therapy, along with a comprehensive approach to manage her diabetes and support her respiratory function. The nursing team must closely monitor her vital signs, oxygenation, and blood glucose levels while providing education on medication adherence and lifestyle modifications to optimize her recovery and prevent further complications.

Section 2

New Complications:

As the clinical team initiates anti-tubercular therapy, the patient begins to experience additional complications. Within 48 hours of starting the medication regimen, which includes isoniazid, rifampin, ethambutol, and pyrazinamide, the patient reports increasing fatigue and abdominal pain, accompanied by dark urine and jaundice. These symptoms raise concerns for drug-induced hepatotoxicity, a known adverse effect associated with anti-tubercular medications. The medical team promptly orders liver function tests, which reveal markedly elevated levels of alanine aminotransferase (ALT) at 275 U/L and aspartate aminotransferase (AST) at 310 U/L, confirming liver injury.

In addition to hepatotoxicity, the patient's respiratory status demonstrates minimal improvement despite supplemental oxygen and the initiation of treatment. Her oxygen saturation remains precariously low at 90% on 2 liters of nasal cannula, and she continues to utilize accessory muscles for breathing. Repeated arterial blood gas analysis shows a pH of 7.32, PaCO2 of 48 mmHg, and PaO2 of 55 mmHg, indicating respiratory acidosis and hypoxemia. This suggests a potential progression to acute respiratory distress syndrome (ARDS), necessitating close monitoring and consideration of more advanced respiratory support, such as non-invasive ventilation or mechanical ventilation.

These developments demand a comprehensive reassessment of the patient's treatment plan. The healthcare team must weigh the risks and benefits of continuing the current anti-tubercular regimen versus modifying it to mitigate liver damage. Concurrently, optimizing the patient's respiratory function requires a multidisciplinary approach, potentially involving consultation with a pulmonologist and critical care specialists. These complications illustrate the intricate balance needed to manage coexisting conditions and adverse effects, emphasizing the importance of vigilant monitoring and timely intervention in the patient's care trajectory.

Section 3

As the medical team evaluates the patient's condition, they decide to temporarily halt the pyrazinamide and adjust the doses of isoniazid and rifampin to reduce the risk of further hepatic injury. Close monitoring of liver function tests is initiated, with repeat tests scheduled every 48 hours. In the meantime, the patient is started on N-acetylcysteine to help mitigate liver damage and support hepatic recovery.

Despite these measures, the patient's respiratory status continues to be worrisome. A high-resolution chest CT scan is performed, revealing diffuse bilateral infiltrates consistent with acute respiratory distress syndrome (ARDS). Her oxygen requirements escalate, and she is transitioned to a high-flow nasal cannula with an FiO2 of 60%, resulting in a slight improvement in oxygen saturation to 93%. However, respiratory symptoms persist, and the patient exhibits increased work of breathing. The team decides to consult with a pulmonologist to determine the appropriateness of initiating non-invasive ventilation or considering early intubation to ensure adequate oxygenation and ventilation.

The unfolding situation requires the healthcare team to maintain a delicate balance between managing the patient’s tuberculosis effectively and addressing the life-threatening complications of hepatotoxicity and respiratory failure. The priority now includes optimizing supportive care and ensuring that the patient remains stable while exploring alternative treatment strategies that could involve second-line anti-tubercular medications, pending further risk assessment and consultation with infectious disease specialists. The patient's case underscores the necessity of interdisciplinary collaboration and dynamic clinical decision-making in the face of evolving complications.

Section 4

As the healthcare team continues to closely monitor the patient, they observe a change in her status that prompts immediate attention. The patient's respiratory rate increases to 32 breaths per minute, and she reports a sensation of increased chest tightness and fatigue. Her heart rate climbs to 118 beats per minute, with a blood pressure of 94/56 mmHg, indicating potential hemodynamic instability. Arterial blood gas analysis reveals a pH of 7.31, PaCO2 of 50 mmHg, and PaO2 of 58 mmHg on the high-flow nasal cannula, suggesting respiratory acidosis and worsening hypoxemia. These findings indicate that her respiratory status is rapidly declining, necessitating a reevaluation of her current respiratory support.

In response to these developments, the pulmonologist recommends initiating non-invasive ventilation (NIV) to improve alveolar ventilation and reduce the work of breathing. The decision is made to start bilevel positive airway pressure (BiPAP) therapy and monitor the patient closely for any signs of further respiratory compromise. Concurrently, the team ensures that the patient is positioned optimally to facilitate breathing and receives bronchodilator therapy to address any bronchospasm contributing to her symptoms.

Despite the implementation of NIV, the patient's oxygen saturation remains borderline, and she continues to exhibit signs of respiratory distress. The multidisciplinary team, including infectious disease specialists, considers the risk-benefit profile of continuing current anti-tubercular therapy versus introducing second-line agents. They deliberate on the possibility of switching to an alternative regimen to mitigate hepatotoxicity while ensuring effective management of tuberculosis. The evolving scenario highlights the critical need for ongoing assessment and adjustment of the treatment plan to address the complex interplay of the patient's conditions, requiring vigilant monitoring and agile clinical decision-making.

Section 5

As the healthcare team continues to monitor the patient closely, they note that despite the initiation of BiPAP therapy, her respiratory status shows minimal improvement. The patient's oxygen saturation fluctuates between 85-88%, and her respiratory distress persists. Arterial blood gas analysis is repeated, revealing a pH of 7.28, PaCO2 of 55 mmHg, and PaO2 of 54 mmHg, indicating worsening respiratory acidosis and hypoxemia. The patient's heart rate escalates to 126 beats per minute, and her blood pressure further decreases to 88/52 mmHg, raising concerns about her cardiovascular stability.

In light of these findings, the healthcare team performs a thorough reassessment of the patient's condition. On auscultation, they detect diminished breath sounds in the left lower lung field, suggesting potential atelectasis or pleural effusion. A chest X-ray is ordered, revealing a moderate pleural effusion on the left side, likely contributing to the patient's respiratory compromise. This new complication prompts the team to consider a thoracentesis to alleviate the pressure on the lung and improve respiratory function.

The multidisciplinary team, including pulmonologists and infectious disease specialists, convenes to discuss the possible need for escalation to invasive mechanical ventilation if the patient's condition does not improve soon. They also reassess the anti-tubercular regimen, considering the possibility of drug-resistant tuberculosis as a contributing factor to the patient's deteriorating status. The team decides to send a sputum sample for culture and sensitivity testing to guide further treatment decisions while maintaining a delicate balance between managing the infection and addressing the acute respiratory needs. This evolving scenario emphasizes the importance of dynamic clinical reasoning and prompt intervention in managing complex cases with multiple complications.