A patient with newly diagnosed active pulmonary tuberculosis has been started on a regimen including isoniazid, rifampin, ethambutol, and pyrazinamide. The nurse is providing education about potential side effects of the medications and infection control measures. Which statement by the patient indicates a need for further teaching?

C) 'I can continue to smoke as it won't affect my treatment for tuberculosis.'

A) 'I should wear a face mask when I'm around others to prevent spreading the infection.'

B) 'If I notice any yellowing of my skin or eyes, I should report it to my healthcare provider.'

C) 'I can continue to smoke as it won't affect my treatment for tuberculosis.'

D) 'I need to have regular blood tests to monitor my liver function while on these medications.'

A nurse is caring for a patient with active pulmonary tuberculosis who has been started on a treatment regimen including isoniazid, rifampin, ethambutol, and pyrazinamide. The patient presents with mild anemia and elevated liver enzymes. Which nursing intervention is most critical to prioritize in this situation?

C) Assessing the patient for signs of jaundice and reporting elevated liver enzymes to the healthcare provider.

A) Monitoring the patient's vision for changes due to ethambutol therapy.

B) Educating the patient on the importance of taking the full course of antibiotics.

C) Assessing the patient for signs of jaundice and reporting elevated liver enzymes to the healthcare provider.

D) Encouraging the patient to increase dietary iron intake to address anemia.

A patient with multidrug-resistant tuberculosis is experiencing clinical deterioration despite treatment, with symptoms of increased fatigue, persistent low-grade fever, and worsening cough. The patient also shows signs of hepatotoxicity. What is the priority nursing action to address the current clinical status and ensure optimal patient care?

C) Collaborate with the healthcare team to review and potentially adjust the current medication regimen.

A) Increase the frequency of vital signs monitoring and report any significant changes to the healthcare provider.

B) Educate the patient on the importance of strict medication adherence to reduce the risk of drug resistance.

C) Collaborate with the healthcare team to review and potentially adjust the current medication regimen.

D) Initiate a nutritional support plan to address the patient's poor appetite and nutritional deficits.

A patient with multidrug-resistant tuberculosis is experiencing clinical deterioration, including increased fatigue, a persistent low-grade fever, worsening cough with hemoptysis, and elevated liver enzymes. What is the most appropriate initial nursing intervention to address the patient's current condition?

C) Notify the healthcare provider about the potential drug-related hepatotoxicity.

A) Increase the patient's oxygen therapy to improve saturation levels.

B) Administer antipyretics to manage the patient's low-grade fever.

C) Notify the healthcare provider about the potential drug-related hepatotoxicity.

D) Encourage the patient to increase oral fluid intake to manage dehydration.

A patient with a primary tuberculosis infection shows progression of pulmonary lesions and a significant drop in albumin levels. Which integrated nursing intervention is most appropriate to address the patient's current health status?

B) Collaborate with a dietitian to develop a nutritional plan to address protein malnutrition.

A) Initiate isolation precautions to prevent the spread of infection.

B) Collaborate with a dietitian to develop a nutritional plan to address protein malnutrition.

C) Administer supplemental oxygen to improve respiratory function.

D) Increase fluid intake to manage anemia of chronic disease.

A patient with pulmonary tuberculosis is not responding to standard therapy and presents with new areas of consolidation on a CT scan, indicating possible superimposed bacterial pneumonia or worsening of the tuberculosis infection. The patient's albumin level is significantly low, and he shows signs of anemia of chronic disease. Which nursing intervention is most appropriate to prioritize in this situation?

B) Collaborate with a dietitian to develop a nutritional plan to address the patient's protein malnutrition.

A) Initiate isolation precautions to prevent the spread of multidrug-resistant tuberculosis (MDR-TB).

B) Collaborate with a dietitian to develop a nutritional plan to address the patient's protein malnutrition.

C) Administer supplemental oxygen to address potential hypoxia due to pulmonary consolidation.

D) Prepare the patient for bronchoscopy to obtain a sample for further diagnostic testing.

A patient with a suspected exacerbation of superimposed bacterial pneumonia is exhibiting increased respiratory rate, decreased oxygen saturation, and productive cough with greenish sputum. His lab results show a decline in hemoglobin, an elevated white blood cell count, and low albumin levels. Which nursing intervention is the priority for this patient?

A) Administer supplemental oxygen to maintain oxygen saturation above 92%.

B) Initiate high-protein nutritional supplements to address malnutrition.

C) Administer packed red blood cells to address anemia.

D) Consult with an infectious disease specialist for antibiotic regimen adjustment.

A patient with suspected superimposed bacterial pneumonia is showing signs of respiratory distress with a respiratory rate of 28 breaths per minute and oxygen saturation levels at 88% on room air. After changes to the antibiotic regimen and initiation of supplemental oxygen, which of the following interventions should the nurse prioritize to address the patient's current status?

B) Educate the patient on deep breathing and coughing exercises to clear secretions.

A) Increase the flow rate of supplemental oxygen to achieve oxygen saturation above 95%.

B) Educate the patient on deep breathing and coughing exercises to clear secretions.

C) Prepare the patient for possible mechanical ventilation due to declining status.

D) Administer a bronchodilator as prescribed to improve airway clearance.

A patient with multidrug-resistant tuberculosis and superimposed bacterial pneumonia is receiving supplemental oxygen and an adjusted antibiotic regimen. Despite these interventions, the patient's respiratory status remains compromised with an elevated respiratory rate and marginal oxygen saturation improvement. What is the priority nursing intervention to optimize the patient's respiratory function?

D) Elevate the head of the bed to a high Fowler's position

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

B) Encourage the patient to participate in physical therapy despite fatigue

C) Prepare the patient for a possible thoracentesis procedure

D) Elevate the head of the bed to a high Fowler's position

A patient with multidrug-resistant tuberculosis and superimposed bacterial pneumonia is receiving supplemental oxygen and a revised antibiotic regimen. Despite these interventions, the patient's respiratory status remains compromised, with an elevated respiratory rate and marginal oxygen saturation improvement. Which of the following nursing interventions is most critical to prioritize in this situation?

C) Prepare the patient for potential thoracentesis to address pleural effusion.

A) Encourage frequent deep breathing exercises and coughing.

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

C) Prepare the patient for potential thoracentesis to address pleural effusion.

D) Implement strict fluid restrictions to prevent pulmonary edema.

turburculosis - Nursing Case Study

Pathophysiology

• Primary mechanism: Inhalation of Mycobacterium tuberculosis leads to initial lung infection, where alveolar macrophages engulf the bacteria but fail to destroy them, allowing the bacteria to multiply within these cells.

• Secondary mechanism: The immune system responds by forming granulomas to contain the bacteria, leading to latent TB infection. If the immune system weakens, these granulomas can break down, causing active TB disease as bacteria spread and damage lung tissue.

• Key complication: Active TB can lead to cavitation in the lungs, where necrotic tissue liquefies and forms cavities, facilitating further bacterial spread and transmission.

Patient Profile

Demographics:

32-year-old male, construction worker

History:

• Key past medical history: Diagnosed with latent tuberculosis infection 3 years ago, history of smoking

• Current medications: Isoniazid, Vitamin B6

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent cough and fatigue for the past 4 weeks

• Key symptoms: Night sweats, weight loss, chest pain, difficulty breathing

• Vital signs: Temperature 38.3°C (100.9°F), Heart rate 110 bpm, Respiratory rate 24 breaths per minute, Blood pressure 132/88 mmHg

Section 1

New Diagnostic Results:

Following the initial assessment, the healthcare team ordered a series of diagnostic tests to confirm the suspicion of active tuberculosis and assess the extent of the disease. A chest X-ray revealed multiple cavitary lesions in the upper lobes of the patient's lungs, consistent with progressive active pulmonary tuberculosis. Sputum samples were collected over three consecutive mornings for acid-fast bacilli (AFB) testing, and the results were positive, confirming the presence of Mycobacterium tuberculosis. Additionally, a complete blood count (CBC) indicated mild anemia, with a hemoglobin level of 11.2 g/dL, and elevated white blood cell count at 14,000/mm³, suggesting an active infection. Liver function tests showed slightly elevated alanine aminotransferase (ALT) levels, raising concerns about potential hepatotoxicity due to isoniazid therapy.

These findings prompted the healthcare team to initiate a more aggressive treatment regimen, including the addition of rifampin, ethambutol, and pyrazinamide to the patient's existing isoniazid therapy. Given the patient's history of smoking and the risk of further lung damage, smoking cessation support was also recommended. The healthcare team emphasized the importance of adherence to the medication regimen and scheduled regular follow-up appointments to monitor both the patient's response to treatment and potential side effects. As the patient was informed about the contagious nature of active TB, infection control measures, including the use of a face mask and isolation precautions, were discussed to prevent transmission to others.

These diagnostic results and subsequent changes in the treatment plan highlight the need for ongoing monitoring of the patient's clinical status and liver function, as well as the importance of addressing lifestyle factors that may impact recovery. The healthcare team must remain vigilant for signs of drug resistance or adverse reactions, which could complicate the patient's treatment journey further. As the patient embarks on this new phase of treatment, the focus will be on achieving bacterial eradication while minimizing complications, ensuring that the patient remains engaged and informed about his care.

Section 2

Change in Patient Status:

Despite the aggressive treatment regimen initiated, the patient begins to exhibit signs of clinical deterioration two weeks into therapy. He reports increased fatigue, a persistent low-grade fever, and worsening cough with hemoptysis, raising concerns about the progression of the disease or potential drug-related complications. A repeat chest X-ray shows no significant improvement in the cavitary lesions, and sputum AFB tests remain positive, indicating ongoing bacterial activity. Vital signs reveal a low-grade fever of 100.8°F, heart rate of 102 bpm, respiratory rate of 24 breaths per minute, and oxygen saturation dropping to 90% on room air, suggesting compromised respiratory function.

The patient's laboratory workup shows worsening anemia, with hemoglobin decreased to 10.5 g/dL, and further elevation in liver enzymes, with ALT now at 85 U/L, which heightens the concern for hepatotoxicity from the anti-tuberculosis medications. A thorough assessment reveals the patient is experiencing symptoms of nausea and abdominal discomfort, which may be contributing to his poor appetite and nutritional status. These findings necessitate a reassessment of the current treatment plan, including the potential need for adjustments in the medication regimen to address the hepatotoxicity and ensure effective management of the tuberculosis infection.

The healthcare team must employ clinical reasoning to determine the best course of action, considering the potential for drug resistance or the need for adjunctive therapies to address the anemia and nutritional deficits. Discussions with the patient about the importance of medication adherence and potential side effects are crucial, as is the consideration of consulting a specialist in infectious diseases or pulmonology for further evaluation. This change in patient status underscores the complexity of managing multidrug-resistant TB and the need for a multidisciplinary approach to optimize patient outcomes and prevent further complications.

Section 3

Following the concerning change in the patient's status, the healthcare team decides to conduct a comprehensive reassessment and orders additional diagnostic tests to better understand the underlying issues contributing to his deterioration. A CT scan of the chest is performed, revealing progression of the pulmonary lesions with new areas of consolidation, suggesting possible superimposed bacterial pneumonia or worsening of the primary tuberculosis infection. The team also orders a repeat sputum culture with drug susceptibility testing, suspecting the possibility of multidrug-resistant tuberculosis (MDR-TB) given the lack of response to standard therapy.

The laboratory results further indicate a significant drop in the patient's albumin level to 2.8 g/dL, confirming protein malnutrition, which could be exacerbating his overall weakness and fatigue. Additionally, a peripheral blood smear is conducted to explore the etiology of the worsening anemia, revealing a normocytic, normochromic profile, consistent with anemia of chronic disease. However, the potential for drug-induced bone marrow suppression cannot be entirely ruled out, necessitating close monitoring.

Recognizing the complexity of the patient's condition, the healthcare team convenes to discuss the need for an individualized treatment approach. They consider adjusting the anti-tuberculosis regimen to address potential drug resistance while initiating nutritional support to improve his caloric intake and address malnutrition. The involvement of a dietitian is recommended to ensure a tailored nutritional plan. Simultaneously, the team anticipates the potential need for an infectious disease specialist to provide insights into alternative therapeutic options. These steps are crucial to stabilize the patient and prevent further deterioration, highlighting the importance of an integrated, multidisciplinary strategy in managing complex cases of tuberculosis with emerging complications.

Section 4

After implementing the revised treatment plan, the healthcare team closely monitors the patient for any indications of improvement or further complications. Within 48 hours, there is a noticeable change in the patient's status. His respiratory rate increases to 28 breaths per minute, and he exhibits decreased oxygen saturation levels, consistently hovering around 88% on room air. The patient also reports increased chest discomfort and a persistent productive cough with greenish sputum. These symptoms suggest the potential exacerbation of the suspected superimposed bacterial pneumonia, prompting the team to reassess the efficacy of the current antibiotic regimen.

In conjunction with these clinical changes, the patient's laboratory results reveal a further decline in hemoglobin levels to 9.5 g/dL, intensifying concerns about his anemia. The patient's white blood cell count rises to 14,000 cells/mcL, indicative of an inflammatory response likely aligned with an infectious process. Despite the nutritional interventions, his albumin level remains stable but low at 2.9 g/dL, emphasizing the persistent challenge of addressing his nutritional deficits amidst ongoing infection.

Given the patient's deteriorating respiratory status and the laboratory findings, the healthcare team decides to escalate care. They initiate supplemental oxygen therapy to maintain oxygen saturation above 92% and modify the antibiotic regimen based on the latest sputum culture results, which confirm the presence of a multidrug-resistant organism. The involvement of an infectious disease specialist becomes critical in tailoring a more effective anti-tuberculosis treatment plan. Meanwhile, the dietitian continues to refine the nutritional strategy, incorporating high-protein supplements to address the malnutrition and support the patient's recovery. This coordinated effort underscores the necessity of adaptive clinical reasoning in navigating the complexities of this evolving case.

Section 5

As the healthcare team continues to monitor the patient's progress, they observe a further change in his clinical status. Despite the initiation of supplemental oxygen therapy and adjustments to the antibiotic regimen, the patient’s respiratory status remains precarious. His respiratory rate remains elevated at 30 breaths per minute, and his oxygen saturation only marginally improves to 90% with 2 liters of supplemental oxygen via nasal cannula. The patient continues to experience significant chest discomfort and reports increased fatigue, making it challenging for him to engage in physical therapy sessions.

New diagnostic imaging, including a repeat chest X-ray and a CT scan of the thorax, reveals a worsening of pulmonary infiltrates, consistent with both the progression of the superimposed bacterial pneumonia and possible complications related to the tuberculosis infection. These findings raise concerns about the development of a pleural effusion or further consolidation, prompting an urgent need for intervention. The infectious disease specialist recommends the addition of a second-line anti-tuberculosis drug, given the multidrug-resistant organism identified, to more effectively target the mycobacterial infection and prevent further pulmonary compromise.

In response to these developments, the healthcare team prioritizes a multidisciplinary approach, including the potential for thoracentesis if pleural effusion is confirmed. The patient's nutritional plan is further modified to include enteral feeding support, ensuring adequate caloric intake to combat the infection and support tissue repair. This comprehensive strategy emphasizes the critical role of fluid balance management, vigilant monitoring of respiratory status, and continuous assessment of infection control measures to optimize the patient’s recovery trajectory. Through adaptive clinical reasoning and ongoing reassessment, the team remains focused on mitigating complications and enhancing the patient’s overall prognosis.