The purpose of the case study is to have you expand on the pathophysiological disease process by searching for evidence-based practice treatment and advanced practice nursing role implications related to the disease.
Maria is a 42-year-old single mother living in New York City with her three sons. She immigrated to New York from Peru two years ago. About six months after she arrived, she began developing night sweats and unexplained fevers. Most recently, she has developed a persistent, worsening cough. Her illegal status has made her hesitant to seek medical treatment, but a neighbor told her that the local community clinic would see her and would not check her residency status.
Screening at the clinic included a questionnaire that addressed some of the problems she was experiencing. The nurse explained to Maria that she might have TB. The physician treating Maria performed a complete physical exam and discussed her questionnaire responses with her, including her response that in Peru, she lived with her grandfather who she believes may have died from TB.
Physical exam findings showed abnormal lung sounds in Maria’s upper lobes bilaterally. The physician found cervical and axial lymphadenopathy. Maria was asked to leave sputum samples to be tested for mycobacterium tuberculosis. A PPD was placed with instructions for Maria to return in two days to have it read. When Maria returned two days later, the result showed a 10 mm raised, red reactive site. Maria was also screened for HIV at the time of initial exam because it is often found in patients with TB. In this case, she tested negative for HIV. Her sputum culture tested positive for M. tuberculosis.
The physician explained that given the findings on the chest x-ray and the clinical findings on exam, he believed that she had reactivation TB. The physician informed Maria that he planned to start her on a four-drug regimen of isoniazid, rifampin, pyrazinamide, and ethambutol (Myambutol) for two months. The physician then explained that a “continuation phase” would follow, which would consist of isoniazid and a rifamycin (rifampin, rifabutin [Mycobutin], or rifapentine [Priftin]) that is administered daily for four to seven months. He also informed her that he would start her treatment at the hospital, where she would stay for least two days because she was still considered contagious. Following the hospital stay, Maria would need to come to the clinic for observed medication administration and to assure compliance.
Two months passed and Maria continued about her day-to-day life including going to the clinic for her medication. She attempted to work full time and to take care of her three sons. She found that her night sweats had become a nightly occurrence, and her cough had become productive with blood along with intense coughing spells. Maria was compliant with the drug regimen but called the clinic because her symptoms were worsening. Maria was scheduled for a visit the very next day.
The follow up chest x-ray showed no improvement, and it was determined that Maria was exhibiting signs of multidrug-resistant TB. Because multidrug-resistant and extensively drug-resistant tuberculosis requires at least 18 to 24 months of therapy, depending on the patient’s response to treatment, the physician decided to extend her therapy to 18 months, beyond the 4 to 7 month time period he had projected. He also stopped the ethambutol and started moxifloxacin. Thoracic surgery for resection of lung lesions is often considered as adjunctive therapy, and this was discussed with Maria at the time of the exam.
Maria was devastated to learn about her multidrug resistant TB because she needed to work. Fortunately, the clinic was able to fund Maria’s drugs at a discounted rate. Nonetheless, the entire situation has put Maria under stress to the point that it is unclear how she will meet this challenge and adequately handle her health crisis.
Conduct an evidence-based literature search to identify the most recent standards of care/treatment modalities from peer-reviewed articles and professional association guidelines (www.guideline.gov). These articles and guidelines can be referenced, but not directly copied into the clinical case presentation. Cite a minimum of three resources.
Answer the following questions:
- What is the transmission and pathophysiology of TB?
- What are the clinical manifestations?
- After considering this scenario, what are the primary identified medical concerns for this patient?
- What are the primary psychosocial concerns?
- What are the implications of the treatment regimen, as far as likelihood of compliance and outcomes? Search the Internet to research rates of patient compliance in treatment of TB, as well as drug resistant TB.
- Identify the role of the community clinic in assisting patients, particularly undocumented patients, in covering the cost of TB treatment. What resources exist for TB treatment in community health centers around the United States? Compare the cost for treatment between, subsidized as it would be for a community health center, and unsubsidized.
- What are the implications of TB for critical care and advanced practice nurses?
The use of medical terminology and appropriate graduate level writing is expected.
Your paper should be 4–5 pages, (excluding cover page and reference page).
Your resources must include research articles as well as reference to non-research evidence-based guidelines.
Use APA format to style your paper and to cite your sources. Your source(s) should be integrated into the paragraphs. Use internal citations pointing to evidence in the literature and supporting your ideas. You will need to include a reference page listing those sources. Cite a minimum of three resources.
Review the rubric for more information on how your assignment will be graded.
Critical Analysis Points Range:42.24 (35.2%) – 48 (40%)
Presents an exemplary articulation and insightful analysis of significant concepts and/or theories presented in the case. Offers detailed and specific examples for all questions. Makes keen observations, making note of essential information provided in the case. Ideas are professionally sound and creative; they are supported by scientific evidence that is credible and timely. Draws insightful and comprehensive conclusions and solutions.
Content Points Range:42.24 (35.2%) – 48 (40%)
Makes insightful, clear and accurate connections to key concepts and relevant theories. Response indicates a comprehensive, high-level understanding of the concepts presented in the case.
Mechanics Points Range:15.84 (13.2%) – 18 (15%)
Answers are well written throughout. Information is well organized and clearly communicated. Assignment is free of spelling and grammatical errors.
APA Format Points Range:5.28 (4.4%) – 6 (5%)
Follows all the requirements related to format, length, source citations, and layout.
Most Recent Standards of Care/Treatment Modalities for TB
Several interventions to support patients in their adherence to TB treatment have been implemented by TB programs for many years (for example, direct observation of treatment or DOT, and social support), while others have been recently introduced (for instance digital health interventions such as SMS messages, telephone calls or other reminders, and video observation of treatment or VOT). Based on evidence, the most treatment modalities are treatment of drug susceptible TB; this checks on the effectiveness of TB treatment with fluoroquinolone containing regimens, treatment for patients with drug susceptible pulmonary TB and management of patients with previous history. Patient care and support uses the effectiveness of treatment supervision and other adherence interventions.
Transmission and Pathophysiology of TB
Mycobacterium tuberculosis is spread by small airborne droplets, called droplet nuclei, generated by coughing, sneezing, talking, or singing of a person with pulmonary or laryngeal tuberculosis. These minuscule droplets can remain airborne for minutes to hours after expectoration. The number of bacilli in the droplets, the virulence of the bacilli, exposure of the bacilli to UV light, degree of ventilation, and occasions for aerosolization all influence transmission. Introduction of M tuberculosis into the lungs leads to infection of the respiratory system; however, the organisms can spread to other organs, such as the lymphatics, pleura, bones/joints, or meninges, and cause extra pulmonary tuberculosis (Centers for Disease Control and Prevention (CDC), 2007). Once inhaled, the infectious droplets settle throughout the airways. The majority of the bacilli are trapped in the upper parts of the airways where the mucus-secreting goblet cells exist. The mucus produced catches foreign substances, and the cilia on the surface of the cells constantly beat the mucus and its entrapped particles upward for removal. This system provides the body with an initial physical defense that prevents infection in most persons exposed to tuberculosis (CDC, n.d.).
Clinical Manifestation of TB
Clinical symptoms are mostly constitutional, including malaise, fever, weight loss, sweats, and anorexia. Pulmonary signs may be similar but often less pronounced than in uncomplicated pulmonary TB. If the brain is involved, neurological symptoms may include headache, reduced consciousness and cranial nerve palsies. Involvement of other organs usually does not elicit localized symptoms. In immunocompromised patients, physical signs may be less apparent and include dyspnea, wasting, lymph node enlargement, hepatosplenomegaly, and cutaneous lesions. The most common clinical manifestation of the central nervous system (CNS) TB is tuberculous meningitis (TBM). Other entities are CNS tuberculoma, which may be present without symptoms or rarely with seizures, tuberculous encephalopathy (rare, only described in children) and tuberculous radiculomyelitis.
Primary Identified Medical Concerns for this Patient
The patient in concern has been infected with TB. This was evidently transmitted by her grandfather whom they lived together before his death from the same disease. This type of TB was airborne since the most common transmission method of TB for individuals living together is air. From the scenario, the patient has been receiving direct observation treatment as well as patient care and support, she has a purified protein derivative device placed on her and she calls the physician when her condition worsens and visits the clinic for checkups regularly depicting adherence to the treatment TB.
Primary Psychosocial Concerns of the Patient
Poor social support has given the patient a feeling of being neglected, isolated and worthless. She has also been having mental distress since she has to work and take care of her sons. The patient is also vulnerable to depression combined with chronic physical illness. This may result from poor adherence to medication and self-care regimens. The patient may also spread the disease to her sons since they still live together thus increasing the rate of TB transmission within her locality.
Implications of the Treatment Regimen
Non-adherence to tuberculosis (TB) treatment can result in an emergence of new strains, prolonged infectiousness, drug resistance and poor treatment outcomes. Patients related factors including feeling better, forgetfulness, lack of knowledge on the benefits of completing a treatment course, running out of drugs at home, distance to the health facility, HIV zero-positivity, alcohol abuse, use of herbal medication, stigma and gender are significantly associated with non-adherence to an anti-TB treatment. There are risks associated with multidrug taking as well as being of age (above certain age limit) where patients being re-treated are significantly associated with unsuccessful treatment outcomes.
Role of the Community Clinic in Assisting Patients
The essential role of the health clinic in TB control is to plan, coordinate, and evaluate TB control and prevention efforts. This role requires that state and local health departments focus and provide oversight on the following critical elements: Planning and policy development, contact investigation, clinical and diagnostic services for patients with TB and their contacts, training and education, Surveillance data and information management, and monitoring and evaluation. The resources existing in subsidized centers are of good quality which can provide adequate services with their well trained staff where else in unsubsidized centers there are untrained staff and poor quality equipment for patient treatment. The cost implications in subsidized health centers are generally low while in unsubsidized health centers the costs are extremely high.
Implications of TB for Critical Care and Advanced Practice Nurses
The risk of developing TB is related to the amount of exposure to the organism M. tuberculosis. In most, but not all cases, close prolonged contact is required. Those most likely to develop TB are people who live or have lived in countries where it is endemic, and people who have impaired immunity. Most cases in the United States therefore occur in those born in countries with a high incidence of TB. Risk factors in the Caucasian population born in the United States include high alcohol intake, old age and homelessness. Infection does not necessarily mean that disease will follow, as the so-called primary complex may be overcome by the host’s defenses and could remain dormant for the rest of that person’s life without the consent of the advanced practice nurse.
In conclusion, tuberculosis has reemerged as a major public health concern and is the second deadliest infectious disease worldwide. Understanding the pathophysiology of this contagious airborne disease, from the primary infection to primary progressive (active) disease or latency, is important. Understanding the pathophysiology will help critical care nurses be aware of the causes of the classic signs and symptoms for tuberculosis. Many different diagnostic tests can be used to evaluate a patient with suspected tuberculosis, and the stage or progression of the disease markedly affects the results. Even in critical care, each nurse has an opportunity to contribute to the control of tuberculosis by learning about the signs and symptoms of the disease, risk factors specific to critical care patients, and the appropriate actions to take should such a case occur. The more nurses know about tuberculosis, the more they can contribute to minimizing its transmission, making early diagnoses, and preventing increases in morbidity and mortality due to this disease.
Centers for Disease Control and Prevention. (n.d.). Chapter 2: Transmission and pathogenesis of tuberculosis: TB disease [self-study module]. . Retrieved from http://www2.cdc.gov/phtn/tbmodules/modules1-5/m1/con6a.htm.
World Health Organization. (2012). Global tuberculosis report 2012. Geneva: World Health Organization. Retrieved from: www.who.int/iris/bitstream/10665/91355/1/9789241564656_eng.pdf. Accessed 15 December 2013.
Doherty AM, Kelly J, McDonald C, O’Dywer AM, Keane J, et al. (2013). A review of the interplay between tuberculosis and mental health. Gen Hosp Psychiatry 35: 398–406 doi:10.1016/j.genhosppsych.2013.03.018 [PubMed]
Extended case study 8 and guidelines (www.guideline.gov)
Centers for Disease Control and Prevention. (2007). World TB day. MMWR Morb Mortal Wkly Rep. 2007;56(11):245