Answer

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.