Complex Case Study Analysis- Tuberculosis

Introduction

The essay deals with the case study of Mr. John a 55 year old man diagnosed with pulmonary tuberculosis (PTB). He is presented to Emergency Department or ED with worsening symptoms.  PTB is caused by the Mycobacterium tuberculosis and is highly contagious.  According to World Health Organisation (WHO), Tuberculosis is one of the leading cause of death worldwide. In lower and middle income countries, 95% of the deaths occur due to TB. As per WHO report, in 2016, 1.7 million died from TB (WHO, 2015). Multi drug resistant TB is a public health crisis.  The sustainable development goal of WHO is to end TB   epidemic by 2030 (Department of Health, 2015). In Australia, the TB is highly prevalent in Indigenous population than the Non-indigenous populations with the incidence rate of 4.6 per 100,000. Despite good TB control measures since 1980s Australia is facing challenges to control TB in migrant population and Indigenous people (Department of Health, 2015).  In relation to the case study, the essay will discuss in details about the pathophysiology of the primary cause of the patient’s hospital admission. The analysis of medication management and relevant treatment pertaining to Mr. John’s will be discussed explicitly in the subsequent sections of the essay.  Further, the appropriate nursing interventions for pulmonary tuberculosis are the focus of the essay in later sections. Other relevant issues pertaining to the health condition is briefly discussed and supported with relevant literature.

1.Provide details of the selected case’s relevant medical history and present status

The essay deals with the case study of Mr. John, a 65 year old Indigenous man lives in Melbourne. He was presented to the emergency department with symptoms like fever, cough, pale skin, shortness of breath, night sweats, weakness, and weight loss. Since three weeks he had haemoptysis. His blood pressure was elevated, 152/93 mmHg. The diagnosis of the patient two months ago was pulmonary tuberculosis. The patient was discharged initially but due to lack of appropriate care at home is readmitted to the emergency department due to worsening symptoms.  

Mr. John has the history of hypertension, pneumonia, Type 2 diabetes mellitus (T2DM), renal failure and chronic obstructive pulmonary disease (COPD). The patient also has the history of pericarditis. The patient is kept in the isolated room to prevent spread of infection to others. On monitoring he was found to be non-adherent to the medication guidelines. He showed willingness to go home and is evident from spending long time outside the hospital premises. His non-compliance led to the worsening of his condition. At times he had cough with blood. The patient has history of smoking for 15 years. The patient’s self care and hygiene were poor. He loves his independence in carrying activities of daily living. The patient lives alone in a large house and there are no sign of allergy observed.   The patient does not participate in any form of physical activity and reports social isolation. 

On examining the vital signs of Mr. John, the levels were in normal range except temperature of 37.9 degrees, low blood sugar level and high blood pressure. The patient had signs of headache, depression and mild edema in legs. The matter of concern was oxygen saturation of 88-90% at room air. The signs of infection were prominent. There were no signs of anaemia. Mr John’s chest X ray resets showed minor lesions in apical segments. The lesions in the upper lobe are significant indicators of tuberculosis. The left lower lobe was found with the focal Opacity and increased consolidation. Respiratory examination showed the audible sounds of crepitation’s on the lung apices. The laboratory tests used for diagnosis are sputum examination, culture for identifying the causative organism and Monteux Tuberculin skin test (18mm). Culture was tested for positive Acid Fast Bacillus – AFBs and obtained positive smear test. The patient had normal blood count test results and urea level. The medications for the patient are as follows-

1. fluticasone salmeterol (250mcg, 50mcg),
2. Rifampicin 300mg daily
3. iptarropium 21mcg/dose
4. salbutamol 100mcg/1doses
5. Pyrazinamide 750mg daily,
6. Nicotine patch 21mg
7. Isonaizid 200mg daily
8. Ethambutol 600mg daily

Other prescribed medication for the regular use of the patient are-

1. frusemide 80mg daily (Diuretic)
2. Nifedipine 20mg TDS (antihypertensive).
3. prazosin 2mg TDS (antihypertensive).

Oxygen therapy and dextrose were given for low oxygen saturation and low blood glucose level.

A comprehensive treatment is followed for Mr. John. The nursing interventions and the individualised care is discussed in subsequent paragraphs.

2.Pathophysiology for the current hospital admission

Tuberculosis is known to be the multisystemic disease with various manifestations. It is caused by the Mycobacterium tuberculosis, a gram-positive acid-fast bacillus. Infection occurs when the lungs and or mucous membranes are exposed to the infected aerosols. In patients with PTB the single cough can results in release of 3000 infective droplet that may have 10 bacilli sufficient to spread infection to others. These droplets when inhaled get deposited in the terminal airspaces of the lungs or upper part of airways. In this location they grow for 2-10 weeks and multiply in number say 1000-10,000 that is enough to trigger the cellular immune response. At this stage it is easy detected by the tuberculin skin test (Raviglione, 2016). The vigorous immune response triggered after infection is due to anetgenic nature of the Mycobacteria. This is known to be the nonspecific immune response. The antigencity of the bacteria is due to multiple components of the cell wall including the phospholipids, Wax D, glycoprotein that can activate the receptors of the lymphocytes, and the polymorphonuclear leukocytes (Wani, 2013).

Tuberculosis or TB may be categorised as latent infection or active disease. Active tuberculosis disease is commonly called as lung disease and is also called an extra pulmonary tuberculosis TB. In the active form the bacteria is rapidly multiplying invading other body organs and is clearly evident from chest x-rays and lung examinations (Department of Health and Human Service, 2015). Host immune system when suppresses the infection and it develops into latent infection. Latent disease does not develop overtly.  Active disease can be evident from reaction to skin tuberculin tests and rapid multiplication of bacteria with great risk of infection transmission (Salgame et al. 2015).   The common site of development of the disease is the lungs and therefore, 85% of the cases the patients have pulmonary complaints. Bacilli are being discharged from the sputum in case of infection as result of which the positive culture of sputum examination is observed. However, a greater infection is indicated by the sputum smear positive case than the positive culture.

The infection is manifested as chronic cough, as also observed in John along with other symptoms such as fever, night sweats, weakness, weight loss and low appetite.  These symptoms are common to PTB patients in Australia and are mentioned in the National Institute for Health and Clinical Excellence guidelines (Hoppe et al., 2016). This was the primary cause of the admission of Mr. John in the ED that was called for intense diagnostic tests followed by comprehensive treatment.  

 There are various risk factors for PTB that increase the chance of active form of TB instead of Latent form. It includes HIV infection, low body weight, chronic lung disease like COPD, smoking and diabetes mellitus. .People with previous history of TB is at high risk along with travellers. In Australia Indigenous people are highly vulnerable to TB when exposed to certain areas such as Queensland. Social factors such as living in overcrowded areas trigger active form of TB.  These risk factors are present in Mr. John as evident from the past medical history that caused his illness to progress. And Smoking causes ineffective airway clearance and chronic cough in COPD and increases risk for TB. These conditions make the clinical suspicion high in Mr. John who is also Indigenous as recommended by the department of health (DOH, 2015).

3.Medication management

Mr. John was prescribed a combination of medication as PTB is treatable. An active form of TB requires multi-drug treatment. Medications usually administered are ethambutol, rifampin and pyrazinamide. These three medicines are given in combination with isoniazid to kill the potentially resistant strains.  For the first two months it is important to take the four drugs together as the sputum smear test was positive. Later the dosage may be two drugs per day.  The patient’s weight was checked before commencing the treatment as some of the medicines affect weight requiring regular monitoring.  An active form of disease is very serious and may be health debilitating. Therefore, there is need of strong adherence to the treatment regime. Success of the TB treatment depends on strong compliance and regular monitoring (Torres & Silva, 2012; Department of Health, 2015). 

Isoniazid is an antituberculosis medicine is usually prescribed as tablet and is recommended to intake along with two or three more medicines. It is used together with the Rifampicin  and Pyrazinamide. Isoniazid has bactericidal; property on rapidly dividing bacterium and inhibits the synthesis of the mycolic acid.  Rifampicin is also an antibiotic which works by inhibiting the RNA polymerase of the bacteria used for transcription (Burhan et al., 2013). Pyrazinamide is the anti-tuberculous agent administered initially for two months due to suspicion of drug resistance disease. It inhibits the growth of the Mycocbacterim by diffusing into its granuloma. It is then converted to the pyrazinoic acid an active form by tuberculosis enzyme pyrazinamidase. On accumulation the pyrazinoic acid inhibits the fatty acid synthesis in the bacteria and also disturbs it membrane potential. Ethambutol is the bacteriostat and hinders the cell wall development of the bacteria in the stage of active development. By inhibiting the enzyme called the arabinosyl transferase necessary for making the peptidoglycan complex the cell permeability is increased (Safi et al., 2013).

When the patient was readmitted in the hospital, he had low oxygen saturation that was treated with the oxygen therapy. Low blood glucose level was treated with dextrose infusion and treat insulin induced hypoglycaemia. Nasal Prongs at the dose of 3L/min was given. To decrease the high blood pressure the patient was prescribed a combination of anti-hypertensive. An effective treatment of hypertension is with diuretic treatment. Thiazide diuretics are also administered that patient takes over the counter. Low dose diuretics may be used in combination with the beta blockers as it will prevent lowering of blood pressure by other are decreased. Also the side effects of the diuretics are decreased when administered as combination therapy. In case of John the combination therapy to reduce hypertension was nifedipine, furosemide, and prazosin.  Prazosin makes urination easier, while nifedipine, reduces blood pressure. In patients with renal failure volume retention drives the hypertension and therefore loop diuretic furosemide used. He is given  frusemide 80mg daily due to history of renal disease (Zanchetti, 2014). Salbutamol (β2-adrenergic receptor) is used to relax the airway muscles in patients with COPD and chronic cough.  It functions as a bronchodilator.  Ipratropium (Atrovent) bromide also has the same function. Both are important for Mr. John as he has COPD.  COPD leads to severe inflammation of lungs therefore a combination of Fluticasone Salmeterol is used to exhibit anti-inflammatory effect by inhibiting the immune receptor activated in allergic response due to chemicals (Lee et al., 2013).

4.Medical diagnostics treatment

 Based on the physical signs, symptoms and past medical history of the patient, various diagnostic tools were used.  The primary diagnosis for TB is the sputum tests where the sample of sputum is collected to test for TB bacteria and drug resistance strains and takes 4-8 weeks to complete.  In case of John active form of disease was indicated. Acid fast staining of the culture sample is used for detecting the acid fast Mycobacterium. The positive acid washed smears   in the specimen confirms PTB in John as also his AFB tests were positive as per CDC recommendations (Centers for Disease Control and Prevention, 2014).

Imaging tests like chest X rays are ordered to notice any white spots in lungs and other changes due to TB. Pulmonary nodules in the upper lobe, opacification of airspaces in lung parenchyma, consolidation of the upper zone, pleural effusion is the hall mark of TB (primary radiological features).  It is necessary to take imaging tests along with Mantoux tuberculin skin test as in most cases the reaction to tuberculin is obtained as false positive result (Centers for Disease Control and Prevention, 2014). In case of John the Tuberculin test showed positive results with elevation of skin upto 18mm in diameter.  As per Department of Health, Australian guideline, diameter greater than 15 mm confirms to be positive even if there are no other risk factors present. The active form of disease was further confirmed by the minor lesions in upper lobe observed in the chest X- ray along with focal Opacity and increased consolidation (Jaeger et al., 2014). Edema in lungs is also caused by pleural effusion as per Raviglione, (2016) that was observed in John. As per CDC, and NSW guidelines the Chest X-ray is essential to distinguish the TB and non-TB related conditions (normal cardiothoracic conditions) (National Institute for Health and Clinical Excellence, 2006; NSW, 2015).

 Blood tests are ordered to rule out any presence or absence of active or latent disease form (Raviglione, 2016).  It is best to use when high risk of TB infections is suspected. The patient blood test and haematology assessment showed no sign of abnormal blood counts or anaemia. Since the patient had history of renal failure, tests were conducted for assessing renal function as well as liver function test.  The results were normal and indicate need of diuretics (Torres & Silva, 2012). On assessing the vital signs to confirm the symptoms of infection high temperature (37.9) instead of normal 37 degree Celsius and high blood pressure was observed (152/93 instead of normal 12/80), As the patient has the history of the  diabetes mellitus, blood glucose test was conducted and  John was found to be hypoglycaemic (2.5 mmol/l).  

Daily monitoring of the patient was essential as he was having chronic illness with several comorbidities.  There was periodic assessment of chest and lungs though chest X ray and   infection was tracked using sputum tests.  Vital signs were regularly monitored as the patients may have side effects due to various medicines prescribed to him. Considering his diabetes insulin monitoring was also essential to determine the right dosage required to avoid side effects of anti-TB medications (Torres & Silva, 2012).   

5.Activity log

Based on the past medical history and symptoms presented in ED, the patient was suspected of tuberculosis. Therefore, he was taken care of separately after shifting him to infectious ward. His room was isolated to other rooms to prevent spread of infectious.  When dealing with the patient for physical examination and administration of medication, nurses used personal protective equipment such as gloves, mask, and apron as recommended by WHO and Department of Health Australia. These measures will help prevent infection to nosocomial spread to other wards or to health care providers. It will make an immunosuppressed individual highly susceptible to TB. Moreover, John’ sputum showed high presence of bacilli. Isolation and treatment may be considered until the further sputum test showed negative results for Mycobacterium. This was necessary as John’s symptoms showed public health risk (Hoppe et al., 2016). As per the guidelines given by the Department of Health Australia, contact investigation was conducted in accordance with history taking, radiographic examination and TST. History taking help determine the medication regime while monitoring for side effects (NSW 2015; Department of Health, 2015).

On the day one after isolation in the infectious  ward, the patient was given oxygen therapy to achieve saturation of 99%.Using nasal prong  will help reduce shortness of breath. The patient was given dextrose infusion to balance the low hypoglycaemic level as John was diabetic. A combination of drugs was used to decrease the high blood pressure along with diuretics. The second day of care included examination of results of the blood tests, radiographic and TST tests ordered on first day (NSW, 2015).  Based on positive test results, DOT intervention was given. A strict regimen of fluid intake, was imposed to reduce oedema. The fluid chart was regularly monitored through input and output (Murray, 2011).  By third day there was improvement in the blood glucose level, and on fourth day oxygen saturation was achieved to 99%. However, the blood pressure, oxygen requirement and blood glucose level was monitored for next three days to notice any fluctuations. On the fifth day the nasal prong and dextrose infusion was discontinued. However, antihypertensive medication was continued due to history of hypertension (Torres & Silva, 2012).). As a part of directly observed therapy or DOT, recommended by various national and international guidelines, Isoniazid, Rifampicn, Ethambutol, and pyrazinamide was administered for period of 6 months. By 10th day there was decrease in fever. Further based on therapeutic guidelines, there was continuous inpatient care and adherence to drug therapy was monitored right from the first day of treatment. It is because there was risk of high complications for TB as well as other comorbidities (National Institute for Health and Clinical Excellence, 2006; Centers for Disease Control and Prevention, 2014; NSW, 2015). The drug adherences were monitored along with other vital signs and for side effects of medications such as nausea, vomiting and others. Mean while the sputum and culture tests were conducted consecutively.  On the 14th day the patient sputum test was found to be negative and thus, he was shifted from infectious ward. There was reduction in cough, temperature,  as well as blood glucose was in normal range on 15th day. The discharge plan was prepared and the patient was assured to arrange for home care nurse as he preferred living at home.  The patient was then educated about self care and hygiene, importance of medication compliance on quality of life as it will promote his independence in activities of daily living after discharge. He was educated to wear mask to avoid recurrence of infection and cough or sneeze while covering with tissue paper. Dietary recommendations were given to promote nutrition and reduce weakness (M’Imunya, Kredo & Volmink, 2012). Since the patient was living alone he was referred to social service program for any personal and financial assistance after discharge. He was also referred to counselling programs to reduce depression before discharge (Baral et al., 2014).

6.Reflection on the nursing care

Reflective practice is essential in nursing as it helps one to evaluate own actions, knowledge and thinking. It acts as a tool to retrospect and introspect, into one’s own judgement and decision making skills to reach a conclusion about need of improvement (Bulman, Lathlean, & Gobbi, 2012) Reflection is important in both personal and professional life to become better human being and an efficient nurse.  Reflecting on the care of Mr. John for PTB, I have learned the effective implementation of various international and national guidelines on PTB care. It helped me proceed with the interventions systematically.

Using these guidelines a rapid diagnosis was conducted which led to effective treatment and patient outcomes. Isolating the patient and consecutive sputum testing helped track the infection and prevent noscomial spread of infection suing drug therapy. By examining the vital signs in detail, I could well set the nursing priorities. It includes need of oxygen therapy, restore the normal blood glucose level and address hypertension. Patient temperature was regularly monitored as fever is the hall mark of infection. Further, sputum test and cultures were ordered consecutively, which helped to indentify the need of multidrug intervention. Based on the literature evidence, the combination of Isonaizid with Rifampicin, Pyrazinamide and Ethambutol is beneficial in reducing the PTB infection when administered regularly for first two months (Burhan et al., 2013). 

The patient was weak and lacking energy; therefore, adequate dietary guidelines were given to enhance nutrition and energy level. The patient was supported by educating about the side effects of medication and to report immediately in case of concern. The patient was educated about illness as he was initially non adherent to the treatment regime.  Patient education is essential to reduce the risk of recurrence of highly contagious PTB as per the CDC, NSW AND guidelines fro Australian Department of Health and Human Services. As per these guidelines it is effective to start antibiotic therapy with combination of drugs for first two months. Thus, it was justified to examine the pathophysiology of the disease in detail.  Also nursing education promotes effective coping in patients and it was essential in case of John as he has no family member to take care. He lives alone and has poor hygiene. Educating him about coughing/sneezing etiquette, hand hygiene; self care will reduce transfer of infection in community (M’Imunya, Kredo & Volmink, 2012).  

Considering his present and past medical records I have given adequate fluid volume to the patient and the input/output was well documented. It was beneficial in preventing dehydration and ensured easy expectoration in John. Since John was suffering from chronic cough due to COPD and had earlier showed shortness of breath, I have educated him about the breathing techniques that will decease his respiratory efforts. To increases his lungs expansion I have positioned the patient in semi-Fowler’s position (Costa, Almeida & Ribeiro, 2015).

 Knowing the patient’s vulnerability due to his social isolation and signs of depression, he was referred to social support group and counselling services respectively. The rationale includes decrease in risk of future infection, assistance with livelihood and supportive environment.  Counselling, and peer support are effective way to verbalise feelings that will reduce stress and depression (Baral et al., 2014). Patient centered care was implemented for John, as he was in need of emotional support in addition to medical intervention.  Integrated patient centered tuberculosis care is the first pillar of the End TB strategy of WHO (Fujita & Narita, 2012). All the international and national guidelines calls for streamlined medical services for TB prevention. It calls for services that customized to the patient’s needs. The use DOT intervention is the need of treatment and it allow to give comprehensive patient centered support (Baral et al., 2014). Ii could optimal patient administration based on profile and past medical records. It worked well as patient centered care facilitates active engagement from the patient. Patient centered care helps decreases the rate of rehospitalisation (Fujita & Narita, 2012). The rationale for this care was to engage patient as a part of the team. Using the regional care pathway I was better able to share the treatment process with John, results of tests and other relevant information. This approach led to treatment adherence in John after 16 days of care in hospital. Using his approach I could consider the patient’s convenience, comfort and risk assessment.  Effective communication skills helped me to collect and analyse the information while giving face to face care. I could well use verbal and nonverbal skills to understand the patient needs.  Patient centered care and DOT provider facilitates in building the relationship of trust with the patient (Fujita & Narita, 2012). Therefore, I could increase the patient adherence to the medication and is evident from negative sputum test. It was possible by motivating him and encouraging him throughout treatment.

 Despite the above measures and evidence based practice at every step of patient care for PTB, some places were noted that could be improved in future practice.   Firstly, John felt discrimination when he was separated and isolated in separate ward. However, this was necessary but could not be well communicated to him. However, later the patient was sifted back to the general ward and after education he was aware of his illness. Eventually it increased adherence to the treatment. If only the reason for isolation was well communicated, John would have been more adherent since beginning of the treatment.  I should have been more positive towards the patient. Also there was no education given to the smoking cessation. The person was a chain smoker in past and currently intakes one cigarette a day. However, this may be a risk for COPD exacerbation and PTB. This should not have been ignored. These deficiencies shall be overcome   in future practice.  I will refer the client to counselling for smoking cessation when he will come for follow up.  It will in effective management of COPD and PTB  as well as reduce depression (Shin et al., 2012).

Conclusion

PTB is highly contagious and hence there is a need of strict following of national and international guidelines for rapid diagnosis and treatment. Nursing intervention must be based on evidence as there is huge research conducted in this field. Traditional mode of care may not be applicable as some strains are highly resistance. The symptoms of the PTB are health debilitating and may be fatal without proper monitoring. It adds to stress and depression in patents. Therefore, nurses need to implement patient centered care and well collaborate with multidisciplinary team to support patient quick recovery. Patient education about underlying pathophysiology, need of multidrug therapy and side effects of medication is very essential to ensure treatment adherence. As a nurse I have given adequate support, encouragement and motivation to the patient to increase medication compliance. However, the care deficiencies include neglecting smoking aspects in care and communicating the patient about isolation after infection. Such deficit will be taken care in future 

 

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