NURS 530 Extended Case Study: TB
Tuberculosis (TB) is a human disease caused by the bacterium Mycobacterium tuberculosis (M. tuberculosis). While TB mainly affects the lungs making pulmonary diseases the most typical manifestation, other commonly affected systems include the gastrointestinal tract, the central nervous system, the reproductive system, the skin, the musculoskeletal system, and the lymphoreticular system (Adigun & Singh, 2022).
There have been considerable gains in the control of TB, a decline in new cases, and reduced mortality. However, TB still causes significant burdens of global mortality and morbidity. Furin et al. (2019) assert that there are more than 10 million new tuberculosis cases globally.
This paper provides an extended analysis of TB through the analysis of a provided case scenario. It also highlights the transmission and pathophysiology of TB, its clinical manifestations, medical and psychosocial concerns of the patient from the provided case scenario, implications of the treatment regimen, and the role of advanced practice nurses in critical care of TB patients.
Transmission and Pathophysiology of TB
TB is transmitted through the inhalation of aerosol droplets containing M. tuberculosis. When people with laryngeal or pulmonary TB disease sneeze, cough, sing, or shout, they generate the infectious droplets. These droplets can remain suspended in the air for several hours, depending on the environment. Transmission occurs when a susceptible person inhales these contaminated air droplets, traversing their nasal passageways to the upper respiratory tract and reaching the alveoli of their lungs (Long et al., 2022).
Alzayer and Al Nasser (2022) state that M. tuberculosis has several features that enhance its virulence, infectivity, and survival. The microorganism is non-motile, facultative, non-spore-forming, obligate-anaerobic, and an intracellular bacterium. It has a high lipid content with several lipids such as Wax-D, cord factor, and mycolic acid on its cell wall.
The high content of lipids on the cell wall of the organism enhances its survival under extreme conditions (low oxygen saturation, excessive alkalinity or acidity, and intracellular survival within the macrophages), contributes to poor Gram staining, and enhances its resistance to antibiotics (Adigun & Singh, 2022). Roughly 90 to 95% of people infected with M. tuberculosis do not develop TB, remaining asymptomatic, while 5 to 10% of individuals develop active tuberculosis (Jilani et al., 2022).
Several pathophysiological factors are essential in determining whether an infected individual develops an active disease. Deposition of M. tuberculosis in the lungs leads to several possible outcomes in an individual depending on innate factors such as one’s immunocompetence.
The organism can be immediately cleared from the body, immediate onset of active disease can ensue, and a latent infection or the disease can be reactivated many years after the latent infection. M. tuberculosis has several virulence factors that make it difficult to eliminate from the body by macrophages. These factors include a high lipid content on its cellular circular wall that makes phagocytosis by macrophages problematic. Additionally, it has a cord factor that directly destroys phagocytes and prevents the formation of phagolysosomes, enhancing its survival (Jilani et al., 2022). Furthermore, M. tuberculosis can resist oxidative stress from the host (Roy Chowdhury et al., 2018).
Following the failure of the immune system to clear the microorganisms, active tuberculosis develops. Cytokines and chemokines produced by phagocytes in the lungs attract other cells. These include alveolar macrophages, neutrophils, and monocytes, creating a tubercle (a nodular granulomatous structure). The tubercle proliferates, with the body responding through cell-mediated immune responses.
As cytotoxic cells, nitrogen intermediates, and tumor necrosis factor-alpha try to respond to the tubercle bacilli, they cause collateral damage and caseating necrosis to the host’s cells, contributing to the histopathology evident in TB patients (Nigsch et al., 2019). Jilani et al. (2022) state that epithelioid granulomas having central caseation necrosis patterns are TB’s diagnostic histopathological hallmark.
Clinical manifestations of TB include prolonged cough for over three weeks, sweating at night, appetite loss, and neck swelling (Adigun & Singh, 2022). Patients also present with fatigue, weight loss, and high body temperatures. Additionally, a patient may simultaneously experience chest pains while coughing and expectorate blood.
Patients whose TB has disseminated to other body parts may experience symptoms related to that specific body part. For instance, extrapulmonary TB in the kidneys may present with blood in the urine. Furthermore, a patient with TB in the spine may experience lower back pains. Chest x-rays and sputum cultures are used to confirm the diagnosis of TB (Rastoder et al., 2019).
Identified Medical Concerns for the Patient
Maria has been experiencing a persistent and worsening cough. When she visits the clinic, the nurse explains that Maria could be having TB, depending on the symptoms she is experiencing. Physical examination demonstrates that Maria has abnormal lung sounds. Additionally, Maria has axial and cervical lymphadenopathy. Chest X-ray confirms that Maria has reactivated TB. She is started on TB medication therapy. She is compliant with the medication regimen.
However, two months after Maria began her medication, she started experiencing more intense coughs, which are more productive, and sweats more at night daily. When she visits the clinic the following day, it is determined that she has multidrug-resistant TB. A chest X-ray shows that there has been no improvement. Therefore, she has to continue with her medication for an extended period of 24 months, beyond the seven months projected earlier.
Primary Psychosocial Concerns
Maria has several psychosocial concerns. First, she is a single mother who takes care of her three sons independently. Additionally, her illegal status in New York City makes her hesitant to seek medical treatment. This demonstrates that she is worried about getting on the wrong side of the law. She also lost a close relative, her grandfather, who died from TB.
When diagnosed with TB, Maria must start medications that she uses the money to acquire and must comply with the medication regimen. Taking drugs daily can be psychologically burdening, and it is costly to obtain the medications. Two months later, despite her compliance and adherence to the medication regimen, it is determined that Maria has multidrug-resistant TB.
The news is devastating to her, and she is worried about whether she will be able to continue working, the cost of acquiring the medications she has to take for an extended period, and she must also meet her parenthood obligations and provide for her sons. Furthermore, Maria is stressed and unsure how she will navigate her current challenges and optimally handle her health crisis.
Implications of Treatment Regimen
With effective and uninterrupted treatment, most patients with TB have positive outcomes (Adigun & Singh, 2022). Anti-TB drugs have side effects such as neurotoxicity, hepatotoxicity, orange discoloration of body fluids, nausea, vomiting, pruritis, and body rash. Therefore, patients must be closely monitored and followed up for these side effects to ensure medication compliance. Non-adherence to drugs increases the severity and length of the illness, increases transmission, and develops drug-resistant TB (Mekonnen & Azagew, 2018).
Furthermore, it significantly impacts the healthcare system in efforts to control and manage the disease and the costs of patients acquiring medications. Non-adherence to TB drugs is related to the side effects, lack of social support, inadequate knowledge, medication stockouts, and poor communication between patients and their healthcare providers (Mekonnen & Azagew, 2018). Research shows that despite years of education, coverage of TB treatment is at 85%, and the treatment success rate is 62% (AlSahafi et al., 2019).
Nellums et al. (2018) state that the WHO targets a treatment success rate of at least 85%. Interruption of treatment regimens and patient non-compliance are the main obstacles hindering achieving these cure targets. The Centers for Disease Control and Prevention (CDC) (2021) states that 56 cases of multidrug-resistant TB were reported in the US out of the 456 cases reported that year.
Role of Community Clinics in Assisting Patients
Community clinics play vital roles in preventing and controlling TB. The community clinics assist patients in covering the cost of their TB treatment by providing medications at subsidized prices and ensuring patients do not experience drug stockouts. These strategies ensure the availability and affordability of drugs, enhancing compliance and adherence to the TB treatment regimen.
The US Department of Health funds tuberculosis clinics to prevent, diagnose, and treat TB (Human Resources & Services Administration (HRSA), 2022). Community health centers provide several resources that help treat TB. These resources include patient support groups, culturally competent care, free education materials, health literacy activities, and free websites from which patients can limitlessly savor. Furthermore, subsidized treatment in community health centers enhances patient affordability for TB services. If unsubsidized, many patients would be unable to access health services due to high costs.
Implications of TB for Critical Care and Advanced Practice Nurses
About 3.4% of TB patients require critical care in the intensive care unit (ICU) (Chaudhry & Tyagi, 2021). Indications for TB-related admissions in the ICU include respiratory failure, severe pneumonia, septic shock, and tubercular meningitis. These patients may have other comorbidities that increase the mortality rates. Challenges for managing TB patients include challenging the administration of anti-TB agents in critically ill patients and interactions with other drugs (Chaudhry & Tyagi, 2021).
With their advanced knowledge and education, advanced practice nurses have the autonomy to take history, order and interpret diagnostic tests, prescribe medications, and monitor patients as primary health providers. With these roles, APNs help bridge the gap and provide high-quality care and more affordable services to TB patients, ensuring positive patient outcomes.
Adigun, R., & Singh, R. (2022, January 5). Tuberculosis. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441916/
AlSahafi, A. J., Shah, H. B. U., AlSayali, M. M., Mandoura, N., Assiri, M., Almohammadi, E. L., Khalawi, A., AlGarni, A., Filemban, M. K., AlOtaibe, A. K., AlFaifi, A. W. A., & AlGarni, F. (2019). High non-compliance rate with anti-tuberculosis treatment: a need to shift facility-based directly observed therapy short course (DOTS) to community mobile outreach team supervision in Saudi Arabia. BMC Public Health, 19(1). https://doi.org/10.1186/s12889-019-7520-8
Alzayer, Z., & Al Nasser, Y. (2022, May 1). Primary Lung Tuberculosis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK567737/
CDC. (2021, October 18). Reported TB in the U.S., 2020- Drug-Resistant Tuberculosis. Centers for Disease Control and Prevention. https://www.cdc.gov/tb/statistics/reports/2020/drug_resistant.htm#:~:text=MDR%20TB%20at%20initial%20diagnosis
Chaudhry, D., & Tyagi, D. (2021). Tuberculosis in Intensive Care Unit. Indian Journal of Critical Care Medicine, 25(S2), S150–S154. https://doi.org/10.5005/jp-journals-10071-23872
Furin, J., Cox, H., & Pai, M. (2019). Tuberculosis. The Lancet, 393(10181), 1642–1656. https://doi.org/10.1016/s0140-6736(19)30308-3
Human Resources & Services Administration (HRSA). (2022). Tuberculosis Clinics | HRSA. www.hrsa.gov. https://www.hrsa.gov/opa/eligibility-and-registration/specialty-clinics/tuberculosis
Jilani, T. N., Avula, A., Zafar Gondal, A., & Siddiqui, A. H. (2022). Active Tuberculosis. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513246/#:~:text=Although%20about%2090%25%20to%2095
Long, R., Divangahi, M., & Schwartzman, K. (2022). Chapter 2: Transmission and pathogenesis of tuberculosis. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 6(sup1), 22–32. https://doi.org/10.1080/24745332.2022.2035540
Mekonnen, H. S., & Azagew, A. W. (2018). Non-adherence to anti-tuberculosis treatment, reasons and associated factors among TB patients attending at Gondar town health centers, Northwest Ethiopia. BMC Research Notes, 11(1). https://doi.org/10.1186/s13104-018-3789-4
Nellums, L. B., Rustage, K., Hargreaves, S., & Friedland, J. S. (2018). Multidrug-resistant tuberculosis treatment adherence in migrants: a systematic review and meta-analysis. BMC Medicine, 16(1). https://doi.org/10.1186/s12916-017-1001-7
Nigsch, A., Glawischnig, W., Bagó, Z., & Greber, N. (2019). Mycobacterium caprae Infection of Red Deer in Western Austria–Optimized Use of Pathology Data to Infer Infection Dynamics. Frontiers in Veterinary Science, 5. https://doi.org/10.3389/fvets.2018.00350
Rastoder, E., Shaker, S. B., Naqibullah, M., Wille, M. M. W., Lund, M., Wilcke, J. T., Seersholm, N., & Jensen, S. G. (2019). Chest x-ray findings in tuberculosis patients identified by passive and active case finding: A retrospective study. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 14, 26–30. https://doi.org/10.1016/j.jctube.2019.01.003
Roy Chowdhury, R., Vallania, F., Yang, Q., Lopez Angel, C. J., Darboe, F., Penn-Nicholson, A., Rozot, V., Nemes, E., Malherbe, S. T., Ronacher, K., Walzl, G., Hanekom, W., Davis, M. M., Winter, J., Chen, X., Scriba, T. J., Khatri, P., & Chien, Y. (2018). A multi-cohort study of the immune factors associated with M. tuberculosis infection outcomes. Nature, 560(7720), 644–648. https://doi.org/10.1038/s41586-018-0439-x
NURS 530 Extended Case Study: TB Instructions
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.
Please review the case study scenario on TB patient first (file is attached)
Review the patient\’s TB questionnaire: FILE is attached (Page 1) (Page 2)
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 (Links to an external site.)). 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:
1) What is the transmission and pathophysiology of TB?
2)What are the clinical manifestations?
3)After considering this scenario, what are the primary identified medical concerns for this patient?
4)What are the primary psychosocial concerns?
5) 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.
6) 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.
7) What are the implications of TB for critical care and advanced practice nurses?
Your paper should be 4â€“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 Current APA Style to format 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.