CASE SCENARIO #3

PULMONARY TUBERCULOSIS

In September 1998, Patient B a 36-year-old male soldier in the French Foreign Legion with
hemoptysis was sent back to France from Djibouti. He expectorated bloody sputum after
running and on a few other occasions. His medical history was not unusual. When the patient
was hospitalized, 2 weeks after the initial symptoms, he began to experience progressive
fatigue. He did not experience fever, weight loss, night sweats, anorexia, cough, dyspnea, or
chest pain, and did not produce sputum.
Results of the clinical examination were normal. The Mantoux test, performed with 10 IU of
purified tuberculin (Aventis-Pasteur-MSD, Lyon, France), yielded a maximum transverse
diameter of induration of 15 mm. Laboratory values were normal (Table). The chest X-ray
showed a triangular consolidation of the left upper lobe with blurred limits and small cavitary
lesions. No other contiguous mediastinohilar anomalies were visible. A computed tomographic
scan confirmed the cavitary syndrome: three excavated nodular images showed radiating
spicules within a micronodular infiltrate. Bronchoscopy showed a moderate inflammation of
airway mucosa, especially in the left upper lobe. Biopsy specimens exhibited nonspecific
inflammation.

Table
Laboratory values for both patients infected with Mycobacterium tuberculosis subsp. canetti

Sedimentation rate (mm) 3 3

C-reactive protein (mg/L) 7.3 4.28

Fibrinogen (g/L) 3.64 6.3

Blood count

Hemoglobin (g/dL) 16.8 14.1

Platelets (x109/L) 194 274

White cells (x109/L) 10.10 9.54

Neutrophils (%) 66.2 69.4

Eosinophils (%) 2 8.6

Lymphocytes (%) 21.3 17.2

Basophils (%) 0.6 0.9

Monocytes (%) 9.9 3.9

Aspartate aminotransferase (U/L) 21 16

Alanine aminotransferase (U/L) 19 23

Creatinine (µmol/L) 89 97

Glucose (mmol/L) 4.7 4.4

PATHOPYSIOLOGY OF PULMONARY TUBERCULOSIS

Mycobacterium Tuberculosis
A bronchial washing smear from the left upper lobe was positive for acid-fast bacilli. Serologic
(Gram-positive,
tests for HIV-1 and HIV-2 were negative. acid fast
No evidence bacillus)was found elsewhere; the
of disease
patient did not experience bone pain. Results of neurologic and ophthalmologic examinations
were normal; no lymphadenopathy or hepatosplenomegaly were found and the genitalia were
normal. Auscultation revealed no pericardial fremitus; no ascitic fluid was detected. The urinary
Inhalation
sediment contained <1,000 red blood of and
cells/L dried<5,000
dropletleukocytes/L.
nuclei Antituberculosis
chemotherapy was begun with four drugs: rifampicin,
(Airborne isoniazid, ethambutol, and pyrazinamide.
droplets)
Cultures revealed a strain identified as M. tuberculosis subsp. canetti that was susceptible to all
primary antituberculous drugs. Therefore, rifampicin and isoniazid were continued for 3 more
months for a total treatment period of 6 months. The patient’s response to treatment was
favorable, and he remained asymptomatic.
Inflammation in Alveoli

1. Lymph nodes filter drainage

2. Primary Tubercle
 NCP

ASSESSMENT DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATION

IS
Subjective> Airway Long term objective: -Assess respiratory -Diminished breath sounds may reflect Long term
Clearanc function noting atelectasis. Rhonchi, wheezes indicate objective:
Patient said that he Within 1 day of nursing
e, breath sounds, rate, accumulation of secretions and inability
expectorated bloody intervention patient After 1 day of
Ineffectiv rhythm, and depth, to clear airways that may lead to use of
sputum after running will maintain patent nursing
e may be and use of accessory accessory muscles and increased work of
and on a few other airway. intervention
related muscles. breathing.
occasions. patient will
to bloody
-Note ability to -Expectoration may be difficult when maintain patent
sputum
Short term objective: expectorate mucus secretions are very thick as a result of airway.
and
Objective> and cough infection and/or inadequate hydration.
fatigue. Within 5 hours of
effectively; Blood-tinged or frankly bloody sputum
Medical History: nursing intervention
document character, results from tissue breakdown Short term
can identify potential
-2 weeks after the amount of sputum, (cavitation) in the lungs or from objective:
complications and
initial symptoms, presence of bronchial ulceration and may require
initiate appropriate After 5 hours of
patient began to hemoptysis. further evaluation or intervention.
actions. nursing
experience
-Place patient in Positioning helps maximize lung intervention
progressive fatigue.
semi or high- expansion and decreases respiratory patient can
Clinical examination Fowler’s position. effort. Maximal ventilation may open identify
result: Assist patient with atelectatic areas and promote potential
coughing and deep- movement of secretions into larger complications
-Bronchoscopy
breathing exercises. airways for expectoration. and initiate
showed a moderate
appropriate
inflammation of -Clear secretions -Prevents obstruction and aspiration.
actions.
airway mucosa, from mouth and Suctioning may be necessary if patient is
especially in the left trachea; suction as unable to expectorate secretions.
upper lobe.
necessary. -High fluid intake helps thin secretions,
making them easier to expectorate.
-Maintain fluid
intake of at least - Prevents drying of mucous membranes
2500 mL/day unless and helps thin secretions.
contraindicated.
-Humidify inspired
air and oxygen
 Nursing Expected
Assessment Planning Implementation Rationale
Diagnosis Outcome
Short term: Short term:
Subjective: Ineffective  After 2-3 Independent: After 2-3
“the patient has a airway hours of hours of
.
bronchial washing clearance nursing 1. Maintain a fluid nursing
1. Helps thin the
smear from the left related to intervention intake of at least intervention
secretions so
upper lobe was presence the patient 2500 ml / day unless the patient
easily removed.
positive for acid-fast will be able contraindicated. was able to
of
bacilli as to demonstrate
bronchial 2. Prevents drying
verbalized.” demonstrate behaviors to
infection of mucous
behaviors to 2. Moisten the air / improve
and membranes.
Objective: improve oxygen inspiration. airway
The urinary secretion. airway clearance.
sediment contained clearance. 3. Assess airway for
3. Maintaining
patency.
 <1,000 red patent airway is
bloodcells/L always the first
 <5,000 priority,
leukocytes/L especially in
cases like
trauma, acute
neurological
decompensation,
or cardiac arrest.
4. Assess breath sounds
4. Abnormal breath
by auscultation.
sounds can be
heard as fluid
and mucus
accumulate. This
may indicate
 airway is
obstructed.
5. Encourage rest, 5. To promote
avoidance of breathing
bronchial irritant and pattern.
a good diet to
facilitate recovery.
Dependent:

1. Give medications: 1. Lowering the

bronchodilators, viscosity of
corticosteroids as secretions
indicated.

Collaboration:
1. Refer to the next 1. To continue
nurse on duty. the
intervention
to the
patient.
DRUG STUDY
Name of drugs Route of General action Indication/ Client’s Nursing responsibilities prior
administration Mechanism of action Purpose response to to, during, and after
, dosage and med. With administration
frequency of actual side
administration effects
Generic name: Route Inhibits RNA synthesis by Acute Tuberculosis Red  Perform mycobacterial studies
Rifampicin/Rifa PO blocking RNA transcription in (with other agents). discoloration of and susceptibility tests prior to
mpin Single dose; susceptible organisms. Elimination of tears, and periodically during therapy
Brand name: may also be meningococcal abdominal pain, to detect possible resistance.
Rimactane given twice carriers. diarrhea,  Assess lung sounds and
weekly flatulence, character and amount of
Frequency heartburn, sputum periodically during
Single dose; nausea, therapy.
may also be vomiting, red  Administer medication on an
given twice discoloration of empty stomach at least 1 hr
weekly urine. before or 2 hr after meals with
Dosage a full glass (240 ml) of water.
600 mg/day  Advise patient that this
medication has teratogenic
properties and may decrease
the effectiveness of oral
contraceptives.
 Emphasize the importance the
importance of regular follow-
up exams to monitor progress
and to check for side effects.
Brand name: Route Inhibits mycobacterial cell First-line therapy of CNS: psychosis,  Be alert for signs of peripheral
Isoniazid PO wall synthesis and interferes active tuberculosis, seizures. EENT: neuropathy (numbness,
Generic name: Frequency with metabolism. Therapeutic in combination with visual tingling, decreased muscle
INH Daily Effects: Bacteriostatic or other agents. disturbances. strength). Establish baseline
Dosage bactericidal action against Prevention of GI: DRUG- electroneuromyographic
300mg susceptible mycobacteria. tuberculosis in INDUCED values at the beginning of drug
patients exposed to HEPATITIS, treatment whenever possible,
active disease nausea, and reexamine these values
(alone). vomiting. periodically to document drug-
Derm: rashes. induced changes in peripheral
Endo: nerve function.
gynecomastia.  Always wash hands thoroughly
Hemat: blood and disinfect equipment
dyscrasias. (whirlpools, electrotherapeutic
Neuro: devices, treatment tables, and
peripheral so forth) to help prevent the
neuropathy. spread of infection. Employ
Misc: fever. universal precautions or
isolation procedures as
indicated for specific patients.
 Instruct patient and
family/caregivers to report
other troublesome side effects
such as severe or prolonged
fever, skin rash, vision
problems, breast enlargement
in men, or GI problems
(nausea, vomiting).
Generic name: Route Inhibits the growth of Active tuberculosis Dizziness,  Asses lung sounds and
Ethambutol PO mycobacteria. Therapeutic or other fatigue, or character and amount of
Brand name: Frequency Effects: Tuberculostatic effect mycobacterial headache, loss sputum periodically during
Myambutol Daily against susceptible diseases (with at of appetite, therapy.
Dosage organisms. least one other upset stomach,  Administer with food or milk to
1200 mg drug). vomiting, minimize GI irritation or tablets
numbness and may be crushed and mixed
tingling in the with apple juice.
hands or free,  Emphasize the importance of
and optic routine exams to evaluate
neuritis-blurring progress and ophthalmic
of vision. examinations if signs of optic
neuritis occur.

Generic name: Route Converted to pyrazinoic acid Used in combination GI:  Advise patient to take
Pyrazinamide PO in susceptible strains of with other agents in Hepatotoxicity,a medication as directed
Brand name: Frequency mycobacterium which lowers the treatment of norexia, and not to skip doses or
Once daily the pH of the environment. active tuberculosis. diarrhea, double up on missed
Dosage Therapeutic Effects: nausea, doses.
15 to 30 mg/kg Bacteriostatic action against vomiting GU:  Advise patients to notify
susceptible mycobacteria. dysuria DERM: health care professional if
acne, itching, no improvement is
photosensitivity noticed.
, rash HEMAT:  Emphasize the importance
anemia, of regular follow-up exams
thrombocytope to monitor progress and
nia. METAB: check for side effects.
hyperuricema
MS: Arthralgia,
gouty arthritis.
LAB TESTS

Analysis and
Diagnostics/ Date Nursing responsibilities prior
Interpretation of
Laboratory ordered/ Indication/Purposes Result to, during, and after the
results (related to
Procedure Date Done procedure
the disease)

The chest x ray showed

triangular consolidation of
It is used to evaluate the the left upper lobe with  Explain to the patient
lungs, heart and chest blurred limits and small the purpose of the test. 
wall and may be used to cavity lesions. No other  Inform the patient for
Chest Xray
help diagnose shortness of contagious mediastinal any abnormalities. 
breath, persistent cough, anomalies were visible.  Record the result. 
fever, chest pain or injury.

An endoscopic technique
 Instruct to the
of visualizing the inside of It shows moderate
patient the purpose
the airways for diagnostic inflammation of airways
of the test. 
and therapeutic purposes. mucosa, especially in the Result interprets
 Monitor patient 
Bronchoscopy   An instrument is inserted left upper lobe. Biopsy that the patient has
 Document the
into the airways, usually showed a moderate asthma.
findings 
through the nose or inflammation of airway
 
mouth, or occasionally mucosa, especially in the
through a tracheostomy left upper lobe.
It is a simple test that
looks at a small sample of  Instruct the patient on
<1,000 red
urine. It can help find hoe she can cooperate. 
blood cells/L
Urinalysis problems that needs Normal  Provide privacy. 
and <5,000
treatment including kidney  Document findings. 
leukocytes/L
disease, diabetes or liver
disease.
Bronchial A mild salt solution is From the left upper lobe Positive for acid  Explain to the patient
Washing washed over the surface of was positive for acid bacilli. the purpose of the test. 
Smear the airways to collect cells, bacilli.  Inform the patient for
 which are then looked any abnormalities. 
under the microscope. It is  Record the result. 
used to find infections.
 Explain to the patient
It determines the presence
the purpose of the test. 
Serological of the human
 Inform the patient for
tests for HIV 1 immunodeficiency virus All findings are normal. Negative
any abnormalities. 
and 2 (HIV) in human serum or
 Record the result. 
plasma,