Lesson Plan pulmonary tuberculosis

OBJECTIVES

CONTENT

TIME  ALLOTMENT

TEACHING STRATEGY

REFERE NCE

EVALUATI ON

Within 1 hour of  discussion, the student nurses should be able to:

GENERAL OBJECTIVES: > Enhance awareness and knowledge regarding Pulmonary Tuberculosis (PTB) and the Multidrug Resistant Tuberculosis (MDR-TB) >Comprehend and recognize salient points that are important to remember in dealing with patients who

 Active Participation during discussion and impart learning regarding the topic after all the discussion

manifest signs and symptoms of  PTB and MDRTB; its causes and nature, clinical manifestations, diagnostic tests medical and nursing management, prevention of  spread and the protection for  healthcare providers SPECIFIC OBJECTIVES: a. Review the anatomy and physiology of  the system involved – involved – respiratory system which includes the lungs

The Respiratory System moves air into and out of the lungs, which are the site of exchange for  oxygen and carbon dioxide between the air and the blood. 

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Upper Respiratory Tract consists of the parts outside the chest cavity: nose and nasal cavities, pharynx, larynx, and upper  trachea. Lower Respiratory Tract consists of the parts found within the chest cavity: lower 

5 minutes

Lecture/  Active Discussion

Sanders, et al. Essential s of   Anatomy and Physiolog th y. 5 Edition

trachea, lungs which include the bronchial tubes and alveoli.  A.

Nose  – made of bone and cartilage covered with skin; hairs inside the nostrils block the entry of  the dust; used for breathing and smelling.

B.

Nasal Cavities  – it is within the skull; nasal mucosa (lining) warms and moistens the incoming air and dust & microorganisms are trapped on mucus.

C.

Pharynx – Pharynx – posterior to nasal and oral cavities

D.

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Nasopharynx-located above the soft palate which blocks it during swallowing; passageway for air only.

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Oropharynx-located behind the mouth; a passageway for both air and food.

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Laryngopharynx-opens anteriorly into the larynx and posteriorly to the esophagus.

Larynx – Larynx – an airway between the pharynx and the trachea; the voice box; during speaking, the vocal cords are pulled across the glottis and vibrated by the exhaled air, producing sounds.

E.

Trachea  – extends from the larynx to the primary bronchi; its mucosa is ciliated to sweep mucus, trapped dust, and microorganisms upward to the pharynx.

F.

Bronchial tree  – the right and left primary bronchi are branches of the trachea; secondary bronchi: to the lobes of each lung (Right-3 lobes; Left-2 lobes); bronchioles: smaller branches.

G.

Lungs – Lungs – on either side of the heart in the chest cavity extending from the diaphragm below up to the level of the clavicles.

H.

b. Define Pulmonary Tuberculosis

Alveoli – Alveoli – functional units of the lungs; sites of  gas exchange in the lungs

Pulmonary Tuberculosis (PTB) is an infectious disease that primarily affects the lung parenchyma (Brunner, et al, 2010). It is a contagious bacterial infection that mainly involves the lungs, but may spread to other  organs.

2 minutes

Lecture/ Recitation

Brunner, et al. Textbook of  MedicalSurgical Nursing. th 12 Edition

Causes and Risk factors c. Site the causes of  Mycobacterium tuberculosis (M. PTB as well tuberculosis) as those who are at risk Individuals who reside in crowded, poorlyventilated, and unsanitary conditions 

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Rapid population growth Poor case detection and cure rates in developing countries Transmission in hospitals and other public places

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Homeless persons

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Smokers

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With multiple sex partners – partners – HIV infection

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Substance abusers

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Individuals with malnourished

low

Health care workers

body

weight  –

3 minutes

Lecture/ Recitation

Crawford, L. and Romaniuk , S.Global Journal of  Health Science. Toronto.  Apr 2011 2011

Signs and Symptoms d. Enumerate the different Low grade fever  clinical manifestation Cough of two weeks or more (may be of PTB nonproductive or mucopurulent sputum patients may be expectorated)

2 minutes

Lecture/ Recitation

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Loss of Appetite

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Significant weight loss

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Night sweats

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Fatigue

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e. Discuss the different diagnostic tests to diagnose PTB

Hemoptysis or recurrent blood-streaked sputum

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Cuevas, et al.Public Health Nursing in the Philippine th s.10 edition

Chest or back pains not referable to any musculoskeletal disorders Body Malaise

Diagnostic Tests Chest X-ray: The most common diagnostic test that leads to the suspicion of infection.  An X-ray will show an abnormality in the mid and lower lung fields such as lesions,

Brunner, et al. Textbook of  MedicalSurgical Nursing. th 12 Edition

10 minutes

Lecture/  Active Discussion

Crawford, L. and Romaniuk , S.Global Journal of  Health

Science. Toronto.  Apr 2011 2011

cavities, scar tissue, and calcium deposits. 

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f. Know the classification of PTB

Sputum testing for acid-fast bacilli is another test that helps confirm a TB diagnosis.

QuantiFERON-TB Gold test: This is a blood test that aids in the diagnosis of TB. The body responds to the presence of the tuberculosis bacteria. By special techniques, the patient's blood is incubated with proteins from TB bacteria. If the bacteria are in the patient, the immune cells in the blood sample respond to these proteins with the production of a substance called interferon-gamma (IFN-gamma). This substance is detected by the test. If  someone had a prior BCG and a positive skin test due to this, the QuantiFERON-TB Gold test will not detect any IFN-gamma.

Classification  

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http://ww w.who.int /tb/labora tory/en/

The Mantoux skin test also known as a tuberculin skin test (TST or PPD test): This test helps identify people infected tuberculosis but who have no with M. tuberculosis but symptoms.

Class 0: no exposure; no infection Class 1: exposure; no evidence of  infection Class 2: latent infection; no disease (PPD

5 minutes

Lecture/  Active Discussion

Brunner, et al. Textbook of  Medical-

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(+), but no clinical evidence of TB) Class 3: disease, clinically active Class 4: disease, not clinically active Class 5: suspected disease; diagnosis pending

g. Discuss the Pharmacological Treatment medical management The goal of treatment is to cure the infection with drugs that fight the TB bacteria. Treatment of  for patients with PTB active pulmonary TB will always involve a combination of many drugs. All of the drugs are continued until lab tests show which medicines work best.

Directly Observed Treatment-Short course (DOTS) is central to TB prevention and treatment, and it involves having TB patients travel to a health care facility to receive their  medications under the supervision of health care personnel that will ensure that medications are taken in the correct order and for the correct duration.  According to the WHO, DOTS consists of  Government five main components: commitment, case detection through qualityassured bacteriology, standardized treatment with supervision and patient support , an

Surgical Nursing. th 12 Edition

10 minutes

Lecture/  Active Discussion

Cuevas, et al.Public Health Nursing in the Philippine th s.10 edition Crawford, L. and Romaniuk , S.Global Journal of  Health Science. Toronto.  Apr 2011 2011

http://ww w.emedic inehealth. com/tube

rculosis/p age6_em .htm

effective drug supply and management system, and a standardized recording and reporting system allowing assessment of treatment (World Health Organization, 2009). The most commonly used drugs include:

h. Be familiar of  the term MDR – MDR –TB TB which stands for Multidrug Resistant Tuberculosis

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Isonizid

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Rifampicin

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Pyrazinamide

MDR-TB is a major public health problem that threatens the success of DOTS, the WHOrecommended treatment approach for detection and cure of TB, as well as global tuberculosis control. Drug resistance arises due to the improper  use of antibiotics in chemotherapy of drugsusceptible TB patients. This improper use is a result of a number of actions, including administration of improper treatment regimens by health-care workers and failure to ensure that patients complete the whole course of treatment. Essentially, drug resistance arises in areas with poor TB control programs. The development of drug-resistant TB is the consequence of  poor adherence to medical

8 minutes

Lecture/  Active Discussion

Crawford, L. and Romaniuk , S.Global Journal of  Health Science. Toronto.  Apr 2011 2011

treatment, inappropriate prescription and irregular availability of medication, poor drug availability, as well as poor medication quality . Resistance develops when bacterial growths susceptible to a medication are suppressed, but the drug-resistant mutants are not eliminated from the patient. Different strains of  Multidrug-Resistant M. Tuberculosis (MDR-TB) are able to evolve due to sequential mutations in target genes, and these resistant bacilli can subsequently be transmitted to other people. These resistant strains can withstand the most-effective and first line antiTB drugs. The treatment of MDR-TB requires more expensive second-line drugs which have more side effects (World Health Organization, 2009). The second-line anti-TB drugs that are available for approved programs are: 

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kanamycin, powder for injection  – 1 gram vial capreomycin, powder for injection – injection – 1 gram vial cycloserin, 250 mg capsule

http://ww w.who.int /tb/challe nges/mdr  /greenlig htcommitt ee/faq6_  secondlin e_drugs/ en/index. html

i. Identify the different nursing management for PTB patients and prevention of  transmission

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ethionamide, 250 mg tablet

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protionamide, 250 mg tablet

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levofloxacin, 250 and 500 mg tablet

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ofloxacin, 200 mg tablet

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PASER, 4 gram granule sachet

Nursing Management 

10 minutes

Promoting Airway Clearance 

Increase oral fluid intake within cardiac tolerance to promote systemic hydration and to serve as an effective expectorant

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Place patient in an a high fowler’s position to promote lung expansion, thus, reducing the work needed for  breathing

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Perform back tapping and vibrations

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Provide nebulization

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Administer prescribed medications to aid in loosening mucus secretions

oxygenation

and

Lecture/  Active Discussion

Brunner, et al. Textbook of  MedicalSurgical Nursing. th 12 Edition

for easy expectoration  Encourage and provide rest periods so

the tuberculosis energy to breathe 

patient

can

have

Advocating Adherence to Treatment Regimen 

Teach the patient that Tuberculosis is a communicable disease

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Inform him that the most effective means of preventing transmission

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Reinforce patient to complete the course of treatment by not skipping or stopping the drug

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Instruct patient to take the medication either on an empty stomach or at least 1 hour before meals since food can interfere with the medication absorption. However, if he complained of gastrointestinal upset, give drugs with food

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Communicate therapeutically

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Introduce to the patient that there are programs by the government that could help them in complying to the treatment regimen such as the

department of health promoting Directly Observe Treatment-Short course (DOTS) and improve his access to this services 

Teach the patient about the importance of taking all prescribed medications because the bacteria that causes TB grows slowly and requires a long time to be eliminated

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Tell patient that if he could not comply with his medications especially if it is not strictly and continuously followed, it will exacerbate making it more difficult to kill the causative agent, thus, drug resistance will occur; more expensive second line of drugs and results to higher bills during long stay in the hospital

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May conduct home visits if not admitted for continuous treatment

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Monitor for the side effects and adverse reactions of the anti-TB medicine

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Monitor liver enzymes, Blood Urea Nitrogen, and serum Creatinine

levels to detect changes in liver and kidney function 

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Sputum culture results are monitored for acid-fast bacilli to evaluate the effectiveness of the treatment regimen

Promoting activity and adequate nutrition 

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Plan and perform a progressive activity schedule that focuses on increasing activity tolerance and muscle strength such as ambulation, range of motion exercises, daily routine such as bathing,toileting, and other self-care activities Assess patient with his willingness to eat that may be altered by fatigue from excessive coughing and chest pain Explain the importance of a nutritious diet including fruits and vegetables for proper nutrition to improve his nutritional status and aid in fighting off infection for the body to heal Monitor patient’s weight for  improvement or maintenance Give small, frequent meals and

administer vitamin supplements to meet basic caloric requirements  Preventing spreading of Tuberculosis Infection  Teach the patient about importance of hygiene measures, including mouth care, covering the mouth and nose when coughing or sneezing by a tissue, proper disposal of waste materials used into a closed plastic bag, and handwashing  The disease must be reported to a health department so that people who have been in contact with the affected patient during infectious stage could undergo screening and possible treatment, if indicated  j. Remember  selfprotection at all times

Reminders for Health Care Providers 

Compliance with universal precautions, hand washing, vaccination and appropriate isolation can markedly reduce the transmission of occupationally acquired infections.  Even the simple routine of regular hand washing can reduce the risk of acquiring or  transmitting infections.  Vaccination should be, and generally is,

5 minutes

Lecture/ Discussion

Brunner, et al. Textbook of  MedicalSurgical Nursing. th 12 Edition

provided to all health workers but, despite its availability, compliance is low. BCG vaccination against TB is recommended by some institutions, although its overall protective effect in preventing TB is only 51%. However, regular 6 to 12 monthly Mantoux testing should be encouraged for  all health care workers.  The adoption of universal precautions is a logical and generally applicable method of  reducing the transmission of occupationally acquired infections. Use of protective clothing such as gowns, masks, goggles and gloves all help to reduce contamination by body secretions from patients.  Health authorities should have protocols for  the management of patients who pose a high risk of infection, the treatment of  personnel who sustain exposure to contaminated material, and insurance for  staff who acquire work-related infections.  Health professionals must realize that failure to comply with these strategies can mean that it is not only their livelihood which is being put at risk, but their life as well.