S3 Exam 3

UTI, Pyelonephritis, Glomerulonephritis, Nephrotic Syndrome, Osteomyelitis, Tuberculosis, School-Age Growth & Development, Atrial Fibrillation, Stroke, Seizure, Rheumatoid Arthritis, Lupus, Immunity

Tuberculosis

TB: A highly communicable disease caused by infection with Mycobacterium tuberculosis

• Initial infection: usually in upper lobes of the lung, inflamed local lymph nodes. Once inside the lung, the body encases the TB bacillus with collagen and other cells (granuloma)

• Latent TB: asymptomatic period following initial infection; can last for years of decades; the person is NOT contagious until symptoms occur

• Secondary TB: reactivation of disease in a previously infected person; occurs in older adults and chronic diseases (especially immunosuppressive diseases like HIV)

TB is transmitted when a person with active TB coughs, laughs, sneezes, whistles, or sings, and infected respiratory droplets become airborne and may be inhaled by others

Signs/Symptoms of Tuberculosis

TB has a slow onset, and patients are often unaware of problems until the disease is advanced

• Progressive fatigue

• Lethargy

• Nausea

• Crackles

• Anorexia

• Weight loss

• Low-grade fever

• Night sweats

• Persistent cough

• Mucopurulent discharge, often streaked with blood (hemoptysis)

• Chest tightness

• Dull, aching chest pain

• Shortness of breath

Risk Factors for Tuberculosis

• Being in constant close contact with an infected person

• Having reduced immunity or HIV

• Living in crowded areas (LTC/SNF, prisons, homeless shelters, mental health facilities)

• Homeless adults

• Older age

• IV drug use and/or alcohol abuse

• Lower socioeconomic status

• Being from or spending significant amount of time in less developed countries

• Healthcare occupation

Tuberculin Skin Test (TST; Mantoux test)

TST: A small amount of purified protein derivative (PPD) is placed intradermally in the forearm. The test is “read” 48 – 72 hours after placement. An area of induration (localized swelling with hardness of soft tissue), not just redness/hyperpigmentation, measuring 10 mm or greater indicated exposure to and possible infection with TB. In adults with reduced immunity, induration of 5 mm is a positive results.

• A positive reaction indicates exposure to TB or the presence of inactive (dormant) disease, not active disease

• Ask whether the patient has had the Bacille Calmette-Guérin (BCG) vaccine which contains attenuated tubercle bacilli. Anyone who has received BCG vaccine within 10 years will have a positive skin test.

• A reduced skin reaction or a negative skin test does not rule out TB disease or infection of the very old or anyone who has severely reduced immunity.

• Failure to have a skin response because of reduced immunity when infection is present is called anergy

Other Labs/Diagnostics for Tuberculosis

• TB Gold/T-Spot: Blood test; A positive result means that the person is infected with TB but does not indicate whether the infection is latent or active. Preferred diagnostic for those who have received the BCG vaccine.

• Xpert MTB/RIF Ultra: A blood test that can detect drug-resistant strains of TB

• Sputum Culture: Confirms the diagnosis of active TB (tested 3 times) and used to evaluate treatment effectiveness. Cultures are usually negative after 3 months of effective treatment. (Gold standard)

• Chest X-Ray: Can detect lesions in lungs but does not indicate whether the infection is latent or active. Results show atelectasis, consolidation, cavity/holes, fibrosis/scaring, pleural effusion, and lung infiltrates.

Abnormal Labs with Diagnosis of Tuberculosis

• WBCs: normal or elevated

• Hemoglobin/hematocrit: decreased

• ESR: elevated

• CRP: elevated

• Albumin: decreased

Medication Therapy for Tuberculosis

• Initial Treatment

  • Isoniazid, rifampin, pyrazinamide, ethambutol

  • All given everyday for 8 weeks

• Continuation Treatment

  • Isoniazid and rifampin

  • Both given daily for an additional 18 weeks

• Sputum culture is performed to check for Mycobacterium tuberculosis. If the sputum is positive, isonazid and rifampin is given for an additional 7 months

Selective Anti -TB meds

Isoniazid, pyrazinamide, ethambutol

• Interactions: Phenytoin toxicity (decreased metabolism of phenytoin); Alcohol, Tyramine containing foods (aged wines, aged cheese, liver, sauerkraut, sourdough, beers, soy products, dried or overripe fruits, yeast and yeast extracts, aged/ processed /cured meats)

• Both cause increased risk for hepatotoxicity

• Complications: Hepatotoxicity, peripheral neuropathy (due to vitamin B6 deficiency), hyperglycemic in Diabetes patients

Broad-Spectrum Anti- TB Meds

• Rifampin

• Adverse Effects: Red orange color of bodily Fluids (urine, sweat, saliva, tears), pseudomembranous colitis, hepatotoxicity

• Interactions: Decreased effectiveness of oral contraceptives, warfarin, and HIV meds; Alcohol, other TB meds (increases risk for hepatotoxicity)

Resistant Medication Therapy for Tuberculosis

Multidrug resistant TB

• Bedaquiline

• Side effects can be life- threatening

• Adverse Effect: Prolonged QT waves (dysrhythmias)



Extensively drug-resistant TB

• Delamanid

• FDA approved in 2019

• Adverse Effects: Myelosuppression, prolonged QT waves (dysrhythmias)

Nursing Interventions for Tuberculosis

• Airborne Precautions

  • Private, negative- pressure room that has at least six exchanges of fresh air per minute

  • Keep door shut

  • Restricted visitation

  • Must wear gown, gloves, eye protection, and PAPR or N95 mask before entering the room

• Administer medications exactly as prescribed

  • Take medications on an empty stomach with full glass of water; can be taken with food if GI upset occurs but will decrease effectiveness

  • Avoid alcohol and acetaminophen (can increase risk for hepatotoxicity)

  • Directly observed therapy: patients at risk of noncompliance with meds or with drug-resistant strains; may be done virtually

• Notify provider if experiencing s/s of liver dysfunction (anorexia, nausea, malaise, fatigue, jaundice), pseudomembranous colitis (diarrhea, bloody stools), or peripheral neuropathy (tingling, pins and needles feeling, numbness in hands and feet)

• Provide patient education on preventing transmission to others while infectious and importance of medication adherence

• Sputum specimens every 4 weeks until 3 consecutive negative cultures (patient is no longer infectious after 3 negative cultures)

Osteomyelitis

Osteomyelitis: Infection in bone caused by bacteria (most often), viruses, parasites, or fungi; the infection may be acute or chronic. Can result in loss of function, persistent pain, amputation, or even death due to sepsis.

• Exogenous: Infectious organisms enter from outside the body as in an open fracture or after surgery (wounds, pressure injuries, stab wounds, ulcers, etc.)

• Endogenous: Infectious organisms are carried by the bloodstream from other areas of infection in the body

• Contiguous: Bone infection results from skin infection of adjacent tissues (periodontal infection, foot ulcers)

Acute osteomyelitis: inflammation in the bone in response to microorganisms leads to vascular leakage and edema (surrounding tissues may also be inflamed); pus forms

Chronic osteomyelitis: as infection progresses, pus can infiltrate bone tissue and cause ischemia & necrosis; necrotic bone separates from surrounding bone and its vasculature (sequestrum), so antibiotics can’t reach the diseased tissue (because there are few or no blood vessels); new bone will often lay over diseased or necrotic bone (involucrum), further complicating ability of antibiotics to reach the infected area

Common Pathogens: Staphylococcus aureus, Psuedomonas aeruginosa, Salmonella (Sickle cell patients), E. coli

S/S Acute vs. Chronic Osteomyelitis

Bone pain that worsens with movement

Acute Osteomyelitis

• Fever; temperature usually above 101°F (38.3°C)

• Swelling around the affected area

• Possible erythema/hyperpigmentation and heat in the affected area

• Tenderness of the affected area

• Bone pain that is constant, localized, and pulsating; worsens with movement

Chronic Osteomyelitis

• Foot ulcer(s) or bone surgery (most commonly)

• Sinus tract formation

• Localized pain

• Drainage from the affected area (usually due to bone abscess)

Common Causes of Osteomyelitis

• Acute hematogenous infection: from bacteremia

• UTIs: can spread to lower vertebrae

• Long-term IV catheters (central lines)

• Hemodialysis patients

• IV drug use

• Salmonella infection (food poisoning)

• Poor dental hygiene or periodontal disease

• Diabetic foot ulcers

• Penetrating trauma (animal bites, puncture wounds, skin ulcerations, bone surgery)

Labs/Diagnostics for Osteomyelitis

• WBCs: High

• ESR: Normal to high

• CRP: High

• Blood cultures/wound cultures: To choose best antibiotic for infection

• MRI/CT/X-Ray: To assess extent of infection and areas of bone necrosis

Treatment for Osteomyelitis

• Antibiotics and antimicrobials

  • At least 6 weeks of IV antimicrobial therapy based on Wound C&S results, followed by oral antimicrobial therapy for 4 to 8 weeks

  • carbapenems, cephalosporins, fluoroquinolone, clindamycin, rifampin, trimethoprim-sulfamethoxazole, vancomycin, linezoid

• Pain management

• Nutrition: Increase protein, vitamin A/C, Zinc

• Surgical debridement of necrotic bone tissue

• Wound care

• Hyperbaric oxygen therapy may be used for chronic osteomyelitis: Increases tissue perfusion

• Amputation in severe cases