Tuberculosis Pathology and Assessment

Tuberculosis (TB) is a bacterial infection that resides inside the lungs caused by Mycobacterium tuberculosis. While books and nursing lectures would insist that tuberculosis is a droplet precaution, the Centers for Disease Control (CDC) and Prevention would say otherwise.

According to the CDC, tuberculosis is an airborne precaution that can spread by breathing in the same air that an infected person breathes in, especially when the person coughs, sneezes, laughs, sings, and even speaks.

Airborne Diseases

Airborne diseases can be categorized with MTV, which can be translated as:

  • MMR (measles, mumps, and rubella)
  • Tuberculosis
  • Varicella (chicken pox)

Varicella and mumps are also under the category of contact precautions. Take note that MTV diseases are required to be placed inside a negative pressure room so that air is taken out, minimizing the risk of spreading the diseases.

Breathing In the Same Air

Regarding pathology, what happens when you breathe in the same air as someone who has tuberculosis? This scary occurrence can happen especially when you’re in a crowded place or a small space. Breathing in the same air as with someone who has tuberculosis can put you at risk of having the disease.

Airborne precautions are mandatory for nurses who are caring for tuberculosis clients. Instead of the usual surgical mask, healthcare providers in charge of clients with tuberculosis wear N95 masks. N95 masks help in preventing inhalation of outside air.

Pathology

As the bacteria goes inside the lungs, it spreads through the lymphatic system and into the bloodstream. Once the body’s immune system is alerted, the B cells will create antibodies against the infection and the T cells, which are the natural born killers, will attack the tuberculosis bacteria. The macrophages will then make a perimeter to quarantine the bacteria and cease reproduction and growth inside the lungs.

Unfortunately, the T cells cannot kill the bacteria; the best thing that they can do is to isolate the bacteria so it cannot spread out. It’s like putting the bacteria inside the prison. Captive bacteria are now called granulomas.

Assessing Tuberculosis

When a client comes into the ER, they usually are not aware that they have TB. Therefore, there are a couple of ways to assess if this client has tuberculosis.

  1. A blood-tinged cough

A blood-tinged cough related to tuberculosis usually comes out in NCLEX® . Hemoptysis is the medical term given to coughing up of blood.

  1. Difficulty of breathing

Along with bloody sputum, there would also be the difficulty of breathing or dyspnea and pallor due to the infection and lack of oxygen exchange inside the lungs.

  1. Crackles (rales)

Crackles are sounds that are distinguishingly heard clients are auscultated that are mainly caused by fluid accumulation inside the small airways of the lungs or the alveoli. Crackles can either be coarse or fine. Aside from tuberculosis, crackles can also be heard from clients with CHF, bronchitis, and pneumonia.

Other Lung Sounds

  • Ronchi is snore-like sounds caused by airway secretions and are usually cleared by coughing.
  • Wheezing is like a whistle, mostly manifested by clients with bronchitis, emphysema, and asthma.

These lung issues are usually resolved by bronchodilators and anti-inflammatories.

  1. Anorexia

Loss of appetite can lead to anorexia or weight loss. When a person is sick and is experiencing lack of oxygen, the craving to eat becomes absent. Furthermore, the client gets easily tired or fatigued.

  1. Night Sweats

Night sweats get worse in time, and it’s because of the infection brewing inside the body.

Laboratory Tests

There are a couple of ways to confirm a diagnosis of tuberculosis.

  1. X-ray

Granulomas that show on the x-ray result as small ducts or bumps indicate positive tuberculosis reading from radiology.

  1. Sputum

The sputum test is done first thing in the morning so that the bacteria can brew overnight. This is done for three consecutive days, always upon waking up in the morning.

  1. Skin test

A skin test, also known as a positive protein derivative (PPD) test that shows a raised lump within 48 hours indicates that there is a positive reaction. This means that the T cells and macrophages have effectively surrounded and caused inflammation to the protein injected in the arm.

  1. Increased WBCs

If the tuberculosis infection has spread to other parts of the body, white blood cells will increase more than 10,000.

  1. ESR

Erythrocyte segment rate (ESR), on the other hand, is more specific because this indicates the presence of inflammation, assisting with the diagnosis of tuberculosis.

A negative tuberculosis screening, also known as latent phase, does not necessarily mean that there is absolutely no sign of the bacteria inside the body. To achieve a negative result in a latent stage, the client should have the following outcomes:

  • A negative chest x-ray
  • Negative sputum cultures (done three times)
  • Positive PPD test

A positive, active result will yield the following:

  • Positive chest x-ray
  • Positive sputum test

For our next video, we’ll be discussing the nursing intervention of tuberculosis clients. For other respiratory lectures and nursing-related topics, you can visit our SimpleNursing website and YouTube channel.

Diseases Requiring Airborne and Droplet Precautions

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In this NCLEX®-focused article, we’ll be talking about the different types of illnesses that require airborne and droplet precautions.

We do have tons of videos and articles that are primarily concentrated on topics that usually come out during the NCLEX®, so you check those out. For the meantime, we’ll go over the types of diseases that require airborne and droplet precautions.

Airborne Precautions

To easily remember the conditions requiring airborne precautions, you just have to keep in mind: MTV. MTV stands for that popular channel, Music Television. MTV is a cable channel that’s on air 24/7.

So, that’s your first clue: MTV is on air.

Airborne means that a person can easily get afflicted by merely breathing the same air or being exposed to an infected individual who is in the same vicinity; whether it’s inside a bathroom, a car, or any closed space.

The next clue for you to remember is that MTV stands for:

  • MMR or measles, mumps, rubella
  • Tuberculosis
  • Varicella (chicken pox)

Take note that varicella or chicken pox, mumps, and rubella are also transmitted through contact with people who have the condition.

Droplet Precautions

With droplet precautions, we have another television reference that will help you remember the different diseases involved. The show is called, “Pimp My Ride,” hosted by Xzibit, wherein they repair and customize old, dilapidated vehicles.

Setting the show aside, the word that you have to keep in mind is PIMP. Though this word is a bit inappropriate, when it comes to recalling important nursing topics, conjuring up words or mnemonics that can help you remember, to the point of passing the exam is necessary. Just don’t use this when interacting with clients or with other professionals; this acronym is created for the purpose of effectively remembering the different droplet precautions.

So, PIMP stands for:

  • Pertussis or whooping cough
  • Influenza or the flu
  • Meningitis (bacterial or viral)
  • Pneumonia

Let’s go through these conditions one by one.

Pertussis is also known as whooping cough which is a highly communicable disease that manifests as a deep, seal bark.

Influenza, also known as the flu, is a contagious lung illness, much like getting a common cold but more severe and deadlier. This is also a condition that requires a flu vaccine to prevent progression into H1N1.

Meningitis can either be bacterial or viral. Bacterial meningitis is the worst that one can have because of its highly infectious nature. Meningitis occurs when the meninges inside the brain become inflamed, and the client will complain about a severe headache. Meningitis is diagnosed by acquiring spinal fluid through a spinal tap or a lumbar puncture. The spinal fluid will be sent to the laboratory for testing. For a more comprehensive discussion about meningitis, you can check out our other videos at SimpleNursing.com.

Pneumonia is an airway infection of the deep portions of the lungs and is also considered as the primary killer complication of people who have undergone surgery. This is the condition wherein nurses instruct their post-operative clients to turn, cough, and deep breathe to cause re-expansion of the alveoli and prevent collapse. If the alveoli will collapse, the infection will settle in and cause pneumonia.

A Summary

Airborne infections are those that belong to MTV while droplet infections are categorized as PIMP. MTV is MMR, tuberculosis, and varicella. PIMP is pertussis, influenza, meningitis, and pneumonia.

For other NCLEX®-related topics, please don’t hesitate to check out our YouTube videos and articles at SimpleNursing.com.

NCLEX® Practice Part 3: The Respiratory System

Hello, guys. So, here’s an intensive NCLEX® practice test review where we will be solely discussing the signs and symptoms, diagnostic tests, and nursing management involving the three main respiratory system conditions – lung cancer, tuberculosis (TB), and pulmonary embolism (PE).

Let’s begin.

Signs and Symptoms

First, we will be focusing our discussion on the main signs and symptoms or quick pathophysiology of every illness. We will be pointing out the manifestations that make one condition different from the other.

Scenario: If a client comes into the ER presenting signs and symptoms of respiratory affectation, how would you know what type of lung illness it is? So, this NCLEX® practice is beneficial in ruling out what the client is or is not experiencing.

  1. Lung Cancer

Usually, with lung cancer, there is a tumor that grows in the lungs and spreads up the respiratory tract, affecting the vocal chords, larynx, and pharynx. Therefore, the primary signs and symptoms are the following:

  • Hoarse or raspy voice
  • A cough with bloody sputum
  • Shortness of breath
  • Weight loss
  • Fatigue
  • Effusion – when the lungs start to fill up with pus (needs to be drained)
  1. Tuberculosis

Bacteria that reside inside the lungs cause tuberculosis; its main manifestations are:

  • Dry, purulent cough with blood-tinged sputum (spots of blood)

Note: One of the main signs and symptoms of a TB client is a cough. Unlike lung cancer’s cough which is bloody sputum (like that of the protagonist in Breaking Bad), TB’s cough produces blood-tinged sputum which is speckles of blood.

  • Anorexia
  • Weight loss
  • Night sweats
  1. Pulmonary Embolism

Blood clots in the lungs cause pulmonary embolism; therefore, the signs and symptoms are:

  • Increased respiratory rate
  • Increase heart rate
  • Increased chest pain
  • Decreased blood pressure
  • Jugular vein distention (JVD)

Take note that chest pain in PE is a primary manifestation due to the blood clots inside or outside the alveolar sac. The occlusion prevents oxygen exchange at the capillaries. For this reason, deep breathing causes chest pain because the heart is compensating for the increased respiratory rate.

How do the heart and lung co-mingle in pulmonary embolism?

Basic anatomy. A lot of nursing students fail to recognize how the anatomy of the heart and the lung co-mingles with each other. The right side of the heart is responsible for transporting deoxygenated blood to the lungs for oxygen and carbon dioxide exchange; at the same time, the lungs eliminate carbon dioxide through respiration. After oxygen exchange, oxygenated blood is then transported to the left side of the heart which is the side responsible for pumping blood throughout the body.

If there is a pulmonary embolism, the blockage causes backing up of fluid or blood from the lungs to the right side of the heart causing cor pulmonale or right-sided heart failure. Blood will continuously back up that it will go back to the body; thus, creating bounding pulses and jugular vein distention.

Why is there decreased blood pressure and not an increased blood pressure?

The different aspect of right-sided heart failure when it comes to pulmonary embolism clients is that there is low blood pressure due to inadequate perfusion to the left ventricle. The left ventricle is mainly responsible for pushing out the cardiac output and stroke volume; thus pushing the oxygenated blood out of the heart and into the different parts of the body. Signs and symptoms of right-sided heart failure are also evident in clients with pulmonary embolism.

Note: There might be chances of experiencing chest pain with lung cancer and tuberculosis, but with pulmonary embolism, there is 100% possibility of the client having chest pain.

Diagnostic Tests

To get a medically accurate conclusion, diagnostic tests are required. Here, we will be discussing the different kinds of tests that are specifically ordered for the three lung disorders.

  1. Lung Cancer Test

The different tests for lung cancer are the following:

  • Spit/sputum culture
  • Chest X-ray and CT scan (to locate tumors or masses)
  • Bronchoscopy

Bronchoscopy is divided into “broncho” which refers to the bronchioles of the respiratory tract, and “scopy” which means video or camera recording. A bronchoscopy is a diagnostic tool that is used to check for masses or tumors and is inserted by shoving it down the throat of the client while doing a biopsy. A biopsy is taking a tissue sample from the suspected mass or tumor and is sent to the laboratory for further testing.

As a nurse, there are important things to remember before bronchoscopy:

  • Don’t give clients anything to eat before the procedure (NPO).
  • After the test, wait until the client’s gag reflex has returned before feeding anything.
  1. Tuberculosis Test

As previously mentioned in the quick pathophysiology above, TB is caused by bacteria growth inside the lungs; therefore, the tests involved are:

  • Spit/sputum culture – tests what kind of bacteria is residing inside the lungs (whether it’s TB or not, ruling out the disease)

Note: All it requires is one positive sputum culture for a client to be declared positive TB. Treatment will ensue. On the other hand, it takes three negative sputum cultures for a client to be discharged, cleared for work, and allowed to mingle and be active in the community.

  1. Pulmonary Embolism Test

As previously mentioned, PE is caused by blood clots; therefore the following tests are required:

  • CT scan (to verify the presence of blood clots in the lungs)

Note: If the CT scan shows a positive result, the nursing management would be putting the client under a heparin drip.

  • D-dimer
  • PTT and INR (coagulating factor tests)

Note: PTT and INR tests determine the client’s clotting rates. Risk factors that affect clotting would be anticoagulation therapy, sedentary lifestyle, and smoking.

Nursing Management

Every respiratory problem requires very specific nursing management.

  1. Lung Cancer Management

Once the tumor inside the lung is diagnosed with lung cancer, the following nursing management processes will take place:

  • No smoking (carcinogen) – can worsen the condition
  • No exposure to asbestos
  • No exposure to heavy metal (carcinogen) – leads to toxic lungs causing cancer
  • Chemotherapy, radiation therapy, or surgery

Since there is a cancerous mass inside the lung, the priority is to stop the tumor from spreading to nearby tissues. Therefore, the primary goal is to prevent cancer from growing and eventually eliminate it.

Understanding the Cancer Line of Treatment

So, the first line of treatment is the least invasive, mildest type of therapy which is the chemotherapeutic drugs. It’s NOT surgery; it should be the last line of treatment since it’s the most invasive type of treatment.

It is important to remember that chemotherapy can severely affect the client’s health because it destroys not only the cancer cells but also the normal surrounding tissues. Chemotherapy kills everything in its path, even the white blood cells.

Chemotherapy stops the tumor from growing by destroying the fastest producing cancer cells. Alopecia is a notable side effect.

Side note: For those who are interested in knowing the different types of chemotherapy drugs, head on to SimpleNursing.com and look for the Medical-Surgical tab, scroll down and find the cancer icon.

Radiation therapy would come in second if chemotherapy did not work. Radiation therapy shrinks the tumor.

Lastly, surgery is done if chemotherapy and radiation therapy did not work. Surgery is done by cutting out the tumor. However, this procedure is not done unless necessary.

  1. Tuberculosis Management

Tuberculosis is caused by bacteria that sits inside the lungs and travels all over the body, blood, and even affects the lymph nodes.

Question: How is TB spread?

Answer: TB is spread through the air; therefore, airborne precaution is required. This information is from the Center for Disease Control.

For the longest time, a lot of medical professionals thought that TB is spread through droplets; however, the CDC has stated that TB is an airborne disease which is why clients with TB are put in a negative pressure room. The thing is, TB is spread by airborne droplets, say, for example, you sneeze on a tissue, and someone grabs that tissue, that person can now be infected with TB. For a more elaborate discussion on TB, drop by SimpleNursing.com.

So, what are the different nursing management?

  • Tuberculosis clients will have six to 12 months’ worth of drug therapy, and they are prescribed two to four drugs
  • All of these medications can severely affect the liver; therefore watch out for jaundice.
  • Teach your clients to wear a mask for two to three weeks to have it quarantined and stop the spread of bacteria to other people and in the community.
  1. Pulmonary Embolism Management

Since PE clients have big clots inside the alveolar sacs and the goal is to stabilize the clot, you need to provide the following nursing management:

  • Anticoagulation therapy (Heparin)
  • Clot buster (TPA)

Warfarin (Coumadin) is not given because it is taken orally and the therapeutic range is about two to three days. PE clients need immediate anti-coagulating drugs since their condition is critical due to respiratory distress.

After stabilizing the clots with Heparin, a clot buster is given in the form of TPA. Since TPA is a strong anti-coagulant, the client is at risk for bleeding and can even go into DIC. Therefore, monitoring is necessary. For those who are unaware of what DIC is, there is an entire lecture about that at SimpleNursing.com.

Conclusion

Hopefully, this article has helped you how to think critically about determining the different signs and symptoms, diagnostic tests, nursing management, treatment options, and respiratory complications.

At SimpleNursing.com, we have a lot more discussions like this which focuses on prioritizing and organizing care for your clients depending on their conditions. So go check out our website and become a member to gain unlimited access to intensive lectures like this.

Until the next lecture!