Case Studies in Tuberculosis: Training in Nurse Case Management

Introduction Dear Healthcare Professional, Prior to reviewing the content of this book, it is highly recommended that you complete the Centers for Disease Control and Prevention (CDC) Self-Study Modules on Tubercul ...

Introduction Dear Healthcare Professional, Prior to reviewing the content of this book, it is highly recommended that you complete the Centers for Disease Control and Prevention (CDC) Self-Study Modules on Tuberculosis (TB). The modules contain basic information regarding transmission, pathogenesis, epidemiology, testing, infection control, managing adherence, patient rights, contact investigations, and outbreak detections. You can access the modules at https://www.cdc.gov/tb/education/ssmodules/default.htm. Seldom does patient-care follow the relatively straight-forward path outlined in the CDC Self-Study Modules on TB. Due to this, the case studies in this book are designed to provide guidance and relevant reference material to gain insight into challenges faced in TB case management. Patients will often have multiple barriers to an accurate diagnosis and completion of their therapy, and thus public helath nurses must develop skills in problem-solving to successfully treat and care for a patient with TB infection or TB disease. The studies in this new book are continue to be based on real-life experiences of TB nurses in the Heartland region and beyond. They are still designed to illustrate key concepts in TB prevention and care and can still be used to train new nurses and other healthcare providers who are inexperienced in TB nurse case management. Each of the case studies presented in this book are created to be independent of one another, and therefore, you may choose to read them sequentially or in any order you desire. This collection of nursing case studies and their accompanying tools are intended to complement a TB programs’s education and training of its nursing staff. It can be incorporated into new employee introduction and training on TB nurse case management or as an individual learning tool. It is our hope that these case studies will help the current and future generations of healthcare providers to hone their skills and enhance their knowledge within TB nurse case management for years to come. The work that healthcare professionals do on a day-to-day basis is undeniably important and affects an immeasurable number of individuals and organizations. On behalf of all those whom you will encounter in the coming years, we thank you for your time, your continued dedication to learning and self-improvement, and for allowing us to become a part of your journey. Acknowledgments Heartland would like to acknowledge Diana Fortune, RN, Nurse Consultant, National Tuberculosis Controllers Association; Nisha Ahamed, MPH, Training Consultant; and the Heartland National TB Center Staff for their support and assistance in bringing this manual to print. A special thank you to all of our reviewers: Rocio Agraz-Lara, MSN, RN, PHN – San Francisco Department of Public Health; Kristin Bertrang, RN, MSN - Nebraska Department of Health and Human Services; Melissa Davis, BSN, MS, RN – Texas Department of State Health Services, Region 11; Veronica “Ronnie” Dominguez, RN, BSN; Lori Eitelbach, BSN, RN – Williamson County and Cities Health District; Delvina “Mimi” Ford, BSN, RN, CIC, CCRN -KGCPH; and Elizabeth Foy, MSN, RN – Texas Department of State Health Services. Table of Contents Case Study 1 Airborne Infection Isolation (AII). ...................................................................................... 9 Participants will learn about the four (4) elements of the nursing process, the sputum collection process, and to describe the criteria for initating/discontinuing use of an AII room in a home and hospital setting. Case Study 2 ContactInvestigation. ............................................................................................................. 19 Participants will learn to describe the conteact investigation process, list factors that are associated with potential transmission of tuberculosis, calculate the infectious period for a person with tuberculosis, and strategies/approaches towards conducting a tuberculosis interview. Case Study 3 TB Infection with Adverse Drug Reaction. ...................................................................... 31 Participants will learn about the persons who are at high risk for exposure to tuberculosis, the current methods for diagnosing latent TB infection, treatment of patients with latent tuberculosis infection, and potential adverse reactions and responses to medications used for latent tuberculosis infection. Case Study 4 TB Treatment in Patient at Risk for Hepatoxicity ........................................................ 41 Participants will learn to list the factors that increase a patient’s risk of hepatotoxicity while undergoing tuberculosis treatment, identify the signs and symptoms of hepatotoxicity and describe the monitoring process for patients at an increased risk of or currently experiencing hepatotoxicity. Case Study 5 Delayed Treatment Response ............................................................................................... 51 Participants will learn to identify indicators of a delayed response to tuberculosis treatment, list potential causes for a delayed treatment response, and outline patient-centered care approaches for improving treatment adherence. Case Study 6 Culture Negative Tuberculosis............................................................................................. 63 Participants will learn to define diagnostic criteria for the diagnosis of culture negative tuberculosis, identify the components of treatment adequacy, discuss challenges in determining the infectiousness of a patient, and list components of patient education regarding culture negative tuberculosis. Table of Contents Case Study 7 PediatricTuberculosis............................................................................................................ 71 Participants will learn about the tests used to diagnose latent tuberculosis infection in children, the process in which to diagnose tuberculosis infection in children, the treatment regimens for both latent tuberculosis infection and active tuberculosis disease for children, and methods to facilitate ingestion of tuberculosis medications. Case Study 8 Patient with Multi-Drug Resistant TB. ............................................................................ 81 Participants will learn about the challenges of drug-resistant tuberculosis, such as: the risk factors, the latest methods of laboratory diagnostics, baseline tests needed to start treatment, and the importance of the monitoring process throughout treatment. Case Study 9 Cutaneous Drug Reaction. .................................................................................................... 95 Participants will learn to identify the characteristics of a true drug rash, prioritize and then implement nursing interventions when a drug rash occurs, recognize when to implement a drug re-challenge, and evaluate interventions and outcomes. Acronyms and Abbreviations AFB acid-fast bacilli AII ALT airborne infection isolation Alanine Aminotransferase AST ATS Asparate Aminotransferase American Thoracic Society BCG BDQ Bacillus Calmette–Guérin bedaquiline CDC CXR Centers for Disease Control and Prevention chest x-ray DOT DST directly observed therapy drug susceptibility testing ED eDOT emergency department electronic directly observed therapy EKG EMB electrocardiogram ethambutol ER ESL emergency room English as a second language ETA HCV ethionamide hepatitis C HIV HNTC human immunodeficiency virus Heartland National Tuberculosis Center ID IGRA infectious disease interferon gamma release assay INH LFTs isoniazid liver function tests LHD local health department LTBI latent TB infection LZD linezolid M. tuberculosis Mycobacterium tuberculosis MDR-TB NAAT multi-drug resistant tuberculosis nucleic acid amplification test OTC PA over-the-counter posteroanterior PCP PHN primary care provider public health nurse PN peripheral neuropathy PZA QFT rifampin pyrazinamide QuantiFERON®-TB Gold in Tube RIF RIPE tuberculosis regimen: rifampin, isoniazid, pyrazinamide, ethambutol RPT RR rifapentine rifampin-resistant SAT SRO self-administered therapy single room occupancy TB TDM tuberculosis therapeutic drug monitoring TdP TNF-α Torsades de Pointes tumor necrosis factor-alpha T-SPOT® TST T-SPOT.TB® test tuberculin skin test VA vDOT Veterans Affairs video directly observed therapy Xpert® Cepheid GeneXpert®