TB Nurse Case Management San Antonio, Texas

Transcription

1 TB Nurse Case Management San Antonio, Texas April 1 3, 2014 Practicum: Monitoring Side Effects & Identifying Toxicities Dawn Farrell, BSN., RN. Texas Center for Infectious Disease Nurse Educator / Training Coordinator April 1, 2014 Dawn Farrell, RN, BSN has the following disclosures to make: No conflict of interests No relevant financial relationships with any commercial companies pertaining to this educational activity. 1

2 Objectives List and discuss monitoring tools used for managing the patient on anti-tb medications Demonstrate various screening methods for monitoring the patient on anti-tb therapy Baseline Monitoring I. All Patients Measure aminotransferases(i.e. AST, ALT) bilirubin, alkaline phosphatase, serum creatinine, and platelet count II. Patients at Risk for Hepatitis B or C serologic tests III. Patients taking EMB Test visual acuity(snellen Chart) Color vision (Ishihara) IV. HIV-infected patients CD4 and lymphocyte count 2

3 Monitoring During Treatment I. All patients daily at the beginning of therapy and then monthly Identify possible adverse reactions to medications Assess adherence II. Patients on EMB Question monthly regarding visual disturbances Repeat monthly testing for visual acuity and color vision for patients whose EMB dose exceeds 15-20mg/kg and have been receiving for >2months III. Patients with abnormal baseline results monitor liver, renal or platelet count. Measure early in the course of treatment to ensure conditions do not worsen Monitoring Tools Heartland National TB Center- Drug-O-gram Texas Center for Infectious Disease(TCID)-Hearing/Vision report TCID-Vestibular Testing Report Texas Department of State Health Services(DSHS)- Directly Observed therapy Log DSHS Clinical Assessment for Tuberculosis Disease Medications Toxicity DSHS Vision/Hearing Screening Form 3

4 Case Question Andrew is a 35 year old patient being treated with first-line anti-tb drugs. He has no abnormalities at baseline and no clinical problems. Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. Case Question Andrew is a 35 year old patient being treated with first-line anti-tb drugs. He has no abnormalities at baseline and no clinical problems. Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. 4

5 Case Question Edward had stable abnormalities of hepatic function at baseline Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. Case Question Edward had stable abnormalities of hepatic function at baseline Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. 5

6 Case Question Karen has been on first-line anti-tb drugs that include ethambutol for greater that 2 months Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. Case Question Karen has been on first-line anti-tb drugs that include ethambutol for greater that 2 months Should you: A. Repeat measurements early in the course of treatment, then less frequently to ensure that condition does not worsen. B. Repeat visual acuity and color vision. C. Not necessary to monitor liver or renal function or platelet count. 6

7 Vision Screening Ishihara Testing Snellen Eye Exan Ishihara Test Things you will need: Ishihara s Tests for Colour Deficiency 24 Plate Edition Well lit room(natural day light is preferred) Comfortable chair for patient Quiet room 7

8 Ishihara Test Plates Test is designed to give a quick and accurate assessment of color vision Plates are designed to be used most effectively in a room with adequate daylight Plates are held 75 cm from the patient(approx. arm length) Tilt the plate so it is at right angle to the patients line of vision Plates are numbered; plates 1-17 should be answered within 3 seconds, plates are winding lines and are traced between the 2 X s with a finger. This should be completed within 10 seconds. It isn t necessary to use all the series of plates. Follow the vision/hearing screening form for the list of plates. Ishihara Test Ishihara Test What numbers do you see revealed in the patterns of dots below? About percent (depending on whose figures you want to believe) of the white, male population ( figures for other racial profiles aren t available) and a tiny fraction of the female population are color blind. Most of the circles below are nothing but spots. Below are the correct answers to what a person with normal color vision would see - and what color blind people would see (and most people with Red-Green color blindness). With red-green color blindness, this is something a relatively large portion of the population lives with on a daily basis. The full Ishihara test consists of a set of 38 plates and tests in-depth for color blindness. The plates here are a small representative sample of the whole, but will help spot the most common forms of colorblindness. Depending on the color balancing of the monitor, the tests may be somewhat more or less effective (e.g. if the monitor is not rendering the proper colors). Results For Ishihara Test(below) Normal Color Vision Red-Green Color Blind Left Right Left Right Top Top 25 Spots Middle Middle Spots 56 Bottom 6 8 Bottom Spots Spots Copyright by Frank Dutton / Toledo-Bend.Com, Many, LA All rights reserved 8

9 Ishihara Test Ishihara Plate Examples 9

10 Snellen Eye Test Things you will need: Snellen eye chart Well lit room Index card/or eye cover Tape to mark floor Ensure the room is well lit(best to use over head lights) Limit the amount of movement in room Use DSHS form for Vision/Hearing or TCID Hearing/Vision Report How to Administer Snellen Eye Test Place the Snellen Chart on a wall with at least 20 feet of clear space looking on to it Measure 20 feet from the wall to where the chart is placed an mark a line on the floor for the patient to stand on Have patient stand on marked line Have the patient cover one eye with an eye cover Have the patient read the letters aloud If patient misses only ONE letter have them continue reading the next line Record the last line the patient reads accurately Note the visual acuity measures marked at the end of each row of letters Ask the patient to repeat the process with the other eye Then repeat with both eyes Each time record the last line patient reads Record the visual acuity for each eye and with both eyes uncovered 10

11 Examples of Snellen Charts Snellen Eye Charts Vestibular Testing Hearing Testing 11

12 Vestibular Testing Vestibular tests are tests of function. The purpose is to determine if there is something wrong with the vestibular portion of the inner ear. Hearing pathway tests(i.e. audiometry) can also be used for the same purpose To detect central disorders(i.e. internuclear opthalmoplegia, a central eye movement disorder) To decide if more expensive tests like MRI are needed To document side effects of medications such as dizziness or vertigo Vestibular Testing Protocol(1) Use the TCID Vestibular testing Report Questions:(Get details and record positive answers) a. How is your hearing? Ears feel full, stuffy? b. Are you weak? c. Are you nauseated?( none, sometimes, all the time) Balance a. Observe for normal balance, teetering and/or falling Walking a. Observe for normal gait, weaving and/or staggering 12

13 Vestibular Testing Protocol (2) Past pointing a. Patient sits facing you, with his/her eyes closed b. Have him/her point their fingers, then place your fingers below theirs c. Hold your position, ask patient to raise both hands and return fingers to yours d. Deviation right or left from target fingers-past pointing Lateral Nystagmus a. Patient sits on exam table 30 seconds b. Lies down, look for nystagmus(jerking of eyeballs side to side) c. Log roll patient to one side, wait 30 seconds, look for nystagmus d. Repeat on the other side Vestibular Testing Protocol (3) Romberg a. Patient stands with feet together b. Encircle the patient with your arms, but do not touch c. Tell the patient I will not let you fall d. Have the patient close their eyes e. Falling-Romberg sign Heel to Toe Walking a. Stand beside standing patient b. Demonstrate walking heel to toe c. Do it together(be prepared to catch patient) d. Observe for jerkiness, falling and/or excess swaying e. (a small degree of hesitancy is acceptable) 13

14 The Audiometer Test Audiometer Test An audiometer consists of four parts. These parts are the oscillator (used to change the frequency of sounds heard), an audio amplifier, an attenuator (used to control volume loudness), and a pair of headphones. The person being tested wears the headphones. The amplitude of a tone is slowly increased until the person hears the sound. The lowest decibel level at which a sound is heard is called the threshold. The oscillator is used to change pitch so a range of sounds can be tested. When manufacturing audiometers and performing audiometer testing, care is taken to eliminate background noise. The result of a hearing test using an audiometer is called an audiogram. The audiogram is a graph that shows the lowest decibel level at which each frequency is heard. The graph gives a profile of the person's threshold of hearing. It compares the profile to a line representing normal hearing in order to detect hearing loss. Using the audiometer, frequency is varied from 64 hertz to over 8,000 hertz. Amplitude can be varied in five decibel increments. In addition to pure tones, speech sounds are sometimes used as test signals. Hearing is considered good if every tone sounded between 64 and 8,192 hertz is heard at a volume of 20 decibels. Hearing loss is generally greatest at the high frequencies. This seems to occur in many people over fifty. Read more: Hearing Test Use DSHS Vision/Hearing Screen form-hearing Sweep Check section Or TCID Hearing/Vision Report-Decibels section To provide the Audiometer screening test nurses should have completed the audiometer training course and have a current certification 14

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