Introduction to TB Nurse Case Management Online February 4, 11, 18 and 25, 2015 Initiation Phase Part 1 Ginny Dowell, RN, BSN February 4, 2015 Ginny Dowell 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
Developing a Patient Care Plan Objectives Description of treatment regimen Methods of monitoring for adverse reactions Methods for evaluating treatment response Methods of assessing and ensuring adherence to treatment Goals of TB Treatment Cure Patient, with minimal risk of death/disability Provide safest, most effective therapy in shortest time. Prevent further transmission to others 2
American Thoracic Society, CDC, and Infectious Diseases Society of America The Responsibility for successful treatment is clearly assigned to the public health program or private provider, not to the patient. It is strongly recommended that the initial treatment strategy utilize patient-centered case management with an adherence plan that emphasizes direct observation of therapy. Developing a Patient Care Plan PATIENT VISIT Home/Hospital Visit Sign consents for treatment and medical information release forms Obtain complete medical/social history, including signs, symptoms & duration of symptoms of TB disease Obtain complete medication HIV, diabetes, hepatitis, kidney disease Obtain evaluations by Primary Care providers, hospitalization records, and clinic notes. Nutritional assessment(including weight, BMI) Begin contact investigation-evaluate pt infectiousness and estimate infectious period 3
Evaluating/Monitoring Treatment Initial Baseline screenings: Chest x-ray Sputum collection x3 for smear and culture Blood work CBC, Metabolic Profile, HIV, Hepatitis screen Weight- BMI Vision (Snellen and Ishihara Plates) Before Starting Medications Patient age, weight, medical conditions(chronic and acute) Current medications- Potential interactions. Review baseline blood work and address any abnormalities with PCP Pt perception of his treatment and what the medications are being given for. Social habits drug use. Pt support system. 4
Developing Patient Plan of Care MMWR Tx of TB 2003 American Thoracic Society, CDC, and Infectious Disease Society of America-- Recommendations 4 drug regimen RIPE INH- Isoniazid Rif Rifampin PZA Pyrazinamide ETH - Ethambutol B6-pyrixidine Doses bases on weight and age of patient Brief explanation of TB Disease TX for Pan Sensitive Initial Phase 8 weeks or 56 doses or 40 DOT doses INH Rif PZA Eth RIPE Continuation Phase 18 31 weeks, 128 or 90 DOT doses 217or 156 DOT doses INH Rif Length of Continuation phase is contingent on the sputum culture results at 8 weeks. 5
Monitoring for adverse affects and Ensuring Adherence to Treatment DOT 1. Provides visual observation of patient tolerance of medication. 2. Provides visual evaluation/observation of pt response to treatment cough, fever, affect 3. Provides daily opportunity for patient education. Tools used to Monitor Pt for Adverse Effects and Pt Response to Treatment Logs/graphs and charts provide staff with pt status at a glance Sputum and wt logs, children growth charts. Medication Administration Records-MAR. 6
Sputum Log 7
Daily- Weekly Monthly Initial evaluation should include how the patient tolerates taking the medication. What his symptoms are and if they are improving Appetite Affect mental status Wt Monitor for Adverse Reactions Potentially Serious Immediately report the following to MD Jaundice Dark Urine Vomiting Abdominal Pain Fever Visual Changes Marked clinical rash Less Severe Report the following to MD Anorexia Nausea Malaise Peripheral neuropathy: tingling or burning sensations in hands or feet Rashes 8
Medication Side effects GI Upset Common early in tx Timing of medication administration Encourage Food intake before medications Rash Consult PCP Location Generalized, Isolated Rash Petechial Rash Erythematous Rash Hepatitis Symptoms Most Serious Common Side Effect Loss of appetite for prolonged period Tiredness- Weakness Moderate Stomach Pain, Nausea and Vomiting Jaundice yellow skin, eyes and dark urine 9
Monitoring for adherence IF Culture positive at two months of therapy Hiding pills under tongue Not releasing pills from the hand to the mouth Keeping pills in the bottle, not pouring into hand Spitting pills back into opaque drinking cup Feigning a cough Intentional vomiting when out of sight of nurse Going to another room to take pills Self administered therapy Unreported Diarrhea Poor absorption Develop Patient Care Plan PATIENT EDUCATION Do not forget that patient education is an ongoing process Use written materials Culture sensitive education Identify what are his/her priorities work? money? family? New support groups on line Facebook and TB Voices 10
References American Thoracic Society, Center for Disease Control and Prevention, Infectious Diseases Society of America Treatment of tuberculosis. MMWR 2003. Tuberculosis Nursing: A Comprehensive Guide to Patient Care, 2 nd Edition, v. 06/13/11. 11