TB Nurse Assessment Ginny Dowell, RN, BSN October 21, 2015 Comprehensive Care of Patients with Tuberculosis and Their Contacts October 19-22, 2015 Wichita, KS EXCELLENCE EXPERTISE INNOVATION 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
ObjectivesObjectives Objectives Elements of a TB Nursing Assessment Gathering information & Collecting Data TB History Medical History Psychosocial History Environmental Assessment Getting Started Hospital Clinic Walk-in Contact Investigation 2
Verify and Confirm TB infection or TB disease? Suspect or Confirmed? Demographic information? Language barrier? Current Treatment initiated? Right drugs Right Dosages Base line screening completed- CXR, Blood work, HIV, eye screen 3
Information to Ask For Screening tests- TST or IGRA Radiology Reports- Past and Present Sputum or Specimen reports: AFB and Pathology Pt medical Hx Hospital and/or Clinic, H&P, Consults, Admission & Discharge notes Blood Work CBC, Chem Profile, HIV Patients: HT, Weight and BMI 4
Review, Process and Organize the Information Do you need to verify/clarify information with provider before talking to patient? What questions do you have to ask the patient when you see him? Look for Co-Morbidities Chronic Health DX Diabetes-Type I or II Renal Problem-dialysis ESRD Hepatitis A,B,C HIV Lung Diseases COPD Nutritional status Mental Health dx- Substance abuse, Personality disorders, Depression 5
Past Treatment for LTBI If patient has a prior treatment of TB Disease or LTBI Determine When, Where, How Long, Sensitivities of MTB Determine Drugs Used to treat: Isoniazid, Rifampin, Other Drug Combinations Compliance Known Exposure Contact to a Known TB Case Foreign Travel Nurse Assessment 6
Initial Interview Interviews should be conducted <1 business day of reporting an infectious person Interviews should be conducted <3 business days for all others Face to Face Interview is Preferred It provides the opportunity to initiate and develop your relationship. Physically viewing the patient helps determine the degree of illness. Home visits VS Hospital visits Vs Clinic visits Vs Telephone Interviews 7
Infectiousness Patients should be considered infectious if they Are coughing Have sputum smears positive for AFB and they Are not receiving treatment Have just started therapy, or Have a poor clinical response to therapy Infectiousness Directly related to the number of tubercle bacilli a TB patient expels in the air The number of tubercle bacilli expelled by the TB patient depends on the following: Cough Presence of Cavities Positive smear/culture Site of disease Cough etiquette Treatment Cough Inducing Procedures 8
Respiratory Protection for Healthcare Workers Surgical masks are inadequate for filtering out TB bacteria. N95 NIOSH-certified respirators should be properly fitted and worn to filter out infectious particles in the air Infectiousness To be considered non-infectious, the patient must meet the following criteria: Are on adequate therapy Have had a significant response to therapy, and Have 3 consecutive negative sputum smears 9
Setting the Stage Environment: Quiet and Private. Inside or outside? Respect for culture and language. Get His/Her Story Learn how the patient feels about his/her diagnosis. Learn from the patient how the diagnosis happened. What has the patient been told about his treatment? Teach him your role is: Provide Medication on Daily basis Monitor patient for side effects and provide non medical recommendations Refer patient to appropriate medical provider if side effects present Refer patient to services to assist patient with coping and adjustments Act as the patient advocate Educate Patient, Family and community 10
Lots of information to get from patient Lots of education to provide to patient A lot to process! Watch the time. Set Priorities. Don t overwhelm patient. 11
Clarify TB Symptoms Dates and Symptom Descriptions Pulmonary Cough SOB Chest Pain Hemoptysis Hoarseness Extra pulmonary Enlarged Lymph nodes Bone Pain Blood in Urine Headache Decreased LOC 12
Systemic Symptoms Fever, Chills Night Sweats Anorexia Fatigue Weight loss History of Signs and Symptoms Most patients will have difficulty remembering when symptoms began Assist patients by referring back to important dates and times Christmas, Thanksgiving, Birthday, Birth of a Baby These cues may prompt patient memory and give us more accurate dates as when symptoms began. This is important in determining the infectious period and conducting the contact investigation. 13
Document All Current Symptoms Your Documentation will be used as a clinical monitoring guide: Improvement of cough? Resolving Fever and Night Sweats? Increased Appetite? Increased Energy activity? INCREASE WEIGHT weekly/ monthly? Diabetes, Kidney Disease, HIV and Liver Disease Identify and clarify with patient his chronic Health conditions. 14
Diabetes Complications Diabetic Neuropathy complicates therapy due to possible INH neuropathy: Baseline assessment of peripheral neuropathynumbness, tingling, temperature, pain. Vitamin B 6 (pyridoxine) is needed for diabetics on INH Diabetic Retinopathy complicates therapy due to Ethambutol related visual changes: Baseline assessment of vision-acuity(snellen) and color discrimination(ishihara) Followed by monthly assessment of vision Renal Disease Determine if Patient has CKD or ESRD? Abnormal BUN, Creatinine, Creatinine clearance, GFR Dialysis schedule Take medications after dialysis Ethambutol/PZA requires dose adjustment 15
HIV Assess Pt risk factors for HIV and date last screened for HIV Patients taking PI s for HIV could require adjustment in TB or HIV therapy Rifabutin could be a substituted for Rifampin CYP450 - Can be inhibitor or inducer of medication metabolism in the liver Find out what his CD4 count Liver Disease Liver disease complicates TB treatment- INH, Rif and PZA are metabolized by the liver Review the baseline blood work. AST,ALT ALK Phos, T. Bili Monthly or more frequent monitoring of lab work may be needed based on the severity of liver disease Medications adjustments may be necessary. Educate pt : s/s of hepatitis Fatigue, Loss of appetite, mild fever, Muscle/joint aches, abdominal pain, N/V, dark urine, light coloured stools, jaundice. 16
Take a Medication History Prescribed Antibiotics Antiretrovirals HIV meds Cardiovascular/Hematological Central Nervous System Musculoskeletal Respiratory Gastrointesetinal Hormonal- Birth Control OTC Tylenol, ASA, Ibuprofen, Naproxen Herbs Vitamins Fish Oil Cultural medications Nutritional Assessment What is his weight loss? Check Albumin and Total Protein lab values? 17
Psycho Social History Occupation work history Education Family support, involvement with pt Significant Other and Friends Community involvement Source of income Spiritual influence Psychological Mental Health diagnosis Personality Disorders Developmental Disorders Substance Abuse-Alcohol /Drug Abuse Depression Coping Skills 18
Document Behavioral Characteristics Alertness Attentiveness Facial Expression Eye Contact Appearance Speech Mood and Affect 19
Environmental Evaluation Home evaluation essential to determine resources available to Patient Living situation home/apartmenthomeless # of adults, # of Children Food availability Culturally Influences Transportation All contacts identified? Visitors? Educate, Reeducate and then Educate AGAIN 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 20
Daily- Weekly Monthly Assessments 1st 2 weeks daily evaluations of pt including- S/S, medication tolerance, Education and Pt Concerns. Wts weekly if indicated, at minimum monthly. Use growth charts and logs. Monthly symptom reviews/medication tolerance. Daily/Monthly Patient concerns Document clinic blood draws, cxrs, and clinic visits. Get reports, clinic notes and review. Review with pt. Documentation 21
SOAP Charting Subjective Objective Assessment Plan Intervention Reevaluate. Summary Obtain a thorough medical history and obtain pertinent hospital records to assist in developing a treatment plan tailored to the patient Identification of co-morbid conditions is essential in developing a plan of care because co-morbid conditions can hinder TB treatment Assessment is ongoing and dynamic and should be continuous throughout the course of the patient s treatment 22
Questions Thank you! Thank You. 23
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. Mental Health Assessment Tool. January 31, 2013. Heartland National TB Center. 24