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TB Nurse Assessment - Heartland National Tuberculosis · PDF fileTB Nurse Assessment Ginny...
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10/23/2015 1 EXCELLENCE EXPERTISE INNOVATION 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 • No conflict of interests • No relevant financial relationships with any commercial companies pertaining to this educational activity Ginny Dowell, RN, BSN has the following disclosures to make:
Transcript of TB Nurse Assessment - Heartland National Tuberculosis · PDF fileTB Nurse Assessment Ginny...
10/23/2015
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EXCELLENCE EXPERTISE INNOVATION
TBNurseAssessment
GinnyDowell,RN,BSNOctober21,2015
Comprehensive Care of Patients with Tuberculosis and Their Contacts
October 19-22, 2015Wichita, KS
• No conflict of interests
• No relevant financial relationships with any commercial companies pertaining to this educational activity
GinnyDowell,RN,BSNhasthefollowingdisclosurestomake:
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ObjectivesObjectivesObjectives 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
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Verify and Confirm
TB infection or TB disease?Suspect or Confirmed?
Demographic information?Language barrier?
Current Treatment initiated?
Right drugsRight Dosages
Base line screening completed-
CXR, Blood work, HIV, eye screen
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Information to Ask For
Screening tests- TST or IGRARadiology 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, HIVPatients: HT, Weight and BMI
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• 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 IIRenal Problem-dialysis ESRDHepatitis – A,B,CHIV Lung Diseases – COPDNutritional status
Mental Health dx-Substance abuse, Personality disorders, Depression
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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
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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 visitsVs
Clinic visitsVs
Telephone Interviews
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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
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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
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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
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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.
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Clarify TB Symptoms Dates and Symptom Descriptions
Pulmonary CoughSOBChest PainHemoptysisHoarseness
Extra pulmonaryEnlarged Lymph nodesBone PainBlood in UrineHeadacheDecreased LOC
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Systemic Symptoms
Fever, ChillsNight SweatsAnorexiaFatigueWeight loss
History of Signs and SymptomsMost 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.
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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.
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Diabetes Complications• Diabetic Neuropathy complicates therapy due
to possible INH neuropathy:– Baseline assessment of peripheral neuropathy-
numbness, 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
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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.
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Take a Medication History
PrescribedAntibioticsAntiretrovirals – HIV medsCardiovascular/HematologicalCentral Nervous SystemMusculoskeletal RespiratoryGastrointesetinalHormonal- Birth Control
OTCTylenol, ASA, Ibuprofen, NaproxenHerbsVitaminsFish Oil Cultural medications
Nutritional Assessment
– What is his weight loss?
– Check Albumin and Total Protein lab
values?
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Psycho Social History
Occupation – work history EducationFamily support, involvement with ptSignificant Other and FriendsCommunity involvement Source of income Spiritual influence
Psychological
• Mental Health diagnosis• Personality Disorders• Developmental Disorders• Substance Abuse-Alcohol /Drug Abuse
• Depression• Coping Skills
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Document Behavioral Characteristics
• Alertness• Attentiveness• Facial Expression• Eye Contact • Appearance• Speech• Mood and Affect
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Environmental EvaluationHome evaluation essential to determine resources
available to Patient
• Living situation – home/apartment-homeless
• # 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
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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
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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
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Questions
Thank you!
Thank You.
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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, 2nd Edition, v. 06/13/11.
• Mental Health Assessment Tool. January 31, 2013. Heartland National TB Center.
