Transmission and Pathophysiology
For this reason, TB is an airborne disease; it is transmitted through the air when an infected person coughs or sneezes, releasing the pathogens to the environment. Transmission occurs when these infected droplets are inhaled by a healthy person who consequently contracts the infection.
When inhaled, the Tubercle bacilli are carried to the alveolar, where they cause infection. They are proliferated in the alveolar macrophages and eventually kill the cells. If proliferation is not controlled, the tubercle becomes larger, forcing bacilli to enter local lymph nodes, causing lymphadenopathy. If the body fails to produce a cell-mediated immune response, bacilli replication continues increasing damage to the lungs. A tuberculosis lesion due to necrosis may be formed at this stage (Adigun & Singh, 2021). If bacteria are allowed to continue replicating, the hematogenous spread of bacilli may be induced, leading to disseminated TB. Tubercle bacilli may also cause erosion along the lung airway rendering the patient infectious.
The process above occurs in people who develop the primary and active phases of the disease. Other people develop a latent tuberculosis infection when infected and are therefore asymptomatic. In this group of people, only 5-10% evolve into the primary condition (Adigun & Singh, 2021). LTBI patients do not manifest any symptoms and are unable to spread the infection. The immune system is triggered for these persons, and macrophages kill or encapsulate the bacilli forming granuloma. They are therefore not considered to have tuberculosis disease (Adigun & Singh, 2021). Some patients may experience reactivation of the disease years later in cases of immunosuppression. It affects mainly the lymph nodes and causes lesions at the lung apices. However, it should be noted that a successfully controlled latent TB infection can confer protection against tuberculosis exposure.
Clinical Manifestations
TB is characterized by:
- Three-week long persistent and non-remitting coughs
- Purulent cough with a hemoptysis characteristic
- Breathlessness as a result of lung damage
- Pleuritic chest pains
- Night sweats
- weight loss
- Fever
- Fatigue
- Malaise
The primary identified medical concerns for Maria were night sweats, fever, and a persistent cough. Further examination showed cervical and axial lymphadenopathy and abnormal lung sounds in her upper lobes. The patient’s sputum was cultured and tested and was found to have Mycobacterium tuberculosis bacteria.
Regarding medical, psychosocial concerns, the patient identified as an immigrant, which made her hesitant to seek treatment. She also spoke of the loss of her grandmother, whom she had lived with in Peru. Maria believed that she had succumbed to tuberculosis; this proved that she had been in contact with a TB-positive person in her recent past. Maria even developed stress since the knowledge of her condition and its persistent nature.
Implications of the Treatment Regimen
The treatment of tuberculosis generally involves drug therapy for many months, up to nine months of drug prescription. As it is in the case of Maria, a two-month dosage of isoniazid, rifampin, pyrazinamide, and ethambutol was prescribed, plus an additional seven months of isoniazid and rapamycin. This type of dosage can lead to a lack of adherence to its long-term nature, especially in patients from less fortunate families and immigrants such as Maria. Failure to complete therapy can lead to disease relapse, continued transmission, development of drug resistance, and even death (Nellums et al., 2017). Patients are therefore encouraged to complete the prescribed treatment to increase their chances of wellness.
In extreme cases, patients develop multi-drug resistance where they are resistant to isoniazid and rifampin, as in Marias’s case. As much as she was committed to completing the prescribed drug therapy, most of her symptoms persisted, including night sweats and a non-remitting cough. Therefore, she was put through a new drug therapy that lasted eighteen months and one drug, ethambutol, replaced with moxifloxacin. Multidrug-resistant tuberculosis (MDR-TB) therapy usually lasts 18-24 months as advised by the physician. MDR-TB is treated depending on individual resistance to the infection profile (Nellums et al., 2017). It may have caused reduced efficacy to the medicine, worse side effects, and even prolonged treatment depending on the specific resistance pattern. However, the very long period is discouraging for many patients. Some even quit along the way, assuming that they are healed. For this reason, hospitals are encouraged to provide support through patient-centered interventions that help increase patient adherence to medication hence increasing the probability of wellness.
Role of Community Health Clinics in the USA
In 2010, a health insurance law was passed in the United States to provide health care for only insured people, which only benefited citizens and legally documented immigrants. Federal grants were then used to fund community health centers created to support immigrants regardless of their immigration status (Beck et al., 2017). These centers provide consultation, evaluation, diagnosis, and treatment of TB at affordable prices. The role of these centers in their mission to reduce or prevent TB infection include:
- Sensitize patients on the implication of tuberculosis and encourage them to agree to take the medication therapies.
- Understand programs that support screening, diagnosis, and treatment of TB and prioritize the prevention and treatment of TB.
- Equip their medical staff with skills on how to handle, diagnose and treat patients with TB (Beck et al., 2017).
- Institute control practices regarding TB infection to protect personnel and patients
- Prepare for new patients with suspected TB by making diagnostic techniques, instrumentation, and consultation available to treat the disease.
The Implications of TB for Critical Care and Advanced Practice Nurses
Nurses play a significant role in the treatment and prevention of tuberculosis. They provide education, medication, and follow-ups to promote drug adherence in TB patients and simultaneously prevent drug resistance. Tuberculosis is difficult to control since it is highly contagious and poses a risk to the nurses involved in treating infected patients. Severe infection may lead to the admission of patients in the intensive care unit due to their critical condition. It may, therefore, require more attention and contact, which may lead to transmission of the contagion.
Advanced practice nurses are trained to care for critically ill TB patients flexibly. They do not work in shifts as junior nurses do and create a familiarity with the patient under treatment, ensuring that they help the patient recover as much as they protect themselves from contracting the disease (Duro et al., 2017). Nurses are therefore able to establish a relationship with the patients making patient education easier to relay. They educate both the patients and their families, assuring them that TB is curable and can only be dealt with if the prescribed dosage is completed. They also motivate the patients to keep working towards their wellness and wear masks in cases of contact with other people.
Critically ill patients with TB sometimes develop stigma due to isolation and wearing masks. Their contact with APNs encourages them to help them deal with the stigmatization (Duro et al., 2017). Patients also exhibit behaviors of stopping medication as soon as they feel better, which leads to using pedagogical skills to motivate them to complete prescriptions. Advanced practice nurses provide primary care, critical patient care, and preventive care to mental health. Therefore, they are the best suited to care for critically ill TB patients since they oversee treatment and prevent its spread and transmission.
References
Adigun, R., & Singh, R. (2021). Tuberculosis. StatPearls publishing.
Beck, T., Le, T., Henry-Okafor, Q., & Shah, M. (2017). Medical care for undocumented immigrants. Primary Care: Clinics In Office Practice, 44(1), e1-e13. Web.
Duro, R., Figueiredo Dias, P., Ferreira, A., Xerinda, S., Lima Alves, C., Sarmento, A., & Santos, L. (2017). Severe tuberculosis requiring intensive care: A descriptive analysis. Critical Care Research and Practice, 2017, 1-9. Web.
Nellums, L., Rustage, K., Hargreaves, S., & Friedland, J. (2018). Multidrug-resistant tuberculosis treatment adherence in migrants: A systematic review and meta-analysis. BMC Medicine, 16(1). Web.