Case: Tuberculosis (TB), HIV

Calvin Umbyuma, Mr. Umbyuma is a 42 y/o male who has been admitted for ​complaints of
shortness of breath with pleuritic chest pain.​ He was​ diagnosed with HIV positive antibodies
over a year ago.​ He has ​recently been traveling back to his home country of Kenya to visit his
sick mother.​ He received traditional medical treatment at his village. His temp is ​100.9 F​, ​38.3 C​,
R 22, P92, ​BP 152/89​. Inflammatory markers – ​Erythrocyte Sedimentation Rate (ESR) and
C-Reactive Protein (CRP) are elevated at 78.9 mm/h and 67.2 mg/L​. He has been placed in a
room at the end of the hall.

The nurse is doing the admission and has trouble pronouncing the patient's name. He tells the
nurse to call him U. Mr. U starts coughing, his sputum is ​greenish-yellow with blood tinge​. He
tells the nurse that it is ​very painful to cough​. The nurse asks him if he ​has night sweats, and he
says yes, for the past 4 weeks​. Mr. U has traveled back to Kenya twice this year as his mother
has been very ill. He tried to convince her to seek medical attention, but his family is ​very
traditional and believes in other methods of treatment​. Mr. U admitted he also has been using
traditional methods to treat his HIV. The nurse has an order for an IV with NS at 125ml/hr.,
blood cultures x2, and​ Tylenol ​for pain and fever.

Mr. U calls the nurse to his room complaining of ​severe pain when he coughs​, and his ​shortness
of breath has become worse​. A ​visitor is in the room without a mask​ and has delivered Mr. U’s
medication from home to include his traditional herbal remedies. Mr. U admits that he was trying
to take his medicine when he started couldn’t stop coughing. Mr. U’s previous ​chest X-ray
showed patchy shadowing in the right upper lobe​.

Mr. U ​does not want to give up his traditional herbal medications​. He tells the nurse that his
father died in the best hospital in Kenya receiving the newest treatment. The nurse inquires as
to the father's illness and Mr. U tells the nurse that he believes it was Tuberculosis. He does not
know what his mother is suffering from as she refuses to seek modern treatment. Mr. U is also
concerned about his wife as she has been having difficulty with her Visa and is still trying to
come back to the US

Mr. U test​ positive for TB ​and new medications are ordered (​kanamycin and moxifloxacin​). His
T-cell count is 160 with CD4 cell at 16%​. A consult has been ordered for an infectious disease
provider to manage his TB and HIV. The nurse is very concerned that this his TB is a resistant
strain as this can be carried with HIV infected patients. The nurse is also concerned about the
social contacts that Mr. U has had in the recent past including his visitor that was not wearing a
mask. The nurse has received multiple diagnostic orders that need to be done ASAP. Current
vital signs are: ​100.6 F, 38.1 C​, R:22, P:86, ​PaO2: 91%​ Prioritize the following: ​Bronchoscopy,
Western blot and Elisa test, Chest x-ray, provide patient teaching about diagnostic testing​.

Mr. U’s condition continues to deteriorate, and his tests come back positive for TB. The nurse is
informed by the CNA that his ​pulse-oximetry is 89​ on room air and he ​looks very dusky​. The
CNA also tells the nurse that while they were taking his VS, he coughed up bloody sputum.
A. SCREENSHOTS
B. MANIFESTATION
➔ NATURE OF CONDITION:
● Tuberculosis​: TB is caused by a bacterium called Mycobacterium tuberculosis.
The bacteria usually attack the lungs, but TB bacteria can attack any part of the
body such as the kidney, spine, and brain (CDC)
● How it spreads: TB bacteria are spread through the air from one person to
another. The TB bacteria are put into the air when a person with TB disease of
the lungs or throat coughs, speaks, or sings. People nearby may breathe in these
bacteria and become infected.
● Generally, persons at high risk for developing TB disease fall into two categories:
○ Persons who have been recently infected with TB bacteria
○ Persons with medical conditions that weaken the immune system

➔ SIGNS & SYMPTOMS:

● complaints of shortness of breath with pleuritic chest pain
● severe pain when he coughs
● sputum is greenish-yellow with blood tinge
● Cough up bloody sputum
● Night sweats for the past 4 weeks
● Fever: 100.6 F, 38.1 C

➔ LABORATORY/VS/PA FINDINGS:
● Vital signs: 38.3 C, 38.1 C, BP = 152/89
 - Indication of a possible infection
- Indication of pain
● Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): 78.9
mm/h, 67.2 mg/L
- Indicators of infection and inflammation
● Greenish-yellow sputum with blood tinge, painful coughing, night sweats
- Signs that body is fighting off an infection
- The yellow color comes from dead white blood cells, which can turn green
if there are a lot of white blood cells and other debris
- Tuberculosis (TB) is associated with bloody sputum, a symptom that
occurs when the blood vessels inside the lungs become eroded and begin
to bleed, night sweats and painful coughing as well.
● Chest X-ray: Patchy shadowing in right upper lobe
- A lung shadow is a description of an abnormal appearance
- Tuberculosis is a bacterial infection of the lungs that often has no
discernible features on X-rays in early disease but can cause the
appearance of a shadow.
● T-cell count and CD4 cell: 160, 16%
- The patient is positive for HIV which can cause depletion of T-cell/CD4
cells
- Abnormal results of T-cell/CD4 count could indicate progression of HIV
infection
- Because of the this possibly, the patient was infected with Tuberculosis
(TB) because of the immunosuppressive action and consequences of HIV
● Pulse Oximetry: 89%, looks dusky
- Patient is already suffering from low oxygen levels
● Bronchoscopy:
- During bronchoscopy, a thin tube (bronchoscope) is passed through the
nose or mouth, down the throat and into the lungs.
- Common reasons for needing bronchoscopy are a persistent cough,
infection or something unusual seen on a chest X-ray or other test.
● Western Blot and Enzyme-linked immunosorbent assay (ELISA) Test:
- The enzyme-linked immunosorbent assay (ELISA), detects HIV
antibodies and antigens in the blood.
- The ELISA test is typically the first test ordered by a healthcare provider.
In case of a positive result from this test, the ELISA test was previously
followed by a test called a Western blot to confirm the diagnosis.
- The Western blot is used to confirm a positive ELISA, and the combined
tests are 99.9% accurate.

C. NURSING CARE PLAN:

Possible Nursing Diagnoses:

1. Deficient knowledge r/t lack of exposure to/misinterpretation of information
 2. Ineffective airway clearance r/t thick greenish sputum with blood secretions secondary to
Pulmonary Tuberculosis
3. Altered comfort: Acute pain r/t persistent coughing secondary to Pulmonary Tuberculosis
4. Ineffective thermoregulation r/t to the infection process secondary to Pulmonary
Tuberculosis
5. Risk for Impaired Gas Exchange r/t decrease in effective lung surface or atelectasis
secondary to Pulmonary Tuberculosis
6. Ineffective management therapeutic regimen r/t lack of knowledge about the disease
process.

CUES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE

Objective: Ineffective At the end of our -Maintain infection -​PTB is

1. Greenish-yel airway care, the patient control through transmitted via
lowish clearance r/t will maintain the use of mask droplet inhalation
secretion thick viscous patent airway and performance so proper
with blood and will manifest of hand washing precaution should
greenish-yello decreased before and after
tinge be performed to
wish, bloody episodes of contact with client
2. Dusky avoid transmission
appearance secretions dyspnea as to other clients.
3. PaO2: 89% secondary to evidenced by the
4. Chest X-ray Pulmonary following: -Elevating the
showed Tuberculosis -Place client in head of the bed
patchy 1. Demonstrate high fowler’s and turning clients
shadowing behaviors to position and every two hours
in the right improve/maintain encourage help in decreasing
upper lobe airway clearance reposition every the pressure
two hours. placed on the
Subjective: 2. Expectorate diaphragm
1. Verbalized secretions
shortness of without -Allergen may
breath assistance -Maintain room or trigger more
environment free accumulation of
3. Sustain from any sorts of secretion due to
normalization of allergen respiratory
V/S and Pulse response
Oxiemter

4. Participate in
treatment -Teach and -These exercises
regimen, within encourage deep hasten the
the level of breathing and expulsion of
ability/situation coughing sputum and aids
exercises in maintaining
airway patency

-Emphasize to -Fluids help

increase fluid loosen secretion
intake in the lungs

-Provide postural -Through the aid

drainage and of gravity and
percussion percussion
secretions are
readily expelled

-TB can be
-Educate client transmitted
and family about through droplet
disease condition inhalation and 6
and the need for months
compliance with compliance to
the therapeutic medication is
regimen needed in order to
be treated with.