Medical-Pediatric23-Tuberculosis

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Tuberculosis is the ______ leading cause of death from an infectious disease.: second
How many million people in U.S. are infected with TB?: 10-15 million
Case rates of TB are higher where?: for all ages in urban, low-income areas and nonwhite racial and ethnic groups...foreign born children have accounted for more than one-third of newly diagnosed cases in children 14 yo and younger in U.S.
What organism is TB caused by?: the human Mycobacterium tuberculosis and the bovine Mycobacterium bovis organisms
Human disease caused by M. bovis occurs in children who ingest what kind of milk?: unpasteurized milk or milk products
Other factors that influence the degree to which the organism produces an altered state in the host include?: heredity, which is resistance
to the infection
genetically transferred
gender, higher in adolescent
girls
age, lower resistance in
infants, higher incidence
in adolescence
stress, emotional or physical
nutritional state
intercurrent infection, esp.
HIV, measles, pertussis
Children with what type of infection have an increased incidence of tuberculosis?: HIV...all children with HIV should be tested for TB
What is the usual portal of entry for the TB organism?: lung
What do the epithelial cells of the lung do when TB bacilli enter it?: a proliferation of epithelial cells surround and encapsulate the multiplying bacilli in an attempt to wall it off, forming a tubercle
Extension of the primary lesion at the original site causes? there's a discharge of material from foci to other areas of the lungs (e.g., bronchi, pleura) or produces PNEUMONIA: progressive tissue destruction as it spreads within the lung...then what happens?
Erosion of blood vessels by the primary lesion can cause widespread dissemination of the tubercle bacillus to near and distant sites. This is called?: miliary tuberculosis
What areas are frequently affected by miliary tuberculosis?: lymph nodes
meninges
bone
What is diagnosis of TB based on?: physical exam
history
tuberculin skin testing
radiographic exam
cultures of organism
The clinical manifestations of TB are extremely?: VARIABLE
What test is the most important indicator of whether a child has been infected from tubercle bacillus?: tuberculin skin test (TST)
The standard dose of purified protein derivative (PPD) is? 27-gauge and what size syringe? volar aspect of forearm: 5 tuberculin units...this is administered using what gauge needle?

1-ml syringe intradermally into what aspect?
What creation is crucial for accurate testing?: a visible wheal
What does a positive reaction indicate? active disease: that the individual has been infected and has developed sensitivity to the tubercle bacillus...however it does not confirm the presence of?
Once individuals react positively, they will always react?: positively
A previously negative reaction that becomes positive indicates?: that the patient has been infected since the last test
What kind of evaluation should promptly be done of all children with a positive TST reaction?: radiographic
Define latent tuberculosis infection (LTBI)?: used to indicate infection in a person who has a positive TST, no physical findings of disease, and normal chest radiographic findings
Define tuberculosis disease?: used when a child has clinical symptoms of radiographic manifestations caused by the M. tuberculosis organism
A diagnosis of LTBI or tuberculosis disease in a child is a sentinel event usually representing recent transmission of which organism?: M. tuberculosis
What are the clinical manifestations of tuberculosis?: may be asymptomatic or produce a broad range of symptoms:
fever
malaise
anorexia
weight loss
cough may or may not be
present (progresses slowly
over weeks to months)
aching pain and tightness in
the chest
hemoptysis (rare)

With progression:
respiratory rate increases
poor expansion of lung on
the affected side
diminished breath sounds
and crackles
dullness to percussion
fever persists
generalized symptoms are
manifested
pallor, anemia, weakness,
and weight loss
Which children should have IMMEDIATE TST done?: Contacts of persons with confirmed or suspected contagious tuberculosis (contact investigation)

Children with radiographic or clinical findings suggesting tuberculosis disease

Children immigrating from endemic countries (e.g., Asia, Middle East, Africa, Latin America)

Children with travel histories to endemic countries or significant contact with indigenous persons from such countries
Which children should have an ANNUAL TST?: Children infected with HIV

Incarcerated adolescents
Which children do some experts think should be tested every 2 to 3 years?: Children with ongoing exposure to the following people:
HIV-infected people
homeless people
residents of nursing homes
institutionalized adolescents
or adults
users of illicit drugs
incarcerated adolescents or
adults
migrant farm workers
foster children with exposure
to adults in the preceding
high-risk groups are
included
Which children do some experts think should be considered for TST at 4 to 6 and 11 to 16 years?: Children whose parents immigrated (with unknown TST status) from regions of the world with high prevalence of tuberculosis

continued potential exposure by travel to the endemic areas or household contact with persons from the endemic areas (with unknown TST status) should be an indication for repeat TST
Children at Increased Risk for Progression of Infection to Disease?: Children with other medical risk factors, including:
diabetes mellitus
chronic renal failure
malnutrition
congenital or acquired
immunodeficiencies deserve
special consideration
An initial TST should be performed before initiation of which kind of therapy?: immunosuppressive..including prolonged steroid administration, for any child with an underlying condition that necessitates immunosuppressive therapy
Medical management of tuberculosis disease in children consists of?: adequate nutrition
chemotherapy
general supportive measures
prevention of unnecessary
exposure to other
infections that further
compromise the body's
defenses
prevention of reinfection
and sometimes surgical
procedures
What is the recommended drug therapy for treating tuberculosis disease?: combinations of isoniazid
(INH)
rifampin
pyrazinamide (PZA)
A 6 month regimen consists of what meds?: INH
rifampin
PZA
(all of these are given for the first 2 months)

then INH and rifampin is given 2 to 3 times a week by DOT (direct observation of therapy) for the remaining 4 months
How does DOT (direct observation of therapy) help?: decreases rates of relapse, treatment failures, and drug resistance
Define direct observation of therapy?: means that a hcp or other responsible, mutually agreed-on individual is present when meds are administered to the patient
What drugs are given if resistance is suspected?: either ethambutol or an aminoglycoside is given until drug susceptibility results are available
If the child has (((HIV AND TB))), optimal therapy has not yet been established so child should visit a? three...and those should be continued for at least how many months? INH, rifampin, and PZA usually with ethambutol or an aminog: specialist...how many drugs should ALWAYS be started initially?

nine months...what should be given for at least the first 2 months?

drug-resistant disease is excluded
What is preventive therapy intended for? latent tuberculosis infection in children: to keep latent infection from progressing and to prevent initial infection in persons in high-risk situations...INH given daily for 9 months is recommended for?
When might surgery be useful?: may be required to remove source of infection in tissues that are inaccessible to chemotherapy or that are destroyed by disease
When might orthopedic services be needed?: for correction of bone deformities
When might a bronchoscopy be needed?: for removal of a tuberculous granulomatous polyp
What has decreased the death rate and the hematogenous spread from primary lesions?: antibiotic therapy
Death seldom occurs in treated children, except in the case of?: TB MENINGITIS
When is TB the most serious?: during first two years of
life
adolescence
when HIV positive
Most children recover from primary TB infection without?: being aware of its presence; however, very young children have a higher incidence of disseminated disease
What is the only definite means to prevent TB?: avoid contact with the tubercle bacillus...infection can occur even though a person is in sound health...pasteurization and routine testing of milk and elimination of diseased cattle have reduced incidence of bovine TB
What is Bacille Calmette-Guerin (BCG) vaccine?: a live virus vaccine prepared from attenuated strains of bovine bacilli...not routinely given in U.S.
Where do children with TB receive their nursing care?: ambulatory settings
outpatient departments
schools
public health settings

(most children are NOT CONTAGIOUS and require standard precautions)
Children with NO cough and negative sputum smears can be hospitalized where?: on an open ward
Children who ARE CONTAGIOUS and hospitalized with TB disease need what special accomodations? use of a personally fitted air-purifying respirator (PAPR) for all patient contacts: airborne precautions
negative-pressure room

and what special precautions should hcp's take?
Definition of Positive TST Results in Infants, Children, and Adolescents Induration greater than or equal to 5 mm?: Children in close contact with known or suspected contagious cases of TB disease

Children suspected to have TB disease:
Findings on CXR consistent with active or previously active TB
Clinical evidence of TB disease
Children receiving immunosuppressive therapy (incl. immunosuppressive doses of corticosteroids), or immunosuppressive conditions, incl. HIV infection
Definition of Positive TST Results in Infants, Children, and Adolescents What are the side notes for this title?: erythema at TST site does not indicate a positive test result

TSTs should be read at 48 to 72 hours after placement
Definition of Positive TST Results in Infants, Children, and Adolescents induration greater than 10mm:: Children at increased risk of disseminated disease:
those younger than 4yo
those with other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition

Children with increased exposure to TB disease:
Those born, or whose parents were born, in high-prevalence regions of the world
those frequently exposed to adults who are HIV-infected, homeless, users of illicit drugs, residents, or nursing homes, incarcerated or institutionalized, or migrant farm workers
Those who travel to high-prevalence regions of the world
Definition of Positive TST Results in Infants, Children, and Adolescents Induration greater than 15mm?: Children 4 years of age or older without any risk factors
Children with TB can attend school or day care facilities if they are receiving?: chemotherapy...and may return to activities if compliant and symptoms diminished
Children receiving chemotherapy for TB can receive which vaccinations?: measles and other age-appropriate live virus vaccine UNLESS they are receiving high-dose corticosteroids, are severely ill, or have specific contraindications to immunization
What can the nurse do to help a TB patient?: assist with radiographic exam
perform skin tests
and obtain specimens for lab
exam
Skin tests reaction time is?: 48 to 72 hours
Why are sputum specimens difficult or impossible to obtain from infants or young children?: because they swallow mucus coughed from the lower respiratory tract
What is the best method for obtaining material for smears or culture?: gastric washing
ex: aspiration of lavaged
contents from fasting
stomach
procedure is carried out and specimen obtained early in morning before customary breakfast time

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