4550 Tuberculosis Leader s Guide
INTRODUCTION This program is intended to inform and update the participants about TB, how it is transmitted, diagnostic tests, medications for treatment and how to control transmission, and information on latent TB infection. NEVCO s Tuberculosis 6 meets the CDC guidelines for health care workers. This program is approved for 2.0 contact hours. OBJECTIVES At the end of the program the learner will be able to: 1. Define what TB is and how it is transmitted. 2. Identify the diagnostic tests for evaluation of TB exposure and active TB. 3. Describe latent TB infection. 4. Describe the significance of a PPD test and positive test results. 5. List the common signs and symptoms of tuberculosis. 6. List the medications used in treating TB and the preventative therapy for inactive TB. 7. Describe what Directly Observed Therapy is. 8. Describe how to prevent the transmission and spread of TB in the health care setting with the use of negative pressure rooms. 9. Describe the types of masks used for respiratory or airborne isolation and the frequency of fit testing. 1
THE NURSING PROCESS The nursing process is a systematic method of problem solving. It is based on the scientific method. The nursing process is called "process" because it is ongoing. These are the steps of the nursing process: Assessment: This is the systematic, ongoing collection of information from multiple sources. Assessment is done when a nurse interviews a client and the client s significant others. A physical assessment of the client is also completed observing the following: laboratory data, daily client actions, assessing the client s ability to carry out daily activities, symptoms and the client s response to treatment. In long term care, resident assessment instruments are used to provide a comprehensive multi-disciplinary assessment. Problem Identification or Nursing Diagnosis: Assessment data leads to identifying client strengths and client problems. These may be actual problems the client currently experiences, or potential problems that may occur with that client in the future. Problems are stated and related to a cause or influencing factor. Planning: The systematic steps that the nurse will enact, with others, to assist the client to meet the goals (or outcomes) that are set. For each problem, a measurable, specific goal is identified. The plan includes nursing actions, based on aspects of nursing theory, nursing science, other sciences, and research findings. The beliefs and values of the nursing profession as well as the values of the client are taken into account. Implementation: Carrying out the plan. Evaluation: This is the systematic process of examining each client goal-related outcome to determine if it were met and to revise the plan accordingly. Evaluation may also identify the resources that are needed for the client or the health care provider in their continuing plan of care. Professional Nursing Roles As the nurse carries out the nursing process, the nurse enacts a variety of professional roles. These are: clinician teacher client advocate leader These roles may overlap. In the clinician role, the nurse may provide direct "hands on" care, or may assess a client's needs and direct others to provide services to meet those needs. The nurse may conduct patient and family teaching in a teaching role. The nurse may also teach other health professionals when a multidisciplinary team addresses the client's needs. The nurse is a client advocate when collaborating with the client, finding resources for the client, and acting on behalf of the client. The nurse is a leader when planning and assigning the care of a client to others, maintaining overall responsibility and accountability for that care, assisting other members of the health care team to set and meet goals or when providing resources to other health care providers. 2
GLOSSARY OF KEY TERMS Review this with the participants after video presentation, then have participants take the Post- Test. Acid-Fast Bacilli (AFB): Mycobacteria that stay stained even after they have been washed in an acid solution; may be detected under a microscope in a stained smear. Alveoli: The small air sacs of the lung that are at the end of the airway; when droplet nuclei reach these air sacs, TB infection begins. BCG: Bacille Calmette-Guérin (BCG), a vaccine for TB disease that is used in many countries but rarely used in the United States; may cause a falsepositive reaction to the tuberculin skin test. Boosted Reaction: A positive reaction to a tuberculin skin test due to a boosted immune response from a skin test given up to a year earlier; occurs in people who were infected a long time ago and whose ability to react to tuberculin had lessened. Two-step testing is used in TB screening programs to tell the difference between boosted reactions and reactions caused by recent infection. Cough-Inducing Procedures: Procedures that make a patient cough, such as sputum induction, bronchoscopy, and the administration of aerosolized pentamidine. Directly Observed Therapy (DOT): A strategy devised to help patients adhere to treatment; means that a health care worker or another designated person watches a TB patient swallow each dose of the prescribed drugs. Droplet Nuclei: Very small droplets (1 to 5 microns in diameter) that may be expelled when a person who has infectious TB coughs or sneezes; they can remain suspended in the air for several hours, depending on the environment. 3
GLOSSARY OF KEY TERMS (Continued) Ethambutol: A drug used to treat TB disease; may cause vision problems. Ethambutol should not be given to children who are too young to be monitored for changes in their vision. False-Negative Reaction: A negative reaction to the tuberculin skin test in a person who has TB infection; may be caused by allergy, recent infection (within the past 10 weeks), or very young age (younger than 6 months old). False-Positive Reaction: A positive reaction to the tuberculin skin test in a person who does not have TB infection; may be caused by an infection with non-tuberculosis mycobacteria or by vaccination with BCG. HEPA Filters: Special filters that can be used in ventilation systems to help remove droplet nuclei from the air. Induced Sputum: Sputum that is obtained by having the patient inhale a saline (salt water) mist, causing the patient to cough deeply; this procedure is used to help patients cough up sputum if they cannot do so on their own. Induration: Swelling that can be felt around the site of injection after a Mantoux skin test is done; the reaction size is the diameter of the indurated area (excluding any redness), measured across the forearm. Infectious: Capable of spreading infection; a person who has infectious TB disease expels droplets containing M. tuberculosis in the air when he or she coughs or sneezes. Isolation Room: A room with special characteristics to prevent the spread of droplet nuclei expelled by a TB patient, including negative-pressure ventilation. Isoniazid: The drug that is most often used for preventative therapy and also used to treat TB disease; although relatively safe, it may cause hepatitis and other adverse reactions in some patients. 4
GLOSSARY OF KEY TERMS (Continued) Malaise: A feeling of general discomfort or illness. Mantoux or PDD Tuberculin Skin Test: The preferred method of testing for TB infection; done by using a needle and syringe to inject 0.1 ml of 5 tuberculin units of liquid tuberculin between the layers of the skin (intradermally), usually on the forearm; the reaction to this test, usually a small swollen area (induration), is measured 48 to 72 hours after the injection and is classified as positive or negative depending on the size of the reaction and the patient s risk factors for TB. Multidrug Resistant TB (MDR TB): TB that is resistant to isoniazid and rifampin; more difficult to treat than drug-susceptible TB. Mycobacterium Tuberculosis: The organism that causes TB and is sometimes called the tubercle bacillus; belongs to a group of bacteria called mycobacteria. Negative Pressure: A ventilation system designed so that air flows from the corridors into an isolation room, ensuring that contaminated air cannot escape from the isolation room to other parts of the facility. Personal Respirators: Special masks designed to filter out droplet nuclei; used in health care facilities and other settings where TB may be spread. Purified Protein Derivative (PPD): The type of tuberculin used in the Mantoux skin test. Pyrazinamide: A drug used to treat TB disease, usually during the initial phase of treatment; should not be given to pregnant women. Rifampin: A drug used to treat TB disease; also used for preventative therapy in people with a positive skin test reaction who have been exposed to isoniazid-resistant TB. Rifampin has several possible side effects (for example, hepatitis, turning body fluids orange, drug interactions). 5
GLOSSARY OF KEY TERMS (Continued) Silicosis: A lung disease caused by inhaling silica dust, which is used in the production of glass and ceramics; occurs most often in mining and foundry workers. Streptomycin: An injectable drug used to treat TB disease; may cause hearing problems. Streptomycin should not be given to pregnant women. Two-step Testing: A strategy used in TB screening programs to distinguish a boosted reaction (caused by TB infection that occurred many years before the skin test) from a reaction caused by recent infection. If a person has a negative reaction to an initial skin test, a second test is given 1 to 3 weeks later; a positive reaction to the second test probably represents a boosted reaction, not recent infection. Two-step testing is used in many TB screening programs for skin testing employees when they start their job. Ultraviolet Germicidal Irradiation: The use of special lamps that give off ultraviolet light which kills the tubercle bacilli contained in droplet nuclei. 6
PRE-TEST Circle T if the statements are true. Circle F if the statements are false. T F 1. Tuberculosis is transmitted by repeated exposure to airborne particles called droplet nuclei which are spread when someone with pulmonary TB sneezes, coughs, speaks or sings. T F 2. Within 2-12 weeks after initial infection, the immune response limits further multiplications of tubercle bacilli; some, however remain dormant and viable for years and this is known as latent TB infection. T F 3. A Mantoux or PPD skin test is read 48 to 72 hours after placement. T F 4. Absence of a reaction to the TB skin test does not exclude the diagnosis of tuberculosis. T F 5. The local county health department must be notified of all TB cases or even suspected cases. T F 6. It is only necessary to place a patient in airborne/respiratory isolation when diagnosis of TB is definitely confirmed. T F 7. After several weeks of drug therapy, most patients with TB feel much better and their rate of being infectious decreases. T F 8. Since TB is transmitted through the air, sterilization of personal items and eating utensils is absolutely necessary. T F 9. Experts generally agree that pulmonary TB is considered noninfectious if three (3) consecutive sputum smears on the same day are negative. T F 10. Isolation rooms for AFB isolation need to have negative pressure capability. 7
DISCUSSION QUESTIONS 1. Discuss when it is best to place a patient in respiratory isolation and why. 2. List some of the signs and symptoms of tuberculosis. 3. List some suggestions for making sure a patient will be compliant with his or her TB medications. 8
POST-TEST Choose the best answer. 1. Which of the following is true about Mycobacterium tuberculosis: a. composed of cell walls that have a waxy coat comprised of fatty molecules b. it is in an acid fast bacteria c. difficult to study in the lab because the bacteria multiply slowly d. all of the above 2. Latent TB infection is becoming a growing health concern because: a. it has no symptoms of active TB but is highly infectious b. HIV infection makes individuals particularly vulnerable for progression to active TB c. the PPD skin testis always negative d. all of the above 3. The primary cause for multidrug-resistant TB infection is: a. prescribing the wrong medications in the treatment of the disease b. stopping the medication after 9 months of therapy c. individuals not completing their antibiotic therapy (stopping often within 2 or 3 weeks) d. the patient is treated with too few drugs 4. The following is true about the Mantoux/PPD skin test: a. it is read 48 to 72 hours after placement b. it is an intradermal injection under the flat surface of the forearm c. the reading is done by measuring the induration or palpable swelling d. all of the above 5. Two-step testing requires repeating a PPD in 1 to 3 weeks if: a. the person being tested is over 50 years of age b. for all newly hired employees in the healthcare setting c. to distinguish boosted reactions from those indicative of a new infection if the initial reading was negative d. all of the above 6. Common symptoms of pulmonary tuberculosis are: a. elevated temperature with night sweats b. productive cough with blood-streaked sputum c. fatigue and loss of appetite d. all of the above 9
POST-TEST (Continued) Choose the best answer. 7. Which of the following are required for a comprehensive diagnosis of TB: a. good history and physical exam b. sputum culture c. chest x-ray d. all of the above 8. Active TB should initially be treated with the following four (4) drugs: a. Rifampin, INH (Isoniazid), Prednisone and Penicillin G b. INH (Isoniazid), Rifampin, Ethambutol, and Streptomycin c. INH (Isoniazid), Rifampin, Pyrazinomide and Ethambutol d. INH (Isoniazid), Hydrocortisone, Ethambutol and Ampicillin 9. The length of time for the patient with TB to become non-infectious after starting on anti- TB medications depends on: a. the patient shows improvement with less symptoms b. the patient has three (3) consecutive negative sputum specimens collected on consecutive days c. there has been adequate therapy for at least 2-3 weeks d. all of the above 10. If caring for a patient with TB at home, which of the following can be done to assure AFB isolation: a. keep the patient confined to his or her bedroom b. make sure the patient does not go outside until there is a negative chest X-ray c. open windows and use fans to promote air flow d. do not allow the patient to ride in a car 10
ANSWER SHEET PRE-TEST POST-TEST 1. T 1. d 2. T 2. b 3. T 3. c 4. T 4. d 5. T 5. d 6. F 6. d 7. T 7. d 8. F 8. c 9. F 9. d 10. T 10. c 11
RESORCE ADVISOR Deborah Unsworth, M.S. ARNP, Received her bachelor of Science Degree from the University of South Florida and her Master of Science Degree from State University of New York. She has worked as a nurse since 1973 in the areas of med-surg, obstetrics and ER. She has been a nurse practitioner and women s health educator since 1990 and is currently the Director of Education at National Educational Video, Inc. NEVCO video educational programs are prepared using specific criteria designed by National Educational Video, Inc. TM All educational programs are coordinated and reviewed under the direction of the NEVCO Director of Education, who is a master s prepared nurse. REFERENCES Centers for Disease Control and Prevention. (2004), Self-study modules on tuberculosis (Modules 1-5) http://www.cdc.gov/nchstp/tb/pubs/ssmodules/htm. Centers for Disease Control and Prevention. (2003), Treatment of tuberculosis. http://www.cdc.gov/nchstp/tb/pubs/slidesets/treatment_guidelines/2003/default.htm While NEVCO strives to remain current with federal and state regulatory requirements, the information contained in this program is always subject to governmental amendment. Therefore, we suggest that you contact your state and federal authorities for any possible revisions to regulatory requirements. 12
PARTICIPATION EVALUATION OF OBJECTIVES Please evaluate this program by circling the number that best represents how well this program met the following objectives: 4=Excell 3=Good 2=Averag 1=Poor ent e 1. Define what TB is and how it is transmitted. 4 3 2 1 2. Identify the diagnostic tests for evaluation of TB exposure and active TB. 4 3 2 1 3. Describe latent TB infection. 4 3 2 1 4. Describe the significance of a PPD test and positive test results. 4 3 2 1 5. List common signs and symptoms of tuberculosis. 4 3 2 1 6. List the medications used in treating TB and the preventative therapy for inactive TB. 4 3 2 1 7. Describe what Directly Observed Therapy is. 4 3 2 1 8. Describe how to prevent the transmission and spread of TB in the health care setting with the use of negative pressure rooms. 9. Describe the types of masks used for respiratory or airborne isolation and the frequency of fit testing. 4 3 2 1 4 3 2 1 Do you feel you met your personal objectives? Time required to complete this program? minutes COMMENTS: Please return this form to the facilitator who distributed the learning materials. Thank you. 13
NEVCO Account # REQUEST FOR CERTIFICATES FOR CONTACT HOURS TYPE the NAMES, LICENSE NUMBERS AND JOB TITLES (RN, LPN, MSW, CNA, PT, etc.) of the people who are to be issued a certificate for contact hours for attending the continuing education program: (Facility Name) (Title and Number of Video Program) This request must be submitted along with the completed roster and evaluation sheets for the above named program. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. NAME LICENSE NO. JOB TITLE
Must be completed by the facilitator EVALUATION OBJECTIVES: TIB Bank Center 599 9 th Street N., Suite 207 Naples, Florida 34102-5625 (800) 252-5604 Fax (888) 877-7255 www.nevcoeducation.com FACILITATOR S EVALUATION (NEVCO Video Education Program) (1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities. Title of Program Date Place of Employment Job Title Please evaluate the presentation by circling the number that best describes your rating. 4 Excellent 3 Good 2 Average 1 Poor ORGANIZATION OF COURSE Material was organized to facilitate learning 4 3 2 1 The amount of material covered was adequate and accurate 4 3 2 1 There was effective use of time to cover the subject 4 3 2 1 CONTENT OF THE FACILITATOR S GUIDE List total number of objectives in this facilitator s guide List by number the objectives that were met The test material reflected the objectives listed 4 3 2 1 Content can be used to improve nursing practice 4 3 2 1 Content reflected knowledge level and needs of learner 4 3 2 1 The material was current 4 3 2 1 Evaluate Test Questions Pre-Test 4 3 2 1 Discussion Questions 4 3 2 1 Post-Test 4 3 2 1 FACULTY PRESENTING (Video) The presentation was 4 3 2 1 The presenter explained the material 4 3 2 1 The presenter demonstrated knowledge of material 4 3 2 1 OVERALL RATING I felt this teaching method was 4 3 2 1 COMMENTS (Please make suggestions for future topics and additional comments about the presentation or instructor) Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO Educational Staff 1995 Revised 10/2004
EVALUATION (NEVCO Video Education Program) TIB Bank Center 599 9 th Street N., Suite 207 Naples, FL 34102-5625 (800) 252-5604 Fax (888) 877-7255 www.nevcoeducation.com Must be completed by every participant EVALUATION OBJECTIVES: (1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities. Title of Program Date Place of Employment Job Title OBJECTIVES Total number of objectives in program Circle the number of objectives that WERE met 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Circle the number of objectives that were NOT met 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Please evaluate the presentation by circling the number that best describes your rating. 4 Excellent 3 Good 2 Average 1 Poor ORGANIZATION OF COURSE Material was organized to facilitate learning 4 3 2 1 The amount of material covered was adequate and accurate 4 3 2 1 CONTENT OF THE PRESENTATION The test material reflected the objectives listed 4 3 2 1 Content and/or skills demonstrated can improve my ability to perform my job 4 3 2 1 Content reflected knowledge level and needs of learner 4 3 2 1 The material was current 4 3 2 1 Time for questions was 4 3 2 1 Effective use of time to cover subject was 4 3 2 1 Graphics were beneficial 4 3 2 1 NEVCO FACULTY (who prepared the program and/or appeared in interviews) The presentation was well prepared 4 3 2 1 The presentation explained the material well 4 3 2 1 The presenter demonstrated knowledge of material 4 3 2 1 OVERALL RATING I felt this teaching method was 4 3 2 1 Facilities and classroom were adequate 4 3 2 1 COMMENTS (Please make suggestions for future topics, content of program and instructors) Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO Educational Staff 1995 Revised 10/2004
PRINT OR TYPE TIB Bank Center 599 9 th. Street N., Suite 207 Naples, FL 34102-5625 (800) 252-5604 Fax: (888) 877-7255 www.nevcoeducation.com CONTINUING EDUCATION ROSTER This form must be completed and returned to NEVCO. Keep a copy for your facility, but return the original to NEVCO. Account # Number and title of Video Program Dates Given Contact Hours Name of Facility Address of Facility City/State/Zip RN Facilitator Signature ROSTER OF PARTICIPANTS Participant Name Participant Signature License # Soc. Sec. # 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. National Educational Video, Inc. TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97.0, California CEP8803 and Kentucky 7-0045. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.
11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. Participant Name Participant Signature License # Soc. Sec. #
599 9 th Street N., Suite 207 - Naples, FL 34102-5625 800-252-5604 Fax: 888-877-7255 www.nevcoeducation.com Certificate of Completion This is to certify that Attended and Completed National Educational Video, Inc. TM Program Number and Title For contact hours On Date Facility / Agency Name Facility / Agency Address RN / Facilitator CERTIFICATE FOR ASSISTANTS ONLY National Educational Video, Inc.TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97.0, California CEP8803 and Kentucky 7-0045. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.
CERTIFICATE OF COMPLETION For each participant who has successfully completed a continuing education program, please make a copy of the blank NEVCO Certificate (on reverse side) and fill in the following information: 1. Name of the learner 2. Program title and number 3. Number of contact hours 4. Date the program was completed 5. Name and address of your Agency / Facility 6. Signature of the RN / Facilitator responsible for offering the program