Complex case study analysis- Tuberculosis

The essay deals with the case study of Mr. John a 55 year old man diagnosed with pulmonary tuberculosis (PTB). The analysis of medication management and relevant treatment pertaining to Mr. John’s will be discussed explicitly in the subsequent sections of the essay.

Running head: COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
Complex case study analysis- Tuberculosis
Name of the Student
Name of the University
Author Note

1COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
Introduction
The essay deals with the case study of Mr. John a 55 year old man diagnosed with
pulmonary tuberculosis (PTB). He is presented to Emergency Department or ED with worsening
symptoms. PTB is caused by the Mycobacterium tuberculosis and is highly contagious.
According to World Health Organisation (WHO), Tuberculosis is one of the leading cause of
death worldwide. In lower and middle income countries, 95% of the deaths occur due to TB. As
per WHO report, in 2016, 1.7 million died from TB (WHO, 2015). Multi drug resistant TB is a
public health crisis. The sustainable development goal of WHO is to end TB epidemic by 2030
(Department of Health, 2015). In Australia, the TB is highly prevalent in Indigenous population
than the Non-indigenous populations with the incidence rate of 4.6 per 100,000. Despite good
TB control measures since 1980s Australia is facing challenges to control TB in migrant
population and Indigenous people (Department of Health, 2015). In relation to the case study,
the essay will discuss in details about the pathophysiology of the primary cause of the patient’s
hospital admission. The analysis of medication management and relevant treatment pertaining to
Mr. John’s will be discussed explicitly in the subsequent sections of the essay. Further, the
appropriate nursing interventions for pulmonary tuberculosis are the focus of the essay in later
sections. Other relevant issues pertaining to the health condition is briefly discussed and
supported with relevant literature.
Provide details of the selected case's relevant medical history and present status
The essay deals with the case study of Mr. John, a 65 year old Indigenous man lives in
Melbourne. He was presented to the emergency department with symptoms like fever, cough,
pale skin, shortness of breath, night sweats, weakness, and weight loss. Since three weeks he had
haemoptysis. His blood pressure was elevated, 152/93 mmHg. The diagnosis of the patient two

2COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
months ago was pulmonary tuberculosis. The patient was discharged initially but due to lack of
appropriate care at home is readmitted to the emergency department due to worsening symptoms.
Mr. John has the history of hypertension, pneumonia, Type 2 diabetes mellitus (T2DM),
renal failure and chronic obstructive pulmonary disease (COPD). The patient also has the history
of pericarditis. The patient is kept in the isolated room to prevent spread of infection to others.
On monitoring he was found to be non-adherent to the medication guidelines. He showed
willingness to go home and is evident from spending long time outside the hospital premises. His
non-compliance led to the worsening of his condition. At times he had cough with blood. The
patient has history of smoking for 15 years. The patient’s self care and hygiene were poor. He
loves his independence in carrying activities of daily living. The patient lives alone in a large
house and there are no sign of allergy observed. The patient does not participate in any form of
physical activity and reports social isolation.
On examining the vital signs of Mr. John, the levels were in normal range except
temperature of 37.9 degrees, low blood sugar level and high blood pressure. The patient had
signs of headache, depression and mild edema in legs. The matter of concern was oxygen
saturation of 88-90% at room air. The signs of infection were prominent. There were no signs of
anaemia. Mr John’s chest X ray resets showed minor lesions in apical segments. The lesions in
the upper lobe are significant indicators of tuberculosis. The left lower lobe was found with the
focal Opacity and increased consolidation. Respiratory examination showed the audible sounds
of crepitation’s on the lung apices. The laboratory tests used for diagnosis are sputum
examination, culture for identifying the causative organism and Monteux Tuberculin skin test
(18mm). Culture was tested for positive Acid Fast Bacillus – AFBs and obtained positive smear

3COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
test. The patient had normal blood count test results and urea level. The medications for the
patient are as follows-
1. fluticasone salmeterol (250mcg, 50mcg),
2. Rifampicin 300mg daily
3. iptarropium 21mcg/dose
4. salbutamol 100mcg/1doses
5. Pyrazinamide 750mg daily,
6. Nicotine patch 21mg
7. Isonaizid 200mg daily
8. Ethambutol 600mg daily
Other prescribed medication for the regular use of the patient are-
1. frusemide 80mg daily (Diuretic)
2. Nifedipine 20mg TDS (antihypertensive).
3. prazosin 2mg TDS (antihypertensive).
Oxygen therapy and dextrose were given for low oxygen saturation and low blood
glucose level.
A comprehensive treatment is followed for Mr. John. The nursing interventions and the
individualised care is discussed in subsequent paragraphs.

4COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
Pathophysiology for the current hospital admission
Tuberculosis is known to be the multisystemic disease with various manifestations. It is
caused by the Mycobacterium tuberculosis, a gram-positive acid-fast bacillus. Infection occurs
when the lungs and or mucous membranes are exposed to the infected aerosols. In patients with
PTB the single cough can results in release of 3000 infective droplet that may have 10 bacilli
sufficient to spread infection to others. These droplets when inhaled get deposited in the terminal
airspaces of the lungs or upper part of airways. In this location they grow for 2-10 weeks and
multiply in number say 1000-10,000 that is enough to trigger the cellular immune response. At
this stage it is easy detected by the tuberculin skin test (Raviglione, 2016). The vigorous immune
response triggered after infection is due to anetgenic nature of the Mycobacteria. This is known
to be the nonspecific immune response. The antigencity of the bacteria is due to multiple
components of the cell wall including the phospholipids, Wax D, glycoprotein that can activate
the receptors of the lymphocytes, and the polymorphonuclear leukocytes (Wani, 2013).
Tuberculosis or TB may be categorised as latent infection or active disease. Active
tuberculosis disease is commonly called as lung disease and is also called an extra pulmonary
tuberculosis TB. In the active form the bacteria is rapidly multiplying invading other body
organs and is clearly evident from chest x-rays and lung examinations (Department of Health and
Human Service, 2015). Host immune system when suppresses the infection and it develops into
latent infection. Latent disease does not develop overtly. Active disease can be evident from
reaction to skin tuberculin tests and rapid multiplication of bacteria with great risk of infection
transmission (Salgame et al. 2015). The common site of development of the disease is the lungs
and therefore, 85% of the cases the patients have pulmonary complaints. Bacilli are being
discharged from the sputum in case of infection as result of which the positive culture of sputum

5COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
examination is observed. However, a greater infection is indicated by the sputum smear positive
case than the positive culture.
The infection is manifested as chronic cough, as also observed in John along with other
symptoms such as fever, night sweats, weakness, weight loss and low appetite. These symptoms
are common to PTB patients in Australia and are mentioned in the National Institute for Health
and Clinical Excellence guidelines (Hoppe et al., 2016). This was the primary cause of the
admission of Mr. John in the ED that was called for intense diagnostic tests followed by
comprehensive treatment.
There are various risk factors for PTB that increase the chance of active form of TB
instead of Latent form. It includes HIV infection, low body weight, chronic lung disease like
COPD, smoking and diabetes mellitus. .People with previous history of TB is at high risk along
with travellers. In Australia Indigenous people are highly vulnerable to TB when exposed to
certain areas such as Queensland. Social factors such as living in overcrowded areas trigger
active form of TB. These risk factors are present in Mr. John as evident from the past medical
history that caused his illness to progress. And Smoking causes ineffective airway clearance and
chronic cough in COPD and increases risk for TB. These conditions make the clinical suspicion
high in Mr. John who is also Indigenous as recommended by the department of health (DOH,
2015).
Medication management
Mr. John was prescribed a combination of medication as PTB is treatable. An active form
of TB requires multi-drug treatment. Medications usually administered are ethambutol, rifampin
and pyrazinamide. These three medicines are given in combination with isoniazid to kill the

6COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
potentially resistant strains. For the first two months it is important to take the four drugs
together as the sputum smear test was positive. Later the dosage may be two drugs per day. The
patient’s weight was checked before commencing the treatment as some of the medicines affect
weight requiring regular monitoring. An active form of disease is very serious and may be
health debilitating. Therefore, there is need of strong adherence to the treatment regime. Success
of the TB treatment depends on strong compliance and regular monitoring (Torres & Silva,
2012; Department of Health, 2015).
Isoniazid is an antituberculosis medicine is usually prescribed as tablet and is
recommended to intake along with two or three more medicines. It is used together with the
Rifampicin and Pyrazinamide. Isoniazid has bactericidal; property on rapidly dividing bacterium
and inhibits the synthesis of the mycolic acid. Rifampicin is also an antibiotic which works by
inhibiting the RNA polymerase of the bacteria used for transcription (Burhan et al., 2013).
Pyrazinamide is the anti-tuberculous agent administered initially for two months due to suspicion
of drug resistance disease. It inhibits the growth of the Mycocbacterim by diffusing into its
granuloma. It is then converted to the pyrazinoic acid an active form by tuberculosis
enzyme pyrazinamidase. On accumulation the pyrazinoic acid inhibits the fatty acid synthesis in
the bacteria and also disturbs it membrane potential. Ethambutol is the bacteriostat and hinders
the cell wall development of the bacteria in the stage of active development. By inhibiting the
enzyme called the arabinosyl transferase necessary for making the peptidoglycan complex the
cell permeability is increased (Safi et al., 2013).
When the patient was readmitted in the hospital, he had low oxygen saturation that was
treated with the oxygen therapy. Low blood glucose level was treated with dextrose infusion and
treat insulin induced hypoglycaemia. Nasal Prongs at the dose of 3L/min was given. To decrease

7COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
the high blood pressure the patient was prescribed a combination of anti-hypertensive. An
effective treatment of hypertension is with diuretic treatment. Thiazide diuretics are also
administered that patient takes over the counter. Low dose diuretics may be used in combination
with the beta blockers as it will prevent lowering of blood pressure by other are decreased. Also
the side effects of the diuretics are decreased when administered as combination therapy. In case
of John the combination therapy to reduce hypertension was nifedipine, furosemide, and
prazosin. Prazosin makes urination easier, while nifedipine, reduces blood pressure. In patients
with renal failure volume retention drives the hypertension and therefore loop diuretic
furosemide used. He is given frusemide 80mg daily due to history of renal disease (Zanchetti,
2014). Salbutamol (β2-adrenergic receptor) is used to relax the airway muscles in patients with
COPD and chronic cough. It functions as a bronchodilator. Ipratropium (Atrovent) bromide also
has the same function. Both are important for Mr. John as he has COPD. COPD leads to severe
inflammation of lungs therefore a combination of Fluticasone Salmeterol is used to exhibit anti-
inflammatory effect by inhibiting the immune receptor activated in allergic response due to
chemicals (Lee et al., 2013).
Medical diagnostics treatment
Based on the physical signs, symptoms and past medical history of the patient, various
diagnostic tools were used. The primary diagnosis for TB is the sputum tests where the sample
of sputum is collected to test for TB bacteria and drug resistance strains and takes 4-8 weeks to
complete. In case of John active form of disease was indicated. Acid fast staining of the culture
sample is used for detecting the acid fast Mycobacterium. The positive acid washed smears in
the specimen confirms PTB in John as also his AFB tests were positive as per CDC
recommendations (Centers for Disease Control and Prevention, 2014).

8COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
Imaging tests like chest X rays are ordered to notice any white spots in lungs and other
changes due to TB. Pulmonary nodules in the upper lobe, opacification of airspaces in lung
parenchyma, consolidation of the upper zone, pleural effusion is the hall mark of TB (primary
radiological features). It is necessary to take imaging tests along with Mantoux tuberculin skin
test as in most cases the reaction to tuberculin is obtained as false positive result (Centers for
Disease Control and Prevention, 2014). In case of John the Tuberculin test showed positive
results with elevation of skin upto 18mm in diameter. As per Department of Health, Australian
guideline, diameter greater than 15 mm confirms to be positive even if there are no other risk
factors present. The active form of disease was further confirmed by the minor lesions in upper
lobe observed in the chest X- ray along with focal Opacity and increased consolidation (Jaeger et
al., 2014). Edema in lungs is also caused by pleural effusion as per Raviglione, (2016) that was
observed in John. As per CDC, and NSW guidelines the Chest X-ray is essential to distinguish
the TB and non-TB related conditions (normal cardiothoracic conditions) (National Institute for
Health and Clinical Excellence, 2006; NSW, 2015).
Blood tests are ordered to rule out any presence or absence of active or latent disease
form (Raviglione, 2016). It is best to use when high risk of TB infections is suspected. The
patient blood test and haematology assessment showed no sign of abnormal blood counts or
anaemia. Since the patient had history of renal failure, tests were conducted for assessing renal
function as well as liver function test. The results were normal and indicate need of diuretics
(Torres & Silva, 2012). On assessing the vital signs to confirm the symptoms of infection high
temperature (37.9) instead of normal 37 degree Celsius and high blood pressure was observed
(152/93 instead of normal 12/80), As the patient has the history of the diabetes mellitus, blood
glucose test was conducted and John was found to be hypoglycaemic (2.5 mmol/l).

9COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
Daily monitoring of the patient was essential as he was having chronic illness with
several comorbidities. There was periodic assessment of chest and lungs though chest X ray and
infection was tracked using sputum tests. Vital signs were regularly monitored as the patients
may have side effects due to various medicines prescribed to him. Considering his diabetes
insulin monitoring was also essential to determine the right dosage required to avoid side effects
of anti-TB medications (Torres & Silva, 2012).
Activity log
Based on the past medical history and symptoms presented in ED, the patient was
suspected of tuberculosis. Therefore, he was taken care of separately after shifting him to
infectious ward. His room was isolated to other rooms to prevent spread of infectious. When
dealing with the patient for physical examination and administration of medication, nurses used
personal protective equipment such as gloves, mask, and apron as recommended by WHO and
Department of Health Australia. These measures will help prevent infection to nosocomial
spread to other wards or to health care providers. It will make an immunosuppressed individual
highly susceptible to TB. Moreover, John’ sputum showed high presence of bacilli. Isolation and
treatment may be considered until the further sputum test showed negative results for
Mycobacterium. This was necessary as John’s symptoms showed public health risk (Hoppe et
al., 2016). As per the guidelines given by the Department of Health Australia, contact
investigation was conducted in accordance with history taking, radiographic examination and
TST. History taking help determine the medication regime while monitoring for side effects
(NSW 2015; Department of Health, 2015).
On the day one after isolation in the infectious ward, the patient was given oxygen
therapy to achieve saturation of 99%.Using nasal prong will help reduce shortness of breath.

10COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
The patient was given dextrose infusion to balance the low hypoglycaemic level as John was
diabetic. A combination of drugs was used to decrease the high blood pressure along with
diuretics. The second day of care included examination of results of the blood tests, radiographic
and TST tests ordered on first day (NSW, 2015). Based on positive test results, DOT
intervention was given. A strict regimen of fluid intake, was imposed to reduce oedema. The
fluid chart was regularly monitored through input and output (Murray, 2011). By third day there
was improvement in the blood glucose level, and on fourth day oxygen saturation was achieved
to 99%. However, the blood pressure, oxygen requirement and blood glucose level was
monitored for next three days to notice any fluctuations. On the fifth day the nasal prong and
dextrose infusion was discontinued. However, antihypertensive medication was continued due to
history of hypertension (Torres & Silva, 2012).). As a part of directly observed therapy or DOT,
recommended by various national and international guidelines, Isoniazid, Rifampicn,
Ethambutol, and pyrazinamide was administered for period of 6 months. By 10th day there was
decrease in fever. Further based on therapeutic guidelines, there was continuous inpatient care
and adherence to drug therapy was monitored right from the first day of treatment. It is because
there was risk of high complications for TB as well as other comorbidities (National Institute for
Health and Clinical Excellence, 2006; Centers for Disease Control and Prevention, 2014; NSW,
2015). The drug adherences were monitored along with other vital signs and for side effects of
medications such as nausea, vomiting and others. Mean while the sputum and culture tests were
conducted consecutively. On the 14th day the patient sputum test was found to be negative and
thus, he was shifted from infectious ward. There was reduction in cough, temperature, as well as
blood glucose was in normal range on 15th day. The discharge plan was prepared and the patient
was assured to arrange for home care nurse as he preferred living at home. The patient was then

11COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
educated about self care and hygiene, importance of medication compliance on quality of life as
it will promote his independence in activities of daily living after discharge. He was educated to
wear mask to avoid recurrence of infection and cough or sneeze while covering with tissue
paper. Dietary recommendations were given to promote nutrition and reduce weakness
(M'Imunya, Kredo & Volmink, 2012). Since the patient was living alone he was referred to
social service program for any personal and financial assistance after discharge. He was also
referred to counselling programs to reduce depression before discharge (Baral et al., 2014).
Reflection on the nursing care
Reflective practice is essential in nursing as it helps one to evaluate own actions,
knowledge and thinking. It acts as a tool to retrospect and introspect, into one’s own judgement
and decision making skills to reach a conclusion about need of improvement (Bulman, Lathlean,
& Gobbi, 2012) Reflection is important in both personal and professional life to become better
human being and an efficient nurse. Reflecting on the care of Mr. John for PTB, I have learned
the effective implementation of various international and national guidelines on PTB care. It
helped me proceed with the interventions systematically.
Using these guidelines a rapid diagnosis was conducted which led to effective treatment
and patient outcomes. Isolating the patient and consecutive sputum testing helped track the
infection and prevent noscomial spread of infection suing drug therapy. By examining the vital
signs in detail, I could well set the nursing priorities. It includes need of oxygen therapy, restore
the normal blood glucose level and address hypertension. Patient temperature was regularly
monitored as fever is the hall mark of infection. Further, sputum test and cultures were ordered
consecutively, which helped to indentify the need of multidrug intervention. Based on the
literature evidence, the combination of Isonaizid with Rifampicin, Pyrazinamide and Ethambutol

12COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
is beneficial in reducing the PTB infection when administered regularly for first two months
(Burhan et al., 2013).
The patient was weak and lacking energy; therefore, adequate dietary guidelines were
given to enhance nutrition and energy level. The patient was supported by educating about the
side effects of medication and to report immediately in case of concern. The patient was
educated about illness as he was initially non adherent to the treatment regime. Patient education
is essential to reduce the risk of recurrence of highly contagious PTB as per the CDC, NSW
AND guidelines fro Australian Department of Health and Human Services. As per these
guidelines it is effective to start antibiotic therapy with combination of drugs for first two
months. Thus, it was justified to examine the pathophysiology of the disease in detail. Also
nursing education promotes effective coping in patients and it was essential in case of John as he
has no family member to take care. He lives alone and has poor hygiene. Educating him about
coughing/sneezing etiquette, hand hygiene; self care will reduce transfer of infection in
community (M'Imunya, Kredo & Volmink, 2012).
Considering his present and past medical records I have given adequate fluid volume to
the patient and the input/output was well documented. It was beneficial in preventing
dehydration and ensured easy expectoration in John. Since John was suffering from chronic
cough due to COPD and had earlier showed shortness of breath, I have educated him about the
breathing techniques that will decease his respiratory efforts. To increases his lungs expansion I
have positioned the patient in semi-Fowler’s position (Costa, Almeida & Ribeiro, 2015).
Knowing the patient’s vulnerability due to his social isolation and signs of depression, he
was referred to social support group and counselling services respectively. The rationale includes

13COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
decrease in risk of future infection, assistance with livelihood and supportive environment.
Counselling, and peer support are effective way to verbalise feelings that will reduce stress and
depression (Baral et al., 2014). Patient centered care was implemented for John, as he was in
need of emotional support in addition to medical intervention. Integrated patient centered
tuberculosis care is the first pillar of the End TB strategy of WHO (Fujita & Narita, 2012). All
the international and national guidelines calls for streamlined medical services for TB
prevention. It calls for services that customized to the patient's needs. The use DOT intervention
is the need of treatment and it allow to give comprehensive patient centered support (Baral et al.,
2014). Ii could optimal patient administration based on profile and past medical records. It
worked well as patient centered care facilitates active engagement from the patient. Patient
centered care helps decreases the rate of rehospitalisation (Fujita & Narita, 2012). The rationale
for this care was to engage patient as a part of the team. Using the regional care pathway I was
better able to share the treatment process with John, results of tests and other relevant
information. This approach led to treatment adherence in John after 16 days of care in hospital.
Using his approach I could consider the patient’s convenience, comfort and risk assessment.
Effective communication skills helped me to collect and analyse the information while giving
face to face care. I could well use verbal and nonverbal skills to understand the patient needs.
Patient centered care and DOT provider facilitates in building the relationship of trust with the
patient (Fujita & Narita, 2012). Therefore, I could increase the patient adherence to the
medication and is evident from negative sputum test. It was possible by motivating him and
encouraging him throughout treatment.
Despite the above measures and evidence based practice at every step of patient care for
PTB, some places were noted that could be improved in future practice. Firstly, John felt

14COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
discrimination when he was separated and isolated in separate ward. However, this was
necessary but could not be well communicated to him. However, later the patient was sifted back
to the general ward and after education he was aware of his illness. Eventually it increased
adherence to the treatment. If only the reason for isolation was well communicated, John would
have been more adherent since beginning of the treatment. I should have been more positive
towards the patient. Also there was no education given to the smoking cessation. The person was
a chain smoker in past and currently intakes one cigarette a day. However, this may be a risk for
COPD exacerbation and PTB. This should not have been ignored. These deficiencies shall be
overcome in future practice. I will refer the client to counselling for smoking cessation when
he will come for follow up. It will in effective management of COPD and PTB as well as
reduce depression (Shin et al., 2012).
Conclusion
PTB is highly contagious and hence there is a need of strict following of national and
international guidelines for rapid diagnosis and treatment. Nursing intervention must be based on
evidence as there is huge research conducted in this field. Traditional mode of care may not be
applicable as some strains are highly resistance. The symptoms of the PTB are health debilitating
and may be fatal without proper monitoring. It adds to stress and depression in patents.
Therefore, nurses need to implement patient centered care and well collaborate with
multidisciplinary team to support patient quick recovery. Patient education about underlying
pathophysiology, need of multidrug therapy and side effects of medication is very essential to
ensure treatment adherence. As a nurse I have given adequate support, encouragement and
motivation to the patient to increase medication compliance. However, the care deficiencies

15COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
include neglecting smoking aspects in care and communicating the patient about isolation after
infection. Such deficit will be taken care in future.

16COMPLEX CASE STUDY ANALYSIS- TUBERCULOSIS
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