Tuberculosis
By: Noel Bautista, Melissa Duldulao, Leslie Garcia, Vanessa Nguyen, Susana Ocampo, Jasmin Umana
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Introduction to Tuberculosis Statistics The Lopez Family ➢ Cultural Beliefs ➢ Medical Beliefs ➢ Communication Bioecological Model and the Lopez Family Family Health Interventions for the Lopez Family
Tuberculosis Tuberculosis (TB) is a highly infectious disease caused by the bacterium known as Mycobacterium tuberculosis. It primarily affects the lungs and is transmitted through the air from one person to another. When a person with active TB coughs, laughs, sneezes, or sings, droplets containing the bacteria are suspended in the air awaiting a susceptible host to inhale the droplets. Upon inhalation, the bacteria makes its way to a susceptible site, such as the alveoli, creating an exudative response that causes pneumonitis (Ignatavicius, 2016). Within the site, the bacilli shaped bacteria grow and create lesions. In response, the immune system is activated and in most cases, active tuberculosis does not develop. If active TB occurs, tissue becomes necrotic and these areas may calcify or liquify (Ignatavicius, 2016). If liquefaction occurs, a cavity develops within the lungs. It is within the cavity that bacteria continue to grow and eventually, scar tissue forms. Upon examination of a chest x-ray, small nodules are observed. In general, there are two forms of tuberculosis: Active tuberculosis and latent tuberculosis. When TB bacteria are in the body, without causing sickness, it is known as latent tuberculosis. People with latent TB are not infectious but TB can be spread if the bacteria become activated. Once TB is in its active form, they may develop symptoms such as a cough lasting longer than three weeks, chest pain, coughing up blood or sputum, fatigue, fever, chills, loss of appetite, weight loss, and diaphoresis (CDC, 2015). Since most symptoms develop slowly, patients may not be aware of the disease until it has advanced.
Diagnosis and Treatment To diagnose tuberculosis, a purified protein derivative (PPD) test is conducted on the patient’s forearm. If the patient’s test is positive, a chest x-ray is taken to confirm the diagnosis. If diagnosed, treatment involves a combination of drugs such first-line drugs isoniazid and rifampin. The combination of drugs is used to minimize the risk of drug resistance and to quickly destroy the bacteria at different stages of development. Those at risk of TB infection are those in frequent contact with an untreated person, immunocompromised individuals, such as people with HIV, older homeless people, abusers of injection drugs or alcohol, people who live in crowded areas, and foreign immigrants especially those from Mexico, the Philippines, and Vietnam (Ignatavicius, 2016).
Statistics Over the years, the incidence of tuberculosis has slowly declined. According to the Center for Disease Control and Prevention (CDC), there were 9,421 TB cases in the US in 2014. Roughly, 3 in 100,000 people were infected. The states with the highest incidence of TB cases include California, New York, Florida, Nevada, and Texas. In general, Asians and Pacific Islanders, including Native Hawaiians, have the highest incidence of the disease with an average of 18 cases per 100,00 persons and 17 cases per 100,000 persons, respectively (CDC, 2015).
The Lopez Family The Lopez family is a Mexican-American family that currently resides in San Diego, CA. They are a nuclear family with a mother, father, and two daughters. All family members are bilingual (Spanish and English). The family is Catholic and attends church every Sunday. The Lopez family is social and likes to attend family events such as birthdays, holiday events, baby showers, graduation parties, etc. Both daughters live in their college dorms which are both close to where the mother and father live. According to Duvall, the families developmental stage is stage 7 (middle aged parents). Stage 7 starts with all their children moving out and ends with retirement. This stage includes the parents refocusing on their marriage, ensuring security after retirement, and maintaining kinship ties.
The Family Members ●
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Jose Lopez (50 years old) is the father of the family and is the main source of income.. He currently works 40 hours a week as a Mechanic at a very busy auto shop in downtown San Diego. He also does office work for the San Diego Naval Base for about 10 hours a week. Jose enjoys gardening and fishing. Jose has a great relationship with his wife and both of his daughters. Maria Lopez (45 years old) is the mother of the family and is the partial breadwinner of the family. She currently works 40 hours a week as a pharmacy technician at a Walgreens in El Cajon, CA. In addition to working 40 hours a week, Maria also cooks dinner every night, cleans the house, does grocery shopping and laundry every Sunday. Maria is typically stressed during the weekdays due to her work and home responsibilities. She enjoys watching telanovelas and knitting in her spare time. She has a great relationship with her husband and eldest daughter. However, Maria Lopez currently does not approve of her youngest daughter’s boyfriend and is not getting along with her daughter.
Family members continued.. ●
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Roxanne Lopez (22 years old) is the eldest daughter of the family and is currently a nursing student at SDSU. She was recently diagnosed with active TB. Roxanne was diagnosed during a routine health screening that was required for an upcoming nursing clinical rotation. Roxanne has not told her family about her diagnosis yet because she fears her family’s reaction. Roxanne has good relationships with everyone in her family. She is the mediator of the family and is protective over her younger sister. She spends the majority of her weekdays studying for school. During the weekends she enjoys going to the beach and watching movies with her friends. Marissa Lopez (20 years old) is the youngest daughter of the family and functions as the “baby” of the family. She is a microbiology major at UCSD and is currently unsure of a career choice. Marissa volunteers at Children’s hospital in San Diego, CA for about 8 hours a weeks. In her spare time, she enjoys playing tennis and shopping. She has good relationships with everyone in the family except for her mother.
Cultural Beliefs
Growing up in a Mexican-American household Roxanne is familiar with the cultural beliefs. She may not follow all but she is aware of them. Beliefs about Tuberculosis in Latino immigrants and Mexican culture is the strong fear of being ostracized by their friends and community if they reveal their TB status. They would feel deep personal shame and expect to be treated differently (CDC, 2010). There is a fear the patient will not be invited in a loved one's home again. May not accurately understand how TB is transmitted, symptoms and prevention. Misconception that TB could be transmitted by smoking, sharing eating utensils or exchanging bodily fluids.
In the CDC study, some Mexicans would use traditional health specialists. Some Mexicans believe there is a humoral imbalance and may use special teas and natural herbs obtained at tiendas naturistas (homeopathic stores) or farmacias (pharmacies). Among some Mexicans, a common perception is that BCG , a common vaccine against tuberculosis, prevented many diseases such as chickenpox and heart problems. Alternately, some perceive their TB infection was caused by the BCG vaccination. (CDC, 2010). How to inform the Latino community of TB?
Present TB information in an easy, useful manner. Pamphlets in Spanish and English are useful tools. Community talks and public service announcements on the local radio station or on Spanish-language TV channels. Culturally appropriate, Spanish-language videos or fotonovelas may also be an effective way to educate about TB (CDC, 2010).
Medical Beliefs
Although Roxanne does not want to tell her biological family about her current active TB diagnosis, as a health provider providing treatment and support is crucial to both her as a patient and who she considers family. According to the Centers for Disease Control and Prevention, “Some patients have strong personal our cultural beliefs about TB disease, how it should be treated, and who they can turn to for help.” (CDC, 2014). “When TB conflicts with these beliefs, patients can become fearful, anxious, or alienated from their healthcare workers” (CDC, 2014). Therefore, building trust and determining Roxanne’s beliefs and perspectives on how TB is caused and is affecting her and how she thinks it would affect her family should be assessed. During this assessment, open-ended questions should be asked to avoid predetermined responses.
Education on how to prevent the spread of TB is important since active TB can be life-threatening. Since this patient is close with her family, involved with an educational institution and is associated with hospitals for nursing clinical rotations, the active form of this disease can be easily passed on and spread. Therefore, medication should be taken as prescribed, a mask should be worn if warranted by a healthcare provider and covering the nose and mouth with a tissue when coughing, and contact with others should be avoided (CDC, 2014).
In addition, the incentives for the treatment process are also crucial since active TB can cause lung damage and even death if not treated with medicine (CDC, 2014). TB disease can take 6 months and possibly as long as one year to kill the germs (CDC, 2014). So, it is crucial for Roxanne to understand why she needs to be isolated as much as possible and should not travel to places like work, school, mall, or participate in any activity where there is contact with people (CDC, 2014).
Communication
According to the Bioecological Systems Theory, TB is not only affecting Roxanne, but also her family, friends, her peers and nursing classmates, people at the doctor’s office, people at church, her neighbors, friends of the family at social events and vice versa. Therefore, it is important to question and consider all people and things Roxanne is involved or associated with when assessing her.
In most cases, patients are treated outside the hospital setting and effective communication with patients and their family is essential. Effective communication requires the person who is receiving the message to interpret and comprehend what is being sent from the person delivering the message. By achieve effective communication, simple terminology should be used, information should be discussed in the order of importance, and the healthcare worker should be positive (CDC, 2014). To be certain effective communication occurred, the healthcare worker should ask the patient to repeat what has been explained and what was understood (CDC, 2014).
Providing care for the patient and their family provides holistic care and can increase the success of treatment. The relationships and interaction amongst the family members can also help determine how one family member can affect each other, if there are financial needs, lack of resources, or lack of understand and support. What are the patient’s spiritual beliefs?
Reminding and guiding Roxanne towards what she and her family finds strength in can help support Roxanne and her family through the difficulties of disease like the need for isolation to prevent spread of the disease.
The Bioecological Systems Theory Based on the work of Urie Bronfenbrenner, the Biological Systems Theory combines children’s biological disposition and environmental forces that come together to shape the development of human beings. The Bioecological Systems Theory uses both Developmental Theory and the Systems Theory to understand family and individual growth. Because of Bronfenbrenner’s work, domains of the family and economic/political influences have become part of the life journey from childhood to adulthood. With the crossover of human development and social sciences, it encourages a better understanding of larger social constructs that have great influence on human development. The following will discuss the major parts to the Bioecological Systems Theory (Kaakinen, 2015, p. 83-87).
The Bioecological Systems Theory ● ●
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Microsystems are the settings where the individual/family undergo and create everyday reality. Some examples are: home, church, school, peers, and doctor’s office. Mesosystems are the relationships among the major microsystems in which the family actively participates and how they interact with each other. Some examples are: family to school, family to church, and family to peers. How do these relationships affect one another? For example, is there a strain because of school demands to the individual? Exosystems are external environments influencing the individuals and/or family secondarily. The individual may have not have active participation within this environment. One example is a parent’s workplace and their responsibilities to the job and how it can affect the child, like a parent that has to travel for their job. Macrosystems are general cultural attitudes, ideas, or belief systems that influence institutional environments within a specific culture that the family or individual live. Some examples are Catholicism, democracy, and societal values. Mesosystems and exosystems are set within macrosystems. Chronosystems refers to time-relations where changes occur over time and have an effect on all levels of the aforementioned levels.
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External influences are just as important as internal influences for a family. Families and their environments are mutually shaping systems, each changing and adapting overtime. Opportunities supply the family with material, emotional, and social encouragement that works towards the families abilities. Risks supply the family with direct threats and/or lack of opportunity.
The Bioecological Systems Theory Important things to remember: ● ●
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Within each level there are roles, norms, and rules that shape the environment. Families develop in relation to a larger environment (i.e., home, school, and society) and not in isolation. The key to understanding human/family development is all environments have different dimensions and always change over time. All relationships are bidirectional between humans and their environments.
Application of the Bioecological Theory ●
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Microsystem: Jose and Maria continue to live at their residence while their daughters Roxanne and Marissa are away for college. Their parents fulfill their roles. Roxanne reaction to her recent diagnosis of active TB has caused her to be concerned with her family’s reaction. Mesosystem: The Lopez’s are very active in church and have a large support system outside of their family unit. Both religious and their friends should be able to be used as tools to support them at this time. Their family is healthy and stable. Exosystem: Roxanne’s school has a significant impact on Roxanne’s situation. It was because of the screening process that she found out she has active TB and may affect her standing as a student. Although the school may not be impacted by Roxanne’s illness, Roxanne will be affected and in turn, her family as well. Since active TB is infectious, Roxanne’s case would need to be reported to local health officials. Macrosystem: The Lopez’s is a working class family whose Mexican heritage and Catholic background may influence their reaction to Roxanne’s diagnosis. These components can influence the way they understand the disease and its treatment. Chronosystem: The timing of this situation has impact on Roxanne and her family. Since she lives away from home she does not have direct familial support on a daily basis. Additionally the timeframe of her college education may be on hold due to her diagnosis.
Family Health Interventions 1.
Identify what Roxanne and/or Lopez family know about TB and adjust teaching accordingly. Teach Roxanne and family about all aspects of TB therapeutic regimen, providing as much knowledge as the client and family will accept, in a culturally congruent manner. â—? Rationale: Roxanne is very close with her family and it is vital to include them in the treatment plan for support. Family support can increase her chances of adhering to the TB therapeutic regime and prevent spread of the disease. â—? Journal: In order to effectively assist patients coping with TB, nurses should counsel and assist patients with disclosure of their TB status to their family and other members of their support system. When possible, nurses should include family members when providing health education about the disease and prevention. During treatment, each participant had to decide what was best for their family, society, and themselves during their treatment for TB. They knew the wrong choice could continue the spread of the disease and put others in their same situation (Zuniga, 2014)
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Assess family for role changes and coping skills. Refer to medical social services as necessary.
Rationale: Having a plan ready is essential to Roxanne’s recovery from TB. It is important in planning out a medication schedule with Roxanne and the family because Roxanne may be overwhelmed with her disease and forget to take her medication. Planning prevents missed doses and highers the chances of effective treatment. Journal: A number of studies have reported that a significant proportion of patients missed medication because they simply forgot. Forgetfulness can be a function of anxiety of one’s life situation and can negatively affect adherence to treatment. Thus, support to infected persons in the form of reminders to take medication plays a vital role in scaling-up of treatment adherence. The usefulness of friends and family members in this regard is dependent on revelation of status by the infected person. (Jegede, 2012)
Establish a plan of care with Roxanne and family based on her needs and caregiver’s capabilities.
Family Health Interventions continued... 2.
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Rationale: It is significant to not only treat the disease but to also help the family and Roxanne cope with her TB diagnosis. In the Mexican community, there is a stigma that comes with having an infectious illness which could lead to improper health management and emotional issues. Providing information about medical services, discussing role changes and coping skills can prevent poor health management. Journal: Participants spoke of feeling stigmatized by family and friends because of their TB. Participants talked about losing friends, their family shunning them, and feeling very depressed. Many knew they were risking their relationships when they told their friends and family about the diagnosis. In some cases their friends would accept the diagnosis and other times they would shun them. (Zuniga, 2014)
References Ackley, Betty J., & Gail B. Ladwig. Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care. Maryland Heights, MO: Mosby, 2010.
Centers of Disease Control and Prevention.Tuberculosis (TB). (2015, September 24). Retrieved October 6, 2015, from http://www.cdc. gov/tb/publications/factsheets/statistics/tbtrends.htm
Center of Disease Control and Prevention Common Perceptions, Attitudes, and Beliefs About Tuberculosis Among Mexicans Findings from Tuberculosisspecific Behavioral (2010, May). Retrieved October 11, 2015 from http://www.cdc. gov/tb/publications/guidestoolkits/ethnographicguides/mexico/chapters/chapter5.pdf
Center of Disease Control and Prevention Patient Adherence to Tuberculosis Treatment. (2014, October). Retrieved October 11, 2015 from http://www.cdc. gov/tb/education/ssmodules/pdfs/9.pdf
Floyd, Susan. (2011) What is the perfect family? Retrieved October 10, 2015 from http://www.ozzienews.com/life/susan-floyd/what-is-the-perfect-happyfamily/
Ignatavicius, D. D., & Workman, L. M. (2016). Medical- surgical nursing: Patient collaborative care (8th ed.). St. Louis: Elsevier Saunders.
Jegede, A.S. & Ushie, B.A. (2012). The Paradox of Family Support: Concerns of Tuberculosis-Infected HIV Patients About Involving Family and Friends in Their Treatment. AIDS Patient Care and STDs. 674-680. (7p) Kaakinen, J. R. (2015). Family health care nursing: Theory, practice and research (5th ed.). Philadelphia: F.A. Davis Co.. Kaakinen, J. R. (2010). Family health care nursing: Theory, practice and research (4th ed.). Philadelphia: F.A. Davis Co..
Zuniga, J.A., Munoz, S.E., Johnson, M.Z., & Garcia, A. (2014). Turberculosis Treatment for Mexican Americans Living on the U.S-Mexico Border. Journal Of Nursing Scholarship. 46(4): 253-262. (10p)