U Assessment

HISTORY. Ask patients about a previous history of TB or Hodgkin's disease, diabetes melli-tus, leukemia, gastrectomy, silicosis (a disease resulting from inhalation of quartz dust), and immunosuppressive disorders. A history of corticosteroid or immunosuppressive drug therapy can also increase the likelihood of TB infection. Other risk factors include a history of multiple sexual partners and abuse of drugs or alcohol. Determine if the patient has had recent contact with a newly diagnosed TB patient or has resided in any type of long-term facility. Take an occupational history as well to determine if the patient is a healthcare worker and therefore at risk.

Ask the patient to describe any symptoms. The patient often reports generalized weakness and fatigue, activity intolerance, and shortness of breath on exertion. Anorexia and weight loss occur because of altered taste and indigestion. The patient may also describe difficulty sleeping, chills or night sweats (or both), and either a productive or a nonproductive cough.

PHYSICAL EXAMINATION. The patient looks acutely ill on inspection, with muscle wasting, poor muscle tone, loss of subcutaneous fat, poor skin turgor, and dry flaky skin. When you auscultate the chest, you may hear a rapid heart rate, rapid and difficult breathing, and stridor. Diminished or absent breath sounds may be present bilaterally or unilaterally from pleural effusion or pneumothorax. Tubular breath sounds or whispered pectoriloquies may be heard over large lesions, as may crackles over the apex of the lungs during quick inspiration after a short cough.

The sputum appears green, purulent, yellowish, mucoid, or blood tinged. The patient may have pain, stiffness, and guarding of the affected painful area. Accumulation of secretions can decrease oxygenation of vital organs and tissues. You may note cyanosis or a change in skin color, mucous membranes, or nail beds and changes in mental status, such as distraction, restlessness, inattention, or marked irritability.

908 Tuberculosis

PSYCHOSOCIAL. Patients dependent on alcohol or drugs, those who are economically disadvantaged, and those who live in crowded conditions are at risk. The living environment needs careful assessment. Ask about living conditions, including the number of people in the household. Patients may have recent or long-standing stress factors, financial concerns, and feelings of helplessness or hopelessness. They may experience feelings of alienation or rejection because they have a communicable disease and are in isolation. They may have changes in patterns of responsibility, physical strength, and capacity to resume roles because of TB. Assess the patient's ability to cope. Assess the degree of anxiety or depression about the illness, the change in health status, and the change in roles.

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